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CORNELL UNIVERSITY 
 
 MEDICAL LIBRARY 
 
 ITHACA DIVISION. 
 
 THE GIFT OF 
 
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 WUi.J3^^S -I^^H^ 
 
CORNELL UNIVERSITY LIBRARY 
 
 3 1924 104 225 416 
 
Cornell University 
 Library 
 
 The original of tiiis book is in 
 tine Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924104225416 
 
THE 
 
 OPERATIONS OF SURGERY. 
 
BOOKS FOR SURGEONS and STUDENTS, 
 
 PUBLISHED BY 
 
 P. BLAKISTON, SON & CO., Philadelphia. 
 
 CAIRD AND CATHCART, a Surgical Handbook for the use of Practitioners and 
 Students. By F. Mitchell Caird, M.B., F.R.C.S. (Edin.), and C. Walker 
 Cathcakt, M.B., F.R.C.S. (Eng. and Edin.). With over 200 Illustrations 
 32mo, 400 pages, pocket size. Full Leather. Just Ready, 
 
 HORWITZ'S COMPEND OF SURGERY, including Minor Surgery, Amputa- 
 tions, Fractures, Dislocations, Surgical Diseases, and the Latest Antiseptic Rules 
 etc., with Differential Diagnosis and Treatment. By Orville Horwitz, B.S 
 M.D., Demonstrator of Anatomy, Jefferson Medical College ; Chief. Out-Patient 
 Surgical Department, Jefferson Medical College Hospital. Third Edition. Very 
 much Enlarged and Rearranged. 91 Illustrations and 77 Formulae. i2mo. No. 
 g ? Quiz Compend? Series. Interleaved for the addition of notes, $1.25. 
 
 Cloth. $1.00. 
 "We have found occasion to speak highly of the entire series of Quiz Compends 
 as far as issued. This little work has met with such favor that already a third edition is 
 demanded. The author has improved it in many ways. The chapters on antiseptic sur- 
 gery, mortification and gangrene, urethrotomy, burns and scalds, venereal diseases, 
 retention of urine and inflammation have been re-written, and brought thoroughly 
 abreast of our present knowledge." — Buffalo Medical and Surgical Journal. 
 WALSHAM. MANUAL OF PRACTICAL SURGERY. For Students and 
 Physicians. By Wm. J. Walsham, M.D., F.R.C.S., Asst. Surg, to, and Dem. of 
 Practical Surg, in St. Bartholomew's Hospital, Surg, to Metropolitan Free Hos- 
 pital, London. With 236 Engravings. 656 pages. Ne'w Series of Manuals. 
 
 Cloth, ^3.00; Leather, ^3.50, 
 " While in no sense a * short cut to surgery ' Mr. Walsham's book seems to be in 
 the main intended as a manual or handbook for the student and practitioner of surgery. 
 The subjects with which every student ought to be thoroughly acquainted are given 
 special prominence, while the rarer forms of injury and disease have either received but 
 short notice or have been entirely omittted. ***** *^ 
 
 " The first two sections, occupying 119 pages, are devoted to ' General Pathology 
 of Surgical Diseases,' and ' General Pathology of Injuries ;' for the introduction of 
 which into a manual the author is to be commended. The illustrations, as a rule, are 
 good, in that they show what they are intended to represent. Many of them are new, 
 and we note with pleasure the conspicuous paucity of many too familiar old ones, The 
 book is a good one, and written in Mr. Walsham's well-known lucid stvle." — foiirnal of 
 t.h" American Medical AssncinHn-n. 
 
THE 
 
 OPERATIONS OF SURGERY 
 
 SYSTEMATIC HANDBOOK 
 
 PRACTITIONEES, STUDENTS and HOSPITAL SURGEONS. 
 
 W. H. A. JACOBSON, F.R.C.S., 
 
 ASSISTANT-SURGEON GUY'S HOSPITAL; TEACHER OF OPERATIVE SURGERY, AND JOINT TEACHER OF 
 
 PRACTICAL SURGERY IN THE MEDICAL SCHOOL ; SURGEON TO THE ROYAL 
 
 HOSPITAL FOE CHILDREN AND WOMEN. 
 
 WITH 
 
 ONE HUNDRED AND NINETY-NINE ILLUSTRATIONS. 
 
 PHILADELPHIA: 
 
 P. BLAKISTON, SON & CO., 
 
 No. 1012 Walnut Street. 
 1889. 
 
SHERMAN & CO., PEINTEKS, PHILADELPHIA. 
 
TO 
 
 THREE OLD FRIENDS' 
 
 ARTHUR EDWARD DURHAM 
 JAMES FREDERIC GOODHART 
 EDWARD CLIMSON GREENWOOD 
 
 I WeiitaU this !3ook 
 
 AS SOME SLIGHT TOKEN Or MY GEATITTJDE 
 AND AFFECTIONATE RESPECT. 
 
PREFACE. 
 
 This book is the outcome of a strong belief, which I have held for 
 many years, that a work on Operative Surgery which aimed at being 
 more comprehensive in scope and fuller in detail than those already 
 published, would be of service to Practitioners and Students. 
 
 I most gladly take this opportunity of acknowledging my good for- 
 tune in being able to profit by the facile pencil and the cultivated 
 knowledge of my old dresser and friend Dr. C. W. Hogarth, of Brix- 
 ton. His happy combination of Art and Medicine, and his friendly 
 patience in carrying out my wishes, have been to me a saving of 
 much trouble. 
 
 To Messrs. Churchill I owe the opportunity of making use of some 
 of those drawings by Thomas and William Bagg, which were so well 
 known in the pages of that master of Surgery, Sir William Fer- 
 gusson. 
 
 Geeat Cumberland Place, 
 Hyde Park, W. 
 
CONTENTS. 
 
 PART I. 
 
 OPERATIONS ON THE UPPER EXTREMITY. 
 
 CHAP. PAGES 
 
 I. Operations on the Hand. — Amputations of fingers. — Amputations 
 of thumb. — Excision of thumb and fingers. — Reunion of severed 
 digits. — Webbed fingers. — Contracted palmar fascia. — Palmar hae- 
 morrhage. — Union of divided tendons, ...... 17-40 
 
 II. Operations on the Wbist. — Excision of the wrist-joint. — Amputa- 
 tion through the wrist-joint. — Ligature of radial on the back of the 
 wrist, 40-53 
 
 III. Operations on the Forearm — Ligature of radial in the forearm. — 
 
 Ligature of ulnar in the forearm. — Excision of radius and ulna. — 
 Amputation of forearm, . 53-64 
 
 IV. Operations in the Neighborhood or the Elbow-joint. — Am- 
 
 putation at elbow. — Excision of elbow. — Excision of superior radio- 
 ulnar joint. — Ununited fracture of olecranon. — Venesection. — 
 Transfusion. — Ligature of the brachial at the bend of the elbow, . 64-92 
 
 V. Operations on the Arm. — Ligature of brachial artery. — Amputa- • 
 tion of arm. — Excision in continuity of the shaft of the humerus. — 
 Operations on musculo-spiral nerve, 92-105 
 
 VI. Operations on the Axilla and Shoulder. — Ligature of axil- 
 lary artery. — Amputation at the shoulder-joint. — Excision of 
 shoulder-joint, 105-138 
 
 VII. Operations on the Scap0LA. — Removal of the scapula, . . 138-146 
 
 VIII. Operations on the Clavicle. — Removal of the clavicle. — Un- 
 united fracture of the clavicle, .... . . 146-150 
 
10 CONTENTS. 
 
 PART II. 
 
 OPERATIONS ON THE HEAD AND NECK. 
 
 CHAP. PAGES 
 
 I, Operations on the Scalp.— Fibro-cellular tumors, or molluscum 
 fibrosum.— Aneurism by anastomosis. — Question of operative inter- 
 ference in growths of tlie cranial bones and dura mater, . . 151-155 
 
 IT. Trephining-. — Operative interference in immediate or recent frac- 
 tures of the sliull. — Trephining in fractured skull. — Trephining for 
 pus between the skull and dura mater. — Trephining for middle men- 
 ingeal haemorrhage. — Trephining and exploration of cerebral ab- 
 scess due to injui-y. — Trephining for epilepsy and other later results 
 of a cranial injury. — Trephining for ma.stoid abscess and cerebral 
 abscess, the results of otitis media. — Operative interference in the 
 case of foreign bodies in the brain. — Trephining frontal sinuses, . 156-209 
 
 III. Operations on the Brain. — Cerebral localization in reference to 
 
 operation. — Tumors of the brain.— Prof. Horsley's method of oper- 
 ating on the brain, 209-230 
 
 IV. Operations on the Face — Operations on the fifth nerve. — Stretch- 
 
 ing the facial nerve. — Eestoration of Steno's duct. — Operative 
 treatment of lupus. — Operative treatment of rodent ulcer. — Re- 
 moval of parotid growths, 230-250 
 
 V. Excision of the Eyeball and Clearing out of the Orbit, . 250-254 
 
 VI. Operations on the Nose. — Plastic operations for the repair of the 
 
 niise. — Rouge's operation. — Removal of nasal polypi, . . . 254-267 
 
 VII. Operations on the Jaws. — Removal of upper jaw, partial or com- 
 plete. — Operations for naso-pharyngeal polypus. — Tapping the 
 antrum. — Removal of the lower jaw, partial or complete. — Opera- 
 tions to relieve fixity of the lower jaw, 267-303 
 
 VIII. Operations on the Lips.— Hare-lip. — Double hare-lip. — Other 
 
 plastic operations on the lips, 303-317 
 
 IX. Operations on the Palate.— Operations for cleft palate.— Re 
 
 raoval of growths of the palate, 317-325 
 
 X. Removal of the Tongde, 325-340 
 
 XI. Operations on the Tonsil.— Removal of new growths of the 
 
 to"siI 340-344 
 
 XII. Operations on the Air-passages in the Neck. — Tliyrotomy. 
 
 Laryngotomy. — Tracheotomy. — Tracheotomy for membranous 
 laryngitis.- Tnbage of the larynx as a substitute for tracheotomy 
 in membranous laryngitis.— Other indications for tracheotomy. — 
 Foreign bodies in the bronchi.— E.xcision of the larynx, partial and 
 complete. — Partial removal of the larynx, 344-385 
 
CONTENTS. 11 
 
 CHAP. PAGES 
 
 XIII. Operations on the Thyroid Gland. — Eemoval of the thyroid, 
 
 partial and complete, 385-407 
 
 XIV. Removal of lakoe deep-seated Growths in the Neck, . 407-411,. 
 
 XV. Operations on the (Esophagus. — ffisophagotomy. — CEsophagos- 
 
 tomy. — (Esophagectomy, 411-416 
 
 XVI. Operations on the Spinal Accessory Nerve. — Division or 
 
 nerve-stretching, .... 417-419 
 
 XVII. Ligature op the Arteries op the Head and Neck. — Liga- 
 ture of the temporal. — Ligature of the facial. — Ligature of the 
 occipital. — Ligature of the lingual. — Ligature of the common car- 
 otid. — Ligature of the external carotid.— Ligature of the internal 
 carotid. — Ligature of the vertebral. — Ligature of the subclavian. — 
 Ligature of the innominate. — Surgical interference in aneurisms of 
 the innominate and aorta, 419-498 
 
 PAET III. 
 
 OPEBATIONS ON THE THORAX. 
 I. Removal or the Breast 499-510 
 
 II. Paracentesis and Incision op Chest. — Empyema. — Resection of 
 
 ribs 511-523 
 
 III. Drainage op Lung-Cavities, 523-527 
 
 PAET IV. 
 
 OPERATIONS ON THE ABDOMEN. 
 
 I. Ligature op Vessels. — Ligature of the external iliac. — Ligature 
 of the common iliac. — Ligature of the internal iliac. — Ligature of 
 the gluteal. — Ligature of the sciatic. — Ligature of the abdominal 
 aorta, ............ 528-558 
 
12 CONTENTS. 
 
 CHAP. 
 
 II. Operations oi» HerjJi a. ^-Operations for strangulated hernia. — 
 Strangulated femoral hernia. — Strangulated inguinal hernia.— 
 Strangulated umbilical hernia.— Strangulated obturator hernia. — 
 Radical cure of hernia.— Badical cure of inguinal hernia.— Radi- 
 cal cure of femoral hernia.— Radical cure of umbilical hernia, . 558-590 
 
 III. CoLOTOMY. — Lumbar or posterior colotomy. — Inguinal or anterior 
 
 colotomy, 590-610 
 
 IV. Operations on the Kidney. — Nephrotomy. — Nephro-lithotomy. 
 
 — Nephrectomy. — Nephrorraphy, 610-645 
 
 V. Operations on the Intestines. — Acute intestinal obstruction. — 
 Exploration' of abdomen in acute intestinal obstruction.— Enterot- 
 omy. — Formation of artificial anus in acute intestinal obstruc- 
 tion. — Operative treatment of suppurative peritonitis. — Closure of 
 artificial anus. — Enterectomy. —Colectomy, 645-666 
 
 VI. Operative IsTTBaFBRENCE IN GrUNSHOT and other Injuries of 
 
 the Abdomen, 666-677 
 
 VII. Operations on the Stomach. — Gastrostomy. — Gastrotomy. — Digi- 
 tal dilatation of the orifices of the stomach. — Dilatation of the py- 
 lorus. — Dilatation of the cardiac orifice. — Excision of pylorus. — 
 Gastro-enterostomy. — Duodenostomy. — Jejunostomy. — Treatment 
 of gastric cancer by the use of the curette, 677-700 
 
 VIII. Excision op the Spleen, 700-702 
 
 IX. Operations on the Liver and Gall- Bladder. — Operations for 
 hydatids. — Hepatic abscess. — Hepatotomy. — Tapping and incising 
 the gall-bladder. — Cholecystotomy. — Removal of biliary calculi. — 
 Cholecystectomy, 702-713 
 
 X. Operations on the Ovary. — Ovariotomy. — Removal of the 
 
 uterine appendages, ......... 713-725 
 
 XI. Operations on the Uterus. — Removal of myomata by abdominal 
 section. — Removal of cancerous uterus by abdominal section. — Re- 
 i,moval of a cancerous uterus per vaginam. — Csesariau section, . 725-734 
 
 XII. Operations on the Bladder. — Removal of growths of the blad- 
 der. — Lateral lithotomy. — Supra-pubic lithotomy. — Median litho- 
 tomy. — Lithotrity. — Litholapaxy. — Litholapaxy in male children. 
 — Treatment of stone in the bladder in the female. — Cystotomy. — 
 Ruptured bladder.— Puncture of the bladder, . . . .735-781 
 
 XIII. Operation.^ on the Urethra and Penis. — Ruptured urethra. — 
 External urethrotomy. — Choice of operation for the relief of stric- 
 ture-retention. — Internal urethrotomy. — Ectopia vesicae. — Hypo- 
 spadias. — Epispadias. — Circumcision. — Amputation of the penis, . 781-806 
 
CONTENTS. 1 3 
 
 CHAP. PAGES 
 
 XIV. Operations on the Scrotum and Testicle. — Eadical cure of hy- 
 drocele. — Varicocele. — Castration, 807-819 
 
 XV. Operations on the Anus and REOTUM.^Fistula. — Haemorrhoids. 
 — Fissure. — Prolapsus. — Excision of the rectum.— Imperforate 
 anus. — Imperfectly developed rectum, 819-838 
 
 XVI. Ruptured Perineum 838-843 
 
 PART V. 
 
 OPERATIONS ON THE LOWER EXTREMITY. 
 
 I. Operations on the Hip-Joint. — Amputation at the hip-joint. — 
 
 Excision of the hip-joint, 844-866 
 
 II. Operations on the Thigh.- — Ligature of the common femoral. — 
 Ligature of the superficial femoral in Scarpa's triangle. — Ligature 
 of the superficial femoral in Hunter's canal — Puncture and stab 
 wound in mid-thigh. — Amputation through the thigh. — Amputa- 
 tion immediately above the knee-joint. — Removal of exostosis from 
 near the adductor tubercle.^Ununited fracture of the femiir, . 866-891 
 
 III. Operations Involving the Knee-Joint. — Amputation through 
 the isnee-joint. — Excision of the knee-joint. — Arthrectomy of the 
 knee-joint. — Wiring the patella. — Removal of loose cartilages from 
 the knee-joint, 891-917 
 
 IV. Operations on the Popliteal Space. — Ligature of the popliteal 
 
 artery, 917-920 
 
 V. Operations on the Leg. — Ligature of posterior tibial. — Ligature 
 
 of anterior tibial. — Ligature of peroneal artery. — Amputation of 
 
 leg. — Operation for necrosis. — Treatment of compound fracture, . 920-937 
 
 VI. Operations on the Foot. — Ligature of the dorsalis pedis. — 
 Syme's amputation. — Roux's amputation. — Pirogoff's amputation. 
 Sub-astragaloid amputation. — Excision of the ankle. — Excision of 
 tarsal joints. — Excision of astragalus. — Excision of os calcis. — 
 Operations for more complete tarsectomy. — Removal of tarsal bones 
 for inveterate talipes. — Chopart's amputation. — Amputation 
 through the tarso-metatarsal joints. — Amputation of the toes, . 938-963 
 
 VII. Osteotomy. — Osteotomy of the femur for ankylosis of the hip-joint, 
 — For genu valgum. — Osteotomy of the tibia. — Osteotomy for dis- 
 placement of the great toe in bunion 964-973 
 
14 CONTENTS. 
 
 CHAP. PAGES 
 
 VIII. Tenotomy. — Tenotomy of the tendons about the foot. — Syndesmotomy. 
 
 Tenotomy of hamstring tendons. — Tenotomy of sterno-mastoid, . 973-978 
 
 IX. Opeeations on Nerves. — Nerve suture. — Nerve stretching, . . 978-984 
 
 PAET VI. 
 
 Operations on the Vertebral Canal. — Spina bifida. — Trephin- 
 ing the vertebral canal, 985-987 
 
 APPENDIX. 
 
 Tapping and Incising the Pericardium, 988-990 
 
 INDEX OF NAMES, . . 991-995 
 
 GENERAL INDEX . . 996-1006 
 
ERRATA. 
 
 Page 110, 33d line, transpose words " latter" and " former.'' 
 119, 7th line,/o)' " thumb " read " forefinger." 
 150, 12th line, /or "of" read "off." 
 
 178, 8th line, /or " external auditory meatus" read " external angular process." 
 195, 9th line, omit "where." 
 210, 7th line, for "roof" read "root." 
 212, 14th line, /or "fissure" read " meatus." 
 272, 15th line, /or " molar" read "malar." 
 295, 39th line, /or " horizontal" read " vertical." 
 
 336, 1st line, for " on the hyoglossus " read " behind or under the hyoglossus." 
 371, 24th line,/o" " suppurative" read "sufiTocative." 
 
 402, 19th line, /or "Fig. 86" read "Fig. 85." 
 
 403, 22d line,/or " vascular " read " evascular." 
 405, 12th line, /or "excision" read "incision." 
 461, 22d line, /or "against" read "below." 
 498, 24th line,/or "Dr. McCall" read "Dr. McCall Anderson." 
 545, 26th line, after " first tied " insert " for aneurism." 
 582, 22d line, /or " cord " read "sac." 
 599, 13th line, /or "face" read " back." 
 607, 40th line, /or "Brunton" read " Brinton." 
 618, in " Difficulties in Nephro-Lithotomy " the headings " 3, 4, 5, 6, 7, 8, 9, 10," 
 
 shovld be "4, 5,6,7,8,9,10, 11" 
 629, 5th line, /or " e" read " vi." 
 
 651, 24th line,/or "peri-typhilitis" read "perityphlitis." 
 929, Fig. 177. The knife should have been passed from (he opposite side. 
 
PART I. 
 
 OPERATIONS ON THE UPPEE EXTREMITY. 
 
 CHAPTER I. 
 OPERATIONS ON THE HAND. 
 
 AMPUTATION OP FINGERS. 
 
 Practical Anatomical Points. — I. Position op Joints (Fig. 
 1). — This has to be remembered — fa) in front, (/J) behind. 
 
 (a) In Front. — Three sets of creases correspond here, though not 
 exactly, to the joints. Of these, the lowest crease is just above the 
 joint; the middle is opposite to the inter-phalangeal joint; the 
 highest, i inch below the metacarpo-phalangeal joint. 
 
 (/?) Behina. — It is to be remembered here (1) that in each case 
 it is the upper bone which forms the prominence — viz., the knuckle 
 t 
 
 Fio. 1. 
 
 ^^^r'"^^'^?^^^??5^^^%s^iiiti« 
 
 ifr 
 
 is formed by the head of the metacarpal bone, the inter-phalangeal 
 prominence by the head of the first phalanx, and the distal one by 
 the head of the second ; (2) that the joint in each case lies below * 
 the prominence, the distal joint being -^ inch, the inter-phalangeal 
 i inch, and the metacarpo-phalangeal joint i inch below. 
 
 II. Shape of Joints. — In the distal and the inter-phalangeal the 
 joint is concave from side to side, and presents ei concavity towards 
 
 * The terms "above" and " below" mean nearer and farther from the trunk. 
 
 2 
 
18 OPERATIONS ON THE UPPER EXTREMITY. 
 
 the tips ; in the metacarpo-phalangeal joint, on the other hand, the 
 convexity is towards the finger-tips.* 
 
 III. The Theca. — This fibrous tunnel running up to the bases 
 of the distal phalanges gapes widely after section. From its prone- 
 ness to conduct upwards spreading sepsis, care should be taken to 
 keep even such a small amputation as that of a finger strictly sweet, 
 and, in amputating through damaged parts, the flaps should not be 
 too closely united with sutures. 
 
 Operations for Amputation of Fingers.— As a fixed rule 
 
 is rarely available, several should be practiced, including among 
 them the following four, viz. : 
 
 1. Long palmar flap (Figs. 2, 3, and 4). 
 
 2. Long dorsal flap. 
 
 3. Two equal antero-posterior flaps. 
 
 4. Two lateral flaps (Fig. 5). 
 
 Of these, the palmar flap is usually the one made use of. Though, 
 as the hands are by far most frequently placed in the prone posi- 
 tion, a dorsal flap falls more easily into place, and gives a more 
 concealed scar, a palmar flap has the greater advantages of not 
 being pressed upon when anything is held in the hand, of pos- 
 sessing finer sensitiveness in touch, and, furthermore, of being 
 available even in the last phalanx, where, from the presence of the 
 nail, a dorsal flap is not obtainable (Fig. 2). 
 
 Amputation of Distal Phalanx by Palnaar Flap (Fig. 
 
 2). — First Method. — The hand being pronated, a strip of lint 
 wound round the phalanx to give a firm grip,t and the adjacent 
 fingers held aside with tapes, the surgeon, having placed his left 
 forefinger just below and behind the joint, and flexed the phalanx 
 strongly with his thumb, cuts, J with a slightly semilunar sweep, 
 straight into the joint. To efi'ect this neatly, the convexity of the 
 sweep should pass Jj inch below the prominence or angle produced 
 by flexion, the sweep being made by laying on the whole edge of 
 the knife, while with the point, as this incision begins and ends, 
 the lateral ligaments are partly cut. The joint being thus freely 
 opened, the knife is insinuated behind the base of the phalanx (a 
 step which is facilitated by depressing and pulling on the phalanx"), 
 and then, being kept close to, and parallel with, the bone, cuts, 
 
 ■* This is shown in Fig. 1. In the lower two joints, a convexity, and not a con- 
 cavity, appears to exist towards the tips. This is due to one of the small lateral 
 condyles, which are present on the digital extremity of each phalanx, being shown, 
 and thus disguising the median concavity. 
 
 t In the drawing this is left out for the sake of distinctness. 
 
 t The knife in all these finger amputations should be narrow, slender short, and 
 strong. 
 
AMPUTATION OF FINGERS. 
 
 ,19 
 
 Fig. 2.t 
 
 with a steady, sawing movement, a flap well rounded at its ex- 
 tremity, about two-thirds in length of the pulp of the finger * 
 
 Second Method.— The hand being supinated, the finger to be 
 operated on extended, and the others fiexed out of the way, a pal- 
 mar flap is cut by transfixion, the 
 knife being entered just below the 
 palmar crease, the joint being then 
 opened from the dorsum as before, 
 and the phalanx lastly disarticu- 
 lated. 
 
 Third Method.— If the sur- 
 geon has no narrow knife by him, 
 he may modify the last method by 
 cutting his palmar flap first, but 
 from without inwards ; he then 
 opens the joint from the dorsum, 
 and disarticulates. 
 
 As a rule, no vessels require liga- 
 ture. Any tendon that is ragged 
 should be cut square. 
 
 DiflQculties and Mistakes in Amputation of Distal Pha- 
 lanx. — The flap may, of course, be made too short; it is often 
 made too pointed. If the phalanx be not sufficiently flexed, or if 
 the site of the joint be forgotten, the latter will not be readily 
 opened, the knife sawing against the second phalanx. It is often 
 difficult to pass the knife easily behind the base of the phalanx, 
 especially in cases where the blade is too broad, or where, as may 
 happen in well-developed hands, the circumference of the base of 
 the phalanx is strongly tuberculated. And if there be any consid- 
 erable hitch in passing the knife behind the phalanx, the base of 
 the flap is very likely to be jagged. 
 
 Amputation of Second Phalanx.— This, as a rule, should 
 
 be performed through the phalanx, and, wherever this is possible, 
 beyond its centre, so as to leave the upper half or third of the pha- 
 lanx, and thus ensure some attachment of the flexor being pre- 
 served. 
 
 While the rule not to amputate a finger at the joint between the 
 first and second phalanges, and a fortiori through the first phalanx, 
 is a sound one, as there is a risk of leaving a stump stiff and inca- 
 pable of flexion, there is no doubt whatever that at times the above 
 amputation has been followed by the flexor tendon taking on a 
 
 * If the flap is insuflicient, the head of the second phalanx will, of course, be 
 removed. 
 
 •f The palmar flap here is made somewhat too short, sharp, and wedge-shaped. 
 
20 OPEEATIONS ON THE UPPER EXTREMITY. 
 
 fresh and sufficiently firm adhesion, and so leaving a longer and 
 withal a mobile stump. 
 
 In the following special cases the whole or part of the first pha- 
 lanx mtiy be left, and in all of them the severed flexor tendons 
 should be carefully stitched with carbolized silk to the cut theca 
 and periosteum, or into the flaps themselves before adjusting these. 
 
 1. In the case of the index finger the proximal phalanx will be 
 a useful opponent to the thumb, as in holding a pen. 
 
 2. In the case of the little finger, leaving the proximal phalanx 
 will give greater symmetry to the hand when this is flexed, and it 
 should accordingly be left, if the patient desire it. 
 
 3. In cases of ami^utation of all the fingers, the proximal pha- 
 lanx of one should, if possible, always be left to oppose to the 
 thumb. 
 
 Fig. 3. 
 
 Amputatiou through inter-phalangeal joint by long palmar flap, the joint 
 being opened first. (Fergusson.) 
 
 4. In the case of a patient who insists on having the proximal 
 phalanx left, after the risk of stiffness has been explained to him, 
 the more care is taken to fix the severed flexors to the theca, th e 
 more quickly the stump heals, and the j'ounger the patient, the 
 greater will be the movement gained. 
 
 Dr. Tiffany, of Baltimore (Trans. Amcr. Surg. Assoc, vol. ii. p. 
 826), says that he has been in the habit " for a number of years " of 
 passing the stitches which unite the skin through the tendons and 
 their sheaths in cases of amputation at the joint between first and 
 second phalanges. " I have never failed, as far as I can remember, 
 
AMPUTATION OF FINGERS. 21 
 
 to secure quite as good movement as if nature had originally made 
 an attachment there for these tendons." 
 Amputation through Middle Phalanx. 
 
 (1) By a Long Palmar Flap (Figs. 3 and 4), or by Dorso- 
 palmar Flaps, the palmar flaps being the longer (Fig. 5). 
 
 By Dorso-palmar Flaps.— The surgeon, marking with his left 
 fore-finger and thumb * where he intends to divide the bone, cuts 
 between these points a short well-rounded dorsal flap of skin ; he 
 then sends his knife across below the bone, making it enter and 
 emerge at the base of the first flap, and cuts a palmar flap about 
 I inch in length, and not pointed. The flaps are then retracted, 
 the bone cleared with a circular sweep of the knife, and divided as 
 above. 
 
 By Lateral Flaps (Fig. 5).— The site where the bone is to be 
 sawn being marked by the left fore-finger and thumb placed on the 
 dorsal and palmar aspect of the finger at this level, the surgeon, 
 looking over the finger, enters his knife in the centre of the palmar 
 
 Fig. 4. 
 
 Amputation through secoEd phalanx by long palmar flap, this being made 
 first by transfixion. (Fergusson.) 
 
 aspect, and carries it, cutting an oval flap, about i inch in length, 
 to a corresponding point on the centre of the dorsum, and then 
 from this point down again over the side of the finger nearest to 
 him, to the point where the knife was first entered. The flaps 
 being dissected up as thick as possible, and the remaining soft parts 
 severed with a circular sweep, the bone is divided with saw or 
 bone-forceps. If necessary, one flap can, of course, be cut longer 
 than the other. In using the bone-forceps the flat or convex sur- 
 face is always to be applied towards the trunk ; if this precaution is 
 
 * These are left out in the drawings, for the sake of distinctness. 
 
22 OPERATIONS ON THE UPPER EXTRBMITy. 
 
 taken, and the bone severed quickly, the section will be clean, and 
 not crushed. 
 
 Amputation of Finger, eg., Second or Third, at Meta- 
 carpo-phalangeal Joint (Fig. 6).— This, the most frequently 
 performed amputation on the hand, should be practiced frequently. 
 It is best performed by the modified oval method, the en raquette 
 of Malgaigne, or by lateral flaps. 
 
 The hand being pronated, the radial and ulnar arteries com- 
 manded by an Esmarch's bandage above the wrist, some lint 
 
 Fig. f). 
 
 In the second finger, amputation through the second phalanx by lateral flaps is shown. 
 The bone has been divided below the insertion of the flexor sublimis ; if there were any 
 doubt about this, the tendon could be stitched to the theca and flaps, as advised above. In 
 the index finger, amputation through the second phalanx by short dorsal and long palmar 
 flaps is given. The left finger and the thumb of the surgeon, which would mark the base 
 of the flaps, are left out for the sake of distinctness. The flaps for amputation of the index 
 finger at the metacarpo-phalangeal joint are also shown, the straight part of the incision be- 
 ing placed rather to the radial side of the head of the metacarpal bone. 
 
 In the thumb, the flaps for amputation at the carpo-metacarpal Joint are indicated. The 
 two ** show where the radial artery may be wounded, near the joint, and in the interosseous 
 space, in this amputation. 
 
 Ligature of the radial artery at the back of the wrist is also represented. The radial vein 
 crosses the wound from angle to angle. The artery, with the ligature under it, is shown be- 
 tween the extensor ossls metacarpi and extensor primi internodii in the lower angle, and the 
 extensor secundi internodii in the upper angle of the wound. 
 
 wrapped round the damaged finger, and the adjacent ones held 
 aside by tapes, the point of the knife is entered f inch above the 
 head of the metacarpal bone, sunk down to the bone itself, and then 
 carried down in the middle line till it gets well on to the base of the 
 phalanx; then, diverging to one side, the knife is carried obliquely 
 below the web across the palmar aspect of the first phalanx below 
 the palm, and then around the other side of the phalanx (also be- 
 low the web) so as to join the straight part of the incision which 
 lies over the head of the metacarpal bone. In practice, especially 
 
AMPUTATION OF FINGERS. 
 
 23 
 
 Fig. 6. 
 
 in the country, where an anffisthetic is not always easily available, 
 it is much preferable, because quicker, to make two separate inci- 
 sions, each beginning f inch above the head of the metacarpal bone, 
 and meeting again on the centre of the 
 base of the palmar aspect of the first pha- 
 lanx, well below the palm, instead of 
 carrying the knife continuously round 
 the finger. This method is not only 
 quicker,* but it does not leave, as in the 
 first method, a small tongue of tissues on 
 the palmar aspect, which is a little diffi- 
 cult to adjust satisfactorily, and behind 
 which discharges tend to collect. 
 
 In either case the knife should be used 
 boldly, the extensor tendon severed in the 
 first incision over the head of the meta- 
 carpal bone, and the soft parts at the sides 
 cut to the bone. Then one lip of cut tissue 
 being taken up with finger and thumb, the 
 flaps are dissected up as thickly as possi- 
 ble, tendons cut clean and square, the 
 lateral ligaments severed, and the joint 
 opened by remembering its site well be- 
 low the projecting knuckle (p. 17, Fig. 1). 
 Disarticulation will be facilitated by twist- 
 ing the finger, first to one side, and then to the other, so as to render 
 tight the parts which remain to be cut. 
 
 Where strength has to be considered rather than appearance, the 
 head of the metacarpal bone should be left, as the transverse liga- 
 ment is thus less interfered with, and the hand less weakened. But 
 where appearance is the most important thing, and the mutilation 
 is to be hidden as much as possible by the approximation of the 
 fingers, the head of the bone should be removed by a narrow-bladed 
 saw or by bone-forceps.f In either case the section should be made 
 obliquely from above downwards and from behind forwards, so as 
 to remove more on the dorsal than the palmar aspect. In such 
 cases, after a little practice, it is not necessary to perform disarticu- 
 lation, the metacarpal bone being severed after dissecting up the 
 flaps to the proper level. Here, too, care must be scrupulously 
 taken not to interfere with the tissues in the palm. 
 
 After removal of the finger and the Esmarch's bandage, one or 
 
 Incisions for amputation at 
 metacarpo-phalangealjoint. If 
 the metacarpal bone requires 
 removal as well, the apex of 
 the incision would be pro- 
 longed upwards. (Fergusson ) 
 
 * Because it avoids the hitch usually met with in carrying the knife around the 
 base of one finger between others. 
 
 f With the precautions already given at p. 22. 
 
24 OPERATIONS ON THE UPPER EXTREMITY. 
 
 more digital vessels will require ligature, lying rather deeply oppo- 
 site the web of the finger.* 
 
 In the case of the index (Fig. 5) or little finger, the straight part 
 of the oval incision should be placed to the radial or ulnar side of 
 the metacarpal bone respectively, rather than in the dorsal mid- 
 line, as, in the former case, the line of incision will be concealed 
 between the thumb and second finger, and, in the latter, be less 
 visible in the ordinary pronated position of the hand. In these 
 cases the bone-forceps should be applied obliquely from without 
 inwards and from within outwards respectively, so as to leave no 
 projecting bone on the radial or ulnar aspect of the hand, and, in 
 the former case, to allow of the thumb being readily, approximated 
 to the adjacent finger. 
 
 It may be worth while to add one hint with regard to the after- 
 treatment, and that is, not to bandage the adjacent fingers too 
 closely or too long together, otherwise a tendency to cross at their 
 points will be noticed later on. 
 
 Conditions requiring Amputation of Fingers usually at 
 the Metacarpo-phalangeal Joint : 
 
 1. Smash (machinery, gunshot, etc.). 
 
 2. Results of thecal trouble at an earlier and later period. f 
 
 3. " Strumous dactylitis," when it does not yield to treatment ; 
 when it interferes with the general health, especially in a patient no 
 longer young ; and when it is likely to end in a useless finger. 
 
 4. Enchondromata, if multiple and crippling the finger ; if single 
 and small, an attempt should be made to save the finger by shaving 
 off the growth and gouging its base, the soft parts being carefully 
 retracted and protected. * (See the case referred to below, p. 27.) 
 
 5. Supernumerary fingers. J 
 
 6. Gangrene, or frostbite. 
 
 * Care should be taken to secure these vessels, especially where they are enlarged 
 in any in6ammatory condition, otherwise profuse bleeding may take place a few 
 hours after the operation. 
 
 f This includes not only stiff and useless fingers, but also those crippled with 
 peripheral neuralgia from implication of digital nerves in the indurated tissues. 
 See a paper by Mr. Callender, Clin. Soc. Trana., vol. ix. p. 104; also a case under 
 Prof. Syme, in which burning sensation and distressing pain followed a wound of 
 a digital nerve, only remedied by amputation at the raetacarpo-phalangeal joint- 
 Annandale, Diseases of Fingers and Toes, p. 203. 
 
 X If a mother object strongly to any cutting operation in the removal of a super- 
 numerary finger in an infant newly born, a suggestion of Sir W. Fergusson's [Pract. 
 Surg., p. 311) may be made use of— to strangle it either by transfixion and double 
 ligature, or by giving the flexible root a twist round once, laying the finger on the 
 back of the hand and securing it there. 
 
AMPUTATION OF THUMB. 26 
 
 AMPUTATION OP THUMB. 
 Amputations of Phalanges of Thumb.— Very little need 
 
 be said about these, as they are very rarely performed. Owing to 
 its numerous muscles, the thumb is extremely mobile, and thus 
 escapes injury. Owing to its abundant vascular supply, trimming 
 of the soft parts after an injury will generally leave more of the 
 thumb to oppose to the fingers than any set operation. 
 
 In cases of necrosis after whitlow, I have twice removed both 
 phalanges, the soft parts consolidating usefully.* For further re- 
 marks on preserving the thumb, see Excision of Thumb, p. 27. 
 
 Operation.— Amputation of the phalanges of the thumb may 
 be performed, in the case of the distal one, by a long palmar flap, 
 as in the case of a finger (Figs. 2, 3, 4) ; in the case of the first pha- 
 lanx, by antero-posterior, lateral, or a modification of the oval 
 method. In any case the incisions should be carried well on to the 
 phalanx to ensure sufficient flaps to cover the head of the meta- 
 carpal bone, together with the sesamoid bones, which should never 
 be removed. 
 
 The line of the metacarpo-phalangeal joint is very nearly trans- 
 verse, and lies just in front of the knuckle. 
 
 After amputation of either phalanx, the severed end of the long 
 flexor should be carefully stitched into the angle of the flaps and to 
 the theca and periosteum. 
 
 Amputation of Thumb at Carpo-metacarpal Joint 
 
 (Figs. 5 and 7). 
 
 Indications. — This operation is rarely called for on the living 
 subject.f Gunshot injuries, enchondrom'ata of phalanges and me- 
 tacarpal bone (see below, p. 27), epithelioma of a scar, melanotic 
 sarcoma, occasionally call for it. 
 
 Operation. — The position of the joint between the trapezium 
 and metacarpal bone, its shape, with two saddle-like articular sur- 
 faces fitting into each other " by reciprocal reception," and the po- 
 sition of the radial artery passing over the back of the styloid pro- 
 cess just above this joint (Fig. 5), and again, when perforating the 
 first interosseous space, lying close to the metacarpal bone, must be 
 remembered. 
 
 The operation is usually performed by the oval method. 
 
 An Esmarch's bandage being applied above the wrist, the hand 
 held midway between pronation and supination, and the thumb 
 
 * This is strongly indicated in those cases where it is especially important to- 
 leave the thumb long for holding a pen or delicate instrument, 
 t It is not unfreqnently used as an examination test. 
 
26 
 
 OPERATIONS ON THE UPPER EXTREMITV. 
 
 Fig. 7. 
 
 held rather over-extended so as to relax the parts, the surgeon 
 enters the point of a strong narrow scalpel or 
 bistoury just above the bony tubercle, which 
 usually marks the insertion of the extensor 
 ossis metacarpi pollicis into the base of the 
 metacarpal bone, and carries it along the 
 dorsum of this bone as far as the base of the 
 first phalanx, where it passes (in the case 
 of the left thumb) obliquely to the ulnar 
 side above the web, and then around the 
 palmar aspect of the phalanx, along the 
 radial side, to join the dorsal incision again. 
 Taking up first one edge of the incision and 
 then the other, the surgeon dissects up the 
 soft parts from the bone, keeping the knife- 
 point very closely to this, especially on the 
 inner side. The extensor tendons and the 
 short muscles of the thumb being severed, 
 the joint between the trapezium and meta- 
 carpal bone is felt for and opened by putting 
 the tissues here on the stretch by twisting 
 the metacarpal bone in different directions. 
 Amputation of Thumb at Carpo- 
 metacarpal Joint by Transfixion (Fig. 
 7). — The hand being held as before, and the 
 parts relaxed by slightly adducting the thumb, an incision is made 
 (in the case of the left thumb) from the base of the metacarpal bone 
 rather to its palmar aspect, along its dorsum, and then obliquely 
 to the ulnar side of the base of the first phalanx ; the knife, a long 
 narrow bistoury, is then pushed from this point at the junction of 
 the web with the thumb, across the palmar aspect of the thumb, to 
 the point where the incision started, over the carpo-metacarpal 
 joint. By cutting outwards, along the line indicated in Fig. 7, a 
 flap is formed of the tissues in the ball of the thumb, the knife 
 being kept close to the bone at first, but used more lightly and kept 
 more superficial afterwards, as it comes out through the skin over 
 the sesamoid bones and base of the first phalanx, to avoid being 
 locked here. This flap being held back, the metacarpal bone is 
 dissected out by keeping the knife close to it, the joint opened, and 
 the thumb removed as before. 
 
 On the right side, it is better to cut the palmar flap by transfix- 
 ion first, making it enter and emerge just as above given. The blade 
 of the knife is then drawn from the base of the first phalanx ob- 
 liquely across the dorsum of the metacarpal bone, from one ex- 
 
EXCISION OF THUMB AND FINGERS. 27 
 
 tremity of the transfixion incision to the other. Tl:ie operation is 
 then completed as before. 
 
 EXCISION OP THUMB AND FINGERS. 
 
 Removal of Fhalauges. — Owing to the exceeding value of 
 the thumb, a phalanx should always be preserved if possible, not 
 only in whitlow-necrosis, but in the case of the first or proximal 
 phalanx, when it is the seat of enchondroma. By this, not only is 
 appearance saved by the lessened shortening, but the use of the 
 long flexor, in particular, is preserved. Thus, Mr. Royes Bell 
 {Lancet, 1872, vol. ii. p. 846) published a case in which he excised 
 the proximal phalanx in a woman, aged nineteen, for a huge 
 enchondroma of sixteen years' growth, the joints being movable. 
 The phalanx was excised by two lunated incisions over the tumor, 
 the knife kept close to the bone, and the joints opened. No 
 tendons were cut. Eighteen months later the condition of the 
 thumb was excellent, both for all general movements and for 
 writing. 
 
 Removal of Metacarpal Bone.— This should always be ex- 
 cised wherever possible, in preference to sacrificing a part of such 
 incalculable value as the thumb. Sir W. Fergusson (Pract. Surg.^ 
 p. 322), in speaking of this operation, says that he saw it once per- 
 formed, and, though the organ was far from strong, the patient 
 could use a needle with tolerable facility not long after, and he 
 further remarks that the comparative shortness of the bone re- 
 moved, and the firm cushion of soft parts that remains after its 
 excision, will make the remaining part useful. 
 
 In removing the metacarpal bone, a straight incision, which 
 reaches i inch beyond each extremity of the bone, having been 
 made along the dorsum, the tendons are drawn aside; the distal 
 end and joint are next cleared and opened, when the bone can be 
 used as a lever whilst it is freed from the soft parts on the palmar 
 aspect and then disarticulated. 
 
 The radial artery must be remembered both on the ulnar side 
 of the metacarpal bone and by the carpo-metacarpal joint (Fig. 5). 
 
 Excision of Metacarpo-phalangeal Joint.— This may be 
 
 very occasionally required in those cases where a dislocation of the 
 first phalanx cannot be reduced, either as a primary operation or 
 later on, in a young and healthy patient, to whom the stiffness is a 
 serious drawback. 
 
 An incision, li inch long, on the radial side will leave least scar; 
 the joint is opened, the bones dislocated, or, if this be found diffi- 
 cult, the ends of the bones may be cleared by keeping the knife- 
 point closely applied to them and by retracting strongly the soft 
 
28 OPERATIONS OlSr THE UPPER EXTREMITY. 
 
 parts ; the ends are then removed in situ by a narrow saw or osteo- 
 tome, which are preferable to bone-forceps. The surgeon should 
 always remove the bones freely, and not content himself with 
 paring off the articular surface, which risks the formation of a stiff 
 joint. 
 
 EXCISION OF FINGERS. 
 Only excision of joints need be alluded to here, as, save in the 
 case of removal of the distal phalanx for necrosis, excision of a 
 phalanx leaves a very useless finger. 
 
 Excision of an Inter-phalangeal or Metacarpo-pha- 
 
 langeal Joint. — This may be called for after a clean cut into the 
 joint (circular saw, etc.) ; in the hope of saving one or more damaged 
 fingers when several have required amputation after a machinery 
 accident; in some cases of compound dislocation ; in a few cases of 
 disease — thus, in young subjects, in the case of the index finger, 
 e. g., where there is only one joint affected, and the mischief is 
 limited to the articular surfaces and the bones themselves are 
 sound. Excision of one of the above joints is best performed by 
 an incision, 1 to I5 inch long, to one side of the dorsum of the joint. 
 The lateral ligament being severed, the joint is dislocated, and the 
 ends of the bones removed with a narrow clean-cutting saw, the 
 soft parts being as carefully protected from damage as possible.* 
 Drainage being provided with aseptic gut or horsehair, the wound 
 is partly closed, and the finger put up somewhat flexed.f Careful 
 passive movement should be commenced about the sixth day. 
 
 Conservative Surgery of the Hand.— While it is a car- 
 dinal principle to preserve every inch of the hand, and that a single 
 finger or the thumb alone is far more useful than the most elaborate 
 artificial limb that can be made, and that to gain this end it is fre- 
 quently advisable to trim up an injured part and to remove dead 
 bone in preference to doing any set amputation, it must always be 
 remembered that a part may be capable of being saved, and yet 
 ultimately be useless, unless it be at least partially movable. Where 
 it is probable that both flexor tendons will die, amputation had 
 best be performed in any finger except the index. 
 
 One condition, which a surgeon in large manufacturing centres is 
 certain to meet with, requires grave consideration, /. e., where a 
 hand, often of a boy or girl, is flayed, owing to its having been 
 caught between rollers which hold, but do not crush ; here, as the 
 patient draws back, the skin is stripped oflT, like a glove, up to the 
 wrist. If any bones are crushed, thecre or the palmar fascia opened, 
 amputation at the wrist should be performed at once; and Billroth 
 
 * If any tendons are cut, they shonld be united with sutnres. 
 
 t On a carefully moulded felt splint, or one of perforated zinc, or of whalebone. 
 
EXCISION OF FINGERS, 29 
 
 {Lect. on Surg., Pathology, and Therapeutics, Sycl. Soc. Tr., vol. i. p. 
 207) advises this step where the skin is completely stripped off 
 without other injurj^, fingers entirely deprived of their skin almost 
 invariably becoming gangrenous, and the result being, "under the 
 most favorable circumstances, nothing more than an unwieldy 
 cicatrized stump." Probably most surgeons would make an attempt 
 in a young subject, and with the aid of antiseptics, irrigation, and 
 skin-grafting as soon as possible, to save part at least of the hand. 
 Dr. Gregory {Trans. Amer. Surg. Assoc., vol. ii. p. 232) mentions 
 such a case, in which a boy's hand had been thus flayed without 
 further injury. " I felt satisfied that amputation was proper, but 
 the patient insisted that he was willing to take the risk ; and I re- 
 
 FiG. 8. 
 
 placed the flap, and stitched it in several places, believing that it 
 would slough. It did slough, and he lost his fingers up to the 
 knuckles, and the only portion that was saved was a small part of 
 the thumb and the metacarpal portion of the hand. This, of course, 
 was a cicatricial surface, which I covered with grafts, and it finally 
 healed. The boy can hold a pen in a little groove by the side of 
 the thumb, and it is probable that the remnant of the hand will 
 finally become useful." 
 
 The foregoing (Fig. 8) is an excellent instance of what may be 
 effected by conservative surgery here. It represents the relic of a 
 hand, consisting of the thumb, stump of the index and of the little 
 finger, and also shows how much flexion the shortened index is 
 still capable of.* 
 
 * The figure is taken from a paper on Kailway Injuries, by Dr. Thomson, of 
 Kentucky. — Trans. Amer. Surg. Assoc, vol. ii. p. 190. 
 
30 OPERATIONS ON THE UPPER EXTREMITY. 
 
 REUNION OP SEVERED DIGITS. 
 
 The question will sometimes arise as to the advisability of at- 
 tempting to reunite portions of severed fingers and thumbs. 
 
 Many such successful cases have occurred, and the surgeon may 
 well make the attempt, when the parts are cleanly severed, and 
 when the patient is young and healthy, as is often the case in 
 country practice. 
 
 The following are instances of the parts severed: The first, 
 second, and third fingers cut off above a diagonal line beginning in 
 the middle phalanx of index finger and ending in last phalanx of 
 third finger near the root of the nail. The parts had been lying in 
 the snow for some time, and were kept for two or three hours before 
 being applied. In other cases the part has been severed longitudi- 
 nally, containing in it a portion of bone split off. The time between 
 the injury and the treatment has varied from twenty minutes to 
 three or four hours, and the severed part has been picked out of 
 sawdust, brought up in dirty paper, whilst in a third the patient 
 was sent back to find it in the field in which he had been reaping. 
 
 When there is the least shred of soft parts left holding on the 
 severed bit, even a bad compound fracture of the finger with severe 
 laceration of the soft parts may be saved. 
 
 The age and condition of the patient, the time which has elapsed 
 since the injury, the part affected, i. e., whether index or thumb, 
 must all be considered. And in any case the patient should be 
 warned that, though the attempt may succeed, the parts uiiite, and 
 sensation be restored, the result may be a stiff and therefore com- 
 paratively useless member. 
 
 If it be decided to make the attempt, the part should be well 
 cleansed with warm mercury perchloride solution (1 in 1000), 
 united exactl}'' with a few points of fine wire, or carbolized silk, and 
 horsehair sutures, enveloped in salicylic wool, and kept in situ with 
 carefully-adjusted splints of whalebone or perforated zinc. The 
 dressings should not be disturbed for three days, if possible.* 
 
 WEBBED FINGERS (Figs. 9 and 10). 
 
 These should always be remedied as soon as possible in early 
 childhood; if left untouched, the fingers may be useful, but the 
 annoyance of the deformity will be serious. 
 
 * Numerous cases of this kind will be found in the Lancet for 1861, vol. ii., and 
 more recently {Annals of Surgery, March, 1887, p. 263) fifteen such cases, with good 
 results, have been tabulated by Dr. Pilcher. 
 
WEBBED FINGERS. 
 
 31 
 
 1. The simpler methods— viz., wearing a large metal ring through 
 a hole made where the cleft should begin, or passing large silver 
 wire or fine drainage-tubing through such a hole, the ends of the 
 tubing or wire being attached to a wristlet or bracelet— may be tried 
 first, and, when the perforation is soundly healed, the web should 
 be slit up, and the fingers kept apart. 
 
 2. If the above fail, one of the following plastic operations should 
 be made use of: 
 
 Didot's* (Fig. 9).— Two narrow longitudinal flaps are dissected 
 up as thick as possible from the palmar and dorsal aspects of the 
 affected fingers, and each flap is then folded round to cover in the 
 
 Fig. 9. 
 
 Fig. 10. 
 
 Didot's operation for webbed lingers. (Reeves.) 
 
 Norton's operation for webbed fingers. 
 
 raw surface of the finger to which it is attached, and secured with a 
 few points of very fine interrupted sutures of carbolized silk and 
 horsehair. 
 
 NoRTON'sf (Fig. 10). — Small triangular flaps are raised between 
 the knuckles on the dorsal and palmar aspects ; the webs are then 
 cut through and the knife carried back so as to sever all the tissues 
 up to the bases of the flaps, which are then very carefully stitched 
 together without tension. The object is to insure rapid union in 
 
 * A good account of these operations will be found in Mr. Eeeves's OrthoptEdie 
 Surgery. 
 
 f British Medical Journal, 1881, ii. 931. 
 
32 OPERATIONS ON THE UPPER EXTREMITY. 
 
 the commencement of the pleft, and thus no redevelopment of the 
 web. The flaps should be sufficiently thick to avoid the risk of 
 sloughing, and somewhat narrow to prevent bulging. To prevent 
 tension they should be sufficiently long, and any tissue between the 
 knuckles that prevents their coming together should be cut away. 
 The line of the natural web should be carefully observed. 
 
 CONTRACTED PALMAR FASCIA (Figs. 11 and 12). 
 
 It is well known that occasionally contraction of the palmar 
 fascia takes place, especially that part of it going to the inner two 
 fingers, being due partly to constitutional, partly to local, causes. 
 Commencing about the transverse palmar creases, it steadily crip- 
 ples the hand by drawing down the fingers, causing flexion at the 
 metacarpo- phalangeal joint (Fig. 11). 
 
 Operation. — This may be either open or subcutaneous ; I much 
 prefer the latter. The best is Mr. Adams's method,* by multiple 
 punctures from above downwards. Either before the skin becomes 
 adherent, or by finding some spot where adhesion of the skin to the 
 fascia has not yet taken place, the surgeon, avoiding the site of the 
 vessels, passes a delicate fascia knife or a fine small tenotomy knife, 
 between the skin and fascia, and divides the band from above 
 downwards, taking care not to dip the point. In cases of contrac- 
 tion of two fingers, multiple punctures — e.g., five to nine — may be 
 required. It is very easy, by operating on the palmar cords, to 
 rectify the contraction at the metacarpo-phalangeal joint. The 
 straightening of the contraction often met with between the first 
 and second phalanges is much more difficult. The digital prolonga- 
 tions of the fascia may be divided by punctures in the web between 
 fingers, extreme care being required to avoid the digital vessels and 
 nerves by not dipping the point. But when the surgeon finds some 
 difficulty in correcting this contraction thoroughly, I am of opinion 
 that he will act most wisely by correcting the remaining contraction 
 gradually by the use of a finger splint with rack and pinion move- 
 ments opposite the metacarpo-phalangeal and inter-phalangeal 
 joints.f. When the punctures are made they are covered with 
 boracic lint, dusted with iodoform, and the hand placed on the 
 above splint, which is worn day and night at first, carefully padded 
 at all pressure points. Some weeks will be required to correct the 
 phalangeal contraction, and in advanced cases relapses can only be 
 
 * Finger Contraction and Depressed Cicatrices (Churchill, 1879). 
 f Loc. supra cit., Fig. 10. 
 
CONTRACTED PALMAR FASCIA. 
 
 33 
 
 prevented by the persevering use of the splint. If the surgeon 
 attempts to straighten completely in an advanced case of phalan- 
 geal as well as metacarpo-phalangeal contraction, he runs the risk 
 (by dividing a digital nerve) of causing slight gangrene of the 
 finger-tips or most intolerable pain. 
 
 Figs. 11 and 12* represent the right hand crippled with contrac- 
 tion of the palmar fascia, before and after operation. The man was 
 
 Fig 11. 
 
 a patient of Dr. J. E. B. Burroughs, of Lee, and was operated on by 
 me in 1883, the contraction of the metacarpo-phalangeal joints 
 being straightened at once after numerous jjunctures made in the 
 manner above given, while that at the inter-phalangeal joints was 
 remedied chiefly by the persevering use of Mr. Adams's splint, 
 already alluded to. The fingers are now, 1887, absolutely straight, 
 perfectly mobile, and free from the slightest tendency to contrac- 
 tion. It will be seen from Mr. Hogarth's drawing that some thick- 
 ening, puckering, and corrugation of the palmar skin and fascia 
 still persists, but this has now no power of producing contraction, 
 
 * The asterisks in Fig. 12 show spots where the fascia l>;nife might be introduced 
 in contraction of the palmar fascia slip going to tlie ring finger. The contracted 
 band or bridle, thus isolated by the punctnres, undergoes softening and atrophy. 
 
 3 
 
34 
 
 OPERATIONS ON THE UPPER EXTREMITY. 
 
 the patient, one of the reheving officers to the Lewisham Union, 
 being able to write, etc., without any hindrance whatever. 
 
 If a method of operating bj^ open wound be preferred, the follow- 
 ing, based upon that of Goyraud, may be made use of. Tt is rec- 
 ommended by Mr. Hardie,* of Manchester, who believes that mere 
 subcutaneous division of the contracted palmar fascia cannot be 
 sufficient if the thickened, puckered, hardened skin ■ is left alone, 
 and also that intimate adhesion of the altered skin to the fascia is 
 
 Fig. 12. 
 
 so general that it is difficult, if not impossible, to get the knife be- 
 tween the two at a sufficient number of spots for adequate straight- 
 ening by the subcutaneous method. While it may be readily ad- 
 mitted that Mr. Hardie's four cases gave good results up to the time 
 reported, and that, if any open operation is really needed, this one 
 is as good as any, the following objections to its general adoption in 
 preference to that of Mr. Adams appear to me to be fair ones: (1) 
 The greater severity of an open operation in these patients, who are 
 often not young, even when the wound is, by hands as careful as 
 those of Mr. Hardie, kept aseptic. (2) The more frequent dress- 
 ings, the need of a drain, the fact that the wound does not heal for 
 
 ■* Medical Chronicle, vol. i. No. 1, p. 9. 
 
CONTRACTED PALMAR FASCIA. 35 
 
 upwards of a week, and then, perhaps, not all by prhnary union ; 
 the presence of sutures which need removal, and the fact that, as 
 in Case III., " general swelling of the hand " may take place and 
 interfere with the use of splints. Finally, Mr. Hardie does not 
 appear to me to attach sufficient importance to the value of Mr. 
 Adams's splint, which, by gradual, quiet, persevering extension, 
 causes atrophy of the now divided fascial cords, and thus renders, 
 as a secondary result, the hardened skin over them more soft and 
 supple, this taking place the more readily, the more extension by 
 the splint, and passive movements, frictions, etc., are persevered 
 with. 
 
 Mr. Hardie thus describes his modification* of Goyraud's opera- 
 tion : 
 
 " An-Esmarch's tourniquet having been applied, an incision is 
 begun i inch above the principal transverse fold of the palm, imme- 
 diately over the tense bridle of fascia proceeding to the finger mainly 
 involved. This is carried along the bridle to a little beyond the 
 base of the last phalanx which is affected. The lips of the incision 
 having been opened up, the knife is then carried close to the bridle 
 along its whole extent, so as to separate from it the adjacent skin, 
 cellular tissue, and fat, first on one side and then on the other. In 
 doing this, it is necessary to go some depth near the upper end of 
 the incision, so as to divide the little bands which attach the web of 
 the finger to the processes of fascia inserted into the sides of the 
 first phalanx. This dissection having been completed, the tense 
 bridle of fascia, now almost isolated, is cut across at the upper end 
 of the incision. This immediately permits of an almost complete 
 extension of the first phalanx. Further transverse incisions are 
 then made opposite the middle of the first and second phalanges, 
 as the case may require. The knife is then applied to any portion 
 of the fascia which appears to prevent complete extension of the 
 fingers. Some portions may then appear to be so much isolated, or 
 may project so much, that they may be cut out entirely. The other 
 fingers of the same hand which are affected are then, in their turn, 
 similarly treated. Complete capability of immediate extension is 
 to be secured. The tourniquet is then removed, but, although the 
 bleeding will be very smart, it is not likely that any vessels will be 
 seen which can be secured. I then lay a catgut or horsehair drain 
 along the extent of the wound, and bring the edges of the latter 
 accurately together with silver wire. A large pad of antiseptic 
 dressing is applied, and the fingers bandaged to a straight splint. 
 
 * The chief points of difference are that more importance is attaclied by Mr. 
 Hardy to complete liberation of the skin, and that the antiseptic treatment is made 
 use of. 
 
36 OPERATIONS ON THE UPPER EXTREMITY. 
 
 I regret to have to use a drain, but the bleeding is so free that I 
 think it a desirable precaution. It should be removed next day, and 
 the dressing re-applied so as to exert some pressure on the part. 
 Should nothing untoward occur, it should be left undisturbed for a 
 week, when it is to be expected that sound union will have taken 
 place. The stitches are removed, and subsequent treatment will 
 consist in manipulation of the fingers and the use of the splint for 
 two or three weeks longer." 
 
 PALMAR HAEMORRHAGE. 
 
 Before considering this, it may be pointed out that there are 
 three arterial arches especially concerned in keeping up the arterial 
 supply here— viz. (a) superficial palmar; (/3) deep palmar arch; (7) 
 the carpal arteries round the wrist. These are supplied with blood, 
 not only from the radial and ulnar, but also from the interosseous 
 arteries. Finally, if the comes nervi mediani is enlarged, it will 
 join the superficial palmar arch or one of the digital arteries. 
 
 Treatment. — This will vary accordingly as the case is seen early 
 or later. 
 
 A. Early Cases. — The surgeon arrests any bleeding=*^ by pressure 
 on the bleeding point while he has the limb raised, and arranges 
 for compressing the brachial, or the radial and ulnar. This securely 
 effected, he cleanses the wound, dries it carefully, and, if it gapes at 
 all, endeavors to secure the cut vessel itself. If this fail, or if the 
 wound be merely punctured, he at once carefully applies compres- 
 sion. And it may be said at once that, if this is wisely and effi- 
 ciently done, no further haemorrhage will take place ; if incompletely 
 or carelessly applied, the patient's limb and life may both be en- 
 dangered. 
 
 The brachial being commanded and the wound dried, a compress 
 ■ — consisting of boracic lint, dusted with iodoform, pieces of sponges 
 wrung out of carbolic acid and dusted with iodoform and powdered 
 steel sulphate, or lint soaked in carbolic oil or tr. benz. co., the 
 pieces of lint or sponge increasing in size from a threepenny bit to 
 half-a-crown — is got ready, together with strapping, bandages, lint, 
 and two bits of pencil or bougie. The fingers are now carefully 
 strapped and bandaged, and the compress is then secured in posi- 
 tion by careful bandaging. If the above precaution is omitted, so 
 much and so painful oedema of the fingers will take place as to 
 
 * The wound somelinies does not bleed when examined. If there is a history 
 of much bleeding, bleeding per sattum, if the depth, etc., of the wound make it 
 probable that an artery is wounded, pressure should be applied. A little later, and 
 the hffimorrhage may break out on the least exertion, and is very likely to occur at 
 night. 
 
PALMAR HiEMOEEHAGE, 37 
 
 inevitably lead to early removal of the compress and recurrence of 
 the ha'morrhage. The compress being in position, two bits of 
 pencil wrapped up in lint are placed over the radial and ulnar, and 
 the bandage carried up to mid-arm. The Esmarch being removed 
 from the brachial, a splint* is then applied, and the patient kept at 
 first well under the influence of morphia. The compress should 
 not be disturbed for three or four days at least. 
 
 B. I,ATER Cases. — If pressure has been tried, but inefficiently, 
 because inadequately at first, inflammation will probably have 
 supervened, and the hand will very likely be red, brawny, painful, 
 suppurating. If htemorrhage still continue after the parts are re- 
 lieved by carefully made incisionsf it will be wiser totie the brachial 
 artery at once in the middle of the arm than to tie the radial and 
 ulnar in the lower third of the forearm {p. 37, 40), and for these 
 reasons : 
 
 i. While the anastomoses round the elbow are so free and so re- 
 lia,ble as to prevent any risk of gangrene after a ligature of the 
 main vessel, ligature of the radial and ulnar is rendered uncertain 
 owing to — 
 
 («) The anastomoses between the two palmar arches ; 
 O^j The anastomoses between these and the carpal arteries ; 
 (jj The blood brought down by the interosseous arteries and 
 the comes nervi mediani, which will not be stopped by 
 ligature of the radial and ulnar ; 
 (4) The fact that, if inflammation has set in, enlargement of 
 the arteries will have taken place, 
 ii. Ligature of the brachial, by cutting off so much blood, will 
 also cut short the inflammation. 
 
 iii. Ligature of the brachial will be performed through healthy 
 and uninflamed parts. 
 
 An interesting instance of what pressure will effect even if de- 
 ferred till the eleventh hour is seen in the following case, published 
 by Mr. Skey, Lancet, 1855. A patient nearly three weeks after the 
 wound, having had attacks of recurrent ha3morrhage, entered St. Bar- 
 tholomew's Hospital, and Mr. Skey tied the radial and ulnar. When 
 
 * The surgeon must choose between one {e.g., an outside angular splint) in which, 
 the hand being extended, the tension of the palmar fascia makes some pressure on 
 the wounded vessel, and one more comfortable, but perhaps less efficient, in which 
 the hand is flexed and the fascia relaxed. 
 
 f Incisions for suppuration in the hand should be made opposite to the centres 
 of the phalanges, opposite to the heads of the metacarpal bones, above the super- 
 ficial palmar arch by Mr. Hilton's method, and, if above the wrist, the position of 
 the arteries, which may, perhaps, be superficial, and of the median nerve lying 
 close to the ipner side of the palmaris longus must be renaembered. 
 
38 OPERATIONS ON THE UPPER EXTREMITY. 
 
 the ligature separated from the ulnar, haemorrhage took place, and 
 the artery was again tied in the middle third. Hsemorrhage recur- 
 ring, the brachial was tied in the lower third. This last operation 
 failed to arrest the hajmorrhage, and the third part of the axillary 
 was tied. Aliout ten days later profuse haemorrhage from the axil- 
 lary wound left the ]iatient almost pulseless. The patient's con- 
 dition not admitting of amputation at the shoulder, the limb was 
 firmly bandaged from the hand to the shoulder. No further bleed- 
 ing took i^lace, and the man made a good recovery, with a useful 
 arm. 
 
 In the Lancet, 1859, vol. i. p. 506, is a good instance of the results 
 of pressure inefficiently applied. The compress, which had been 
 applied to the palmar wound (the man having been made an out- 
 patient), was removed every day, and followed by haemorrhage. 
 Severe bleeding occurred on the fifth day, ligature of the radial was 
 performed on the seventh, and on the ninth ligature of the brachial 
 low down. On the eleventh, owing to recurrence of hEemorrhage, 
 the arm was amputated just above the ligature. Chronic pytemia 
 followed, from which the patient was slowly recovering at the close 
 of the report. No abnormal distribution of vessels was found in 
 the arm. 
 
 OPERATIONS FOR UNION OF DIVIDED TENDONS. 
 
 These may be referred to here from the frequency with which the 
 flexor and extensor tendons of the fingers and wrist are liable to be 
 severed. 
 
 As in the case of divided nerves, the union of tendons ma}' be 
 primary or secondary, according as the surgeon is called to the case 
 at once or later. For general details the reader is referred to the 
 chapter on Nerve-suture. 
 
 The ujiper end will probably give more trouble than in the case 
 of a nerve, owing to its greater retraction. In laying open the 
 sheath to follow up the tendon, most scrupulous care must be taken 
 to use every aseptic precaution. Sutures of fine silk, salmon-gut, 
 or silk combined with horsehair are preferable to those of chromic 
 gut.* In the case of secondary suture, refreshing the ends must be 
 made use of 
 
 When several tendons have been divided, uniting each end accu- 
 rately to its fellow is often troublesome. 
 
 If the upper end cannot be found after careful search and suffi- 
 cient slitting up of the sheath, the lower end may be successfully 
 attached to a neighboring tendon. 
 
 * Silk or wire sutures should always be used when suppuration is likely to take 
 place. 
 
UKION OP DIVIDED TENDONS. 39 
 
 When the ends are widely apart, and apposition is unobtainable, 
 attempts have recently been made, with some success, to connect 
 the two ends by long threads—" distance-sutures." B. Anger first 
 made use of sutures of this kind for the tendon of the extensor 
 minimi digiti ; the two ends were 9 cm. apart, but traction reduced 
 the distance to 2 cm., and they were connected by a silver suture, 
 with a satisfactory result. M. Assaky,* and M. Fargin, have more 
 lately used distance-sutures, and think that the tendons regenerated 
 along the threads are always stronger than those spontaneously 
 regenerated, the number of tendinous fasciculi being greater. The 
 operation is clearly indicated whenever apposition is impossible; it 
 is more particularly applicable to tendons without a sheath. 
 
 M. Peyrotf has succeeded in transplanting the tendons of a dog, 
 and, in another case, that of a cat, into the gaps of divided tendons 
 in man. The transplanted piece is said to have lived, and a fair 
 amount of flexion of the finger to have been obtained. Whether 
 this will be found preferable in its results to distance-sutures re- 
 mains to be seen. 
 
 The following cases are good instances of tendon suture ; they 
 are reported by Dr. v. Fillenbaum, of Vienna :| 
 
 Case I. — Oblique cut with a bread-knife, involving the common 
 extensor of the index and middle finger, and the extensor indicis, 
 the central end of the latter retracted so far that it could not be 
 reached, unless by slitting up its sheath. The tendons of the com- 
 mon extensor were each united by two fine silk sutures. 
 
 The accessible peripheral end of the extensor indicis was attached 
 to both ends of the sutured tendon from the extensor commu- 
 nis to the index finger. The strongly stretched extensor tendons 
 of the second and third fingers were now fixed (to prevent retrac- 
 tion by muscular action) by silk sutures passed, 2 cm. higher up, 
 through skin and tendon sheath, and tied over a roll of iodoform 
 gauze. These were removed on the fifth day. Passive movement 
 was begun on the sixteenth day. Six months later the man had 
 perfect use of his fingers. 
 
 Case II. — Razor cut on back of left thumb ; operation six weeks 
 later. The thumb was found strongly adducted, and bent into the 
 palm. Active extension impossible. A serous fistula was left. The 
 parts being made evascular, the tendon-ends, found but a few mm. 
 
 * The above remarks on distance-sutures are taken from an abstract of a paper 
 by M. Assaky, Sevue de Chirurgie, November, 1886, in the Annals of Surgery, April, 
 1887, p. 348. 
 
 t Bull, de la Soc. de Chir., 1886, p. 357. 
 
 X Wien. Med. Woch , Nos. 29 and 30, 1885; Annals of Surgery, November, 1885, 
 p. 427. 
 
40 OPERATIONS ON THE UPPER EXTREMITY. 
 
 apart and closely adherent to the sheath, were trimmed with 
 scissors and united with silk sutures. Two mm. above the central 
 end on the radial side a fine silk suture was passed outwards, and 
 again in towards the palm, through the whole thickness of the ten- 
 don, then back again towards the palm, and out at the ulnar side. 
 After closely adapting the two tendon-ends, the silk was passed 
 through the peripheral end in a reverse order, and finally the two 
 suture ends were tied on the radial side of the tendon. A fixation- 
 suture was used as in the previous case. Four months later the 
 movements of the thumb were normal, only at the place of the 
 fixation suture the skin and tendon sheath were adherent, as shown 
 by the folding in of the skin on extension. 
 
 Case III.— The tendon of the extensor minimi digiti was severed. 
 Its central end was only found after slitting up the sheath 2i cm. 
 Result excellent. 
 
 Case IV — Extensor of left middle finger was severed close to the 
 head of the second phalanx, the adjacent joint being opened. The 
 articular capsule was first closed, then the tendon was sutured as 
 well as possible, much difficulty arising from the thinness of the 
 middle crus of the extensor here. The wound united well. The 
 finger, at first straight, gradually became more and more flexed, 
 and worse than useless. A further 023eration was refused. 
 
 CHAPTER II. 
 OPERATIONS ON THE WRIST. 
 
 EXCISION OP THE WRIST JOINT (Figs. 13 and 14). 
 
 The reasons for this operation often failing, and the conditions 
 needful for success, may be first considered. 
 
 1. Whether the disease begins in the synovial membrane as a 
 synovitis, pulpy, gonorrhoeal, rheumatic, etc., or whether, as more 
 rarely, it begins primarily in the bones, it extends rapidly, not only 
 to the wrist-joint, but to the two rows of carpal bones and the bases 
 of the metacarpals, along the complicated sj'novial membranes,* 
 
 * The arrangement of these, five in number, mnst be remembered, and their 
 close vicinity to each other. (1) The membrana sacciformis of the inferior radio- 
 ulnar articulation, passing from the lower end of the ulna to the sigmoid cavity of 
 the radius, and lining tlie upper surface of the triangular fibro-cartilage. (2) That 
 of the wrist-joint proper, passing from the lower end of the radius and the inter- 
 articular fibro-cartilage above to the bones of the first row below. (3) The common 
 
EXCISION OF THE WRIST. 
 
 41 
 
 which hring all these hones into contiguity with euch other. The 
 disease, thus extensive, is also most obstinate, and is by no means 
 unfrequently further compHcated by the presence of phthisis. Thus, 
 partial operations are useless, and often worse than useless. Sir J. 
 Lister* was the first to insist on the importance, and to show the 
 possibility, of removing every atom of the disease, including the 
 ends of the radius and ulna, the two rows of carpal bones, and the 
 bases of the metacarpus (Fig. 13). 
 
 2. From the close relation of the flexor and extensor tendons in 
 front and behind these complicated joints, and from the numerous 
 grooves on the bones, it is most difficult to extirpate the disease 
 
 Ftg. 13. 
 
 Parts removed in excision of the wrist. (Lister.) 
 
 without disturbing the tendons. On the other hand, however stiff 
 the wrist may be left, flexion and extension of the fingers is abso- 
 lutely needful for the operation to be a success ; hence it is impera- 
 tive that, throughout the prolonged operation, the tendons should 
 be disturbed as little as possible, a direction very difficult to follow, 
 as their cellular sheaths are often " pulpy," and the necessary dealing 
 
 synovial membrane of the carpus, the most extensive of all, passing from the lower 
 surface of the scaphoid, semilunar, and cuneiform above to the upper surface of the 
 bones of the second row, sending up two prolongations between the scaphoid and 
 semilunar and the semilunar and cimeiform, and also sending downwards three 
 processes between the four bones of the second row, prolonged down into the carpo- 
 metacarpal joints of the four inner metacarpal bones. (4) A separate one between 
 the cuneiform and pisiform. (5) Another separate one between the trapezium and 
 metacarpal bone of the tliumb. 
 * Lancet, 1865, vol. i. p. 308. From this paper Fig. 13 is taken. 
 
42 
 
 OPERATIONS ON THE UPPER EXTREMITY. 
 
 with this, as well as the manipulations of the tendons * during the 
 operation, may easily lead to their sloughing, and thus to a useless, 
 " fin-like " hand. 
 
 3. Passive movement of the fingers should be begun as early as 
 possible, and most perseveringly maintained. 
 
 Sir J. Lister's Operation. t — An antesthetic being given, and 
 the parts rendered bloodless by Esmarch's bandages, any adhesions 
 of the tendons are thoroughly broken down. The radial incision 
 
 is then made, as in Fig. 14. This 
 "*■ ■ incision is planned so as to avoid 
 
 the radial artery and also the 
 tendons of the extensor secundi 
 internodii and indicis. It com- 
 mences above at the middle of 
 the dorsal aspect of the radius 
 on a level with the styloid pro- 
 cess. Thence it is at first directed 
 towards the inner side of the me- 
 tacarpo-phalangeal joint of the 
 thumb, running parallel in this 
 course to the extensor secundi in- 
 ternodii ; but on reaching the 
 line of the radial border of the 
 second metacarpal bone, it is car- 
 ried downwards longitudinally 
 for half its length, the radial 
 artery being thus avoided, as it 
 lies a little farther out. These 
 directions will be found to serve, 
 however much the parts may be 
 obscured by inflammatory thick- 
 ening. The tendon of the ex- 
 tensor carpi radialis longior is next detached with the knife, guided 
 by the thumb-nail, and raised, together with that of the extensor 
 
 A, Radial artery. B, Extensor secundi in- 
 ternodii poUicis, c, Extensor indicis. D, 
 Extensor communis, e, Extensor minimi 
 digiti. F, Extensor primi internodii. G, 
 Extensor ossis metacarpi. H, Extensor carpi 
 radialis lougior. i, Extensor carpi radialis 
 brevior. K, Extensor carpi ulnaris. L L, 
 Line of radial incision. (Lister.) 
 
 * Mr. Erichsen (Surg., vol. ii. p. 383) writes thus of this point: ''If we look at 
 the tendons which surround the wrist, we shall find them divisible into five groups 
 — (1) Those special to the thumb ; (2) The extensors of the fingers ; (3) The flexors 
 of the fingers ; (4 and 5) The flexors and extensors of the wrist. Now, the incisions 
 should be so planned as to save absolutely the whole of the first three groups and to 
 divide only the tendons of the wrist proper, and these are cut so close to their in- 
 sertions that, as a rule, they form new attachments and resume their functions as 
 recovery takes place.'' 
 
 f This account is taken from Sir J. Lister's original paper in the Lancet, loc. 
 supra cit. 
 
EXCISION OF THE WKIST. 43 
 
 brevior, also cut, while the extensor secundi internodii, with the 
 radial artery, is thrust somewhat outwards. The next step is the 
 separation of the trapezium from the rest of the carpus by cutting' 
 forceps applied in a line with the longitudinal part of the incision, 
 great care being taken of the radial artery. The removal of the 
 trapezium is left till the rest of the carpus has been taken away, 
 when it can be dissected out without much difficulty, whereas its 
 intimate relations with the artery and neighboring parts would 
 cause much trouble at an earlier stage. The soft parts on the ulnar 
 side are next dissected up as far as possible, the hand being bent 
 back to relax the extensors. 
 
 The ulnar incision should be made very free by entering the 
 knife at least two inches above the end of the ulna immediately 
 anterior to the bone, and carrying it down between the bone and 
 flexor carpi ulnaris, and on in a straight line as far as the middle 
 of the fifth metacarpal bone at its palmar aspect. The dorsal lip of 
 the incision is then raised, and the tendon of the extensor carpi 
 ulnaris cut at its insertion, and its tendon dissected up from its 
 groove in the ulna, care being taken not to isolate it from the in- 
 teguments, which would endanger its vitality. The finger extensors 
 are then separated from the carpus, and the dorsal and internal 
 lateral ligaments of the wrist-joint divided, but the connections of 
 the tendons with the radius are purposely left undisturbed. Atten- 
 tion is now directed to the palmar side of the incision. The ante- 
 rior surface of the ulna is cleared by cutting towards the bone so as 
 to avoid the artery and nerve, the articulation of the pisiform bone 
 opened, if that has not been already done in making the incision, 
 and the flexor tendons separated from the carpus, the hand being 
 depressed to relax them. While this is being done, the knife is 
 arrested by the unciform process, which is clii^ped through at its 
 base with pliers. Care is taken to avoid carrying the knife farther 
 down the hand than the bases of the metacarpal bones, for this, 
 besides inflicting unnecessary injury, would involve risk of cutting 
 the deep palmar arch. The anterior ligament of the wrist-joint is 
 also divided, after which the junction between carpus and meta- 
 carpus is severed with cutting pliers, and the carpus is extracted 
 from the ulnar incision with sequestrum forceps, and touching with 
 the knife any ligamentous connections. The hand being now for- 
 cibly everted, the articular ends of the radius and ulna will pro- 
 trude at the ulnar incision. If they appear sound, or very super- 
 ficially affected, the articular surfaces only are removed. The ulna 
 is divided obliquely with a small saw, so as to take away the 
 cartilage-covered rounded part over which the radius sweeps, while 
 the base of the styloid process is retained. The ulna and radius 
 
44 OPERATIONS ON THE UPPER EXTREMITY. 
 
 are thus left of the same length, which greatly promotes the sym- 
 metry and steadiness of the hand, the angular interval between the 
 bones being soon filled up with fresh ossific deposit. A thin slice 
 is then sawn off the radius parallel with the articular surface. For 
 this it is scarcely necessary to disturb the tendons in their grooves 
 on the back, and thus the extensor secundi internodii may never 
 appear at all. This may seem a refinement, but the freedom with 
 which the thumb and fingers can be extended, even within a day 
 or two of the operation, when this point is attended to, shows that 
 it is important. The articular facet on the ulnar side of the bone is 
 then clipped away with forceps applied longitudinally. 
 
 If the bones prove to be deeply carious, the pliers or gouge must 
 be used with the greatest freedom. The metacarpal bones are next 
 dealt with on the same principle, each being closely investigated, 
 the second and third being most readily reached from the radial, 
 the fourth and fifth from the ulnar side. If they seem sound, the 
 articular surfaces only are clipped off, the lateral facets being re- 
 moved by longitudinal application of the pliers.* 
 
 The trapezium is next seized with forceps and dissected outf 
 without cutting the tendon of the flexor carpi radialis, which is 
 firmly bound down in the groove on the palmar asi^ect, the knife 
 being also kept close to the bone so as to avoid the radial. The 
 thumb being then pushed up by an assistant, the articular end of 
 its metacarpal bone is removed. Though this articulates bv a sep- 
 arate joint, it may be affected, and the symmetry of the hand is 
 promoted by reducing it to the same level as the other meta- 
 carpals. 
 
 Lastly, the articular surface of the pisiform is clipped off, the rest 
 being left if sound, as it gives insertion to the flexor carpi ulnaris 
 and attachment to the anterior annular ligament. But if there is 
 any suspicion as to its unsoundness, it should be dissected out 
 altogether, and the same applies to the process of the unciform. 
 
 The only tendons divided are the extensors of the carpus, for the 
 flexor carpi radialis is inserted into the second metacarpal below 
 its base, and so escapes. Merely one or two small vessels require 
 ligature. Free drainage must be given. The hand and forearm are 
 
 * As an instance of what may be taken away, in one case Sir J Lister not only 
 removed the base of the third metacarpal bone, but drilled its shaft into a hollow 
 tube, a sound and most useful hand being retained. 
 
 t Mr. Williams {Lancet, 1880, ii. p. 932) advises that the trapezium should be 
 left, as, owing to the special synovial sac, disease there is less frequent than might 
 be expected, and as there is thus no risk of dividing the radial artery or the flexor 
 carpi radialis. A single incision along the back of the wrist at the inner border is 
 recommended for excision of the wrist, but no cases are given. 
 
EXCISION OF THE WEIST. 45 
 
 put up on the well-known splint of Sir J. Lister, with the cork wup- 
 port for the hand, which helps to secure the principal oljjects in the 
 after treatment, viz., frequent movements of the fingers, while the 
 wrist is kept fixed during consolidation. 
 
 Passive movement should be commenced on the second day, 
 whether the inflammation has subsided or not, and continued daily. 
 Each joint should be flexed and extended to the full extent possible 
 in health, the metacarpal bone being held quite steady to avoid dis- 
 turbing the wrist. By this means the suppleness gained by break- 
 ing down adhesions under chloroform is maintained. 
 
 Pronation and supination, flexion and extension, abduction and 
 adduction, must be gradually encouraged as the new wrist acquires 
 firmness. When the hand has acquired sufficient strengtli, freer 
 play for the fingers should be allowed by cutting off all the splint 
 beyond the knuckles. Even after the hand is healed, a leather 
 suf)port should be worn for some time, accurately moulded to the 
 front of the limb, reaching from the middle of the forearm to the 
 knuckles, and sufficiently turned up at the ulnar side. This is 
 retained in situ by lacing over the back of the forearm. 
 Other Methods of Wrist Excision : 
 
 West's. — In this method two dorsal incisions are made use of, 
 each about four inches long, the radial one keeping to the uh:iar side 
 of the extensor secundi internodii poUicis, the ulnar being rather to 
 the anterior surface of the ulna, but close to the bone. No tendons 
 of the thumb or fingers are divided, being drawn aside with 
 retractors. The two cases reported (Dublin Med. Journ., Feli., 1870) 
 recovered with very useful hands. 
 
 By Single Dorsal Incision. — Dr. Gillespie {Edin. Med. Journ., 
 Dec, 1870) gives two cases in which a single dorsal median incision, 
 about three inches long, was made use of on the outer side of the 
 finger extensors. The ends of the ulna and radius were first dealt 
 with, then the bones of the carpus, and, lastly, those metacarpals 
 which required it. Very useful hands resulted, especially in one 
 case, a child of six. My old friend G. A. Wright, of the Manchester 
 and Pendlebury hospitals, has made use of a similar incision. The 
 following account is taken from the Abstracts of Medical and Sur- 
 gical Cases treated at the Pendlebury Hospital, 1884, p. 133. The 
 patient was a child of nine, with phlyctenular ophthalmia, enlarged 
 glands, and many marks of strumous disease. The right wrist was 
 disorganized. " A single longitudinal incision for 3 to 4 inches was 
 made between extensor communis and extensor secundi, the carpal 
 joints opened, and the bones easily shelled out ; the ends of the 
 metacarpal bones and of the radius and .ulna were removed with a 
 
46 OPERATIONS ON THE UPPER EXTREMITY. 
 
 gouge ; one vessel was twisted ; no tendon was divided, except in 
 tlie sense of turning bacli the extensors of the carpus from their 
 attachments." The result was that, six months later, " the hand, 
 which before the operation was bulbous, flabby, and useless, was 
 all but healed, and had well shrunken ; there was excellent power 
 and mobility."* 
 
 A further trial of this simple method is required, especially in 
 adults, before a decided opinion can be given as to its merits. In 
 children the tendons can be more readily drawn out of the way, 
 and the parts are altogether less rigid. In endeavoring to perform 
 an extensive excision, such as Sir J. Lister has shown to be useful 
 in the wrist in the adult, care must be taken not to cause sloughing 
 of the tendons later on by too vigorous use of the retractors, as 
 their blood-supply is already impaired by the disease of their 
 sheaths. 
 
 If a single dorsal incision be made use of, the best is that of Von 
 Langenbeck. The following account is taken from Stimson :t The 
 hand is bent toward the inner side, and an incision is begun at the 
 ulnar border of the second metacarpal bone and carried upwards 
 on to the radius for 4 inches, crossing the ulnar edge of the tendon of 
 the extensor carpi radialis brevior where it is inserted into the base 
 of the third metacarpal bone, and splitting the dorsal ligament of 
 the wrist exactly between the tendons of the extensor secundi in- 
 ternodii and extensor of the forefinger. This incision should be 
 carried down to the bone, and the soft j^arts detached on the radial 
 side with an elevator; the tendons of thumb and fingers, where 
 they lie in the grooves, are raised bodily with the periosteum, and 
 their sheaths are not opened. 
 
 The hand is flexed so as to make the first row of carpal bones 
 present in the wound ; the scaphoid is separated from the trapezium 
 and taken out; then the semilunar and cuneiform, the interosseous 
 ligaments being cut, and the bones prised out with a small eleva- 
 tor. The trapezium and pisiform are left if possible. 
 
 To take out the second row the operator steadies the rounded 
 articular extremity of the os magnum with the fingers of his left 
 
 * In the very young, when disease occurs in this joint, which is very rare, exten- 
 sive scooping out of carious bones and scraping out of sinuses may be undertaken, 
 although no set operation can be done, owing to the tiny size of the parts. In 1877 
 I removed five of tlie carpal bones by a single dorsal incision in an infant aged two 
 years and a half, a patient of Dr. T. Eastes, of Folkestone, the sinuses present being 
 thoroughly scraped out with a sliarp spoon. The result was most satisfactory both 
 as to the permanency of the cure and the usefulness of the fingers. 
 
 t Operative Surgery, p. 1(33. 
 
EXCISION OF THE W^EIST. 47 
 
 hand, and, while an assistant abducts the thumb, he divides with a 
 knife the connection between the trapezium and trapezoid, passes 
 the knife into the carpo-metacarpal joints, and into the ligaments 
 on the dorsal side of the ends of the metacarpal bones, while an 
 assistant strongly flexes them; in this way the trapezoid, os mag- 
 num, and cuneiform can Ije brought out together. 
 
 The ends of the radius and ulna are next protruded, and the dis 
 eased portions removed. 
 
 In this, as in Sir J. Lister's, or any excision of the wrist, great 
 care must be taken not to open the radial artery, not to interfere 
 with the palmar surface more than can be helped, to preserve any 
 sound though inflamed periosteum, not to damage the tendons* 
 with retractors, etc., and finally to adopt early, and to persevere with, 
 movements of the fingers. 
 
 Excision of the Wrist for Injury. — This will be still more 
 rarely required. Mr. Pye (Med. Times and Gaz., 1879, vol. ii. p. 582) 
 has published a case of compound dislocation in an adult. Some 
 bones were protruding through a transverse rent on the front of the 
 wrist, the radial artery was uninjured, the ulnar could not be felt. 
 The flexor carpi radialis and flexor longus pollicis were torn across. 
 The ends of the radius and ulna were sawn off and the carpal bones 
 removed, piecemeal, until only the trapezium and the distal part 
 of the OS magnum, which was apparently uninjured, were left. 
 Strict antiseptic precautions were taken, and the wound healed 
 rapidly. There was a steady regain of power in the wrist and hand, 
 the patient being again able to carry his milk-pails.f 
 
 Excision of Wrist for G-unshot Injury.— Dr OtisJ states that 
 ninety-six cases of excision of the wrist, varying much in extent, 
 were returned. Six of these were complete, and five recovered with 
 the functions of the hand much impaired, but, all things taken into 
 consideration, in a better condition than if they had been submitted 
 to amputation. In the ninety partial excisions, ankylosis and 
 extreme deformity appear to have been common. Generally, the 
 
 * If any of the tendons are unavoidably so interfered with that a portion is 
 likely to slough, it might, perhaps, be well to cut out this part, and unite the ends 
 with a carbolized silk suture. And where such manipulation of a tendon is un- 
 avoidable, it would be better to divide it, and unite it subsequently. 
 
 f Sir W. MacCormac (Dub. Quart. Journ. Med. Sei., 1867, p. 281) publishes the 
 case of a girl, aged ten, in whom he removed the whole of the left carpus and most 
 of the metacarpal, for a machinery accident, the patient recovering with a useful 
 limb. 
 
 X Med. and Surg. Hist, of the War of the Rebellion, part ii. p. 999 et seq. 
 
48 OPERATIONS ON THE UPPER EXTREMITY. 
 
 hand was strongly deflected to the radial side * the fingers rigidly 
 fixed, the skin over the projecting end of the ulna irritable and ex- 
 posed to injury. "With our present experience of excisions of the 
 wrist for injury, it seems probable that recovery unattended by 
 ankylosis is seldom to be anticipated, yet that this result is not dis- 
 astrous, provided the hand is in good position and the functions of 
 the fingers are in some degree preserved." In a* very few, loose, 
 flail-like joints were observed, remediable by apparatus. Finally, 
 Dr. Otis concludes by saying that the " question whether the wrist- 
 joint, from its complexity, is altogether unfitted for the favor- 
 able performance of excision for injury is still not fully eluci- 
 dated." 
 
 The chief English authority, Sir T. Longmore, writes thus on this 
 operation:! "Gunshot wounds of the wrist are usually attended 
 with so much injury to the tendons and other structures surround- 
 ing the joint that it is scarcely possible in such cases for the opera- 
 tion of resection to produce satisfactory results. Just as extensive 
 laceration of the forearm, by destroying the motor power, renders 
 the hand useless, so does destruction of the flexor or extensor ten- 
 dons, by which the wrist-joint is embraced, effect the same re- 
 sult." 
 
 Causes of Failure after Excision of the Wrist.— These are 
 mainly : 
 
 1. Persistent sinuses and discharge set up by remaining caries or 
 necrosis. Sir W. Fergusson {Path. Soc. Trans., vol. viii. p. 391) 
 showed a specimen in which all the bones had been supposed to 
 have been removed by a single incision on the ulnar side. The 
 pisiform, trapezium, and part of the unciform had been left. The 
 movement of the fingers was good, but sinuses remained on both 
 sides communicating with a bare piece of radius. Death took place 
 from phthisis. Mr. J. Hutchinson (ihid., vol. xvii. p. 239) showed 
 a specimen of wrist-joint after partial resection by Mr. Stanley. 
 Though no active caries was present, discharge was kept up by a 
 necrosed bit of bone in a cavity at the back of the carpus. Death 
 here also took place from chronic phthisis. 
 
 2. Matting and sloughing of tendons, and consequent stiffness of 
 fingers. 
 
 3. Phthisis. 
 
 * As this appears to be irremediable by any apparatus, Dr. Otis suggests that it 
 should be met by always removing the carpal end of the ulna at the same level 
 with the section of the radius, whenever it is necessarj' to remove the lower end of 
 the latter. 
 
 f Syst. of Surg., vol. i. p. 552. 
 
AMPUTATION AT THE A\'RIST. 49 
 
 AMPUTATION THROUGH THE WRIST-JOINT. 
 
 The value of this operation has heen a good deal disputed. It 
 has been thought by some* " that it possesses no particular advan- 
 tage ; the- length of the stump is of no great consequence ; the 
 flajas, with the numerous tendons in them, may not heal readily." 
 Othersf have goiTe farther, and said that the long stump is found 
 by instrument makers difficult to fit with an artificial hand. That 
 this is certainly not always the case is shown by Mr. H. Bigg,J 
 from two cases, one a Commander R.N., the other an artisan in 
 the Woolwich Arsenal, both of whom, after being fitted with artifi- 
 cial hands, were able to engage actively in their respective em- 
 ployments. 
 
 As the above objections are scarcely sufficient, and as this ampu- 
 tation preserves, if the parts heal quickly, good pronation and 
 supination, it should be practiced whenever opportunities arise. 
 These, however, as is shown below, will not be numerous. 
 
 Indications. 
 
 1. Extensive injuries (gunshot and otherwise) of a hand not ad- 
 mitting of the preservation of any fingers, and in which the damage 
 of soft parts does not necessitate amputating through the forearm. 
 
 2. Disease of carpus locally too far advanced for excision, or 
 rendered by age, condition of health, etc., inappropriate for excision. 
 
 3. Cases of failed excision. 
 
 But in carpus disease the soft parts are often so much damaged 
 by sinus formation and other results of the disease that the surgeon 
 is driven to amputate higher up ; and where this may not be the 
 case, the articular surfaces of the radius and ulna, owing to disease, 
 have to be removed, the operation thus ceasing to be correctly am- 
 putation through the wrist-joint. 
 
 4. 5, and 6. More rarely still, for the results of palmar suppura- 
 tion, gangrene, or burns. 
 
 Operationf). — As in other amputations where the amount of 
 skin available varies considerably, several methods will be given. 
 The first of these is the best. 
 
 Diflferent Methods. 
 
 1. Long palmar flap (Figs. 15, 16). 
 
 2. Equal antero-posterior flaps. 
 
 3. Method of Dubreuil (Fig. 16). 
 
 4. Circular amputation. 
 
 5. Long dorsal flap, by Teale's method. 
 
 , * Sir W. Fergusson, Pracl. Surgery, p. 325. 
 
 f John Bell, Manual of Surgical Operations, p. 53. 
 X Artificial Limbs and Amputations, p. 83. 
 4 
 
50 
 
 OPERATIONS ON THE TIPPER EXTREMITY. 
 
 Fig. 15. 
 
 1. Amputation by a Long Palmar Flap (Figs. 15 and 16).— 
 This has the advantage of preserving skin thick, well used to pres- 
 sure, and abundantly supplied with 
 blood ; thenerves are also cut square, 
 and disarticulation is easy. 
 
 The hand being supinated and the 
 wrist extended, an incision is made (on 
 the left side) from the top of the styloid 
 process of the radius straight down well 
 on to the thenar eminence, and then, 
 curving across (about on a line with the 
 superficial palmar arch*), and marking 
 out a well-rounded flap by passing up- 
 wards over the hypothenar eminence to 
 the tip of the styloid process of the idna. 
 This flap is next dissected up without 
 scoring as far as the level of the wrist- 
 joint; it should contain on its under 
 surface some of the fibres of the thenar and hypothenar muscles. 
 If this precaution is taken, the flap will contain the superficiaHs 
 voire and ulnar arteries, and thus run no risk of sloughing. 
 
 The hand being now pronated and flexed at the wrist-joint, an 
 incision is made slightly convex across the wrist from one styloid 
 process to the other. The palmar flap being now retracted, the 
 hand is strongly flexed and the joint opened ; the soft parts in front 
 and behind are now severed with a circular sweep (the assistant 
 pulling slightly on the hand), the remaining ligaments divided, and 
 the hand removed. If the articular cartilages of the radius are dis- 
 eased, they n)ust be dealt with either by gouging or, if necessary, 
 by a clean section above the articular cartilage, a step which will 
 interfere with free pronation and supination later on. The apices 
 of the styloid processes should, in any case, be removed, but the 
 base of that of the radius should always be left, if possible, to secure 
 the action of the supinator longus. 
 
 The radial, ulnar, the two interosseous, and the superficialis volse 
 arteries will probably need securing. Any sinuses are now scraped 
 out with sharp spoons and the tendons trimmed. From the facility 
 with which these last slip up into their sheaths, antiseptic precau- 
 tions should be carefully taken. 
 
 Another Method. — This consists of marking out the palmar 
 flap (but not dissecting it up), opening the joint by a dorsal incision 
 
 * This level is usually low enough. If the parts on the dorsum are damaged, the 
 palmar incision may be made longer. Mv. Barwell British MedicalJournal, August 
 30, 1873) advises bringing the incision as low as llie crease in the palm, which is 
 due to flexion of the fingers. 
 
AMPUTATION AT THE WRIST. 51 
 
 as above given, and then cutting the pahnar flap by transfixion, the 
 knife being passed behind the bones. As in this method it is diffi- 
 cult not to hitch the knife on the pisiform and unciform bones, and 
 to avoid a jagged edge to the palmar flap, and as the flexor tendons, 
 being relaxed, are pulled out by the knife 
 instead of being cut cleanly, I do not Fig. 16. 
 
 recommend it. 
 
 2. Amputation by Equal Antero- 
 posterior Flaps.— The surgeon may be 
 obliged, where the soft parts are scanty, to 
 make use of this method. The objections 
 to it are that if the tissues are thin there is 
 some risk that the cicatrix may be adhe- 
 rent to the bones, and. that these will be but poorly covered. Dur- 
 ing healing the drainage is less satisfactory. 
 
 3. Amputation at the Wrist by the Method of Du- 
 breuil* (Fig. 16).— In a few rare cases, e.g., where the soft parts 
 on the back and front of the wrist are much damaged, perforated 
 by sinuses, etc., this ingenious method may be made use of. 
 
 The hand being pronated, the surgeon commences, at a point at 
 the junction of the outer with the middle third of the back of the 
 forearm, a little below the level of the wrist-joint, a convex incision, 
 which reaches at its summit the middle of the dorsal surface of the 
 thumb, and terminates in front, just below the palmar aspect of the 
 wrist, at the junction of the outer with the middle thirds of the 
 forearm. The flap, consisting of skin and fasciae, having been 
 raised, the two ends of its base are joined by an incision at a right 
 angle to the long axis of the forearm. Finally, disarticulation is 
 performed, beginning at the radial side. 
 
 4. Circular Amputation at Wrist. — This method is only 
 suited to patients with thin, lax skins, and even in them it is often 
 difficult to raise quickly and neatly the skin, which is here adherent 
 to some of the adjacent parts, as at the base of the hypothenar emi- 
 nence. ^Moreover, cutting through these thin, lax skins may be 
 followed by sloughing, especially if their vitality is impaired by 
 sinuses, etc. 
 
 The hand being supported by an assistant, the surgeon draws up 
 the skin of the forearm, and makes his first circular incision through 
 the skin on a level with the carpo-metacarpal joints of the little 
 finger and thumb, encroaching thus upon the thenar and hypo- 
 thenar eminences, an inch or an inch and a quarter below the sty- 
 loid processes. The skin being retracted by freeing the soft parts 
 with light touches of the knife, another circular sweep is made just 
 
 * Precis d' Operations de Chirurgie, p ir le Dr. J. Chauvel, p. 171. 
 
52 OPERATIONS ON THE UPPER EXTREMITY. 
 
 above the level of the pisiform bone, so as to sever cleanly the 
 numerous tendons, together with the vessels and nerves. The joint 
 is then opened and the styloid processes removed. 
 
 5. Amputation of Wrist by Long Dorsal Flap.— This 
 method on Mr. Teale's principle is not to be recommended. If a 
 skin-flap alone were taken, its poor vitality would probably end in 
 sloughing, while, if the tendons are taken up as well, but little addi- 
 tional vascularity is gained, while the flap is inevitably somewhat 
 ragged. 
 
 LIGATURE OP RADIAL ARTERY ON THE BACK OP 
 THE WRIST* (Fig. 5). 
 
 Guide. — Aline drawn from a point just internal to the apex of 
 the styloid process to the back of the first interosseous space. 
 Relations : In Front. 
 
 Skin, fascice; branches of superficial radial 
 vein, and of radial and musculo-cuta- 
 neous nerves. 
 Three extensor tendons of thumb. 
 
 Eadial artery 
 on back of wrist. 
 
 Outside. Behind. Inside. 
 
 V. comes. Styloid process ; external lateral ligament ; V. comes. 
 
 trapezium ; carpal ligaments. 
 
 Indications. — Few ; usually wounds, e.g., by the slipping of a 
 
 chisel, by breaking crockery, etc. In such cases both endsf would, 
 
 of course, be secured, and the surgeon would examine as to injury 
 
 to any of the extensor tendons (p. 38). 
 
 Operation. — The incision, l\-2 inches long, may be in the 
 
 above line or parallel with the tendons. In either case it should 
 
 be over the lower part of the vessel, just before it dips between the 
 
 heads of the first dorsal interosseous into the palm. It should be 
 
 made lightly, so as not to damage the radial vein or, deeper down, 
 
 the tendons. The radial vein being drawn aside with a blunt hook, 
 
 and the deep fascia being carefully opened, the tendons are pulled 
 
 out of the way and the artery separated from its veins. The liga- 
 
 , ture may l^e passed from either side. If the parts need relaxing, 
 
 the hand should be hyper-extended. All injury to the closely con- 
 
 * The so-called " tabatiere anatomiqiie," a triangular space bounded externally 
 by the extensor ossis nietacarpi and extensor priini internodii, internally by the 
 extensor secundi internodii; its apex is formed by the meeting of these tendons, 
 and its base by the lower edge of the posterior annular ligament or base of the 
 radius. 
 
 f Mr. Butcher (Operative Surgery, p. 407) states that the distal end of the artery 
 is, after the division of the vessel, difficult to find, owing to its tendency to retract. 
 
LIGATURE OF RADIAL. 53 
 
 tigous tenclon-sheaths must be avoided; and, for the same reason, 
 union of the wound without suppuration is particularly indicated 
 here. 
 
 CHAPTER III. 
 OPERATIONS ON THE FOREARM. 
 
 LIGATURE OF RADIAL IN THE FOREARM (Fig. 17). 
 
 In the upi)er two thirds the arterj' is sub-muscular ; in the lower 
 third it is sub-fascial. 
 
 Line. — From the centre of the bend of the elbow (where the ar- 
 tery is given off opposite to the neck of the radius) to a point just 
 internal to the styloid process of the radius. 
 
 Guide. — The above line, and the inner aspect of the supinator 
 longus. 
 
 Relations: In Front. 
 
 Skin, fasciffi. 
 
 Branches of musculo-cutaneous nerve, espe- 
 cially below. 
 Superficialis volte below. 
 Transverse :b ranches of venae comites. 
 Supinator longus overlapping. 
 Outside. Inside. 
 
 Supinator longus. Pronator radii teres. 
 
 Radial nerve (middle third). Flexor carpi radialis. 
 
 Vein. Vein. 
 
 Eadial artery 
 in forearm. 
 
 Behind. 
 Biceps. 
 
 Supinator brevis. 
 Pronator radii teres. 
 Flexor sublimis digitorum. 
 Flexor longus pollicis. 
 Pronator quadratus. 
 Radius. 
 Indications. 
 
 (1) >Vounds; stabs; cuts with glass, etc. 
 
 (2) Traumatic aneurism. 
 
 In these cases, the limb having been rendered evascular by Es- 
 march's bandages, the surgeon opens the swelling, turns out the 
 clot, and ligatures the artery above and below. If he prefer it, he 
 
51 
 
 OPERATION'S ON THE UPPER EXTREMITY. 
 
 FiQ. 17. 
 
 may snip out the swelling and twist both ends of the artery. The 
 
 first method is, on the whole, the 
 most generally applicable. 
 
 (3) Punctured wounds of palmar 
 arch. Ligature of the radial and ul- 
 nar is preferred by some, but the 
 reader is referred to the remarks at 
 p. 36. 
 
 A. Ligature in Lower Third 
 of Forearm (Fig. 17).— The hand 
 being completely supinated and the 
 wrist extended at first, the surgeon, 
 seated comfortably, makes an incision 
 2 inches long, midway between the 
 tendons of the supinator longus and 
 flexor carpi radialis, or (if there be 
 much swelling) exactly in the line of 
 the artery, going lightly* through 
 the skin and subcutaneous tissue. 
 A large branch of the radial vein, 
 which is usually met with subcuta- 
 neous and just under the incision, is 
 now drawn aside or divided between 
 two ligatures. The deep fascia is slit 
 u-p on a director, and the wrist now 
 flexed to relax the parts. The artery 
 being separated from the vena; com- 
 ites,t the needle may be passed in 
 either direction. Damage to any of 
 the tendon-sheaths should be most 
 carefullj' avoided. 
 
 B. Ligature of Ea.dial Artery 
 in Middle Third of Forearm. 
 
 Guide. — Line of artery, p. 53. 
 
 Relations, p. 53. The nerve is 
 now on the outer side of the artery, 
 but not very close to it. 
 
 The steps are very much as above, 
 but the artery is lying deeper. The 
 
 In the upper drawing ligature of the 
 brachial in front of the elbow is shown. 
 The biceps tendon is outside the artery, 
 giving off in the upper angle of the 
 wound the bicipital fascia ; along the 
 lower border of the wound lies the 
 median nerve. 
 
 The remaining drawings show liga- 
 ture of the radial and ulnar. In the 
 lower two figures too much of the arte- 
 ries is shown. 
 
 * So as to avoid the radial vein, which always, and the siiperficialis voipe, which 
 sometimes, lie superficial here, just under the deep fascia, which is very thin. On 
 the dead subject, especially, it is easy (or the student to get down to or below the 
 artery with his first incision. 
 
 t These, owing to the free collateral venous currents, may be tied in if it is found 
 very difficult to separate them from the artery. 
 
LIGATURE OF ULNAR. 55 
 
 incision over the middle third of the artery should he fully two 
 inches long, the parts well relaxed when the deep fascia is opened, 
 the inner aspect of the supinator longus must be defined, and tliis 
 muscle drawn well outwards. The needle must be passed from 
 without imvards. 
 
 C. Ligature of Radial Artery in Upper Third of Fore- 
 arm (Fig. 17). 
 
 Guide. — Line of artery, and inner aspect of supinator longus. 
 
 Relatioks, p. 53. — The nerve is on the outer side, but well re- 
 moved from the artery. The vessel itself lies somewhat obliquely 
 as it passes from the middle of the elbow triangle to the outer side 
 of the forearm. 
 
 In a muscular arm it is very easy to get into difficulties by not 
 hitting off the right inter-muscular septum, and thus getting too 
 near the middle line of the forearm, unless the line of the artery is 
 remembered. An incision, at least 2J inches long, is made over the 
 upper third of the artery, in the above line. Any branches of the 
 radial vein are drawn out of the waj', and secured with catgut liga- 
 tures. The deep fascia is slit uja to the full extent of the wound, 
 ■along a white line which marks the interval between the supinator 
 longus and pronator radii teres. These muscles may be known by 
 the direction of their respective fibres (Fig. 17), the former goinj^ 
 straight down along the radius, and the latter obliquely downwards 
 and outwards to the centre of this bone. The muscles being re- 
 laxed by bending the elbow and wrist joints, and the cellular 
 iiiterval between them having been opened cleanly with a director, 
 they are drawn aside with blunt hooks, and the pvdsation of the 
 vessel felt for. The vense comites having been separated, the needle 
 may be passed from without inwards. 
 
 LIGATURE OP ULNAR ARTERY IN THE FORE- 
 ARM (Fig. 17). 
 
 Line. — As this artery takes a very oblique course inwards to thc^ 
 ulnar border of the forearm before it runs down parallel with this 
 border to the wrist, the surface-marking for the lower two-thirds of 
 the vessel will be a line drawn from the front of the internal con- 
 dyle to the outer side of the pisiform bone. 
 
 Guide. — The above line, and, in the lower third, the outer aspect 
 of the flexor carpi ulnaris. 
 
 Relations in Forearm : 
 
 In Front. 
 
 Skin ; superficial and deep fascise. 
 Branches of internal cutaneous, ulnar cutaneous 
 nerve, and anterior ulnar vein. 
 
56 OPERATIONS OX THE UPPER EXTREMITY. 
 
 Median nerve. 
 
 Pronator radii teres. 
 
 Flexor carpi radialis. 
 
 Palmaris longus. 
 
 Flexor digitorum sublimis. 
 
 Outside. Inside. 
 
 Flexor digitorum sublimis. Flexor carpi ulnaris. 
 
 Vein. Ulnar nerve. 
 
 Vein. 
 
 Ulnar artery 
 in forearm. 
 
 Behind. 
 Brachialis anticus. 
 Flexor profundus digitorum. 
 
 Indications. — These are the same as for the radial, Tpp. 53, 54. 
 Ligature of Ulnar Artery in Lower Third of Forearm 
 
 (Fig. 17). — Position of hand supinated, to begin with. An incision 
 two inches long, is made, lightly at first, along the outer border of 
 the flexor carpi ulnaris, the superficial veins avoided, and the deep 
 fascia opened. The wrist is then flexed, the flexor carpi ulnaris 
 drawn gently inwards, the veins separated from the artery if pos- 
 sible, and the ligature passed from within outwards away from the 
 nerve. Care is to be taken to avoid opening the sheaths of the 
 tendons. 
 
 Ligature of Ulnar Arteiy in Middle Third* of Fore- 
 arm (Fig. 17j. — The position of the limb being as before, an in- 
 cision, quite 3 inches long in a muscular arm, is made in the above- 
 given line of the artery over its middle third. Any superficial 
 veins being drawn aside or secured with double ligatures, and the 
 wound sponged dry, a white line,t which indicates the intermuscu- 
 lar septum between the flexor carpi ulnaris and the flexor sublimis, 
 is looked for. If the incision is not directly over this, the edges of 
 the superficial wound may be carefullj^ cleared a little to one side 
 or the other till the septum is found, or, with the finger-tip, the 
 sulcus between the above muscles may be sought for. The deep 
 fascia having been slit up to the full length of the wound on a 
 director, a muscular branch which will serve as a guide to the 
 artery will often be found coming up in the inter-muscular space. 
 
 * The artery is only ligatured in its upper third for wounds; it is necessary to 
 remember the course of the vessel — oblique from without inwards -and to divide 
 sufficiently the superficial fle.xors which lie over it. 
 
 t Tliis line may be wanting. It is often but little marked, and occasionally 
 fatty, in the bodies of the aged. 
 
EXCISION OP RADIUS OK ULNA. 57 
 
 The cellular tissue here being carefully torn through, the muscles 
 are relaxed by bending the wrist and elbow ; retractors are now 
 introduced well into the wound, this sponged dry, and the artery 
 looked for. The nerve which lies to the inner side, and wliich 
 joins the artery at the junction of the middle and ujjpcr thirds of 
 the forearm, may be seen first. The artery being cleared, and the 
 venae comites separated from it, the ligature is passed from within 
 outwards. 
 
 This is the only ligature in the forearm which will give troulile 
 in the dead subject owing to the depth, and sometimes the difficulty 
 of hitting off the intermuscular septum. Being frequently set as 
 an examination test, the operation should be carefully stvidied by 
 those at work on the dead body. 
 
 Difficulties and Mistakes. 
 
 1. Depth of the vessel in a well-developed limb. 
 
 2. Making the incision too short, or too much to the inner or the 
 outer side, and thus finding a wrong septum, e.g., one between the 
 flexor carpi ulnaris and the flexor digitorum profundus, or that 
 between the flexor digitorum sublimis and the palmaris longus. 
 
 Aids. 
 
 1. Keeping carefully to the above-given line. 
 
 2. Hitting off the right intermuscular septum and corresponding 
 sulcus. 
 
 3. Finding a muscular branch, and using it as a guide to the 
 arterj'. 
 
 If a wrong space is much opened up in the living subject, the 
 contiguous muscles should be brought together with chromic cat- 
 gut sutures cut short, due drainage being provided. 
 
 EXCISION OF RADIUS OR ULNA. 
 
 Indications. — (1) Sequestra; (2) Compound fractures; (3) New 
 growths, especially myeloid. It is only in the last class of cases 
 that any special difficulty will occur, and it is to these, accordingly, 
 that the following account applies. 
 
 Operation for Reraoval of Radius.— This is the bone of 
 
 the forearm in which myeloid sarcomata usually originate. The 
 following is taken from a most successful case by Mr. H. Morris,* 
 in which he removed the radius and ulna extensively, for a mye- 
 loid growth originating in the former, and firndy attaching the 
 ulna to it. Esmarch's bandage being applied, a long incision was 
 made over the outer side of the radius, from the styloid process 
 to the upper third. The radial nerve was used as a guide to the 
 
 * Ciin.Soc. Trans., vol. x. p. 138. 
 
58 OPERATIONS ON THE UPPER EXTREMITY. 
 
 interval between the supinator longus and extensor carpi radialis 
 longior, Mr. Morris having found on the dead subject that he could 
 most readily separate the soft structures from the front and back of 
 the radius by going between those muscles, and keeping the supi- 
 nator to the fore part of the incision. The supinator longus and 
 pronator teres at their insertions being detached from the radius, 
 the bone, when freed of its muscles in front and behind, was sawn 
 through at the lower edge of the supinator brevis. A second lon- 
 gitudinal incision, of less extent than the first, was made along the 
 inner side of the ulna from the wrist-joint upwards, and through it 
 the rest of the soft parts separated from the tumor and ulna. This 
 bone was sawn between 3 and 4 inches above the wrist, and the 
 lower ends of both bones disarticulated by opening the wrist-joint 
 on the inner side. The entire tumor, with the ulna and pronator 
 quadratus, was then removed en masse. The anterior interosseous 
 artery was divided just above the pronator quadratus, but no other 
 large branches were injured. The wounds healed in about seven 
 weeks. As soon as a light leather splint was moulded on to the 
 forearm and wrist, the usefulness of the hand steadily increased. 
 Four years later Mr. Morris brought the patient before the Clinical 
 Society (Trans., vol. xiii. p. 155, pi. vi.). The following was her 
 condition : There was no sign of recurrence. By the aid of a 
 simple leather splint, the patient was able to nurse, dress, carry, 
 and wash and care for her children, do her ordinary household 
 work, and wash the house-linen. She could also stitch and darn, 
 and pick up a pin. Latterly, since contraction has taken place, she 
 could hold her hand out straight without any support.* 
 
 Operation for Removal of Ulna. — In the very much rarer 
 .cases of myeloid tumors springing from the ulna, the following may 
 be the course adopted. The account is taken from a paper by Mr. 
 Lucas (Clin. Soc. Trans., vol. x. p. 135). A longitudinal incision, 
 about 4 inches long, exposed the tumor between the flexor and ex- 
 tensor carpi ulnaris. In making this the dorsal branch of the ulnar 
 nerve was divided. The soft parts being next retracted, the bone 
 was exposed above the level of the tumor, and sawn thro\igh. The 
 piece connected with the tumor was next drawn out of the wound, 
 while the interosseous membrane was divided, and the extensor 
 indicis on the posterior and the pronator quadratus on the anterior 
 separated from the tumor. The removal was completed by divid- 
 ing the ligaments of the lower radio-ulnar joint, the attachment of 
 the triangular fibro-cartilage to the ulna and the internal lateral 
 
 * After these operations, as in any in wliicli the flexors and extensors of the 
 fingers must, of necessity, be medrlled witli, passive movement of the finger slioidd 
 be commenced very early, and energetically persevered with. 
 
EXCISION OP RADIUS AND ULNA. 59 
 
 ligament. The patient left the hospital in five weeks, the resulting 
 usefulness being excellent. 
 
 Excisiou of Radius and Ulna in Military Surgery — 
 
 By this is meant deliberate removal of portions of these bones 
 damaged by gunshot or other injuries, not the mere picking away 
 of spicula and fragments. 
 
 Dr. Otis* divides the cases into the three groups of primary, in- 
 termediary (before the thirtieth day), and secondary (after the 
 thirtieth day). Though caries and attempt at repair were met 
 with in these latter cases, there was no time for invagination of 
 sequestra. Thus they were very different from necrosis operations, 
 and hence, in great measure, the high mortality. Of the primary 
 10 per cent., of the intermediary 19 per cent., ended fatally ; the 
 mortality of the secondary was nearly as high as that of the primary 
 excisions. 
 
 The concluding observations of Dr. Otis are worthy of the most 
 careful attention of military and naval surgeons. 
 
 " Of this large number of excisions in the continuity of the fore- 
 arm there is little to remark save that, in the aggregate, the mor- 
 tality of shot fractures of the bones of the forearm appears to have 
 been sensibly augmented bj' operative interference, and that I have 
 sought in vain for a single instance in which a formal excision of a 
 portion of the shaft of either radius or ulna had a really satisfactory 
 result as regards the functional utility of the limb. The represen- 
 tations of Baudens of his Algerian experience led the German sur- 
 geons to practice these excisions in the shafts of long bones to some 
 extent in the Danish and Austrian campaigns, with very unsatis- 
 factory results. Similar operations were resorted to with compara- 
 tive frequency during the American War, and the results plainly 
 indicate, I think, that formal primary operations of this nature 
 should be banished from the practice of military surgery. It is 
 bad enough to remove adherent primary sequestra, for our museum 
 abounds in examples where such fragments have retained their 
 vitality, and maintained the continuity of long bones; it is worse 
 to deliberately remove unoffending healthy portions of the bone. 
 The mortality greatly exceeding that of the expectant conservative 
 treatment, the numerous consecutive amputations, and the large 
 proportion of hopelessly deformed limbs sutficiently condemn such 
 operations. I have found nothi-ng in the reports of surgery of the 
 late Franco-German War that was not conformable to these con- 
 clusions." 
 
 Sir T. Longmoref brings the following striking experience to 
 
 * Med. and Surg. Hist, of the War of the Rebellion, pt. ii. p. 93-5 et seq. 
 t Si/st. of Surg., vol. i. p. 544. 
 
60 OPERATIONS ON THE UPPER EXTREMITY. 
 
 bear on these cases : " I have seen many of these fractures in which 
 primary resection of a portion of the entire shaft by a shot has 
 occurred, and have not met with bony union in any case where the 
 gap was a full inch in amount." 
 Causes of these Resections doing 111 or Failing. 
 
 1. Osteo-myelitis. 
 
 2. Pyasmia. 
 
 3. Hectic. 
 
 4. HaBmorrhage. 
 
 6. Painful irritable cicatrices. 
 
 6. Non-union. False joint. Flail-like limb. 
 
 7. Displacement of the hand at the wrist. 
 
 8. Permanent contraction of flexor or extensor tendons. 
 
 AMPUTATION OP FOREARM (Figs. 18, 19, 20). 
 
 Practical Anatomical Points. — In this frequently performed 
 operation the following should be kept in view : 
 
 («) The two bones are not fixed, like those in the leg, but mov- 
 able. This mobility may prevent their being parallel when the 
 knife is sent across in transfixion, and thus lead to penetration of 
 the interosseous membrane ; it must also be remembered in sawing 
 the bones. Lastly, on this mobility in pronation and supination 
 depends the usefulness of the stump, which must therefore be left 
 as long as possible, the bones being always, when practicable, sawn 
 well below the insertion of the pronator radii teres into the middle 
 of the outer surface of the radius. 
 
 (/J) In the upper part of the forearm, both in front and behind, 
 are fleshy bellies ; below, the soft jjarts are increasingly tendinous. 
 Furthermore, the anterior border of the radius and the posterior of 
 the ulna, especially of the latter, are largely subcutaneous. 
 
 Different Methods. 
 
 1. Skin flaps, with circular division of muscles, etc. 
 
 2. Transfixion flaps. 
 
 3. Circular. 
 
 4. Teale's. 
 
 1. Amputation of Forearm by Skin Flaps, with Circu- 
 lar Division of Muscles, etc. (Figs. 18, 19).— While, in an ampu- 
 tation so often called for, it is well to practice several methods, none, 
 on the whole, answer so well as this, for the following reasons : (a) 
 By cutting one flap a little longer than the other, sufficient skin 
 can always be obtained to give a good stump. (/?) Transfixion, 
 while quite unsuited to the lower third, owing to the numerous 
 tendons, can only be performed in the upper third in moderately 
 
AMPUTATION OP THE FOREARM. 
 
 61 
 
 Fig. 18. 
 
 muscular forearms with ultimate satisfaction. For in a bulky, 
 fleshj^ limb (as in a case of accident in a male adult) it is not easy 
 always to cut the skin longer than 
 the muscles in bringing out the 
 knife, and so to prevent the ten- 
 dency of the fleshy bellies to pro- 
 trude while the flaps are being 
 united; and a little later, these 
 muscles, with large surfaces cut 
 obliquely, give rise to a good deal of 
 blood-stained oozing, which is very 
 likely to cause tension, suppuration, and delay in healing. 
 
 The brachial being secured with an Esmarch's bandage, the arm 
 extended from the side, with the forearm pronated and the hand 
 steadied by an assistant, the surgeon, standing outside the limb on 
 the right, and inside it in the case of the left side, places his left 
 index and thumb on the borders of the radius and ulna, at the spot 
 where he intends to saw the bones (Fig. 18). The point of a nar- 
 
 FiQ. 19. 
 
 row-bladed knife (about 4 inches long), or a small catlin, is then 
 inserted just below the index, carried along the bone for 3 inches, 
 and then curved suddenly across, so as to mark out a broad arched, 
 not a pointed, flap (Fig. 19), and carried up along the bone nearest 
 to the surgeon to a point just below the thumb. 
 
 This flap is then dissected up without scoring, consisting of skin 
 and fasciffi.* The forearm is next raised by the assistant holding 
 
 * The under surface of a so-called skin flap should always, when possible, show 
 a few muscular fibres ; this shows that the deep fascia is present, in which the 
 vessels run down to send up branches to supply the skin. 
 
62 OPERATIONS OX THE UPPER EXTREMITY. 
 
 the hand, so that its palmar aspect faces the surgeon * who cuts a 
 similar flap from the anterior surface, but one only about 2 inches 
 in length. The flaps being retracted, the soft parts are divided with 
 a circular sweep close to the base of the flaps, this being repeated 
 once or twice till the bones are quite exposed. The knife is then 
 passed between the bones, so as to divide the interosseous mem- 
 brane, and the periosteum next cleanly cut in a circle where the 
 saw is to pass. The bones are then sawn through, with the following 
 precautions : The heel being placed on the bones, it is drawn lightly 
 but firmly towards the operator two or three times, so as to make a 
 groove. With a series of light sweeps, in which the whole length 
 of the saw is used, the two bones are then cut through together,t 
 the limb being kept supinated during the use of the saw, so as to 
 keep the bones as parallel as possible. 
 
 The assistant in charge of the lower part of the limb must be 
 most careful to hold it steady; if he depress at all, the bones will 
 certainly splinter when half sawn through ; if, on the other hand, he 
 raise the parts, the saw will be locked. 
 
 Any tendons requiring it are then trimmed, and the vessels liga- 
 tured or twisted. These are usually four — viz., the radial, under 
 cover of the supinator longus, close to its bone ; the ulnar, covered 
 by the flexor carpi ulnaris, on the front of the ulna. Their respec- 
 tive nerves are good guides to the arteries, save quite low down, 
 when the radial has gone to the back of the limb. The anterior 
 interosseous is found on the front of the interosseous membrane, 
 and the posterior interosseous between the deep and superficial 
 extensors. 
 
 If the surgeon prefer it, instead of having the forearm raised so 
 as to face him while he shapes the flap from the anterior or flexor 
 surface, he will tell the assistant to completely supinate the forearm, 
 and proceed to make the flap Avith the limb in this position. 
 
 2. Amputation of Forearm by Transfixion Flaps (Fig. 
 20). — In the case of a moderately muscular forearm the surgeon 
 may make use of this method in amputating through the middle of 
 the forearm. For reasons already given (p. 60), this method is not 
 
 * Care must be taken to keep the bones parallel now and thronghout the opera- 
 tion. 
 
 f Some advise that the more movable radins should be divided before the section 
 of the ulna is completed. If the saw is used lightly and swiftly, both bones will be 
 sawn simultaneously. The student usually commits these faults in the use of the 
 saw — he bears too heavily on it, thus locking it or fracturing the bone, and he 
 makes but short sweeps, using half of the instrument only. 
 
AMPUTATION OF THE FOUEARM. 
 
 63 
 
 (Fergusson.) 
 
 recommended, but the rapidity with which it can be done recom- 
 mends it to the notice of 
 
 those who may have to treat ^'^*- 20. 
 
 wounded in war on a large 
 scale, or railway accidents 
 where more than one limb 
 requires amputation. The 
 limb being abducted, and the 
 forearm supported and pro- 
 nated, with the bones as par- 
 allel as possible, the surgeon, 
 standing outside the right 
 and inside the left limb, lifts 
 up the soft parts* at the spot 
 where he intends to saw the 
 bones, and sends a narrow- 
 bladed knife (4 to 5 inches 
 long) across the limb, enter- 
 ing it, and bringing it out 
 just above the bones. He 
 then, by cutting downwards and forwards, shapes as broad a flap 
 as possible with a steady sawing movement, taking care, before 
 bringing out the knife, to cut the skin longer than the muscles by 
 continuing the. use of the knifu after the latter are felt to be cut 
 through. The flap should be 3 to 4 inches long, according to the 
 condition of the tissues on the other surface of the limb, and each 
 made as broad as possible and bluntly rounded as they are finished. 
 
 The tissues on the front are then lifted from the bones and trans- 
 fixed by passing the knife across immediately above the bones at 
 the base of the first-made flap, the limb being now supinated. As 
 in this second transfixion the skin on the farther side of the limb 
 may be punctured, it is well for the surgeon to hold down its cut 
 edge with a finger. The second flap is then cut, broad, well-rounded, 
 and 2? to 3 inches long according to the length of the anterior. 
 The flaps are then retracted, the soft parts severed with a circular 
 sweep, the interosseous membrane divided, and the rest of the 
 operation completed as in the method first described (p. 62). 
 
 A verj' rapid and effective modification of the above is the fol- 
 lowing : As, owing to the inequality of the soft parts on the back as 
 comijared with those on the front of the forearm, and also from the 
 proximity of the ulna to the surface here, transfixion of a dorsal 
 flap is not always easy, a quicker method is as follows : A skin 
 flajj, 3* inches long, broad and well rounded, being marked out on 
 
 * This step is most useful — in fact, essential. It is often forgotten. 
 
64 OPERATIONS ON THE UPPER EXTREMITY. 
 
 the posterior aspect of the limb, the knife is immediately, without 
 being taken off', pushed across in front of the bones and made to 
 cut a flap, by transfixion, 22 inches long, the skin being cut longer 
 than the muscles (p. 63 ). The dorsal skin flap is then dissected up, 
 the flaps retracted, and the bones cleared as before. 
 
 3. Amputation of Forearm by Circular Method.— This 
 method is not recommended here owing to the flat shape of the 
 limb and the adhesion of the deep fascia above to the muscles. It 
 may be performed as follows : The surgeon, standing outside the 
 limb, which is kept supinated, having drawn the skin well ui> 
 wards, passes a knife under the forearm, then above, and so around 
 it till, by dropi^ing the point vertically, the back of the knife looks 
 towards him, and its heel is resting on the part of the forearm which 
 is nearest to him. An incision is then made circularly through 
 skin, superficial and deep fascise,* round the whole circumference 
 of the limb 2J inches below the point where the bones are to be 
 sawn. 
 
 A circular flap of tissues having been turned back as high as the 
 point of bone section, a second and much firmer circular sweep is 
 here made through everything down to the bones, this being re- 
 peated till all the soft parts are cut clean and square. If there is 
 any doubt about the sufficiency of coverings to the bones, the soft 
 parts around these may be freed a little higher (care being taken 
 not to prick the radial or ulnar) ; the soft parts are then vigorously 
 and finally retracted, and the bones sawn through, with the pre- 
 cautions given at p. 62. 
 
 CHAPTER IV. 
 
 OPERATIONS IN THE NEIGHBORHOOD OP THE 
 ELBOW-JOINT. 
 
 AMPUTATION AT ELBOW-JOINT (Fig. 21). 
 
 This operation gives excellent results, good flaps being obtain- 
 able from the thick soft parts in front and from the skin behind, 
 which is well used to pressure. Furthermore, there are no bones to 
 saw. 
 
 It has not been performed as often as it might have been, owing, 
 
 * If, in raising tlie cnff lil<e flap, muscular fibres are seen on the under surface, 
 the presence of the deep fascia and, thus, a, t)etter blood supply will be assured 
 than by the quicker method of simply peeling the skin and subcutaneous tissue off 
 the deep fascia. 
 
AMPUTATION AT ELEOW-JOIXT. 65 
 
 perhaps, to the belief which some surgeons have held that car- 
 tilaginous surfaces left in a wound are a source of delay in healing ; 
 from the fact that any disarticulation, however simple, ia considered 
 to complicate an amputation ; and because, owing to tlie expanded 
 end of the humerus, the resulting wound is somewhat larger than 
 in amputation through the lower third of the humerus. 
 
 Practical Points. 
 
 ■(«) The internal condyle is nearly i inch below the level of the 
 external. 
 
 (/9) The joint is opened most easily on the outer side. 
 
 (y) There are masses of muscles on the front and sides ; of the 
 latter, those on the outer side (owing to the presence of the supinator 
 longus) retract more powerfully than those on the inner. 
 
 (<?) The skin on the back of the joint is well used to pressure, and 
 is connected by fibrous bands to the back of the ulna. 
 
 Methods.— Owing to the vascularity of the parts, any of the 
 following may be made use of. I would advise the student to 
 practice the first especially. 
 
 i. Long anterior flap with short posterior (Fig. 21). 
 
 ii. Lateral skin flaps, or a modification of this by a single ex- 
 .ernal flap. 
 
 iii. Circular. 
 
 iv. Long posterior flap. 
 
 V. Long anterior flap. 
 
 i. Long Anterior Flap (usually by Transfixion), with 
 Short Posterior Flap (Fig. 21). — This method gives an excellent 
 covering to the front of the humerus, allows of easy drainage, and 
 preserves skin which is well used to pressure. 
 
 The brachial being controlled a little above its centre,* the fore- 
 arm being held somewhat flexed and completely supinated, the 
 surgeon, standing on the inner side in the case of the left, and out- 
 side the right limb, raises the soft parts in front of the elbow tri- 
 angle, and sends his knife, held horizontally, across, just in front of 
 the joint. Thus, entering it an inch below the internal condyle 
 and bringing it out IJ inch below the external one, he cuts a well- 
 rounded flap, 3 inches long, taking care, as the knife emerges, that 
 the skin is cut longer than the muscles. Then, passing his knife 
 behind the limb, and looking over, the surgeon joins the two ends 
 of the base of his first incision by a convex cut through the skin 
 over the back of the olecranon, so as to mark out a flap H inch 
 long. This is raised without scoring, care being, taken to keep 
 
 * The assistant who has charge of the Esmarch's bandage, and who is steadying 
 the arm, should draw the skin on the back of the elbow-joint somewhat upwards. 
 
 5 
 
66 
 
 OPERATIOXS ON THE UPPER EXTREMITY. 
 
 the knife towards the uhia, for fear of "button-holes." The two 
 flaps being then held back, any remaining structures in front are 
 
 Fig. 21. 
 
 Amputation through the elbow-joint by anterior and posterior flaps at the moment of 
 
 disarticulation. 
 
 severed, the joint first opened on the outer side, and the forearm 
 removed bj^ dividing the lateral ligaments and triceps.* 
 
 During the last steps the assistant in charge of the forearm pulls 
 this away from the arm. 
 
 The brachial artery is next secured, together with any other 
 vessels which continue to bleed on removal of the Esmarch's 
 bandage. Any nerves which require it are then cut short, a drain- 
 age-tube inserted, and the flaps carefully united. 
 
 Modifications of the Above. — The flaps can be cut of different 
 lengths, according to the state of the soft parts. If the surgeon pre- 
 fer to do so, he can cut his anterior flap _ from without inwards 
 instead of by transfixion, a course which may well be adopted in 
 an unusually bulky, muscular limb. The posterior flap can be 
 made by cutting from within outwards, but this, while quicker, is 
 usually less preferable. 
 
 ii. Amputation by Lateral Skin Flaps, or by an Ex- 
 ternal Flap. — The advantages of the lateral-flap method are, that 
 it is very easily done, and that, if more skin is available on one side 
 than on the other, flaps unequal in length can readily be made. 
 
 * In Fig. 21, by mistake, the operator has been shown commencing disarticula- 
 tion on the inner instead of on the outer side, which is usually the easier. The 
 flaps also are rather too long. For these errors I alone am responsible. 
 
EXCISION OF ELBOW-JOINT. 67 
 
 Supposing the surgeon to be amputating by equal lateral flaps — 
 standing as before, and having his left index finger on the centre 
 of the elbow triangle and left thumb at the corresponding point 
 behind, he looks over, and enters his knife close to his thumb, and 
 marks out, on the side farthest from him, a flap well rounded, and 
 about 22 or 3 inches long, reaching to the finger in front. He then 
 marks out a corresponding flap from this point, on the side nearest 
 to him, to that where he began. These flaps are then dissected up 
 of skin and fasciae as thick as possible, the soft parts severed with a 
 circular sweep, and disarticulation performed, beginning at the 
 outer side. 
 
 iii. Circular Method. — The surgeon, standing as before, makes 
 a circular incision round the forearm, 21 or 3 inches below the 
 joint, going through skin and fascife. A cuff of skin is then turned 
 back as far up as the joint, the muscles severed with one or two 
 firm sweeps, the lateral ligaments divided, and disarticulation per- 
 formed as before. The edges of the wound maj' be united either 
 horizontally from side to side, or vertically from above downwards. 
 
 EXCISION OF ELBOW (Figs. 22, 23, 24). 
 
 Practical Points. — These bear upon the success of this opera- 
 tion. 
 
 (1) It is a comparatively simple joint, with small articular sur- 
 faces readily got at. (2) Its synovial membrane is simple. (3) 
 Its vascular supply is abundant. (4) The surrounding muscles 
 are powerful, ensuring, if they regain firm attachment, an excellent 
 range of movement. From the above, and from the untoward 
 effects of ankylosis, a natural cure in the elbow is often not so use- 
 ful as that given by excision. This operation should be performed 
 oftener than it is, especially in the first six of the following condi- 
 tions. 
 
 Indications. 
 
 1. Pulpy disease. Where this has resisted treatment in a patient 
 who shows no sign of tuberculosis, lardaceous disease, etc., where it 
 is the only large joint affected, and where the powers of repair are 
 sufficient. If treatment fails to promise a movable joint, there is 
 no good losing more time; the muscles will only be more wasted, 
 sinuses will only form more extensively, and the patient's health 
 be more impaired. 
 
 2. Injury and its results. (A) Primary excision. When the joint 
 is much opened, the cartilages much damaged, when the shaft is 
 intact and the tissues in front are sound. (B) Secondary excision. 
 
68 OPERATIONS ON THE UPPER EXTREMITY. 
 
 When acute arthritis-, not yielding to incision and drainage of the 
 joint, has followed on an injury, and ankylosis is the best result 
 which can be hoped for without operation. In such cases, as the 
 inflamed condition of the bones and soft parts may produce septic 
 cellulitis and osteo-myelitis after an operation, it will be wiser, be- 
 fore excising, to wait till the inflammation has somewhat subsided. 
 It must be remembered that, in excising after injury, reaction will 
 probably be greater, suppuration more certain, and a tendency to 
 bony ankylosis more marked, especially if the periosteum is pre- 
 served. 
 
 3. Ankylosis in a faulty position. When this, as the result of 
 injury or disease, whether bony or densely fibrous, renders the 
 limb useless. In deciding whether to excise for ankylosis, the sur- 
 geon should make out how far the limb is really useless, whether 
 there are any cicatricial bands, especially in front, and whether the 
 wasting of the muscles is very marked, for these mnj be so long 
 and so utterly atrophied that the limb may be but little more use- 
 ful after operation. 
 
 4. Osteo-arthritis. If the patient is healthy, not advanced in 
 years — i.e., not much over forty and not broken down — and if this 
 is the only joint attacked. The surgeon must be prepared for saw- 
 ing very dense bones here. 
 
 5. Disorganizing arthritis of elbow after pj'aemia or rheumatic 
 fever. 
 
 6. Unreduced dislocation or fracture causing pressure on the 
 nerve-trunks near the elbow, especially if the patient is young and 
 the limb useless. 
 
 Rarer Indications. 
 
 7. Mr. Annandale (Lancet, 1879, vol. i. p. 251) has excised the 
 elbow two or three times in cases of extensive sores on the back of 
 the joint in order to allow the sore to close by removing the bones 
 beneath, and to ensure movement. 
 
 8. In one case the same surgeon excised, with an excellent result, 
 where a dense scar had formed on the back of the elbow, drawing 
 up the forearm and fixing the joint. 
 
 9. For growths of the bones, especially if innocent and affecting 
 one bone— e.g'., exostosis. 
 
 The following points call for consideration in any case where ex- 
 cision of the elbow is being discussed : 
 
 1. Age. — This must always have much influence. In very young 
 children due attention must be paid to the naturally great power of 
 repair. After thirty-five or forty the surgeon should weigh very 
 carefully all the points of the case, and only excise where all else 
 
EXCISION OP ELBOW-JOINT. G9 
 
 is favorable. From puberty* to thirty-five I consider the best 
 age. 
 
 2. Complications. — These are most liliely to present themselves in 
 the shape of diseases of other bones and joints, for such a complica- 
 tion as phthisis calls for amputation. Caries of the metacarpal or 
 metatarsal bones is not of itself a contraindication. If diseased 
 spine is present, the question of excision will depend on whether 
 the vertebral caries is old, or recent and active. If old, is the elbow 
 a source of much irritation? Two large joints are rarely diseased 
 at the same time. Mr, Holmes {Clin. Soc. Trans., vol. i. p. 143) 
 records a case of a boy aged five in which he excised, with excel- 
 lent result, both elbow-joints, only a few weeks intervening between 
 the two operations. 
 
 Mr. Clement Lucas {Brit. Med. Journ., 1881, vol. ii. p. 897) relates 
 a case in which disease of the left elbow came on about two years 
 after excision of the right joint, and was also successfully operated 
 on. In 1886 I excised the elbow-joint with good result in a London 
 lad, in whom three years before I had successfully excised one 
 knee-joint. 
 
 3. Question of the Value of Preserving the Periosteum. — While the 
 periosteum may be easily preserved in cases where it is swollen and 
 loose, its preservation is in others a matter of very great difficulty, 
 rendering the operation much more laborious and prolonged, and 
 it is extremely doubtful if its advantages are equivalent in this 
 joint, where the ordinary operation gives such excellent results. 
 
 Sub-periosteal resection is said to lead to less haemorrhage, less 
 disturbance of the capsule and attachments of muscles, and greater 
 completeness of the new joint. While the last of these is undoubted,t 
 it may bring about impaired movement;!:, and I am of opinion that 
 the surgeon should only trouble- to preserve the periosteum in 
 cases where an unusually large amount of bone has to be removed. 
 Whenever the periosteum is preserved, passive movement should 
 be begun early. 
 
 Operation. — The single vertical incision at the back gives such 
 excellent results that this only will be described. The H-shaped 
 
 ■"^ As is stated below (p. 73), young children are not satisfactory subjects for afier- 
 treatment and movement. Mr. Annandale (loo, supra cit.) has excised successfully 
 in patients aged three and seventy-five. No details are, however, given. 
 
 t In one case Langenbeck {Arch., vol. viii. p. 136 ; Syd. Soc. Bien Retr., 1867-8, 
 p. 265) had " to treat a dropsy of the new elbow-joint by painting with iodine, and 
 ultimately by the plaster-of-Paris bandage.'' 
 
 X A case is given (Langenbeck, loc. supra cit.) in which, after sub-periosteal 
 resection, the condyles had been very perfectly reproduced, and the olecranon had 
 been reformed to even an inconvenient extent, for it was so long and curved as 
 somewhat to limit extension. 
 
70 
 
 OPERATIONS ON THE UPPER EXTREMITY. 
 
 incision, while giving more free exposure and rendering the opera- 
 tion more easy, has the serious disadvantage of damaging the inser- 
 tion of the triceps, and of leaving additional scars, which may 
 hamper the movement of the new joint. Any transverse incision 
 should only he added to the longitudinal when the parts are ex- 
 tremely fixed and thickened. Esmarch's bandage having been 
 applied at mid-arm, or the whole limb being rendered evascular as 
 far as the above point by the use of two bandages, a pillow is placed 
 under the shoulder of the affected side, and the limb flexed and 
 carried over the front of the limb so as to present it fairly to the 
 surgeon, who usually stands on the opposite side of the body. 
 
 Fro. 22. 
 
 Excision (if tlie elbow by the H-shaped incision. Tlie thickened soft parts, the sinuses, tbe 
 carious ends of the bones, together with the position of the ulnar nerve, are admirably shown. 
 (Fergusson.) 
 
 The surgeon, then, noting the relative position of the condyles 
 and the course of the ulnar nerve, makes a straight incision of suffi- 
 cient length* (3 to 4 inches in the adult), with its centre at the tip 
 of the olecranon, a little internal to the centre of the back of the 
 joint, and jiarallel with the ulnar nerve. This incision should begin 
 above or below, as is most convenient, and go down to the bone 
 throughout its whole extent, splitting the triceps muscle and ten- 
 
 * An insufficient incision will only inciease tlie difficulty of the operation, and, 
 by the bruising then consequent upon the strenuous use of retractors, lead to sup- 
 puration. 
 
EXCISION OP ELBO^Y-JOINT. 
 
 71 
 
 don. Partly with the point of the knife, partly with an elevator or 
 blunt dissector* (Fig. 23), the surgeon then raises, as far as possible 
 in one piece and without tearing or jngging, the outer half of the 
 triceps, which, with its expansion into the deep fascia of the fore- 
 arm over the anconeus (this latter muscle being taken up at the 
 same time), is peeled up as thickly as possible from its insertion 
 into the ulna. 
 
 The deeper parts on the outerf side of the joint are then sepa- 
 rated from the bones with the point of the knife, thumb-nail, and 
 blunt dissector, untilthe external condyle and head of the radius 
 are completely exposed. Next, the parts on the inner side should 
 
 Fig. 23. 
 
 To show the level to which the bones are to be cleared, and the wny in which 
 the thumb-nail is kept between the knife and the soft parts. 
 
 be detached from the inner condyle and inner border of the ole- 
 cranon, great care being taken, by the following precautions, to 
 keep intact the ulnar nerve ; (a) By keeping the knife parallel with 
 the nerve and close to the bone; (6) By the use of the thumb-nail, 
 which peels off the soft parts before the knife. By these means 
 the soft parts will be satisfactorily cleared from the bones ; retrac- 
 tors, well applied, will be found most useful, as the process of peel- 
 ing off the soft parts is somewhat fatiguing to the thumb. This is 
 especially the case in excision for accidents or on the dead body, 
 and it is in these only that the nerve may be seen, though indis- 
 
 * The more readily the periosteum and soft parts separate, the more will the 
 blunt instruments be used. 
 
 t For the sake of practice, it is well to take the outer side first, before clearing 
 the inner, with the ulnar nerve in proximity to it. 
 
72 OPERATIONS ON THE UPPER EXTREMITY. 
 
 tinctly. Where the parts have been long inflamed, they peel off 
 much more readily, and the nerve is buried in the swelling. 
 
 The joint is now strongly flexed, the lateral ligaments severed, 
 and the capsule opened just above the olecranon ; the bone-ends 
 are then turned out and prepared for the saw by passing the knife 
 down to the bone, along the lines of intended section, the soft parts 
 being well retracted beyond these lines. 
 
 Site of Bone Section.* — The ulna should be sawn (towards the 
 joint with a small Butcher's saw set firmly) so as to remove the 
 greater and lesser sigmoid cavities with the olecranon. The radius 
 is removed just below its head, above the biceps. The section of 
 the humerus should be through the base of the condyles, so as to 
 remove all the articular cartilage. Any soft, caseous jDatches in the 
 
 Fig. 24. 
 
 To show the application of the saw. The dotted line across the humerus shows 
 that the saw should pass well above the articular cartilage. 
 
 bone-ends are now gouged, any possible sequestra removed. In 
 very bad cases the bones are very fatty, with little natural marrow ; 
 such, however, are not necessarily irrecoverable. If the bone above 
 the levels of section appears roughened, and the site of periostitis, 
 this need not be touched ; all will probably subside when the 
 cause of irritation is removed. Any sinuses should now l)e laid 
 open, with due regard to the ulnar nerve, and their contents scraped 
 out with sharp spoons. A zinc chloride solution (gr. x-^j) may be 
 applied cautiously if there is any doubt about the parts being 
 aseptic ; liut any solution stronger than this runs the risk of caus- 
 ing sloughing wliere the vitality of parts is low. One or two 
 points of suture may, perhaps, be inserted, so as to close just the 
 ends of the wound ; but all the rest of this should be left open, 
 and a drainage tube inserted. If the parts are softened by in- 
 
 * See the remarks below on the amount of bone to be removed (p. 74). 
 
EXCISION OF ELBO\V-JO]NT. 73 
 
 flammation, blistering, etc., or if it is a case of extensive disease, 
 sutures had better not be used. Very varied forms of splint have 
 been advised.* Some surgeons, to keep the bones apart, from the 
 first put the limb upon some form of right-angled splint; others, 
 fearing a flail-like condition of the joint, prefer to begin with the 
 arm and forearm on a straight splint, or on one with an obtuse 
 angle (about 135°— Ashhurst, Encydopmlia of Surgery, vol. iv. p. 477 ). 
 As ankylosis is, in children especially, to be dreaded (vide infrd), I 
 prefer to put cases up from the first on a right-angled splint, usiiig 
 some such cheap form as that ^Yhich I have described in the Brilish 
 Medical Journal, 1877, vol. i. p. 774, in which the anterior metal bar 
 supports the limb, while it leaves the wound exposed and is easily 
 kept clean, the movable hand-piece readily admitting of early pas- 
 sive pronation and supination. f 
 
 Passive movement of the fingers and hand should be begun on 
 the second or third day. The joint itself should be moved as 
 soon as all irritation has subsided and the deeper part of the 
 wound is well healed.J In children an anaesthetic may have to be 
 given several times. The angle of the splint should be altered or 
 the limb put up straight for a few days, and then flexed. Later 
 on, weight-extension should be used, by securing a bag of shot, 
 which is added to from day to day. Later, the sound limb may 
 be fastened up, so that the child must use the excised joint. This 
 getting children to use the joint is often most difficult, and friends 
 are often too foolish to see that the surgeon's directions are carried 
 out daily, because they cause a little short, but most necessary, 
 suffering. Parents are far too ready to think that because an 
 operation has been performed, and the wound nearly, if not quite, 
 healed, no more is necessary. § In commencing pronation and 
 supination early, the ulna should be steadied while the hand and 
 radius are very carefully moved. When the parts are sufficiently 
 consolidated, the splint may be left ofi' and a sling substituted. 
 
 * By some surgeons a splint is here dispensed with. I strongly advise the use 
 of one which is light and simple [vide supra], especially in children, as during the 
 first two weeks, where a splint has been dispensed witli, the bone-ends have been 
 known to project from the wound. 
 
 t Mr. Heath's and Mr. Mason's splints are intended to aid in restoring the 
 movements of the Joint, while they also separate the ends of the bones. Prof. 
 Esmarch's double-bracketed splint, Prof Butcher's box splint, and Prof Volk- 
 mann's wire splint (based on tliat for the lower extremity of Prof Nathan Smith) 
 have all been highly spoken of in military surgery. 
 
 J That is, about tlie tenth day. The movements should be practiced daily, with 
 dne care and gentleness. 
 
 I Pronation and supination in a child are often only apparent, the forearm and 
 arm being moved together from the shoulder. 
 
74 OPERATIONS ON THE UPPER EXTREMITY. 
 
 Falls must be carefully avoided, and no liberties taken with the 
 new union — i.e., by a patient attempting to do too much with the 
 limb, as in lifting. 
 
 Amount of Bone to be Removed.— This should be, roughly 
 speaking, all the articular cartilages,* including about H inch from 
 the humerus, and the same from the ulna, the radius being sawn 
 through just below its articular head. In cases of ankylosis,t most 
 bone must be removed from the humerus, that from the bones of 
 the forearm being limited by attachment of important muscles. 
 Mr. Annandale {loc. supra cit.) considers that an interval of 11 inch 
 should intervene between the bones after the sawn sections have 
 been made and the bones placed in the position of extension. 
 Certainly, no locking whatever should take place; I2 inch interval 
 is probably the full amount, an interval of 2 inches being liable to 
 lead to '-flail union. "J 
 
 Mr. Holmes has pointed out long ago that if, after removing as 
 much bone as is wise, disease is still felt on the anterior surface — 
 e.g., of the ulna— it is not necessary to make further sections in 
 order to get beyond it ; scraping will be sufficient, and save any 
 further interference with attachment of muscles. 
 
 Test of Success.— The movements should so increase after the 
 first six or eight weeks that within about four months from the 
 operation the patient should be able to move the new joint almost 
 as well as the other, to dress and feed himself, and to lift weights of 
 good size. 
 
 Repeated Excision. — This may be occasionally done with suc- 
 cess. It is of doubtful benefit, and should only be attemirted when 
 the general and local conditions are satisfactory, not in cases of per- 
 sistent pulpy disease, where this will very likely be found to have 
 passed out amongst the muscles of the forearm, and to be accom- 
 panied with ostitis and osteo-myelitis of the bones. It is more 
 likely to be successful in cases of ankylosis after a first excision, 
 but every surgeon must have seen how persistent in some cases is 
 the tendency to ankylosis. In flail-like union, where the limb re- 
 mains quite useless in spite of the use of a leather support.§ where 
 
 * Tlie greater breadtli and depth of tlie trochlear surface on the back than on 
 the front of the humerus must be remembered. 
 
 t In ca'^es of bony ankyhjsis, it is best, before attempting to make sections of the 
 bones, either to break down the union forcibly (care being taken not to fracture the 
 possibly atrophied bones above and below), or to divide the bony ankylosis with 
 an osteotome or saw. 
 
 X Mr. AVhitehead {Brit. Med. Journ., 1872, vol. ii. p. 534) records the case of an 
 adult in which 2J inches of the shaft of the humerus had to be removed after saw- 
 ing off the condyles. Nine montlis later the patient had full nse of the elbow. 
 
 ? See the case mentioned below. 
 
EXCISION OF ELBOW JOINT. 75 
 
 the muscles are not helplessly Avasted, and no neuralgia is present, 
 re-excision should be trie<l in preference to amputation, and a trial 
 may be made of uniting the bones witli stout silk or with wire. 
 
 Where pulpy disease persists, as indicated by continued swell- 
 ing, sinuses, cedematous granulations, the sinuses should be per- 
 severingly laid open again and again, scraped out with sharp spoons, 
 carious soft bone chipped away or gouged. The hsemorrhage is 
 often free, but yields to pressure. As soon as the parts admit of it, 
 firm strapping should be applied for a few days. 
 
 As long as no disease exists elsewhere, as long as the shafts of 
 the bone are sound, and the pulpy mischief has not burrowed out 
 into the muscles beyond a ruptured capsule, a hopeful prognosis 
 may be given. 
 
 Excision in Cases of G-unshot Wounds, — The following 
 points are brought out by Dr. Otis as the results of this operation 
 in the great Civil War of America {Med. and Siinj. Hist of the War 
 of the Rebellion, pt. ii. p. 845 et seq.). Compared with excision of 
 the shoulder, the results were less brilliant. The cases are divided 
 into the following groups : I. Primary Excisions. — 250 cases, with a 
 death-rate of 21.3 per cent. 27 of the 250 were ultimately ampu- 
 tated. II. Intermediate Excisions, i.e., during time of inflammation, 
 three to four weeks. — 197 cases, with a death-rate of 35.2 per cent., 
 nearly 14 per cent, greater than that of primary excision. 19 were 
 submitted to amputation later on; 62, or nearly half of the cases, 
 were reported to have complete ankylosis.* III. Secondary Ex- 
 cisions, thirty days or more after the injury. — 54 cases, with a mor- 
 tality of 9 per cent. 
 
 Period of Election. — Dr. Otis, after remarking that this has hitherto 
 been unsettled, states : " I believe that the evidence, when fully 
 analyzed, will demonstrate that this resection conforms to the gen- 
 eral rule in shot fractures of the limbs, that primary operations are 
 preferable whenever it is certain that recourse must eventually lie 
 had to operative interference." 
 
 Amount of Bone to be Removed. — While complete resectionf gives 
 more favorable results both as to life and the utility of the limb. 
 Dr. Otis evidently considers it as yet unsettled whether, in cases 
 where the joint is freely opened, but only the humerus or the bones 
 
 * Thus, if patients escape the risks of operations on inflamed soft parts, bones, 
 etc. (p. 68), the ultimate result may be a fixed joint. 
 
 t In some of the above cases removal of detached fragments seems all ihat was 
 done. This incomplete operation does not appear to be more successful in military 
 than in civil surgery. As pointed out by Prof. Esniarch, free division of tlie cap- 
 sule of the joint deprives the wound of much of its danger. 
 
76 OPERATIONS ON THE UPPER EXTREMITY. 
 
 of the forearm are injured, removal of the injured bones alone will 
 not be better. 
 
 Of other recent wars, the results of the Dano-Prussian War of 
 1864 are disputed. The Prussian surgeons have claimed good 
 results after excision of the elbow, owing to (1) the part taken in 
 the care of the wounded by such eminent men as Esmarch, (2) by 
 there being no need to transport the wounded very far. The truth 
 of the above success has been called in question,* owing to the fre- 
 quency with which flail joints were met with l>y Danish surgeons 
 amongst Danes operated on by Prussian surgeons. 
 
 With regard to the results of this operation in the Franco- 
 German ^^"ar, Dr. Otis (p. 904) says that the average results met 
 with by the Prussian surgeons are not discouraging, but the results 
 reported by the surgeons attached to the French army of that day 
 are "simply ai:ipalling." 
 
 Unfavorable Results of Elbow Excision. 
 
 1. Persistence of pulpy disease. This is especially likely when, 
 previous to the operation, the capsule has been perforated and 
 pulpy disease has burrowed out amongst the flexors or extensors. 
 
 2. Caries and chronic osteo-myelitis. These are not unlikely to 
 supervene when the reparative jjower is poor and the wound be- 
 comes septic. 
 
 3. Ankylosis. This is not uncommon in children, owing to the 
 great tendency of inflammatory products to organize quickly in 
 early life. Furthermore, there is the difficulty of getting them to 
 use the joint or submit to passive movement. All they will do is 
 to move their arm and forearm from the shoulder-joint (p. 73). 
 
 4. A flail-like joint.f A limb may remain weak for some time, 
 owing to the muscles not taking on fresh attachments. Friction 
 and galvanism should be used perseveringly. If there is too much 
 separation between the ends, the patient should wear a well- 
 moulded support; the use of the hand and fingers will thus be re- 
 tained, and, if the patient is young, gradual and great improvement 
 will very likely take place in the elbow. 
 
 If the wound becomes septic — 
 
 5. Cellulitis, erysipelas, etc. 
 
 * See a review of a paper by Dr. Hannover {Brit, McJ. Jnnrn., January 1."), 1870, 
 and Med.-Chir. Rev., 1871), and «, reply by Dr. Loeffler {Brit. Med. Journ., May 28, 
 1870). 
 
 t Mr. C. Forster [Lancet, 1872, vol. i. p. 3). In a case in wbich the right limb 
 was a perfect flail, with the help of a leather monlded splint all the movement.s'of 
 the fingers were good, and the patient could do needlework and write well. Such 
 a splint is capped to the shonlder and moulded to the limb down to the wrist, leav- 
 ing the fingers free, and strapped round the chest. 
 
TJKUNITBD FEACTURE OF OLECEAKON. 77 
 
 6. Secondary haemorrhage. This occurred in 11 out of 250 cases. 
 Otis, he. ciL, p. 860. 
 
 7. A useless limb, owing to utterly wasted muscles from long dis- 
 ease and disuse. 
 
 8. Adherent scar. 
 
 EXCISION OF SUPERIOR RADIO-ULNAR JOINT. 
 
 Indications. — This operation may be, very occasionally, called 
 for and justifiably made use of, with antiseptic precautions, in old 
 cases of dislocation of the head of the radius, where reduction has not 
 been effected owing to the amount of swelling, etc., and where the 
 movements of the forearm are much hampered, especially in a young 
 and healthy adult. 
 
 Operation. — An incision about 2 inches long is made over the 
 projecting head of the bone behind or through the posterior part of 
 the supinator longus.* The soft parts being separated with a blunt 
 dissector and held aside with retractors, the neck of the radius is -oare- 
 fully divided with a fine saw or cutting bone-forceps. Sufficient bone 
 must be removed here or from the external condyle to leave a gap 
 and avoid risk of fresh ankylosis. The musculo-spiral nerve lies to 
 the inner side, and great care must be taken not to interfere with this 
 or the biceps tendon. The forearm should be put through its move- 
 ments freely, but carefully, while the patient is under the ansesthetic, 
 so as to break down adhesions. Sufficient drainage must be provided, 
 and every care taken, by not interfering with the soft parts more than 
 is absolutely needful, and by keeping the wound aseptic, to secure 
 primary union, and thus avoid the risk of stiffness again occurring. 
 After a few days a sling may be substituted for a splint, and passive 
 movements made use of daily, with the aid of an ansesthetic if needful. 
 
 Mr. Wainewright (C/m. Soc. Trans., vol. xix. p. 332) records a some- 
 what analogous case, in which, in an adult, he removed the head of 
 the radius, which was vertically fractured, and the coronoid process, 
 which had been imperfectly united with fibrous tissue. The accident 
 had taken place three months before. The movements of the linib 
 were distinctlj^ improved by the operation. 
 
 UNUNITED FRACTURE OF OLECRANON. 
 
 Wiring the fragments of this bone is not often required. For fuller 
 details the reader is referred to the remarks on treatment of ununited 
 
 patella by wiring. 
 
 _ _ .1^— ^ — 
 
 * The operation will be somewhat easier in the backward dislocation, when the 
 radius rests on the back and outer surface of the external condyle, than in the forward 
 displacement, when the head rests on the front of the humerus in the hollow above the 
 condvle. 
 
78 OPERATIONS ON THE UPPER EXTREMITY. 
 
 Indications. — (1) Where, in spite of careful treatment previously 
 employed, the limb is weak and its usefulness seriously interfered 
 with, especially where the occupation of the patient requires vigorous 
 extension of the elbow* (2) Where such treatment has not been 
 used, but the time for it has gone by. In either case the patient 
 should be in a good condition of health, and the younger the better. 
 The object of the operation and its possible risks should be fully ex- 
 plained to him. It is taken for granted that a surgeon understanding 
 this operation has good reason for feeling confident in his knowledge 
 of antiseptic surgerj'. 
 
 Operation. — The parts being rendered evascular l>y properly ap- 
 plied Esmarch's bandages, and the region of the elbow-joint duly 
 cleansed,t a longitudinal incision is made for 2-1 or o inches over the 
 back of the joint, opening into this and exposing the fragments. Any 
 adhesions — e.;/., between these and the condj^es — are then removed 
 or broken down. Retractors being placed in the wound, the j)eri- 
 osteum is separated from the contiguous edges of the fragments, and 
 a thin layer of bone removed from each fragment, either with a chisel 
 or a narrow, sharp saw. A hole is then drilled obliquely through 
 each fragment with a brad-awl or drill, and stout| silver wire passed§ 
 and twisted up. Two half-twists or one complete twist should be 
 sufficient. If the surgeon decides to leave the wire in, he now cuts 
 the ends short and hammers them down upon the olecranon with a 
 small hammer. If he is going to remove them later on, he leaves the 
 ends, not cut too short, projecting through the wound, which is next 
 closed with silk or wire sutures. 
 
 Two questions arise here. One, Should the wire be left or no ? I 
 have alluded to this question more fully later on, in the treatment of 
 fractured patella by wiring. While one objection there given is want- 
 ing here — viz., the inability to bear pressure on the wire, as in kneel- 
 ing — two others remain, viz., the fact that, in some patients, attention 
 will be constantly attracted to the presence of the wire, and that, after 
 a time, ulceration may set in around the wire and cause trouble. 
 
 * The surgeon will examine how far this power is lost, to what extent wasting of 
 the triceps has occurred, and what evidence of union there is in the sutures between 
 the fragments. 
 
 f First by the use of soap and carbolic oil, and then with carbolic acid lotion (1 in 
 40), a piece of lint soaked in this being worn over the joint for an hour or two before 
 the operation. 
 
 I Sir J. Lister {Lancet, 1883, vol. ii. p. 761) gives wire about ,^ inch as amply 
 sufficient for the olecranon, while for the shaft of the femur, in an adult male, a piece 
 of wire about y'j inch in thickness is requisite in order to resist with certainty the 
 enormous force of tlie great muscles of the thigh. 
 
 I For difficulties in this, and how to meet them, see " Wiring of the Patella." 
 
VENKSECTION. 79 
 
 Thus I believe it to be better in most cases to leave the wire ends 
 fairly long, not short and hammered down, and to remove them in 
 about six or eight weeks' time. The other course, no doubt, enables 
 the surgeon to allow his patient to return to work after a much shorter 
 interval, viz., three or four weeks, but, as I think, at an undoubted 
 risk. 
 
 The other question is about the drainage. If the parts have not, 
 been much interfered with, if no separation of adhesions has been 
 necessary, probably no drainage will be needful if dry-gauze dressings 
 are applied, and firm and even support given with bandaging. If 
 drainage is considered advisable, a catgut drain will probably be suf- 
 ficient. 
 
 In about six or eight weeks' time the wire may be removed, careful 
 note having been made, at the time of the operation, of the number 
 of half-twists. Occasionally here* as in the case of the patella, 
 removal of the wire is a matter of some difficulty. 
 
 VENESECTION. 
 Indications. 
 
 1. Some cases of traumatic pneumonia and injury to ribs, as where 
 a stout young farmer breaks several ribs when riding, and acute pneu- 
 monia sets ill and extends rapidly. Here the cyanosis, orthopnoea, 
 the distressing pain, may all be relieved by a bleeding of 8 to 10 
 ounces, which very likely will have to be repeated. 
 
 In other cases of acute pneumpnia which are not traumatic, bleed- 
 ing may be resorted to with great advantage when the patient is young 
 and plethoric, the breathing much oppressed, and the heart's action 
 becoming embarrassed. 
 
 2. In some cases of chronic bronchitis. Dr. Haref draws this 
 graphic picture of such a case. A middle-aged man with chronic 
 bronchitis and some congestion of the lungs has exposed himself to 
 chill. " He is sitting in a chair (to lie down is impossible for him), 
 his face is blue and sunken, his lips purple, the eyes suffused and 
 staring, .... his chest heaving, and each short gasping inspiration 
 followed by a long wheezing and moaning expiration ; his lungs are 
 full of moist, sonorous, and mucous rhonchi, scarcely a trace of 
 vesicular murmur is to be heard, and he is pulseless. He looks to 
 
 * In a case of Sir J. Lister's (loc. supra cit.), the wire was not completely renioved 
 from the olecr.anon, for, the loop having given way near the twist, the twisted part was 
 alone taken away, and the loop left behind, but without causing any inconvenience 
 when the patient was last heard of. 
 
 t Srit. Med. Journ., 1883, vol. i. p. 156 : " Good Remedies Out of Fashion," Other 
 forms of blood-abstraction, such as leeches and cupping, are spoken of here. The 
 whole address is well worthy of careful study. 
 
80 OPERATIONS ON THE UPPER EXTREMITY. 
 
 you beseechingly, and gasps out, in scarcely articulate words, that he 
 is dying. This is but true. Now the treatment for such a condition 
 at the present day is to ' pour in stimulants ' (though the patient can 
 scarcely swallow). Brandy and water are given, and ammonia, and 
 perhaps ether; then, if the patient lives long enough, mustard poul- 
 tices are applied to the chest and the calves and feet, and the patient 
 
 is fanned, and the patient dies Appearances have been saved, 
 
 but not the patient's life. The fact is that here the danger lay in the 
 right side of the heart being gorged with blood, so that it was impos- 
 sible for its stretched and distended walls to contract and to propel 
 
 forwards the thick and blackened blood Open one of these 
 
 veins, which are, with every systole of the heart, tending to carry 
 more and more blood to this already distended right ventricle, and all 
 may yet be well with your patient." 
 
 3. Where a tendency to apoplectic seizures exists,* Dr. Hare (foe. 
 supra cit.) thus speaks of this class of case. Nature speaks " in unmis- 
 takable language when by a copious epistaxis she efficiently relieves, 
 the congested turgid face,t the beating temples, the dull heavy head- 
 ache, the sleepiness, the confusion of thought, and other symptoms, 
 which in a plethoric individual betoken, if they are not relieved, 
 serious danger, if not an apoplectic attack." 
 
 4. In aneurisms, especially thoracic. As part of the treatment of 
 Valsalva in a modified form. Formerly the bleedings in aneurism 
 were copious, even to syncope. Nowadays they are made use of in a 
 different way. They are small in amount, and are only repeated so 
 far as to reduce excessive action of the heart, or to relieve certain 
 symptoms (as they imdoubtedly do) — viz., dyspnoea and pain. 
 
 Operation. — The patient being usually in a sitting position, and 
 a bandage tied round the middle of the arm with sufficient tightness 
 to retard the venous circulation without arresting that of the arteries, ;{: 
 the surgeon selects a vein for his purpose, either the median cephalic 
 or the median basilic, whichever is most prominent.§ Steadying this 
 vein by placing his left thumb upon it just below the point of intended 
 
 * This does not mean those cases wliere a rupture of a cerebral vessel has occurred, 
 where bleeding would interfere with tliat process of repair on which the patient's life 
 depends. 
 
 t Dr. Copeman {Brit. Med. Journ., 1879, vol. ii. p. 932) points out that in these 
 cases, in addition to plethora and a full habit, evident distension of the superficial 
 veins of the head and neck is a valuable indication that bleeding is proper. 
 
 J The surgeon makes use of the pulsation in the arteries to tell the relation of the 
 brachial, or one of its branches given off abnormal l_v high up and running superficially, 
 to the veins at the bend of the elbow. 
 
 I If the patient is nervous, or if the veins are small, he should be told to hold a 
 walking-stick or book. This steadies his arm, distracts his thoughts, and by producing 
 muscular contraction supports and fills the veins. 
 
VENESECTION. 81 
 
 puncture, and with his left hand steady also, he opens the vein with 
 the point of a lancet or small, sharp scalpel (whichever is used should 
 be scrupulously clean), making with a gentle sweep of his wrist a 
 small incision, and not a mere puncture, into the vein. The anterior 
 wall of this being divided, and the blood flowing, the point, without 
 penetrating any deeper, is thrust onwards, iirst increasing the slit in 
 the vein, and then being brought out vertically, care being taken to 
 make the skin wound larger than that in the vein. The lancet or 
 scalpel being laid aside and the bleeding-glass held near, the thumb 
 is now raised and the stream directed into the glass.* While the 
 blood is escaping, the limb should be kept in the same position, lest, 
 by the skin slipping over the wound in the vein, the blood should 
 be prevented from escaping freely and make its way into the cellular 
 tissue. 
 
 The required amount of blood having been removed, the thumb is 
 placed on the puncture while the bandage is taken from the arm. A 
 small pad of lint dusted with iodoform or of dry aseptic gauze is then 
 placed on the puncture, and secured with tape or bandage applied in 
 the figure of 8. This pad may be removed in twenty-four or forty- 
 eight hours, and for a day or two the patient should carry his arm in 
 a sling. 
 
 DiflBculties during, and Complications after, Venesection. 
 
 1. Difficulty in finding a vein. This may be due to their small 
 size, the feebleness of the circulation, or the abundance of fat. If a 
 vein cannot be made suflSciently distinct by hanging down the limb, 
 putting it in warm water, flexing and extending the wrist and fingers, 
 and chafing the limb, a vein should be opened on the back of the 
 hand, or blood withdrawn from the external jugular or internal 
 saphena at the ankle. 
 
 2. In other cases, where the patient is much emaciated, owing to 
 the absence of steadying fat the mobility of a vein may enable it to 
 avoid puncture unless a very sharp instrument is used and the vein 
 well steadied. 
 
 3. When the vein has been opened, sufficient blood may not escape 
 owing to — 
 
 {a) The opening being a mere puncture. 
 
 (6) The skin-opening being insufficient in size, or not parallel in 
 position to that in the vein. These impediments are re- 
 moved by a freer use of the knife, carefully made, or by 
 bringing the wound in the vein parallel with that in the 
 skin. 
 
 * Kot a drop of blood should be allowed to go on to (he bed or patient's linen. 
 
 6 
 
82 OPERATIONS ON THE UPPER EXTREMITY. 
 
 (c) A pellet of fat may block the opening in the vein. This 
 
 should be snipped away. 
 
 (d) The patient may faint. 
 
 (e) A thrombus may form. This will disappear when the venous 
 
 current becomes more active. 
 (/) The bandage may be tied too tightly round the arm. 
 
 4. Wound of the brachial or some other artery — e. g., an abnormal 
 ulnar. This can always be avoided by a careful use of the lancet or 
 scalpel, and by noting beforehand the existence of any pulsation. The 
 force of the jet and the mixture of bright with dark blood will tell of 
 this accident. Pressure should be carefully applied and maintained, 
 and blood taken from the opposite arm if required. 
 
 5. Escape of blood into the cellular tissue. This will lead to ecchy- 
 mosis, and perhaps formation of a thrombus, which may be absorbed, 
 but which also may suppurate. 
 
 6. Phlebitis, Qv inflammation of the lymphatics. These may be 
 due to use of dirty instruments, aided by the low condition of the 
 patient. They should be most carefully guarded against, as likely to 
 lead to the following two most grave results. 
 
 7. Erysipelas and cellulitis. 
 
 8. Intense pain in the limb, with gradual flexion of the elboAV-joint. 
 This is due to puncture of the external or internal cutaneous nerves, 
 which are connected through the brachial plexus with the motor 
 nerves to the brachialis anticus and biceps, which flex the elbow- 
 joint.* The injured nerves should be divided, subcutaneously if pos- 
 sible. 
 
 TRANSFUSION. 
 
 This operation is rarely performed — (1) from fte fact that it is 
 apparently very fatal, though the bad results are, as in tracheotomy 
 for croup or in herniotomy in cases of strangulation, not due so much 
 to the operation itself, as to the condition which calls for it. (2) From 
 the difficulties attending the operation. These, of late years, have 
 been much diminished, but, while we have simpler apparatus at hand, 
 it is probably still correct that there is none which has been used suf- 
 ficiently often to be called perfect. Yet it is an operation with which 
 every iiractitioner should be acquainted, owing to the critical nature 
 of the cases in which he is called upon to perform it, and the sudden- 
 ness with which the call is liable to come. 
 
 There are two methods : A. Direct, in which blood is conveyed 
 directly from one person into another ; and B. Indirect, in which 
 blood is separated from its fibrin, or some other fluid is thrown in. 
 
 A. Direct. — These will be described first and most fully, as it is 
 
 * Hilton, Rest and Pain, p. 190. 
 
TRANSFUSION. 83 
 
 probably far preferable to inject blood without exposure to air and 
 without manipulation, and as, save in a very few cases, one of the 
 direct methods with the simple apparatus of the present day will be 
 usually available. 
 Chief Methods. 
 
 1. Dr. Galabin's. 
 
 2. Dr. Aveling's, and Mr. Cripps's modification of it. 
 
 3. Roussel's. 
 
 1. Dr. Galabin's (Fig. 25). — This is by far the simplest of the direct 
 transfusion methods ; it is, furthermore, cheap, and easily and quickly 
 cleaned — points of much importance in an instrument which is wanted 
 at a few minutes' notice, and then may be laid by for a long time. 
 Finally, it can be used both for direct and indirect transfusion. Its 
 disadvantage is that when used for direct transfusion the quantity of 
 blood cannot be easily and exactly measured. 
 
 It consists (Fig. 25) of a piece of elastic tubing, about a foot long, 
 which can be easily replaced from time to time at very slight cost, 
 
 Fig. 25. 
 
 Galftbin's transfusion apparatus. 
 
 A and E. Terminals of the cannula;. The Intervening india-rubber tube should not be more 
 than a or 6 inches long, to diminish the risks of clotting. 
 
 c. Receiving cannula, with a conical end to fill the opening into the vein. 
 
 c. Delivering cannula, with a pointed end so as to slip readily into the probably empty vein 
 of the patient. 
 
 even by ordinary drainage-tube, there thus being no risk of finding 
 the apparatus cracked and useless at the moment of need. At either 
 end are terminals and cannulse, after the shape of Dr. Aveling's pat- 
 tern, with as little projection of rim as possible when united to the 
 
84 OPERATIONS ON THE UPPER EXTREMITY. 
 
 tubing or cannulse. For the same purpose — i.e., to avoid starting- 
 points for clotting — Dr. Galabin does away with any taps at the junc- 
 tion of the terminals and cannulse, using spring-clips instead (Fig. 
 25). The following is the way of using the apparatus, taken from Dr. 
 Galabin's paper* (p. 268): "Place the transfusion tube, including 
 terminals and cannulee, in a hot solution of common salt (3j~0j). 
 When the tube is full, and all air removed from it, place a spring-clip 
 on it at each end, close to the terminals. Tie tapes round the arm of 
 the receiver, first above and then below the vein which is to be opened. 
 Prepare the vein by exposing a portion of it, and passing a probe 
 underneath it. Then tie tapes round the arm of the donor, first above 
 and then below the point where the vein is to be opened. Expose 
 the vein and pass a probe beneath it. Now let the donor sit by the 
 bedside and place his arm close to that of the patient. Take the 
 delivery cannula, d, out of the saline solution, open the receiver's 
 vein by a snip with sharp-pointed scissors,t and see that the cannula 
 slips readily into it. Removing the cannula, pass a small director 
 into the vein, that the opening may not be lost, and remove the tape 
 above the opening. Now take the transfusion tube, with both can- 
 nulse affixed, ojDen the donor's vein by a snip with scissors, and slip 
 the receiving cannula, c, into it, passing it gently on so far that by its 
 conical shape it fills the vein and does not allow blood to escape by 
 the side. Let an assistant hold the cannula in place, remove the 
 lower tape from the donor's arm, and remove the spring clips, keeping 
 the delivery cannula slightly raised above the donor's vein. As soon 
 as blood begins to flow from the delivery cannula, slip the cannula 
 into the receiver's vein and hold it there, having passed it in far 
 enough to prevent escape of blood by the side, as in the case of the 
 receiving cannula. The flow will be aided if the receiver's arm is 
 raised on a pillow slightly above the level of the shoulder." 
 
 As by this method the quantity of blood transfused cannot be 
 measured, the surgeon must judge when to leave off by the time of 
 the flow, which should not be less than five minutes, and partly by 
 the effect on the pulses of the donor and receiver. When the cannulse 
 are withdrawn the remaining tapes are removed, and the veins closed 
 by a pad and bandage. 
 
 2. Dr. Aveling's, with Mr. Ceipps's Modification (Fig. 26). — 
 While this method has the advantage of being amongst the simpler 
 and inexpensive forms of direct transfusion, it is, in my opinion, in- 
 ferior to that above described, for reasons given below. It has, how- 
 
 * Guy's Hospital Ee.porta, vol. xlii. p. 255. 
 
 t All the instruments nsed should be scrupulously clean, and taken, previously to 
 use, out of a solution of carbolic acid or mercury perchloride solution. 
 
TRANSFUSION. 
 
 85 
 
 ever, one advantage over it, of measuring the amount of blood sent— 
 viz., 2 drachms at each squeeze of the central bulb. 
 
 Mr. Cripps has removed one source of clotting by replacing the taps 
 shown in Pig. 26 by clips, as in Dr. Galabin's apparatus. But though 
 made of the best rubber, and in one piece, it is more likely, when put 
 aside for long intervals, to be found cracked and rough, and thus less 
 easily replaced than the simple bit of tubing of which Dr. Galabin's 
 instrument consists. 
 
 The veins being exposed, as already directed (p. 84), the apparatus 
 is filled with a warm solution of sodium chloride, and a clip placed at 
 either end. The arms of receiver and donor being in the position 
 given below, the vein of the receiver is opened, and pressure being 
 made just below the opening in the vein, so as to prevent blood ob- 
 
 FiG. 26. 
 
 A and B are the hands of as.sistaiits holding the afferent and efferent tubes and the lips of each 
 venesection wound together. Thecannulse being inserted into the veins, the syringe and tubing, 
 filled with warm saline solution, and kept so by the taps or clips, is fitted into the cannulee. Then 
 the taps are turned or the clips removed, and the tubing compressed by d, and the bulb squeezed 
 by c. The tube is then squeezed by shifting p to D'. The bulb then expanding draws in blood, 
 when the manipulation just described is repeated. The bevelled end of the afferent tube is so 
 made that it may slip easily into the collapsed vein of the patient. (Aveling.*) 
 
 scuring the opening, the cannula is inserted. The other cannula is 
 then inserted into a vein of the giver, and both held steadily by an 
 assistant. Transfusion is then performed as follows :t 
 
 " The clips having been removed from the tube at either end, the 
 operator makes the necessary valve to prevent regurgitation by com- 
 pressing, with the finger and thumb of one hand, the tube between 
 the central ball and the giver. He then slowly squeezes the ball, with 
 
 *• Obst. Trans., vol. vi. May 4, 1874. 
 . f Cripps, Did. of Surg., vol. ii. p. 660. 
 
86 OPERATIONS ON THE UPPER EXTREMITY. 
 
 the effect of driving the water it contains gently into the vein of the 
 recipient ; then, having compressed the tube between the ball and the 
 recipient, he removes the finger and thumb from off the tube on the 
 opposite side, allowing the ball to expand with the blood coming into 
 it from the arm of the giver. When the ball is full, the manipulation 
 just described is repeated, and the blood passes into the vein of the 
 receiver.- In this manner, each time the ball is compressed, 2 drachms 
 of blood are injected into the veins of the patient. Should the syringe 
 appear to become blocked,* or work unsatisfactorily, it can be detached 
 and washed out without removing the cannulse from the veins." 
 
 3. M. Roussel's. — This method appears to me to have the following 
 grave objections: (1) Its cost,t which is very high for an instrument 
 so rarely used. (2) Its complicated nature. (3) The fact that its 
 safety depends on its being used rapidly. As Dr. Galabin remarks, 
 " A general practitioner, having occasion to operate but once in a life- 
 time, might occupy more time, and the risk to the patient is thus 
 immediately increased."! (4) Although the first few ounces of blood 
 pass quite successfully, yet, after a while, clots usually form in the 
 tube.§ 
 
 B. Indirect Transfusion. — Points which have here to be con- 
 sidered are|| — (1) What is the best fluid to use. (2) What is the best 
 apparatus and method. 
 
 Dr. Galabin's very simple apparatus has the great advantage of 
 being available for indirect^ as well as for direct transfusion. 
 
 The terminal d, and delivery cannula b, are fitted to an elastic tube, 
 about 3 feet long, and not less than ^ inch in calibre. The other end 
 is attached to a glass funnel. The mode of procedure will then be as 
 follows: First expose the receiver's vein and place a probe under it; 
 then draw, defibrinate, and filter the blood through muslin, place it 
 
 * A case in which this occurred will be found related by Dr. Hoggan, lirit. Med. 
 Journ., 1877, vol. ii. p. 726. 
 
 t Five guineas — Dr. Galabin's costing 18s., aud Dr. Aveling's £1 12s. 
 
 X Mr. Ciipps {toe. supra cit.) further condemns it as most unsurgical, and as '" merely 
 an attempt to substitute the haphazard, blind puncture of a machine for the human 
 fingers and eyesight, which are alone to be relied on in performing so delicate an 
 operation as transfusion, with ease, safety, and precision." 
 
 I It is, however, only fair to the inventor to state that in the Yearbook of Treatment 
 for 1886, p. 90, M. Eoussel is stated to have performed transfusion by his method suc- 
 cessfully eighteen times in thirty-nine surgical cases; and in medical cases twenty- 
 eight times, with ten recoveries. No information is, however, given in the book just 
 quoted as to the severity of the cases or the condition of the patients. 
 
 II With regard to the fluid, blood, if available and taken from a healthy patient, is 
 undoubtedly the best; and it is quite clear that venous blood answers every ]mriiose. 
 
 T[ As in cases where the only douor available is nervous and excited, and cannot be 
 relied upon to go throgh direct traasfusioa steaiily. 
 
TEANSFUSIOX. 87 
 
 in a small jug, which is kept warm in a basin of warm water, place a 
 spring clip at the end of the transfusion tube close to the terminal, 
 hold the tube vertical, with the funnel uppermost, and fill the funnel 
 with hot solution of common salt (5j-0j), previously prepared, open 
 the spring clip, and let the solution run out till the funnel is just 
 en^pty and the tube alone full, then close the clip again. Now pour 
 the blood into the funnel, open the clip till the blood begins to escape 
 from the cannula, and then close it again ; open the receiver's vein, 
 and slip the cannula into it, keeping the arm sotaewhat elevated on 
 a pillow above the level of the shoulder. When the clip is taken off 
 and the funnel raised, the blood will generally flow in by the force of 
 gravity. The funnel must, of course, be kept replenished as the level 
 of the blood in it falls. If necessary, the flow may be accelerated by 
 running the oiled finger and thumb down the tube. But if the flow 
 seems to be arrested, or nearly arrested, it is better first to withdraw 
 the cannula for a moment from the vein, and make sure that the flow 
 is not stopped by a clot in the cannula or tube. 
 
 Dr. Galabin considers this simjjle arrangement of funnel and tube 
 equal to, and even superior to, any more complicated india-rubber 
 apparatus, which is apt to be found unfit for use when wanted unex- 
 pectedly. 
 
 If the surgeon prefer, he can make use of much the same apparatus, 
 and a cannula of glass, or any nozzle of appropriate size, always re- 
 membering that the end must be fine to enter the vein, usually col- 
 lapsed, of the patient, and that any taps, changes of calibre, etc., in 
 the cannula or nozzle are all sources of coagulation, and thus perhaps 
 of fatal embolism. 
 
 The same precautions as to defibrination, filtering, keeping up the 
 temperature of the blood, filling the tubing with warm saline solu- 
 tion — in fact, taking every possible step to prevent coagulation and 
 the transmission of emboli — must be most carefully followed. 
 
 Other fluids which have been recommended as well as blood must 
 be here briefly considered. 
 
 Milk* has been used by some — e.g., Dr. Thomas, of New York- 
 being thought to be safer and more nutritious than saline fluids. Pos- 
 sibly this last advantage is somewhat theoretical, being based on the 
 supposed resemblance to chyle. If milk be injected, it should be 
 
 * Prof. Schafer (Trans. Obst. Soc, vol. xxi.), from experiments on dogs, found that 
 the injection of milk, after they had been reduced by bleeding to almost a lifeless con- 
 dition, caused a temporary rise in the blood pressure, but no permanent benefit. 
 After death, the blood corpuscles were found to be disintegrated, and the blood swarm- 
 ing with bacteria. He was strongly of opinion that no fluid lacking haemoglobin 
 could be of anv benefit in cases of acute ancemia. 
 
88 OPERATIONS ON THE UPPER EXTREMITY. 
 
 first most carefully filtered to prevent any capillary embolism in the 
 lungs. 
 
 Saline solutions have also been used, being always available in the 
 absence of a fitting blood donor, and in the hope that thus sufficient 
 fluid would be supplied to stimulate the failing action of the heart, 
 and to give it something to contract upon until the processes of 
 assimilation, which are in these cases suspended, can once again 
 supply natural fluid to the heart and vessels. The transfusion of 
 saline solutions received at one time some impetus from a certain 
 amount of success which attended their use in cholera. Thus Mr. 
 Little* reports four recoveries out of fifteen cases so treated at the 
 London Hospital. The fluid used consisted of a drachm of sodium 
 chloride, 6 grains of potassium chloride, 3 grains of sodium phos- 
 phate, 20 grains of sodium carbonate, and 2 drachms of pure alcohol 
 to a pint of distilled water. Four pints were introduced at a time, at a 
 temperature of about 110°, the transfusion taking about half an hour. 
 
 My own impression as to the use of these saline solutions alone is 
 that their benefit is fugitive, but in this I attach, perhaps, too much 
 importance to two cases in which, some years ago, I injected a saline 
 solution analogous to that above given in haemorrhage after amputa- 
 tion of the thigh. About 6 ounces were used in one case, and about 
 10 or 12 in the other. The patients were actually moribund on each 
 occasion. Both rallied after the transfusion, but both ultimately 
 sank, in the one case eighteen hours, in the other about ten, having 
 elapsed since the transfusion. 
 
 It has been suggested that some saline solutions which have the 
 power of delaying the coagulation of blood — e.g., sodium phosphate 
 — should be added to the blood before it is transfused. Dr. Hicksf 
 brought this method before the profession, having found experiment- 
 ally on dogs that blood mixed with sodium phosphate, after being 
 kept out of the system for some time, could be injected back into the 
 animal without any detriment. He therefore hoped that this plan 
 might be useful where there is no time for defibrinating, or where the 
 quantity of blood obtainable is so small as to render defibrination 
 difficult. Dr. Hicks recommends a solution of 3 ounces of the fresh 
 sodium phosphate dissolved in a pint of water, using one part of the 
 solution to three parts of blood, and injecting from 6 to 8 ounces of 
 the combined fluid, this being done very slowly and at intervals if 
 the heart's action is embarrassed by the use of more than 2 ounces at 
 a time. Prof Schafer,J who investigated the subject of transfusion 
 
 * London Hasp. Reports, vol. iii. p. 132. 
 t Ouy's Hasp. Meports, vol. xiv. p. 1. 
 X Obsl. Trans., vol. xxi. 
 
TRANSFUSION. 89 
 
 scientifically for the Obstetrical Society, considered that this solution 
 was too strong, and certain to kill the blood corpuscles. 
 
 There is one more method of transfusion, or rather of re-infusion, 
 which has been used lately by the Edinburgh surgeons — viz., Dr. 
 Duncan^"" and Messrs. Annandale and Cotterillf — and which, being 
 especially adapted to amputation cases, is of great interest to the 
 hospital surgeon. Dr. Duncan used it successfully in a case of am- 
 putation of the thigh for a railway injury. The patient, who had lost 
 so much blood before the operation that it was difficult to say whether 
 he was alive or dead after the arteries were tied, made a good recovery 
 after the injection of the 3 ounces of blood which he had lost during 
 the operation mixed with solution of sodium phosphate — in all, about 
 8 ounces being thrown into the femoral vein. 
 
 Dr. Duncan's method is as follows : 
 
 For introduction into the vein, a short glass tube, of the size of a 
 No. 6 catheter, having a pen-shaped point, is used. To its other end, 
 slightly bulbous, about 2 inches of india-rubber tubing are attached. 
 A simple glass syringe, holding 4 ounces, whose nozzle fits the 
 tubing, is perfectly effective, the temperature being kept up with boric 
 lint wrung out of hot water. A graduated glass vessel, kept floating 
 in warm water, contains the solution of sodium phosphate and re- 
 ceives the blood. 
 
 All instruments are washed in aseptic solutions. The most con- 
 venient vein being selected on the face of the stump, the glass point 
 is inserted and a catgut ligature put round it. While the process of 
 ligaturing the arteries is going on, the blood is caught by one assist- 
 ant, who adds the soda solution as required, and is slowly injected 
 by another. 
 
 The solution of sodium phosphate was one of 5 per cent., one part 
 of the solution being added to three parts of blood. A slightly larger 
 proportion was frequently used in the amputation cases. 
 
 About five minutes were occupied in injecting the 8 ounces, and, in 
 a case of amputation of the hip, 16 ounces were injected in about 
 fifteen minutes, without any disturbance, and with a good result. 
 
 Dr. Duncan points out that the process of re-injecting the patient's 
 own blood is incompatible with the use of spray or irrigation during 
 the operation. In most cases, however, the use of the germicide may 
 safely be delayed till near the end of the operation, as, with pure 
 hands and instruments, the risk from the air is trifling, and is not 
 worth considering when a patient is in imminent danger from haemor- 
 rhage or collapse. 
 
 * Brit. Med. Journ., 1H86, vol. i. p. 192. 
 f Ibid., vol. ii. October 2. 
 
90 OPERATIONS ON THE UPPER EXTREMITY. 
 
 The same apparatus was thus used in a case of pernicious ansemia 
 by Dr. Duncan: 
 
 A vein in the arm of the receiver was exposed, and under it a double 
 thread of catgut passed. Blood was then drawn from the donor into 
 a dish containing the sodium phosphate, with which it was gently 
 mixed by means of a glass rod. While an assistant fitted the syringe, 
 the exposed vein of the receiver was opened, the lower thread of cat- 
 gut was gently pulled upon to prevent bleeding. The tube was now 
 inserted, the upper thread tied round it with one knot, and the lower 
 definitely secured and cut short. The blood was next slowly injected, 
 the tubing being pinched when the syringe required to be refilled. 
 The upper catgut was finally tied and cut short when the operation 
 was completed, and the little wound was stitched up. 
 
 Arterial Transfusion. — While transfusion into veins is in prac- 
 tice, on the whole, tiie most generally convenient and apiDlicable 
 method, the above is, theoretically, so superior that it deserves atten- 
 tion. Prof Schafer {loc. supra cit.) recommends the following method 
 to be used in the dorsalis pedis artery, which, for the sake of com- 
 pleting the subject, may be mentioned in this place : 
 
 The arteries of each are first to be exposed and sejDarated from their 
 sheath for about f inch. The distal ends of the exposed portions of 
 arteries in both are then tied, ligatures are placed loosely round the 
 upjjer ends also, and these upjaer ends secured by spring clips. The 
 transfusion apparatus itself consists simply of an india-rubber tube 
 having a glass cannula at each end. The cannula has a tapering 
 bevelled end, grooved to hold the ligature. One of the cannulse is 
 tied into the artery of the donor, the other into that of the receiver, 
 the ends of both being directed towards the heart. The clips are then 
 opened for about a minute, or a little longer if it seem desirable. 
 Both arteries are then to be tied just above the clips, and finally the 
 cannula:' are to be cut out, together with the pieces of artery into 
 which they are tied. 
 
 Advantages of Arterial Transfusion. 
 
 1. The blood transfused is oxygenated. 
 
 2. Any clots produced are washed into the peripheral arteries of 
 the foot, instead of into those of the lungs. 
 
 3. The arterial tension of the patient is more quickly raised, and 
 the tendency to syncope thus more rapidly averted, than when the 
 blood is thrown into a vein. 
 
 Disadvantages of Arterial Transfusion. 
 
 1. An artery is more difficult to find and deal with, especially in 
 cast's of hurry and emergency, than a superficial vein. 
 
 2. Emboli, if produced, and carried into the peripheral arteries, may 
 produce gangrene of the part. 
 
LIGATURE OF BRACHIAL AT BEND OF ELBOW. 91 
 
 3. It is a more serious operation for the donor at the time, and 
 requires him to be more careful later on. 
 
 4. An artery thus used is only available once. 
 
 Risks and Dangers of Transfusion.— Amongst these are : 
 
 1. Emboli and their results. 
 
 2. Evidence of blood being thrown in too rapidly for the system of 
 the receiver — e.y., headache, flushing, prajcordial oppression, etc. 
 
 3. Perhaps septic absorption, if the blood has been exposed too 
 long, or if milk is used without precautions to purify it. 
 
 4. Many of the risks already given under the head of venesection 
 (p. 82) will, of course, be present here also. 
 
 LIGATURE OF THE BRACHIAL ARTERY AT THE 
 BEND OF THE ELBOW (Fig. 17). 
 
 This operation, common enough fifty years ago owing to the fre- 
 quency of bleeding and the facility with which the brachial artery 
 was wounded, will be briefly described here. 
 
 Indications. — (1) Wound of artery, especially after bleeding. (2) 
 Traumatic arterio-venous aneurism, also occurring after bleeding. 
 Guide. — The inner side of the biceps tendon. 
 Relations: In Front. 
 
 Skin; fasciae; bicipital fasciae; median basilic 
 vein. Branches of internal and external 
 cutaneous nerve. 
 Outside. Inside. 
 
 Biceps tendon. Brachial artery Median nerve. 
 
 Tx at bend of elbow. ■*!-„„„ „ 
 
 Vena comes. Vena comes. 
 
 Behind. 
 
 Brachialis anticus. 
 
 Operation (Fig. 17). — The limb being steadied with the elbow 
 slightly flexed, the site of the bicejjs tendon should be defined, and 
 also that of any large veins, by making pressure a little above the 
 proposed site of ligature. An incision about 2 inches long is then 
 made, a little to the inner side of the biceps tendon, through the 
 superficial fascia carefully, so as to avoid the median basilic vein and 
 its companion, the internal cutaneous nerve. The deep fascia is then 
 divided on a director, this and the semilunar fascia of the biceps 
 which strengthens it being interfered with as little as possible. The 
 artery, with its venaj comites, lies directly underneath. The needle 
 should be passed, after the veins are separated and the artery cleaned, 
 from within outwards, so as to avoid the median nerve. 
 
 In the case of traumatic arterio-venous aneurism resisting other 
 
92 OPERATIONS ON THE UPPER EXTREMITY. 
 
 treatment, the old operation of placing double ligatures* will be pre- 
 ferable to the Hunterian one, which runs the risk of overlooking the 
 possibility of a rather higher division than usual of the brachial into 
 radial and ulnar. If much hasmorrhage is expected, the brachial 
 should be compressed about the middle of the arm with an Esmarch, 
 or the vessel controlled by a reliable assistant. The median basilic 
 vein will, in such cases, be often found much dilated by the entrance 
 of arterial blood. In others it has been obliterated. 
 
 This operation at the bend of the elbow should always be performed 
 with the utmost carefulness at the time and pains taken with the 
 after-treatment, so as to ensure the minimum of disturbance and the 
 smallest amount of cicatrix, and thus to interfere as little as possible 
 with the movements of the elbow. 
 
 CHAPTER V. 
 OPERATIONS ON THE ARM. 
 
 LIGATQRE OF BRAOHIAL ARTERY (Fig. 31). 
 
 This is performed (a) in the middle of the arm, and, much more 
 rarely, (b) at the bend of the elbow, the operation last described. 
 
 (a) In Middle of Arm (Fig. 31). 
 Indications. 
 
 1. Chiefly wounds of palmar arch, resisting pressure (p. 37). 
 
 2. Wound of the artery itself by penknife, bayonet, bullet, etc. 
 
 3. Gunshot wound of the elbow, leading to secondary haemorrhage, 
 resisting other treatment. 
 
 4. Wound of one of the arteries of the forearm, when haemorrhage 
 has occurred from a wound of one of these and the parts are in a 
 sloughy condition. In the year 1882 a patient came under my care 
 for secondary haemorrhage from a wound of the forearm, inflicted by 
 the bursting of a gun in rook-shooting. The parts were much swollen 
 
 * Here ligatures will be required above and below the comraunication with the 
 vein in the case of aneurismal varix, and above and below the sac if the surgeon is 
 dealing with a varicose aneurism, it being understood that palliative treatment has 
 not sufficed, and that pressure, applied locally and on the main trunk above, or by 
 means of Esmarch's bandage, has failed. If ligature is decided upon, it will be better 
 (the artery being commanded above) to open the sac, and thus find the apertures into 
 the artery by the aid of a director. As Mr. Holmes {Sijsten of Surgery, vol. iii. p. 92) 
 points out, the other plan of attempting to find and tie the artery without opening the 
 sac presents these difficulties— viz., that the artery is surrounded by dilated and closely 
 packed veins, and that below the sac it is of small size. 
 
LIGATURE OF BRACHIAL IN THE ARM. 93 
 
 and sloughy; the ulnar artery in its middle third, from which the 
 hiumorrhage was coming, was greenish in color, and apparently not in 
 a condition to hold a ligature. A good recovery, with no further 
 hfemorrhage, took place after ligature of the brachial in the middle of 
 the arm. In 1885 I had occasion again to tie this artery for haemor- 
 rhage occurring repeatedly a few days after a suppurating palmar 
 bursa had been opened in the usual way, above and below the ante- 
 rior annular ligament. The patient recovered with a weakened limb. 
 
 5. Traumatic aneurism. 
 
 6. Sijontaneous aneurism. As is well known, spontaneous aneurisms 
 are very rare in the upper extremity, and usually associated with car- 
 diac disease. Treatment here should not be too active (see below) ; 
 ligature should only be thought of where the aneurism is rapidly in- 
 creasing or causing painful pressure upon a nerve. Traumatic aneu- 
 rism is decidedly under the influence of pressure. If this fails, it is 
 a question if the old operation is not superior to the Hunterian, for 
 the sac is often imperfect.* 
 
 Dr. Holt {Amer. Journ. Med. Sci., April, 1882) only succeeded in col- 
 lecting thirteen cases of spontaneous aneurism of the brachial arter3\ 
 From his paper he concludes that pressure should always be tried 
 first. This is more likely to be successful in aneurisms low down in 
 the brachial artery than in those in its upper third, as pressure is 
 more easily applied in the former case, owing to the less close relation 
 of nerves to the artery. Amongst these cases is the following one, 
 which is of much interest. It occurred in 1857. It is probable that 
 antiseptic precautions will enable the surgeon to deal successfully 
 with spontaneous aneurism in the upper extremity, even when asso- 
 ciated with cardiac disease. Aneurism of left brachial at its middle ; 
 ligature of the brachial at upper third ; secondary htemorrhage ; liga- 
 ture of the axillary ; cure. A butcher, aged thirty-two, had a tumor,, 
 the size of a small hen's egg, at middle of the left brachial artery. It 
 was steadily increasing. The patient had valvular disease and great 
 cardiac hj^pertrophy. The brachial was tied in its upper third ; the 
 aneurism shrunk to a small hard lump, without pulsation ; the liga- 
 ture did not come away ; and, on the sixteenth day, with the thread, 
 still hanging, the patient butchered a calf A few days afterwards he 
 called attention to a rapidly forming tumor just above the ligature.- 
 Ligature of the axillary was advised, but refused. Two weeks later 
 the surgeon was called for haemorrhage, the false aneurism having 
 burst. The axillary was then tied in its lower third, the ligature came- 
 away properly, and the artery between the ligatures, as well as the 
 aneurism, was completely obliterated. The patient died six months- 
 later of dropsy. 
 
 ■* Holmes, Roy. Coll. Surg. Lect , Lancet, October 25, 1873. 
 
94 
 
 OPERATIONS ON THE UPPER EXTREMITY. 
 
 Line. — Prom the junction of the middle and anterior thirds of the 
 axilla, along the inner edge of coraco-brachialis and biceps, to the 
 middle of the elbow triangle. This line is of especial importance 
 when, owing to swelling, etc., the edge of the biceps is difficult to 
 make out. 
 
 Guide. — The above line and the inner edge of biceps. 
 
 Relations in arm : In Front. 
 
 Skin ; fasciae ; branches of internal and external 
 
 cutaneous nerves. 
 Median nerve* (about centre of arm). 
 
 Outside. 
 Coraco-brachialis (above). 
 Biceps. 
 Vena comes. 
 
 Brachial 
 
 artery 
 
 in arm. 
 
 Inside. 
 
 Ulnar nerve. 
 
 Internal cutaneous nerve. 
 
 Vena comes. 
 
 Basilic vein, superficial to 
 
 deep fascia in lower half, 
 
 beneath it above, usually. 
 Behind. 
 
 Triceps (middle and inner heads) ; coraco- 
 brachialis ; brachialis anticus. 
 Musculo-spiral nerve and superior profunda 
 artery (above). 
 Collateral Circulation. 
 
 (a) If the ligature be placed above the superior profunda, the 
 vessels chiefly concerned will be : 
 
 Above. Below. 
 
 The subscapular 1 . 
 
 The circumflex | ^^*^ The superior profunda. 
 
 (6) If the ligature be placed below the superior profunda : 
 Above. 
 
 The superior profunda with 
 
 Below. 
 
 The radial recurrent. 
 The posterior ulnar recurrent. 
 The interosseous recurrent. 
 (^ The anastomotica magna, 
 (c) Jf the ligature be placed below the inferior profundi^ : 
 
 \ 
 
 Above. 
 
 The superior profunda 
 The inferior profunda 
 
 with 
 
 Below. 
 The radial recurrent. 
 The ulnar recurrents. 
 The interosseous recurrent. 
 The anastomotica magna. 
 
 * In one out of every six cases, tlie median nerve lies under the artery: Skey, foe. 
 supra ciL, p. 269. 
 
LIGATURE OF BRACHIAL IN THE ARM. 95 
 
 Abnormalities.— These are so far from infrequent* tliat the 
 surgeon must be prepared for the following: 
 
 1. The artery being in front of the nerve (foot-note, p. 94). 
 
 2. A high division of the artery. According to Mr. Quain, in one 
 out of every five cases there were two arteries instead of one in some 
 part, or in the whole, of the arm. The point of bifurcation is thus 
 described by Gray : " It is most frequent in the upper part, less so in 
 the lower part, and least so in the middle, the most usual point for 
 the application of a ligature; under any of these circumstances, two 
 large arteries would be found in the arm instead of one. The most 
 frequent (in three out of four) of these peculiarities is the high division 
 of the radial. That artery often arises from the inner side of the bra- 
 chial, and runs parallel with the main trunk to the elbow, -wlnre it 
 crosses it, lying beneath the fascia; or it may perforate the fascia, and 
 pass over the artery immediately beneath the integument. "t 
 
 3. The artery may be partially covered by a muscular slip given off 
 from the pectoralis major, biceps, cora-co-brachialis, or brachialis 
 anticus. 
 
 4. One or more slender vasa aberrantia may be met with in the 
 arm, passing from the axillary or the brachial to one of the arteries 
 in the forearm. 
 
 Operation (Fig. 31). — The arm being extended and abducted from 
 the side, with the elbow-joint flexed and supported X by an assistant, 
 the surgeon, sitting between the limb and the trunk,§ makes, be- 
 ginning from below or above as is most convenient, an incision 21 
 inches in length along the inner border of the biceps, going through 
 the skin and fascite, and exjjosing just the innermost fibres of this 
 muscle. II This is then drawn outwards with a retractor, the median 
 nerve next found and drawn inwards or outwards with a strabismus 
 hook, and the artery defined and sufficiently cleared, when the liga- 
 
 * iSTumerous instances of these are figured by Mr. Reeves in the Appendix to his 
 Human Morpholngy, vol. i. p. 692 et seq. 
 
 t The possibility of this superficial position of the radial or ulnar should always be 
 remembered when venesection at the elbow is about to be performed. See also the 
 foot-note, p. 80. 
 
 X Mr. Heath has pointed out (Operative Surgery, p. 18) tliat if the arm when at a 
 right angle to the body be allowed to rest upon the table, the triceps is pushed up, and 
 displacing the parts may bring into view the inferior profunda and the ulnar nerve, 
 instead of the brachial and the median nerve. 
 
 I This i.s, to my mind, a much more comfortable position than standing on the outer 
 side and looking over. 
 
 II Authorities differ as to this step. I strongly advise the operator to avail himself 
 of this guide. If it be done carefully, and the wound kept sweet afterwards, it can do 
 no harm. The fibres of the muscle are a distinct help, and (as stated below) ligature 
 of this artery is not as easy a one as it would appear. 
 
96 OPERATIONS ON THE UPPER EXTREMITY. 
 
 ture is passed from the nerve. In doing this the basilic vein and the 
 venio comites, which increase in size as they ascend, must be carefully 
 avoided. 
 
 I would point out that the brachial artery is by no means so easy 
 a vessel to tie as might be supposed from its superficial position. 
 This is especially the case when the artery is concealed by the median 
 nerve at the point where it is sought, and when its beat is feeble and 
 the vessel itself small and but little distended after repeated heemor- 
 rhage lower down.* 
 
 AMPUTATION OF ARM (Figs. 28, 29, and 30). 
 
 Indications. — Amongst these are : 
 
 1. Accidents, e.<i., compound fractures, machinery accidents, etc., 
 which do not admit of any part of the forearm being saved, or of 
 amputation of the elbow. 
 
 The advisability of amputation in these cases is discussed, once for 
 all, in the chapter on the antiseptic treatment of compound fractures. 
 
 2. New growths involving the forearm, and not admitting of ex- 
 tirpation. 
 
 3. Disease of the elbow-joint not admitting of excision, or in which 
 this operation has failed (p. 67). 
 
 4. Gunshot injuries of upiaer part of forearm, elbow, and arm not 
 admitting of conservative treatment or excision. 
 
 So inestimable is the value, even when only partial, of the hand, 
 and so good are the results of conservative treatment and secondary 
 amputation, that the tissues must be almost disorganized for the sur- 
 geon to think of primary amputation here.f 
 
 ■ This was so marked in the second of the two ca^es mentioned at p. 93, that on 
 my exposing the vessel, several bystanders I'elt certain that it was not the brachial, 
 but one of its branches. 
 
 t Dr. Otis (he. supra cit. p. 916) thns sums up on the question of conservative sur- 
 gery, excision, and amputation in gunshot injuries of the elbow-joint: "The practical 
 conclusions that appear to me deducible from the foregoing investigations are — (1) 
 That in shot wounds in young healthy subjects attended with slight injury of the ar- 
 ticular extremities of the bones of the elbow, such as fractures of the olecranon, of the 
 outer condyle, or of the trochlea, without much splintering and without lesion of the 
 important vessels and nerves, it is justifiable in many instances to attempt an expect- 
 ant conservative treatment, keeping the injured extremity in entire rest, after removing 
 any detached fragments or foreign bodies, in a semi-prone and very flexed position, 
 employing ice or other cold applications. If the inflammatory action becomes intense, 
 the wound should be freely enlarged, and the joint-cavity freely laid open, and easy 
 escape provided for the altered wound secretions by position and drainage-tubes. The 
 strength should be sustained by a tonic regimen, and when the inflammatory stage has 
 completely abated, and not before, if healing is slow, secondary excision or amputation 
 may be liopefully re.sorted to. Unless all the favorable conditions mentioned are pres- 
 
AMPUTATION OF THE ARM. 97 
 
 Amongst the special conditions whicli will have to be considored 
 are the size of the projectile, the gravity of the laceration of the soft 
 parts, the amount of longitudinal splintering of the bones, the extent 
 of lesions to the vessels and nerves, and the degree to which suitable 
 conservative measures can be adopted in the absence of hospital 
 facilities or of easy transportation* 
 
 If the surroundings of the surgeon and patient admit of it, at- 
 tempts will nowadays be made to suture the nerve ends, especially 
 when only one or two of the chief trunks are involved. Whether the 
 old doctrine, that shot-fracture of the humerus with wound of the 
 brachial artery imperatively indicates amputation, is correct must 
 remain uncertain. Dr. Otis (he. supra cit. p. 674) writes on this point : 
 " I confess that the evidence in the reported cases ai)pears to me in- 
 sufficiently circumstantial and precise to decide affirmatively this 
 controverted point." 
 
 Methods. 
 
 i. Skin-flaps with circular division of muscle — («) antero-posterior 
 flaps, {b) lateral flaps. 
 
 ii. Transfixion flaps, usually antero-posterior. 
 
 iii. Skin and transfixion flaps comljined. 
 
 iv. Circular. 
 
 i. Skin Flaps with Circular Division of Muscles.— This 
 
 should be made use of in bulky muscular arms. 
 
 (ft) Antero-posterior Flaps. — The brachial having been controlled,! 
 the limb supported at a right angle to the body, and the surgeon, 
 standing outside the right and inside the left limb, with finger and 
 
 ent at the outset, it would be safer to resort to primary excision or to amputation. (2) 
 In grape-shot comminutions with lesions of the principal vessels or nej-ves, amputa- 
 tion should be practiced immediately after the reception of the injury. (3) In severe 
 .shot fracture, without extensive lesion of the soft parts, the joint should be freely ex- 
 posed by a longitudinal posterior incision, and the full extent of the fracture ascer- 
 tained. Unless there is extraordinary Kssuring, the injured joint ends should then be 
 sawn otr as close to the limits of injury as possible, save that the bones of the forearm 
 should be shortened to the sanie level. If the splintering extends very far, or if there 
 is reason to believe that the humeral vessels are injured though not wounded, the 
 incision should be so modified as to convert the operation into an amputation." 
 
 * On this point Dr. Otis writes (loc. supra cit. p. 811), "The surgeons, doubtless, 
 sometimes yielded to what John Bell called ' an argument of necessity as well as of 
 choice, and limbs, that in happier circumstances might ha;ve been preserved, had 
 often, in a flying army or a dangerous campaign, to be cut off,' since ' it is less dread- 
 ful to be dragged along with a neat amputated stump than with a swollen and fractured 
 limb, where the arteries are in constant danger from the splintered bones ' " 
 
 t With an Esmarch usually ; in amputation high up, either the axillary jjuist be 
 controlled by elastic tubing applied by a modification of the method given at p. 1 17, 
 or the subclavian mu.st be controlled by a reliable assistant. 
 
 7 
 
98 OPERATJONS OX THE UPPER EXTREMITY. 
 
 thumb of left hand marking the site of intended bone section (Fig. 
 28), enters the knife on the side of the limb farthest from him, oarrits 
 it first down •'], o], or 4 inches, according as he is going to make one 
 flap longer than the other or not,* then across the limb, with well- 
 rounded edges, and up the side nearest to him to the point opposite 
 to that from which the incision started. Next, passing the knife 
 under the limb, he marks out a posterior flap, usually somewhat 
 shorter than the anterior. These flaps, consisting of skin and fascisa, 
 are then dissected up, the muscles cut through at the flap-base with 
 a circular sweep, and the bone sawn through as high as possible. 
 Especial care should be taken here, as in forearm amputations, to 
 divide the nerve-trunks square and high up.f 
 
 (6) Lateral Flaps. — This method may be made use of, one flap 
 being cut longer than the other, whe^i the skin is more damaged on 
 one side. 
 
 The surgeon, standing as before, marks the site of bone-section by 
 placing his left forefinger and thumb, not now on the two borders of 
 the arm, but on the central points of the anterior and posterior sur- 
 faces of the limb. Looking over, he enters his knife at the latter 
 spot, and cuts a well-rounded flap, ending at the thumb on middle 
 of the anterior aspect, and then, from this point, without removing 
 the knife, another flap is marked out by a similar incision ending at 
 the middle of the back of the arm. The flaps are then dissected up, 
 and the operation completed as in the method already given. 
 
 ii. Transfixion Flaps, usually Antero-posterior (Fig. 27.)— 
 
 In an arm of moderate size, or in cases where rapidity is required, as 
 in warfare or in cases of double amputation, this method may be 
 made use of. The surgeon, standing as before,! and with his left hand 
 marking the flap base, and lifting up the soft parts in front of the 
 humerus so as to get in front of the brachial vessels, and thus avoid 
 splitting them, sends his knife across the bone and in front of the 
 above vessels, and makes it emerge at a point exactl}' opposite ; he 
 then cuts a well-rounded flap, about 3 inches long, with a quick sawing 
 movement, taking care, after he feels the muscular resistance cease, to 
 carry his knife on a little, so as to cut the skin longer than the muscles, 
 
 * If tlie flaps are cut of equ.al length, the cicatrix will be opposite, and perhaps ad- 
 herent to, the bone; this is very undesirable, though of less importance in a stump of 
 the upper than of the lower extremity. 
 
 •f- In an amputation which passes through the musculo spiral groove, great care 
 must be taken to divide completely the nerve lying in this, before the bone is sawn. 
 The depth of this groove varies much. When it is considerable, the nerve may easily 
 escape division and be frayed by the saw, giving rise, if overlooked, to a most painful, 
 bulbous end. 
 
 I In Fig. '27 the surgeon is supposed to be standing outside the left arm. 
 
AMPUTATION OF THE ARM. 
 
 99 
 
 the knife being finally brought out quickly and perpendicularly to 
 the skin. The flap being then lightly raised, without forcible retrac- 
 tion, the knife is then passed behind the bone at the base of the 
 wound already made, and a posterior flap cut similar to the anterior, 
 but somewhat shorter. Both flaps are then retracted, any remaining 
 
 Fig. 27. 
 
 (Fergusson.) 
 
 muscular fibres divided with circular sweeps of the knife, and the 
 bone exposed a little above the junction of the flaps. The saw is 
 then applied after careful division of the periosteum. The brachial 
 artery will either be found in the posterior flap, or if, as both flaps are 
 
 Fig. 28. 
 
 made, the soft parts are drawn a little from the humerus, the main 
 artery and nerves will be left, and must be cut square with the circu- 
 lar sweeps of the knife. 
 
 If it be preferred, lateral flaps can be made by transfixion, one, of 
 course, being cut longer than the other if this is rendered desirable by 
 the condition of the soft parts. 
 
100 
 
 OPERATIONS ON THE UPPER EXTREMITY. 
 
 iii. Combined Skin and Transfixion Flaps (Fig. 28).— This, 
 
 a. very speedy and efficient method, may be made use of here. An 
 anterior flap of skin and fascire, al)oiit 3 inches long, having l^een 
 marked out (p. 98) and dissected up, the bulk of the soft parts behind 
 the bone are drawn a little away from it, the knife passed behind the 
 humerus, and a posterior flap, somewhat shorter, cut by transfixion. 
 
 iv. Circular (Fig. 29).— Owing to the moderate size of the limb, 
 and its circular shape, this is the place, above all others, where this 
 method can be made use of, especially in limbs which are not very 
 
 Fig. 29. 
 
 bulky. Whether he make use of it in after-life or no, the student 
 should always perform a circular amputation here on the dead 
 subject. 
 
 Standing as before, or on the outer side of either limb, the surgeon, 
 with his left hand, draws up strongly the skin, and passes his knife 
 under the arm, then above, and so around it, till, by dropping the 
 point vertically, the back of the knife looks towards him, and the heel 
 rests on the part of the arm nearest to him. A circular sweep is then 
 made round the limb, the completion of this being aided by the assistant 
 in charge of the limb, who should rotate it so as to make the tissues 
 meet the knife. A cuff-like flaj) of skin and fasciae* is then raised, for 
 2J or 3 inches, with light touches of the knife, and, having been 
 folded back, the muscles are cut through close to the reflected skin.f 
 The cut muscles are next retracted by the operator's left hand, and 
 the remaining soft parts, with the main vessels and nerves, are 
 severed clean and square. | The bone is then freed for f inch, and 
 the periosteum, having been divided, is sawn through as high as 
 possible. 
 
 * See p. 61. 
 
 t By some it is advised to cut the biceps i-atlier longer tlian the rest, owing to its 
 retracting more, as it is not attaciied to the liumerns. 
 
 X See the remarks (foot-note, p. 98) on the importance of secnring thorough and 
 clean division of the nnisculo-spiral nerve wlien the amputation passes through the 
 groove. 
 
EXCISION OF THE SHAFT OF THE HUMERUS. lOl 
 
 EXCISION IN CONTINUITY OP THE SHAFT OP THE 
 
 HUMERUS. 
 
 This operation has been especially discussed in its application to 
 gunshot wounds. By the term " excision in continuity," deliberate 
 removal, the periosteum being preserved as far as possible, of portions 
 of the shaft of the humerus— e..g., 2-G inches— is meant; and from it 
 such operations as incision and removal of splinters, operations for 
 necrosis and for pseudo-arthrosis, should be excluded. 
 
 Dr. Otis* thus writes of this operation : " I cannot discern that the 
 experience of the war lends any support to the doctrine of the justi- 
 fiability of operations of this nature except in very exceptional cases. 
 The numerical returns, and the necessarily abbreviated summaries, 
 may appear, at first glance, to represent the results in a favorable 
 light, but a more precise analysis reveals most lamentable conclu- 
 sions The mortality rate is nearly double that observed in the 
 
 cases treated by expectant measures, and more than 12 per cent, 
 higher thaia the fatality in a larger series of primary amputations in th e 
 upper third of the arm. Moreover, in the 477 cases of recovery there 
 were no less than 99 instances in which ' no bony union ' was rejjorted, 
 and 65 others recorded as examples of 'false joint.' There were also 
 amongst the cases reported as ' successful ' 37 instances of consecutive 
 amputation of the arm. Recourse was had to ulterior exarticulation 
 or amputation in 64 patients, of whom 27 perished. 
 
 "Such evidence warrants the assertion that early excision in the 
 continuity of the humerus after injury can seldom be justifiable, a 
 conclusion at which European surgeons had already arrived from the 
 experience of the Schleswig-Holstein and Danish wars, and which 
 had been confirmed by more recent observations. The coaptation of 
 the resected ends of the bones by silver wires was sometimes prac- 
 ticed, with few illustrations of favorable results. Examination of the 
 details of many of the formal primary excisions in the shaft strengthens 
 the impression that they were for the most part unnecessary and in- 
 jurious." 
 
 Causes of Pailure after Excision of the Humerus in Con- 
 tinuity. — Amongst these are : 
 
 1. Osteo-myelitis and pytemia. 
 
 * Med. and Surg. Hist of ih^ War of the Rebellion, pt. ii. p. 695 et seq. In Circular 
 No. 3, p. 223, seven "snccesafiil" cases are briefly reported. In one of tliese, two' 
 months after tlie removal of 3 inche.9 of the shaft (the operation being performed for 
 caries a year after a gunshot injury), bony union liad taken place, the functions of the 
 hand and arm were well performed. The patient could lift 8 or 10 lbs., and the arm 
 was still becoming stronger. The bone renewed is said to have been completely 
 denuded of its periosteum in its entire circumference. 
 
102 OPERATIONS ON THE UPPER EXTREaMITY. 
 
 2. Secondary haemorrhage. 
 
 3. Secondary necrosis. 
 
 4. Non-union, leading to a limb which dangles* or is flail-like, and 
 is more or less useless in spite of a support. 
 
 While excision in continuity of the humerus is to be condemned 
 as a primary operation, and while the same operation performed sec- 
 ondarily for necrosis may lead to a limb which is of little use without 
 an artificial support, the following case of Dr. Macewen'sf shows what 
 ingenuity and perseverance may effect in such cases, and jDroves that 
 detached portions of bone deprived of their periosteum are capable of 
 living and growing after transplantation : 
 
 A boy, aged two, had complete! necrosis of the shaft of his right 
 humerus after suppurative periostitis. The necrosed bone was re- 
 moved about nine weeks after the onset of the periostitis, leaving 
 the layer of granulations covering the periosteum intact, and forming 
 a tube, which was kept patent by dressings suitably inserted until the 
 whole space had granulated up. No bone grew from the periosteum, 
 except a small part next the proximal epiphysis, where, at the out- 
 set, the periosteum was found covered by plaques of adherent osseous 
 tissue. From the whole of the remainder there was no osseous de- 
 position, the result being a flail-like arm. Fifteen months subse- 
 quently he returned to the Glasgow Royal Infirmary, his parents 
 desiring that the arm should be removed, it being worse than useless, 
 inasmuch as he required the other hand and arm to look after the 
 flail-like one, which was constantly dangling in the way. The con- 
 dition of the arm was as follows: The bone had not increased in 
 length since he left the hospital. When the limb was allowed to hang 
 bjr the side, the measurement, from the tip of the acromion process to 
 the distal extremity of the humeral shaft, was nearly 2 inches. The 
 proximal fragment was conical, and tapering from the rounded head 
 to a narrow spike-like extremity. From this to the condyles there 
 was a complete absence of bone, there being nothing but soft tissues 
 in the gap. The muscular power was good, but when he attempted 
 to raise his arm a contraction of the muscles took place, the condyles 
 
 * Tliere is a good illustration of this result in Fig. 506, Inc. supra cit, p. (582. Fur- 
 ther details are needed of the amount of use made of, and the ultimate advantage 
 accruing from, the ingenious apparatus of Dr. Hudson, which was stipplied to many of 
 these cases. In one (Circular 3, p. 223), the arm being unreliable owing to want of 
 leverage, the incipient usefulness of this apparatus, supplied two years and a half after 
 the injury, is stated to have been "liighly gratifying and efficacious." 
 
 t Annals of Surgery, vol. vi., No. 4, p. 301. 
 
 J Dr. Macewen points out that it is probable that in the outset of this case the 
 nutrient artery of the humerus was occluded or separated in the intensity of the sup- 
 purating process. The periosteum whicli remained, not only did not produce bone, 
 but fifteen months later appeared to have been completely absorbed. 
 
EXCISION OF THE SHAFT OF THE HUMERUS 103 
 
 being drawn towards the proximal extremity, while some fibres 
 of the deltoid raised the spike-lilie process of the upper portion, 
 causing it to project, as if about to penetrate the skin. Here the 
 action ceased, the soft parts in the gap appearing like a rope during 
 the muscular contraction. He could not raise his forearm to his 
 breast, the lever and fulcrum needed being wanting. It was deter- 
 mined to supply these by transplantation from other human bones. 
 In the wards there were numerous cases of marked anterior tibial 
 curves, from which wedges of bone had to be removed, and these were 
 used as transplants. An incision was made into the upper third of 
 the humerus, exposing the head of the bone. Its extremity, for fully 
 i inch, was found to be cartilaginous. The cartilaginous spilie-like 
 process was removed, leaving there a portion of bone, which measured 
 
 1 f inch from the tip of the acromion. From this point a sulcus, about 
 
 2 inches long, was made, downwards, between the muscles. The 
 former presence of bone was nowhere indicated, and there was no 
 vestige of periosteum, and the sole guide as to the correct position into 
 which the transplant was placed was an anatomical one.* Two 
 wedges of bone were then removed from the tibia of a patient, aged 
 six, affected with anterior curves. The base of these osseous wedges 
 consisted of the anterior portion of the tibia, along with its periosteum. 
 After removal they were cut into minute fragments with the chisel, 
 quite irrespective of the periosteum. The bulk of the fragments had 
 no periosteum adhering to them, they having been taken from the 
 interior of the hone. They were then deposited into the muscular 
 sulcus in the boy's arm, and the tissues drawn over them and care- 
 fully adjusted. The wound healed without pus production.! Two 
 months after, a portion of bone 1 inch in length and I inch in thick- 
 ness, was found firmly attached to the upper fragment of the humerus. 
 In moving the finger from the head of the bone towards the graft, the 
 latter could be easily distinguished by the sudden increase in the 
 breadth. Now, instead of the former sharp spike, the upper fragment 
 ended obtusely. Two other wedges of bone, of larger size than the 
 first, were similarly dealt with and inserted two months after the first. 
 These filled up the gap in the arm to the extent of 4i inches, the arm 
 then measuring 6 inches in length. Soon the utility of the arm was 
 greatly restored. 
 
 Seven years afterwards the patient was seen and examined. The 
 shaft of the humerus was found to have increased in length by If 
 inches, being now 71 inches ; it had increased in circumference to a 
 
 * I.e., the only guide was by recognizing tlie relative po-iitions which the muscles 
 ought to occupy towards the humerus. 
 
 t The importance of this statement, and its effect upon the very happy result of the 
 case, will not escape the reader. 
 
104 OPERATIONS ON THE UPPER EXTREMITY. 
 
 marked extent, and had assumed a somewhat irregular shape. The 
 patient could use his arm for a great many purposes — taking his food, 
 adjusting his clothes, and in many games. 
 
 in some remarks on this case, Dr. Macewen advances the following 
 arguments against the supposition that the new bone grew from old 
 periosteum: (1) If any of this had existed and possessed osteogenic 
 power, it had ample time to reveal itself by osseous growth during the 
 fifteen months which had elapsed between the removal of the dead 
 bone and the transplantation of the new. (2) In opening the sulcus 
 between the muscles for the reception of the transplants, no perios- 
 teum or anything like fibrous membrane was seen. (3) The growth 
 of the bone was at first only commensurate with the insertion of the 
 transplants, there being no indication of any osseous growth in the 
 vicinity of these which might have arisen from the supposed stimu- 
 lation of the periosteum. (4) The solid humerus still retains the 
 irregularities of shape which the transplants were permitted to assume 
 in the tissues. 
 
 OPERATIONS ON MUSCULO -SPIRAL NERVE. 
 
 Suture of this nerve after injuries to it in different parts of its course 
 is referred to under the heading of " Xerve-suture." 
 
 There is another lesion to which this nerve is, owing to its close 
 connection with the shaft of the humerus, occasionally liable after 
 fracture of that bone — viz., compression by callus.* ISI. Oilier f many 
 years ago recorded a case of this kind successfully treated by surgery. 
 A man, aged twenty-two, had suffered a compound fracture of the 
 right humerus, through the musculo-spiral groove. Four months 
 later, the fracture having firmly united, the extensors of the wrist and 
 fingers were completely paralyzed, and sensibility along the course of 
 the radial was much diminished. The integrity of the functions of 
 the triceps seemed to show that the lesion must be seated below the 
 commencement at the musculo-spiral groove, where the branches to 
 that muscle are given off. M. OlUer concluded that the nerve was 
 compressed either by one of the fragments or by exuberant callus. 
 Prolonged treatment directed towards the removal of the callus having 
 failed, the patient was submitted to operation. An incision having 
 l)een made in the presumed direction of the nerve, so as to expose it 
 in the external intermuscular septum, it was found by tracing a 
 branch ujiwards. A gutter was next cut with chisel and mallet for lA 
 inches through the callus, this step exposing the nerve, swollen and 
 
 * The iiccnsional nbnnditme of tliis callus may, perhaps, be in part accounted for 
 by the great thickness of the periostenm of the huinerns. 
 
 + Sycl. Snc. JSin,. Retr., ISt'.a, 1866, ji. 294; Guz. Hebd., 186-5, p. hlo. 
 
OPERATIONS OX THE MUSCULO-SPIEAL NERVE. 105 
 
 hypertrophied in its lower part, and above, strangled (as if by a liga- 
 ture) by a point of bone apparently belonging to the lower fragment. 
 This point being cut off, and a probe passed behind the nerve to secure 
 its complete isolation, the nerve was then followed for J inch above 
 and below the bony canal, so as to ensure its liberation, and, in order 
 to obviate any rej^roduction of bone, the periosteum was removed all 
 round. The nerve was not disturbed from its gutter for fear of con- 
 tusing or stretching it. The wound healed rapidly. From the sixth 
 day the patient experienced some pricking sensations on the back and 
 outer part of the forearm, and sensibility began to increase in the 
 thumb and forefinger. On the twentieth day he could raise his hand 
 a little hj voluntary efforts, and when he left the hospital six months 
 and a half after the operation, he insisted on going back to his work 
 in the fields. 
 
 A second case of this nature occurred in the practice of M. Trelat, 
 and a third has been recorded by M. Tillaux.* The patient was a 
 man of fi-ft}', who had fractured the middle of his humerus without 
 any lesion to the nerves at the time. When the splints were removed 
 there was complete paralysis of the extensors. Four months after the 
 accident, T\I. Tillaux operated to free the nerve from the pressure of 
 the callus. The trunk of the musculo-spiral was easily discovered by 
 an incision made below the fracture between the brachialis anticus 
 and the supinator longus. The nerve was then followed up, set free 
 from the fibro-bony material which surrounded it, and the bony 
 edges of the gutter were removed with the chisel. Three months after 
 the operation the patient was completely cured. 
 
 CHAPTER VI. 
 
 OPERATIONS ON THE AXILLA AND SHOULDER. 
 
 LIGATURE OF AXILLARY ARTERY (Figs. 30 and 31). 
 
 Indications. 
 
 1. Wound of the artery.f 
 
 2. Aneurism of the brachial high up.| 
 
 * Traiti d'Ancitoviie topngraphique, p. 511. 
 
 t In some wounds of the artery, the surrounding parts— <!..(/ , veins and nerves— may 
 be so injured that the vitality of the limb is impaired beyond what ligature and nerve- 
 suture can do, and the advisability of amputating at the shoulder-joint must be con- 
 sidered. 
 
 X Dr. Holt (Amer. Jonrn. Med. Sci., April, 1882) mentions a case (p. 385) of aneu- 
 rism of the right brachial at its upper third; ligature of the a.xillary in its lower 
 tliird ; secondary ha;raorrhage ; ligature of the axillary artery in its upper third ; cure, 
 
106 OPERATIONS ON THE UPPER EXTREMITY, 
 
 More rarely still — 
 
 3. As a distal operation for aneurism of the subclavian. 
 
 4. Very occasionally, as the old operation after rupture of the axil- 
 lary artery in shoulder dislocations (p. 112). 
 
 5. Very occasionally, as the old operation for axillary aneurism 
 
 (p. 111). 
 
 6. For hemorrhage from malignant disease in the axilla. 
 
 These cases are extremely rare, but a good instance, and one showing 
 the difficulty of meeting them, has lately been published by Mr. 
 Savory {Med. Chir. Trans., vol. Ixix. p. 157). During an attempt made 
 to remove a sarcomatous growth from the axillary region, it was 
 found, after division of the pectoral muscles, that the growth com- 
 pletely invested the axillary vessels for 3 or 4 inches in the upper 
 part of their course. Though the knife was not used here at all, arte- 
 rial blood began to gush up from this region, and, as no artery could 
 be found even after division of the axillarj^ vein, two pressure forceps 
 were applied to the bleeding spots and left in dhi, as all attempts to 
 apply ligatures were futile. 1 he man rallied from the operation, and 
 for just a week went on as well as possible. Then, on a sudden, vio- 
 lent htemorrhage recurred, and death followed at once. 
 
 On tracing the axillary artery from below, an irregular aperture 
 was found in the artery, just above the lower border of the tumor, 
 and from this point upwards the artery was completely broken up, 
 so that for 2 or 3 inches no further trace of arterial wall could be 
 discovered. The boundary of the cavity beyond, through which the 
 blood must have passed, appeared to be simply the substance of the 
 tumor, until at its upper part, just below the clavicle, arterial wall 
 was again found. 
 
 Operations. — Ligature of the first and the third parts of the artery 
 will be first described, and then the old operation. 
 
 i. Ligature of the First Part (Fig. 30).— This operation is very 
 rarely performed on the living subject.* Owing to the depth of the 
 vessel here, its most important and intimate surroundings, and the 
 risk of secondary haemorrhage from the vessels which lie so close to 
 the knot, ligature of the third part of the subclavian is preferred if 
 ligature be required for axillary aneurism. On the dead subject the 
 student should always take the oportunity of tying the first part of 
 the axillary, as it is an excellent test of anatomical knowledge and 
 practical skill. 
 
 Line. — From the centre of the clavicle (with the arm drawn from 
 the side) to the inner margin of the coraco-brachialis. 
 
 Guide. — The above line, and the inner margin of coraco-brachiahs 
 (p. 109). 
 
 See the last note. 
 
LIGATURE OF THE AXILLARY ARTERY. 107 
 
 Relations: In Front. 
 
 Skin; fascife; fibres of platysma. Supra-clavicular nerve. 
 Pectoralis major (with muscular branches). 
 Costo-coracoid membrane. 
 Cephalic vein. Acromio-thoracic vessels. 
 
 Outside. j^^.^^^^^ ^^^^^^^ Inside. 
 
 Outer and inner cords first part. Axillary vein, 
 
 of brachial plexus. 
 
 Behind. 
 First digitation of serratus magnus. 
 First intercostal space and muscle. 
 Posterior thoracic nerve. 
 Collateral Circulation. 
 
 (a) If the artery be tied in its first part, and the ligature be placed 
 above the acromio-thoracic, the vessels concerned will be the same as 
 those which carry on the blood supply after ligature of the third part 
 of the subclavian iq.v.). 
 
 (b) If the artery be tied in its third part and the ligature be placed 
 below the circumflex arteries, the anastomosing vessels will be the 
 same as after ligature of the brachial above the superior profunda 
 (p. 94). 
 
 (c) If the artery be tied in its third part, and the ligature be placed 
 between the circumflex and subscapular arteries, the chief vessels 
 concerned are : 
 
 Abovr Below. 
 
 The supra-scapular 1 .,, m, , . . n 
 
 „! -A, • r with Ihe posterior circumflex. 
 
 The acromio-thoracic J '■ 
 
 (d) If in tying the third part of the artery the ligature be placed 
 above the subscapular, the anastomoses are more numerous — viz., in 
 addition to those just given : 
 
 Above. Below. 
 
 The supra-scapular 1 .,, mi i ^ 
 
 „, \ ■ T y with Ihe subscapular. 
 
 The posterior scapular J ^ 
 
 Operation. — The vessel may be secured in the following ways. 
 
 The first two are recommended. 
 
 A. By a curved incision below the clavicle. This gives the neces- 
 sary room, but has the disadvantage of dividing the pectoralis major 
 and its large muscular branches. 
 
 B. By an incision in the interval between the pectoralis major and 
 deltoid (Fig. 30). This method scarcely gives sufficient room, espe- 
 cially if the parts are displaced by effused blood, etc., and it is well 
 to supplement the incision in the interval by one partly detaching 
 
108 OPERATIONS ON THE UPPER EXTREMITY. 
 
 the pectoralis from the clavicle (p. 109). While this plan involves less 
 haemorrhage from the pectoralis major, care must be taken to avoid the 
 cephalic vein and acromio-thoracic branches which lie in this interval. 
 C. By an incision in the line of the artery — viz., one 3'.-4 inches 
 long, starting from just outside the centre of the clavicle and passing 
 downwards and outwards. This has the disadvantage of cutting the 
 muscular branches of the pectoralis major, and gives less space than 
 the first two. 
 
 A. The limb l)eing at first abducted, the surgeon, standing between 
 it and the body, which is brought to the edge of the table, makes a 
 curved incision, with its convexity downwards and about i inch from 
 the clavicle, reaching from just outside the sterno-clavicular joint to 
 the coracoid process, the knife being used lightly at the outer end of 
 the incision, so as to avoid wounding the cephalic vein and branches 
 of the acromio-thoracic vessels. The clavicular origin of the pecto- 
 ralis major is then divided in the whole extent of the wound, and any 
 muscular branches which require it tied or twisted at once. The 
 cellular tissue beneath the muscle being next explored with tip of 
 finger and director, the upper border of the pectoralis minor is defined, 
 and this muscle drawn downwards. The costo-coracoid membrane 
 must next be most carefullj^ torn through close to the coracoid pro- 
 cess, which is a good guide, by means of a fine-pointed steel director, 
 the cephalic vein and acromio-thoracic vessels being most scrupulously 
 avoided. The wound all this time must be kept dry, and, if needful, 
 a large laryngeal mirror may be usefully employed in throwing light 
 into the bottom of the deep wound. The pulsation of the artery being 
 felt for and the sheath exposed,* the vessel itself is to be carefully 
 cleaned and separated from the vein, which lies below and in front, 
 and from the brachial cords, which are above the artery. The needle 
 should be passed from below so as to avoid the vein.f 
 
 B. By an incision made between the pectoralis major and deltoid 
 (Fig. 30). 
 
 The limb and the surgeon being in the same position as in the 
 ojjeration just given, an incision is made obliquely downwards and 
 outwards lietwecn the above muscles, commencing a little below the 
 clavicle opposite to the coracoid process. Care being taken to avoid 
 the cephalic vein and branches of tlie acromio-thoracic vessels, the 
 muscles are separated, and, to gain more room,I a transverse incision 
 is made running inwards along the lower border of the clavicle, and 
 
 * Tlie parts may now be advantageously relaxed by adducting the arm. 
 t The patient ninst be prepared for probably weakened or limited use of his limb 
 for some time, at least, after the main arterial trunk has been ligatured. 
 
 t This step is advocated by Mr Rivington (Brit. Med. Journ., 1885, vol. i. p. 1040). 
 
LIGATURE OF THE AXILLARY ARTERY. 
 
 109 
 
 detaching as much as is required of the clavicular origin of the pecto- 
 ralis major from the bone. This flap can be turned inwards and 
 downwards without au}^ interference with the nerve supply of the 
 
 Fig. 31. 
 
 Fig. 80.— Part of the clavicular origin of the pectoralis mtijor has been turned inwards with 
 the flap of skin. The costo-coraeoid membrane is been cut above and beiow the artery, in the 
 latter case being turned down over the pectoralis minor. 
 
 The cephalic vein runs up along the inner edge of the deltoid ; another vein lies on the cords 
 of thebrachialplexuaabove the artery, while someother veins cross the upper part of the wound. 
 
 Fig. 31.— The lower incision shows ligature of the brachial in the middle of the arm (p. 95), 
 The artery is immediately internal to the inner edge of the biceps, the median nerve having 
 crossed the vessel rather high up. 
 
 In the ligature of the third part of the axillary, the artery, with the mediannerve on theouter 
 and the ulnar on the inner side, lies just internal to the coraco-brachialis. In both the opera- 
 tions too much of the nerves is shown. 
 
 muscle, and, owing to its high division, less haemorrhage is met with 
 by this method. The deltoid being strongly drawn outwards with a 
 retractor, the upper border of the pectoralis minor is defined, and the 
 
110 OPERATIONS ON THE UPPER EXTREMITY. 
 
 operation completed as in the account already given, the parts being 
 relaxed at this stage by adduction of the arm. 
 
 ii. Ligature of the Third Part of the Axillary Artery 
 
 (Fig. 31). 
 
 Line. — From the centre of the clavicle with the arm drawn from 
 the side to the inner margin of the coraco-brachialis. 
 
 Guide. — The above line. A line drawn from the junction of the 
 middle and anterior thirds of the axilla, along the inner border of the 
 coraco-brachialis. 
 
 Relations: In Front. 
 
 Skin ; fascife. 
 Pectoralis major. 
 Outside. Inside. 
 
 Musculo-cutaneous.me- . .„ , Internal cutaneous; 
 
 ' Axillary arterv, . ' 
 
 dian. Inner border t^ird part. ' ulnar. Axillary vein 
 
 of coraco-brachialis. or vense comites. 
 
 Behind. 
 Subscapularis. Latissimus dorsi. Teres major. 
 Circumflex. Musculo-spiral. 
 
 Operation (Fig. 31). — This resembles somewhat that for ligature 
 of the brachial in the middle of the arm. As with the brachial, so 
 with the axillary here ; though the vessel is comparatively superficial, 
 it is not an easy one to hit off at once, owing to the numerous sur- 
 rounding nerves, which may resemble the artery closely, especially if 
 blood-stained. 
 
 The arm being extended from the side and rotated slightly out- 
 wards, the surgeon, sitting between the limb and the trunk, makes an 
 incision, 2J or 3 inches long, at the junction of the anterior and mid- 
 dle thirds of the space along the inner border of the coraco-brachialis 
 (Fig. 31). The incision may be begun above or below, as is most 
 convenient. Skin and fascite being divided, and the point of a direc- 
 tor used more deeply, the axillary vein and the median nerve should 
 be identified, the latter drawn inwards and the former, together with 
 the coraco-brachialis, outwards. The artery is then made sure of, 
 cleaned, and the needle passed from within outwards, the neighbor- 
 hood of any large branch, such as the subscapular or the circumflex, 
 being avoided, and the needle being kept very close to the artery. 
 
 iii. Old Operation of Ligature of Axillary Artery for 
 Some Cases of Axillary Aneurism, and Injured Axillary 
 
 Artery. — This method may be made use of in the following in- 
 stances : 
 
 1. When pressure has failed in the above cases. 
 
 2. Where pressure is unsuitable owing to the rapid increase, and 
 
LIGATURE OP THE AXILLARY ARTERY. Ill 
 
 large size, of the aneurism ; the condition of the parts over it ; or the 
 inability of the patient to bear pain. 
 
 3. Where, owing to the displacement of the clavicle, ligature of the 
 subclavian is not likely to be practicable, or where the condition of 
 the coverings of the aneurism is such that this step, even if carried 
 out, wilLnot avert suppuration, sloughing, etc. 
 
 Prof. Syme (Observations in Clin. Surgery, p. 140 d seq.), holding that 
 the old method would certainly remedy cases not amenable to liga- 
 ture of the subclavian, and that even in cases where the latter is prac- 
 ticable the former might be preferable, made use of it in three cases, 
 the patients being aged fifty, forty-seven, and about fifty respectively. 
 In the first case, the skin in the neighborhood of the shoulder-joint 
 was dusky red and vesicating, and the patient beginning to wander 
 in his mind. In the third, after the operation, delirium tremens set 
 in, with excessive suppuration and sloughing of the tissues of the limb. 
 All three recovered. 
 
 The following is an account of the operation in Prof. Syme's words 
 (loc. supra cit. p. 148) : '' I made an incision along the outer edge of 
 the sterno-mastoid through the platysma myoides and fascia of the 
 neck, so as to allow a finger to be pushed down to the situation where 
 the subclavian lies upon the first rib. I then opened the tumor,* 
 when a tremendous gush of blood showed that the artery was not ef- 
 fectually compressed ; but while I plugged the aperture with my hand, 
 Mr. Lister, who assisted me, by a slight movement of his finger, which 
 had been thrust deeply under the upper edge of the tumor and 
 through the clots contained in it, at length succeeded in getting com- 
 mand of the vessel. I then laid the cavity freely open, and with both 
 hands scooped out nearly 7 pounds of coagulated blood. The axillary 
 artery appeared to have been torn across, and, as the lower orifice 
 still bled freely, I tied it in the first instance, next cut through the 
 lesser pectoral muscle close .up to the clavicle, and, holding the upper 
 end of the vessel between my finger and thumb, passed an aneurism 
 needle so as to apply a ligature about J inch above the orifice. The 
 extreme elevation of the clavicle, which rendered the artery so inac- 
 cessible from above, of course facilitated this procedure from below. 
 Everything went on favorably afterwards." 
 
 Sir J. Paget and Mr. Callender {St. Bartholomew'' s Hasp. Reps., vol. 
 ii.) made a H-shaped incision, cutting parallel with the lower margin 
 of the pectoralis major, and a second at right angles to the first 
 straight up through the whole width of the pectoralis major. 
 
 A short space may be allotted here to that most important accident 
 
 * In one of his cases, while laying open the cavity, Prof. Syme had to avoid the 
 radial artery, which ran over the surface of the sac. 
 
112 OPERATIONS ON THE UPPER EXTREMITY. 
 
 which has happened to so many surgeons — viz., rupture of the ax- 
 illary artery while dislocations of the shoulder are being reduced. Of 
 late years the great fatality which the old operation has met with here 
 has been pointed out. Dr. Stimson (Ann. of Surg., Nov., 1885) draws 
 the following conclusions from forty-four cases : " Conservative treat- 
 ment—viz., complete rest with direct pressure— may properly be tried 
 at first, especially if the tumor is small, recent, and not increasing, 
 but should not be prolonged if the symptoms do not promptly yield ; 
 and, secondly, in case of resort to operation, ligature of the subclavian 
 or disarticulation at the shoulder is to be preferred to incision of the 
 sac and double ligature of the artery." Of seven cases of double liga- 
 ture of the artery, all were fatal. Of fourteen of ligature of the sub- 
 clavian, five recovered. Without operation, thirteen died, six re- 
 covered. Of four cases of amputation at the shoulder, only one 
 recovered. Repeated puncture is always fatal. Korte, of Berlin 
 (Arch. f. hlln. Chir., Bd. xxvii. Hft. 3, quoted by Dr. Stimson), is of 
 opinion that in many cases the injury to the artery is caused at the 
 time of, the accident, but haemorrhage does not come on till after re- 
 duction is brought about, as the vessel is compressed by the head of 
 the bone. As to the exact cause of the injury to the vessel when it 
 takes place at the time of the reduction, it is probable that some special 
 condition exists to account for it, as so many old dislocations are re- 
 duced with much force, used with impunity— e.gf., atheroma; adhe- 
 sion of the artery to the head of the bone ; too great or misapplied 
 force in reduction, viz.,- use of the boot, in elevation; projection of a 
 fragment or a spicule of bone. It is usually the axillary artery, or 
 one of its branches, which gives way ; much more rarely (four out of 
 forty- four cases), the axillary vein. 
 
 The following remarks with which Mr. Holmes* (Hunterian Lect- 
 ures) summed up the treatment of axillary aneurism are well worthy 
 of thoughtful perusal : 
 
 " 1. There are a great number of these aneurisms, both traumatic and 
 spontaneous, which are amenable to gradual intermitting pressure 
 when carefully applied to the artery above the tumor. 
 
 " 2. That in cases where this is not possible, from the pain which 
 the person experiences on pressure, the application of rapid total com- 
 pression under anaesthesia may effect a cure. 
 
 " 3. That the ligature of the subclavian is so dangerous an operation, 
 both from its own risks and the i)roximity of the sac, that it ought to 
 be restricted to cases where pressure has failed, and to those in which, 
 from the size and rajiid growth of the axillary swelling the surgeon 
 thinks pressure unadvisable. 
 
 * Lancd, September 27, 1873. 
 
AMPUTATION AT THE SHOULDER-JOIKT. 113 
 
 "4. That the old operation is to be preferred to Hgature of the suli- 
 clavian in cases of ruptured artery, and that it n:ia3' be practiced in 
 cases where, from the elevation of the shoulder or from the extent of 
 the swelling, the surgeon would find it difficult to tie the subclavian, 
 or fears, in doing so, to injure the sac, but that the anatomical rela- 
 tions of axillary aneurisms render this a peculiarly hazardous pro- 
 ceeding, and the surgeon should always be prepared to amputate if 
 necessary. 
 
 "5. That in very large axillary aneurisms, if any treatment be 
 adopted, the arm sliould be amputated at the shoulder-joint* after 
 ligature of the subclavian." 
 
 AMPUTATION AT THE SHOULDER-JOINT. 
 
 Indications. 
 
 i. Compound comminuted fractures — c. g., railway and machinery' 
 accidents. 
 
 ii. Gunshot injuries. — Amputation here is divided by Dr. Otisf intu 
 — (1) Primary, or before the third day ; (2) Intermediary, or cases in 
 which the operation was performed between the third and the thirtieth 
 days ; (S) Secondary, in which the operation was performed later tlinn 
 the thirtieth day. 
 
 (1) Primary. — The mortality here was 24 per cent. The indica- 
 tions for amputations so soon after the injury are chiefly — (a) A limb 
 torn off partially, but too high to admit of any other amputation ; (6) 
 Severe comminuted fracture of the upper end of the humerus, with 
 extensive injury to the vessels and nerves ; (c) Such a fracture high 
 up, with severe splintering extending down below the insertions of the 
 pectoralis major and the latissimus dorsi. 
 
 (2) Intermediary. — The mortality here, 45 per cent., was nearly 
 double that of the primary. This seems to have been brought about 
 largely by the fact that the operation was now performed through 
 soft parts, the seat, at this time, of unhealthy inflammation, and thus 
 prone to lead to secondary ha?morrhage, pyiemia, sloughing, etc. 
 
 (3) Secondary. — The causes for this deferred operation were chiefly 
 hffimorrhage, gangrene, profuse suppuration, hopeless disease of the 
 humerus, sometimes with consecutive implication of the joint, chronic 
 osteo-myelitis, or necrosis of the entire humerus. The mortality was 
 28 per cent. 
 
 From the above it is evident that the necessary examination should 
 be made, and the operation performed, as soon after the injury as 
 possible consistent with the state of the patient, the difference between 
 
 * P. no. 
 
 t Med. and Surg. Hist, of the T(a/- of the. Rebellion, pt. ii. p. 613 et scg. 
 
 8 
 
114 OPERATIONS ON THE UPPER EXTREMITY. 
 
 operating in sound and diseased parts, and the neighborhood of the 
 joint to the chest, if a septic condition of the wound sets in, being 
 borne in mind. 
 
 iii. New growths. — If these involve the scapula or its processes, 
 amputation at the shoulder-joint should be combined with removal of 
 the scapula (p. 144).* 
 
 iv. Disease of the shoulder-joint unsuited for, or persisting after 
 failure of excision. 
 
 V. For osteo-myelitis and necrosis of humerus resisting other treat- 
 ment, or complicated with early blood-poisoning. 
 
 vi. For raiiidly spreading gangrene or gangrenous cellulitis with 
 threatening septicemia. 
 
 Mr. Heath {Cliit. Sue. Trans., vol. xiv. p. 114) has recorded such 
 a case in which this amputation was needed to save life. A nurse 
 had pricked her finger deeply with a pin hidden in some of the 
 clothes of a lady who had died of virulent puerperal septicaemia; gan- 
 grenous cellulitis rapidly set in, and extended in spite of incisions ; on 
 the sixth day the gangrene appeared to be arrested in the forearm, 
 though there was a blush of advancing mischief up the arm. In the 
 afternoon of the same day sudden extension took place, and Mr. 
 Heath removed the arm at the shoulder-joint, the patient ultimately 
 making a good recovery. 
 
 The operation chosen was by outer and inner flaps, the former 
 giving a fairly healthy flap of deltoid, the latter having to be cut very 
 short owing to the infiltration of the axilla. The dressings became 
 offensive, but the stump healed well. 
 
 vii. Amputation at the shoulder-joint may be called for in the fol- 
 lowing cases of aneurism : 
 
 A. In some cases of subclavian aneurism where other means have 
 failed or are impracticable; where the aneurism is rapidly increasing; 
 where the pain is constant and agonizing; and where the limb is 
 threatening to become gangrenous. While the principle of this opera- 
 tion appears to be physiologicallj' sound^/.c, to enable distal ligature 
 to be performed on the face of the stump, and that, by removal of the 
 limb, the amount of blood passing through the aneurism may be 
 diminished — the results hitherto have not been very successful. Thus, 
 in Prof. Spence'st case, a man aged thirty-three, with a subclavain 
 aneurism, probably encroaching on the second, if not the first, part of 
 the artery, with excruciating pain and threatening gangrene, amputa- 
 tion at the slioulder-joint was followed liy diminution in the pulsation 
 
 * The C|iiestion of (lie possibility of saving the limb and removing the growth by 
 e.xcision of tb.e head of the humerus i.s considered at p. 12S. 
 t MciL Chlr. Tiiiji.t., vol. Iii. p. 300. 
 
AMPUTATION AT THE SHOI'LDER- JOINT. 115 
 
 and size of the sac, but with little formation of coagula. Death took 
 place four years afterwards, probably from extension of the aneurism 
 to the innominate and aorta. In this case the operation, though it 
 had but little effect in consolidating the sac, undoubtedly prolonged 
 life, as gangrene was threatening, and the second part of the artery 
 was almost certainly affected, thus rendering the case a most unfavor- 
 able one. In Mr. Holden's* case the patient was almost in extremis, and 
 the sac gave way. In Mr. H. Smith'sf case an intra-thoracic portion 
 of the aneurism also ruptured, there being no evidence as to benefit 
 or otherwise. In Mr. Heath's| case (the aneurism being perhaps 
 traumatic in origin, and of the false circumscribed kind) the effect on 
 the aneurism was so transient as to be practically nil. Two months 
 after the amputation, as the aneurism continued to increase in size, 
 Mr. Heath introduced into the sac three pairs of fine sewing needles, 
 making each pair cross within the sac. Considerable clotting took 
 place around the needles, which were withdrawn on the fifth day. 
 The aneurism gradually became solid, but the patient sank soon 
 after from bronchitis. Mr. Heath concluded that amputation at the 
 shoulder-joint for aneurism is not a satisfactory proceeding, but the 
 majority of surgeons present were in favor of further trials of this 
 mode of treatment if it could be resorted to early. 
 
 B. \Mth the same objects in view, amputation at the shoulder-joint 
 may be required in some cases of axillary aneurism complicated with 
 extension of the sac upwards, much elevation of the shoulder, condi- 
 tions which may render compression or ligature of the subclavian im- 
 possible, removal of the limb being additionally called for if agonizing 
 pain or threatening gangrene is present. 
 
 Prof Syme§ briefly alludes to two such successful cases, in one of 
 which gangrene was threatening : " In a case of axillary aneurism in 
 a gentleman of about fifty-two years of age, where ligature was pre- 
 vented by intense inflammation of the arm, rapidly running on to 
 gangrene, I performed amputation at the shoulder-joint, cutting 
 through the sloughy sides of the aneurism and tying the artery where 
 it lay within the sac." 
 
 C. In some cases of inflamed axillary aneurism threatening sup- 
 puration, Mr. Erichsen|| jDoints out that the question of this amputa- 
 tion may arise. As the old operation of opening the sac, turning out 
 
 * St. Barthol. Hasp. Reports, vol. xiii. 
 
 t Quoted by Mr. Heath, loc. infra cit. 
 
 J In a paper brought before the Medico-Chirurgical Society (Trans., vol. Ixiii. p. 
 65). For the discussion on this, see Lancet, 1880, vol. i. p. 169; Brit. Med. Journ ,. 
 1880, vol. i. p. 205. 
 
 § Med. Chir. Trans., vol. xliii. p. 139. 
 
 II Surg., vol. ii. p. 217. 
 
116 OPERATIONS ON THE UPPER EXTREMITY. 
 
 the clots, and securing the vessel above and below is impossible, owing 
 to the fact that the coats of the vessel, now softened, will not hold a 
 ligature, two courses only are open to the surgeon— viz., ligature of the 
 third part of the subclavian or amputation at the shoulder-joint. 
 M''hile the former may be followed when the aneurism is moderate in 
 size and when there is no evidence of threatening gangrene, amputa- 
 tion must be resorted to when less favorable conditions are present. 
 
 If hajmorrhage occur from an inflamed axillary aneurism which 
 has ruptured after the subclavian has been already tied, Mr. Erichsen, 
 of the two courses now open — viz., either to open the sac and try and 
 include the bleeding spot between two ligatures, or to amputate at the 
 shoulder-joint— strongly advises the latter. 
 
 The coats of the artery " in the immediate vicinity of the sac could 
 not, in accordance with what we know to be almost universally the 
 case in spontaneous aneurisms of large size or old standing, be ex- 
 pected to be in anything like a sound, firm state, and would almost 
 certainly give way under pressure of the noose; or the vessel might 
 have undergone fusiform dilatation, as is common in this situation, 
 before giving rise to the circumscribed false aneurism, in which case 
 it would be impossible to surround it l\v a ligature ; or, again, the 
 subscapular or circumflex arteries might arise directly from, and pour 
 their recurrent blood into, the sac or dilated artery, and, as they would 
 lie in the midst of inflamed and sloughing tissues, no attempt at in- 
 cluding them in a ligature could be successfully made. In such cir- 
 cumstances as these the danger of the patient would be considerably 
 increased by the irritation and inflammation that would be occasioned 
 by laying open and searching for the bleeding vessel in the sac of an 
 inflamed, suppurating, and sloughing aneurism, and much valuable 
 time would be lost in what must be a fruitless operation, at the close 
 of which it would, in all probability, become necessary to have re- 
 course to disarticulation at the shoulder-joint, and thus to remove the 
 whole disease at once." 
 
 D. In the words of the same writer,^ "there is another form of 
 axillary aneurism that requires immediate amputation at the shoulder- 
 joint, whether the subclavian artery have previously been ligatured or 
 not; it is the case of diffuse aneurism of the arm-pit, with threatened 
 ■QT actual gangrene of the limb." 
 
 Different Methods. — Of the thirty-six different methods which 
 have l^een enumerated, most will be found to differ in some unimpor- 
 tant detail. Five methods will be described here, which will be found 
 suflieient, if modified when needful, for all cases. The circumstances 
 under whicli this amputation is performed do not admit of any one 
 
 * Loc. supra cit., p. 21t 
 
AMPUTATION AT THE SHOULDER-JOINT. 117 
 
 definite method being followed. Thus, after a railway accident or 
 gunshot injury, the soft parts will be destroyed on at least one sur- 
 face. In amputating for malignant disease, skin flaps must be made 
 use of, transfixion being usually inadmissible, as the muscles should 
 be cut as short and as close as possible to their upper attachments, to 
 minimize the risk of extension and recurrence. Instead of remember- 
 ing the length and size of differently named flaps, the surgeon will 
 have to be familiar with the anatomy of the parts, the position of the 
 vessels, and the best means of meeting hemorrhage. 
 
 The joint is so well covered that sufficient flaps can* nearly always 
 be provided, while the blood supply is so abundant that sloughing 
 very rarely occurs, and even if it do so, from the results of injury or 
 hospital gangrene, the tissues of the chest will come forward suffici- 
 entl}' to close the wound. The fact that the cavity of the axilla gives 
 good drainage below is of much importance. 
 
 The following methods will be described here : in the first two, skin 
 flaps are made; in the others (save in the Furneaux- Jordan method), 
 transfixion is made use of, in part at least. 
 
 i. By lateral skin flaps. The oval, or en raquette methods, 
 ii. Spence's method, 
 iii. Superior and inferior flaps, 
 iv. Superior or deltoid flap. 
 V. Anterior and posterior flaps, 
 vi. Furneaux-Jordan method. 
 
 Means of arresting Haemorrhage in Amputation at the 
 Shoulder-joint. — These are mainly two : 
 
 1; Pressure on tpie Subclavian. — I am of opinion that the more 
 the surgeon trusts to this plan solely, the more often will he have 
 cause to regret it. Pressure, however well applied at the first with the 
 thumb, aided by a padded key or a weight, is too often rendered un- 
 certain by the necessary changes in position of the limb "during the 
 operation, or by the pressure of assistants, a violent gush of blood at 
 the last showing to the surgeon that his confidence in the artery being 
 secured is misplaced. Furthermore, an assistant so used is neces- 
 sarily much in the way of the others aiding the surgeon. For the 
 above reasons I much prefer trusting to one or other of the two next 
 given. 
 
 2. Compression of the Inferior or Anterior Flap, and so of the 
 Vessels before they are cut (p. 123, Figs. 35, 36). 
 
 3. Ligaturing or twisting the Vessels on the Inner Aspect of 
 THE Limb before they are cut (p. 119, Fig. 33). 
 
 * In some cases of gunshot injury, it is necessary to get tlie chief flap from the 
 axillary region, and to bring this up and unite it to the cut margin of fekin over the 
 acromion. 
 
118 
 
 OPERATIONS ON THE UPPER EXTREMITY. 
 
 4. Securing the Vessels lower down, in the Furneaux-Jordan 
 Method (p. 125). 
 
 5. Use of an India-Rubber Band. — This is applied after the same 
 method as that fully given in amputation at the hip-joint. In my 
 opinion, it is unreliable, especially in those cases of accident in which, 
 the limb being mutilated high up, this operation is chiefly required. 
 For in these the band, being applied under the axilla and across the 
 body, slips up as soon as the head is disarticulated, allowing of 
 bleeding from the vessels, and coming, itself, most inconveniently into 
 the way of the operator. 
 
 i. Lateral Flaps— Oval— En Raquette (Figs. 32 and 33).— 
 
 The method of lateral fiajjs, or the above modifications of it, are those 
 which the student is especially recommended to practice. The fol- 
 
 FiG. 32. 
 
 lowing are the advantages : («) Cutting from without inwards, and by 
 lateral flaps, the surgeon can leave the internal one to the last, expose 
 the vessels by cutting down upon them, and secure them before going 
 farther. (/3) One flap can be cut long and the other short, according 
 to the soft parts available. (7) Part of the incisions in this method 
 may be made use of to explore the condition of the shoulder-joint in 
 cases where the surgeon is in doubt whether excision or amputation 
 will be the wiser course ; and again, this method is easily employed 
 after failure of excision by an extension of the incision of the above 
 operation. 
 
 Tlie methods of arresting ha?morrha.ge are given at j). 117. The 
 patient 1 icing propped up sufficiently, brought to the edge of the table, 
 and rolled over to the opposite side, the surgeon, standing outside the 
 
AMPUTATION AT THE SHOULDEK-JOIN'J'. 
 
 119 
 
 abducted* limb on the right side, and inside it on the left, and havinfr 
 marked with his left forefinger and thumb a point just below and out- 
 side the coracoid process, and a corresponding point behind in the 
 mid-axilla (Fig. 32), then reaches over, and, entering the knife in the 
 axilla, close to the thumli, cuts an oval flap, about 4 inches long, con- 
 sisting of skin and fascia;, from the outer side of the limb, and ending 
 close to his thumb. Without removing the knife, the surgeon next 
 marks out a similar flap on the inner side, cutting from above down- 
 wards, commencing just below the finger, and ending where the outer 
 flap began in the mid-axilla. The assistant in charge of the limb aids 
 the above by rotating the limb into convenient position. The flaps 
 
 Fig 33. 
 
 Fig. 34. 
 
 t^f 
 
 Fig. 33. — Amputation at the shoulder-joint by lateral flaps. These are turned aside while the 
 axillary artery is secured by torsion before disarticulation is completed. 
 Fig. 34. — Amputation at the shoulder-joint by Spence's method. (Stimson.) 
 
 are then dissected up and held out of the way. The vessels are next 
 exposed, sejDarated from the surrounding nerves, and secured, either 
 by applying two pairs of torsion-forceps (Fig. 33), dividing the vessel 
 between them and twisting both ends, or by passing an aneurism 
 needle, loaded with carbolized silk or chromic gut, under the artery, 
 and thus securing it with a ligature. The limb being then carried 
 across the chest, the outer part of the capsule is freely opened by 
 cutting on the head of the bone and the muscles attached to the great 
 
 * Three assistants are required in an amputation at tlie shoulder-joint — (1) To 
 manipulate the limb; (2) To grasp the artery in the inner or inferior flap, if desired ; 
 (3) To be ready with sponges or instruments. If it be desired to have the subclavi.'in 
 controlled, this must be done by No. 3, p. 117. If short-handed, the surgeon will 
 manipulate the limb himself. 
 
120 . OPERATIONS ON THE UPPER EXTREMITY. 
 
 tuberosity thoroughly severed. The limb is next rotated outwards, 
 and the subscapularis tendon severed ; the biceps tendon being cut 
 and the capsule freely opened, the joint is well oj^ened on the inner 
 side. The head being then dislocated,* by the assistant pressing the 
 elbow forwards and against the side, the knife is passed from the 
 outer side behind the dislocated head, and, being kept close to the 
 inner side of the bone, is brought out through the structures on the 
 inner aspect of the arm, care being taken, as the knife cuts its way out, 
 that it does so below the point where the large vessels have been 
 secured. 
 
 ii. 'Spence's MetllOd (Fig. 34). — This modification of the oval 
 method is especially suited to cases of failed excision,! or to cases of 
 injury — e.c/., gunshot — where the surgeon has to cut into and explore 
 the condition of the joint before deciding on excision or amputation. 
 By its means an excision can readily be converted into a disarticu- 
 latiiin, if this step is found needful. 
 
 Other advantages, but less important ones, are: 
 
 1. The posterior circumflex artery is not divided, except in its small 
 teniiinal branches in front, whereas, both in the large deltoid flap and 
 the double flap methods, the trunk of the vessel is divided in the 
 early steps of the operation, and, retracting, often gives rise to embar- 
 rassing haemorrhage. 
 
 2. The great ease with which disarticulation can be accomjjlished. 
 ?>. The better form and greater fulness of the stump. Prof. Spence 
 
 points out that, however excellent are the results soon after other am- 
 putations at the shoulder-joint, some time later the shape of the stump 
 is much altered, not merely from the atrophy common to all stumps, 
 but from retraction of the muscular elements of the flaps, the pecto- 
 ralis major retracting towards the sternum and the latissimus dorsi 
 and teres major towards the spine and scapula. By this tendency to 
 separation, a deep, ugly hollow results under the acromion. 
 
 The operation is thus described in Prof Spence's words :J " Sup- 
 posing the right arm to be the subject of amputation. The arm being 
 slightly abducted, and the head of the humerus rotated outwards if 
 possible, with a broad strong bistoury I begin by cutting down upon 
 the head of the humerus, immediately external to the coracoid pro- 
 
 * In any e:i;-e wliere the leverage of the hiinienis is wanting, owing to this bone 
 being brol<en liigh np, Ihe use of lion-forceps will facilitate disarticulation ; or the sur- 
 geon will follow (he expedient of Prof Syme, quoted by Sir J. Lister (Sysf. of Surg., 
 vol. iii. p. 712', and intrndnce his finger into a wound in the capsule, for the purpose 
 iif drawing down ihe head of the bone, so as tn gain access to its attachments. 
 
 t At the present day, in cases of failed excision, the surgeon will often prefer to 
 make use of the modification of the Furneaux-.Iordan method, p. 125. 
 
 t Lined, 1SC7, vol. i. p. 143; and Lect. on Surg., vol. ii. p. 662. 
 
AMPUTATION AT THE SHOULDER-JOINT. 121 
 
 cess, and carry the incision down, through the clavicular fibres of the 
 deltoid and pectoralis major, till I reach the humeral attachment of 
 the latter muscle, which I divide. I then, with a gentle curve, carry 
 the incision across and fairly through the lower fibres of the deltoid 
 towards the posterior border of the axilla, unless the textures be much 
 torn. I next mark out the line of the lower part of the inner section 
 by carrying an incision, through the skin and fat only, from the point 
 where my straight incision terminated, across the inside of the arm, to 
 meet the incision at the outer part. This insures accuracy in the line 
 of union, but is not essential. If the fibres of the deltoid have been 
 thoroughly divided in the line of incision, the flap so marked out can 
 be easily separated (l>y the point of the finger, without further use of 
 the knife) from the bone and joint, together with the trunk of the pos- 
 terior circumflex, which enters its deep surface, and drawn upwards 
 and backwards, so as to expose the head and tuberosities. .The ten- 
 dinous insertions of the capsular muscles, the long head of the biceps, 
 and the capsule are next divided by cutting directly on the tuberosities 
 and head of the bone, and the broad subscapular tendon especially, 
 being very fully exposed bj' the incision, can be much more easily and 
 completely divided than in the double flaj) method. By keeping the 
 large outer flap out of the way by a broad copper spatula or the finger 
 of an assistant, and taking care to keep the edge of the knife close to 
 the bone, as in excision, the trunk of the posterior circumflex is pro- 
 tected. Disarticulation is then accomplished, and the limb removed 
 by dividing the remaining soft parts on the axillary aspect. The only 
 vessel which bleeds is the anterior circumflex, divided in the flrst in- 
 cision, and here, if necessary, a pair of catch-forceps can be placed on 
 it at once. In regard to the axillary vessels, they can either be com- 
 pressed by an assistant before completing the division of the soft parts 
 on the axillary aspect, or, as I often do in cases where it is wished to 
 avoid all risk, by a few touches of the bistoury the vessel can be ex- 
 posed, and can then be tied and divided between two ligatures, so as 
 to allow it to retract before dividing the other textures."* 
 
 Surgeon-Major Porter, in his useful Surgeonh Pocket-book,^. 185, thus 
 describes a very similar operation which he accredits to Hamilton, of 
 the U. S. Army : " The arm lying nearly against the side of the body, 
 with a large bistoury an incision is commenced at the middle point of 
 the extremity of the acromion process, or two or three lines above this 
 point,t and carried perpendicularly downward 11 inch, the knife 
 
 * Wliere the limb is very muscular, Prof. Spence recommended to raise the .skin 
 and fat from the deltoid at the lower part, and then to divide the muscular fibres 
 higher up by a second incision, so as to avoid excess of muscular tissue. 
 
 t But, as pointed out in a foot-note below, p. 122, this carrying the incision above 
 the acromion may lead to the protrusion of this process through the wound. 
 
122 OPKRATIONS ON THE UPPER EXTREMITY. 
 
 being made to cut deeply until it touches the head of the humerus ; at 
 this point the knife is carried obliquely, and rather abruptly, out- 
 wards and downwards to the centre of the lower margin of the axilla 
 on the under surface of the arm ; in this second step of the incision, 
 the tissues are divided down to the bone until the axillary margin is 
 reached ; from this point to the termination of the incision, only in- 
 teguments are divided, so that we may avoid wounding the axillary 
 artery. The knife is again introduced over the head of the humerus, 
 at the point where the perpendicular incision became oblique, and it 
 is carried down upon the inside of the arm in the same manner as we 
 have described upon the outside. One assistant pulling asunder the 
 lips of the wound upon the top of the shoulder, while a second carries 
 the elbow slightly across the body, and rotates the head of the hu- 
 merus outwards so as to expose the capsule and long head of the bi- 
 ceps, the surgeon divides them, and at the same moment the head of 
 the humerus springs from its socket. The knife is then passed under 
 the head of the bone from above, and, as soon as the face of the in- 
 strument has fairly reached the surgical neck, an assistant, standing 
 at the head of the patient, pushes the thumbs of both hands into 
 the wound above the knife, while the fingers remain in the axilla. He 
 thus grasps and controls the axillary artery. The operation is com- 
 pleted by carrying the knife downwards close to the bone until the 
 apex of the integumentary wound in the axilla is reached, and then 
 cutting almost directly outwards. Care must be taken not to sever 
 the parts containing the artery until the knife has arrived atthe.lower 
 margin of the axilla." 
 
 iii. Amputation by Superior and Inferior Flaps (Figs. 35 
 
 and 36). — The patient being brought to the edge of the table, turned 
 sufficiently over, and his shoulders supported by pillows, the assistants 
 are arranged as before. The arm being a little raised* so as to relax 
 the deltoid, the surgeon, standing inside the limb on the right side 
 and outside it on the left, lifts the deltoid muscle with his left hand 
 and sends the knife (narrow, strong, and no longer than needful) 
 across beneath the muscle, entering it on the right side, just below the 
 coracoid process, and bringing it ovit a little below the most prominent 
 part of the acromion,! or rice versa, according to the side operated upon. 
 The knife should pass close to the anatomical neck of the humerus, with- 
 out hitching upon it, and the flap should be cut broadly rounded, and 
 well down to the insertion of the deltoid. It is then raised and re- 
 tracted, and, the capsule being now exposed, the joint is opened by 
 
 * If tlie surgeon is short-handed, and especially if the limb is a small one, he can 
 nianipnlale the limb himself. 
 
 t Unless faro is taken to keep ihns below the acromion process, there will be some 
 tendency for this bone to protrude in the wound. 
 
AMPUTATION AT THE SHOULDER- JOINT. 
 
 123 
 
 cutting strongly upon the head of the bone. The arm being now ro- 
 tated upwards vigorously by an assistant or by the surgeon, the sul)- 
 scapularis, thus made loose, and the biceps are brought into view and 
 severed ; the limb is next rotated inwards, being carried across the 
 chest, and the muscles attached to the great tuberosity are divided. 
 The capsule is next still more freely opened, and the head of the bone, 
 now freed, is pushed up by the assistant and pulled away from the 
 glenoid cavity. The knife is next slipped behind the head (Fig. .3.5), 
 and cuts its way along the under aspect of the neck and shaft of the 
 humerus so as to shape an inferior flap half the length of the upper 
 one.* As soon as the knife is passed behind the bone, an assistant 
 
 Fig. 35. 
 
 Fig. 36. 
 
 ./*-/'>'' 
 
 To show the manner in which bleeding is controlled in the inferior 
 flap : the axillary vessels are compressed by one thumb, the posterior 
 circumflex by the other. 
 
 shps his hands in behind the back of the knife (Fig. 35), following it 
 so to grasp firmly the soft parts in the interior flap, and thus control 
 the axillary vessels (Fig. 86). 
 
 The large vessels are next secured, then the circumflex, and any 
 muscular branches that require it; any large nerves that need trim- 
 ming are then cut short, drainage provided, and the flaps brought into 
 position. 
 
 This amputation has the advantage of being very quickly done, and 
 of giving a flap which keeps in piosition by its own weight, and -thus 
 gives good drainage. If the soft parts below the humerus are much 
 damaged, the upper flap must be cut proportionately long. 
 
 * The snrgeon should not cut this till he is told tliat the flap is held firmly ; and, in 
 ending it, he must be careful of his assistant's fingers. 
 
124 
 
 OPERATIONS ON THE UPPER EXTREMITY. 
 
 iv. Amputation by Deltoid or Upper Flap.— This is merely 
 
 a modification of the last. The deltoid or upper flap may be cut by- 
 transfixion or made by cutting from without inwards. In either 
 case it must be of very full size, and thus is useful when the axilla is 
 damaged, but it has the disadvantage of leaving next to no flap in 
 which an assistant can seize the axillary vessels ; and, owing to the 
 powerful retraction of the muscles in the axillary folds, unless the up- 
 per flap is cut full in length and size it will not cover the resulting 
 wound. Finally, as the trunk of the posterior circumflex is cut, 
 sloughing of the large deltoid flap may take place, especially if the 
 tissues composing it are at all damaged previous to the amputation. 
 Owing to these disadvantages, which outweigh the rapidity of disar- 
 ticulation possible by this method, amputation by a deltoid flap alone 
 is not to be reconimended, a short under flap being always cut if pos- 
 sible, the deltoid flap thus not needing to be made so long. When 
 the surgeon, having disarticulated, is cutting straight down, unable to 
 make any flap below, assistant (2) should try to draw up the skin of 
 the axilla, while assistant (3), in charge of the limb, should be careful 
 not to draw down the skin, otherwise, owing to the laxity of the skin 
 in the axilla, any downward traction will bring the skin of the thoracic 
 wall under the knife. 
 
 V. Amputation by Anterior and Posterior Flaps (Fig. 
 
 37). — The position of the patient being as before, and the limb being 
 
 Fig. 37.* 
 
 (Furgussoii.) 
 
 carried somewhat upwards, Itackwards, and outwards, the surgeon, 
 standing, if on the left side, behind and outside the shoulder, enters 
 
 * The knife in tliis drawing is represented as far too large. 
 
AMPUTATION AT THE SHOULDER-JOINT. 125 
 
 his knife just in front of the posterior fold of the axilla, thrusts it 
 across the back of the humerus as near the head as possible, so as to 
 get in front of the tendons of the teres major and latissimus dorsi, and, 
 bringing it out close to the acromion, cuts, with a sawing movement, 
 a flap, 4 to 5 inches long,* which is next well retracted by an assist- 
 ant. The arm being then carried across the chest, the joint is freely 
 opened behind, the muscles attaclied to the tuberosities severed, the 
 knife passed between the head and the glenoid cavity (to facilitate 
 this, the limb should now be carried over the chest, and the head of 
 the bone pushed backwards), then between the bone and the pector- 
 alis major, and an anterior flap,t 4 inches long, cut from within out- 
 wards. Hemorrhage from the large vessels is arrested either by an 
 assistant grasping this flap as it is cut, much as at p. 123, or by the 
 surgeon isolating the axillary vessels (the biceps and coraco-brachialis 
 will guide him) and securing them by torsion or ligature (Fig. 33) be- 
 fore he completes the operation by cutting the anterior flap. When 
 operating on the right limb, the patient being turned well over on to 
 his left side, the surgeon, standing here inside the arm, which is held 
 upwards and backwards so as to relax the deltoid, lifts this muscle 
 up with his left hand, and then passes his knife from just below the 
 acromion, transfixing the base of the deltoid, grazing the back of the 
 humerus, and finally thrusts the point downwards and backwards 
 through the skin till it comes out at the posterior margin of the axilla. 
 This flap, 4 or 5 inches long, should be dissected up, the joint opened 
 behind, and the operation completed as before. 
 
 vi. Furneaux-Jordan Method.— This may be made use of both 
 as a primary and a secondary amputation. The following are suita- 
 ble cases : 
 
 a. Certain cases of injur3\ Where, though the parts about the 
 shoulder-joint are intact, the humerus is badly split up into the joint. 
 The soft parts are divided down to the bone by the circular method, 3 
 to 4 inches below the axilla, the main vessel secured, and the humerus 
 then shelled out by a longitudinal incision along the outer and poste- 
 rior aspect of the limb, meeting the circular one at a right angle. 
 
 b. In cases of failed excision. Here, after amputation of the limb 
 by the circular method, the rest of the bone is turned out through the 
 excision wound prolonged into the circular one. 
 
 c. After amputation in the middle of the arm in some cases. E.g., 
 when the stump is the seat of osteo-myelitis, necrosis, or otherwise 
 does not do well. 
 
 * In the posterior flap will be the posterior part of the deltoid, the latissimus dorsi, 
 and teres major. 
 
 t In tliis anterior flap will be the remaining fibres of the deltoid, the pectoralis ma- 
 jor, and the large vessels and nerves. 
 
126 OPERATIONS OX THE CTPPER EXTREMITY. 
 
 EXCISION OF SHOULDER-JOINT (Figs. 38 and 39). 
 
 This operation is but rarely performed— (1) owing to the compara- 
 tive infrequency of diseases of the above joint, especially of pulpy 
 disease, usually so difficult to treat save by operative measures ; (2) 
 from the fact that epiphysitis and septic synovitis usually give after 
 free incision and drainage as good a result as can be obtained after 
 operation. This is mainly owing to the fact that much of the stiffness 
 that otherwise would be present is made up for by the supplementary 
 mobility of the scapula, and thus the natural cure may be expected, 
 especially in young subjects, to give as good results as that after 
 excision.* 
 
 The above remarks naturally lead up to the consideration of the 
 amount of movement which is gained after the operation of excision . The 
 arm can never be abducted and elevated beyond the horizontal line; 
 in the majority of cases it hangs close to the chest. Even if the del- 
 toid retained its power of elevation, it could not exert it, as in most 
 operations, owing to the amount of bone removed, the fulcrum of the 
 head of the humerus against the glenoid cavity has been removed. 
 Prof. Longmore {Resection of the Shoiddcr-joint in Mditanj Snrc/enj. p. 12) 
 writes : " The loss of the elevating action of the deltoid must be ac- 
 cepted, like the loss of the rotating power from the division of the 
 muscular insertions into the two tubercles, as a necessary consequence 
 of resection of the head of the humerus. But the holding or support- 
 ing power of this muscle exerted upon the whole upper extremity ow- 
 ing to its position, its extensive origin, and the manner in which it 
 embraces and protects the mutilated parts, as well as its faculty of as- 
 sisting in carrying the arm backwards and forwards, are all functions 
 which may still remain, and serve to point to the great importance of 
 preserving its integrity as fully as possible. The wasting of the in- 
 ternal fibres (Fig.' 38), however, seems a necessary result of resection 
 by the single incision, but it has this compensating feature, that it is 
 a less serious loss to the patient than an atrophied condition of the 
 outer and posterior fibres would be, because the upper clavicular fibres 
 of the great pectoral can take the place of the^ inner deltoid fibres to a 
 considerable extent in supporting the shoulder and drawing it forwards 
 to the chest." 
 
 Mr. Erichsen (Surgery, vol. ii. p. 251) sa3's of the four natural move- 
 ments of the shoulder-joint — viz., " (1) abduction and elevation, (2) 
 adduction, (3) and (4) movements in the antero-posterior direction — 
 
 * In future, by the use of a simple longitudinal incision with a minimum of inter- 
 ference with the deltoid, aided by antiseptic precautions from the first, and with earlier 
 and persevering adoption of passive movements, the above statement may have to be 
 reversed. 
 
EXCISION OF THE SHOTJLDER-JOIKT. 127 
 
 these are requisite in all ordinary trades for the guidance of the hand 
 in most of the common occupations of life. The movements of eleva- 
 tion are seldom required save by those who follow climljing occupa- 
 tions, as sailors, masons, etc. Now, the mode of performing the 
 operations, as well as the operation itself, will materially influence 
 these different movements. Thus, if the deltoid be cut comjdetely 
 across by means of an elliptical incision the power of abduction of 
 the arm and of its elevation will be permanently lost. If its fibres be 
 merely split by a longitudional incision, they may be preserved or 
 regained in great part. All those movements of rotation, etc., which 
 are dependent on the action of the muscles that are inserted into the 
 tubercles of the humerus will be permanently lost; for, in all cases of 
 caries of the head of the humerus requiring excision, the surgeon will 
 find it necessary to saw through the bone below the tuberosities — in 
 its surgical, and not in its anatomical, neck.* Hence the connections 
 of the supra-spinatus and infra-spinatus, the teres minor, and sub- 
 scapularis will all be separated, and their action on the bone after- 
 wards lost. But those muscles which adduct, and Avhich give the 
 autero-posterior movements — viz., the coraco-brachialis, the biceps, 
 the pectoralis major, latissimus dorsi, and teres major — will all be pre- 
 served in their integrity ; and hence it is that the arm, after this ex- 
 cision, is callable of guiding the hand in so great a variety of useful 
 under-handed movements." 
 
 Indications. 
 
 i. Different forms of arthritis disorganizing the joint, resisting care- 
 ful treatment, in subjects whose age, general condition, etc., are satis- 
 factory — viz. : 
 
 (a) Pulpy synovitis, resisting other treatment and going on to 
 
 caries. 
 (iS) Synovitis after rheumatic fever, gonorrhoeal rheumatism, 
 wrenches, etc., resulting in crippling ankylosis in a 
 young subject, 
 (y) Ostitis going on to suppuration, caries, etc. 
 {S) Epiphysitis, suppurating or acute necrosis, where discharge, 
 sinuses, etc., are exhausting the patient, and the out- 
 look as to natural cure is not good, 
 (s) Disease of the deltoid bursa ulcerating into the joint and 
 setting up destructive arthritis, 
 ii. Gunshot injuries, where the large vessels and nerves have escaped, 
 where fragments of shell, bullets, etc., are lodged in the head of the 
 
 * With all proper deference to tlie opinion of Mr. Ericlisen, this opinion appears to 
 be too definite and inelastic. I wonld refer the reader to the remarks below on the 
 site of section of the bone, and on partial resection (p. 134). 
 
128 OPERATION'S OX THE UPPEK EXTREMITY. 
 
 bone, especially if the shaft of the bone is not much damagefl (p. 
 137). 
 
 iii. Compound dislocation and compound fracture with much dam- 
 age to the capsule and cartilage of the head of the bone, the large ves- 
 sels and nerves being intact. 
 
 iv. Perhaps in cases of unreduced dislocation of the head of the 
 humerus. Mr. Holmes (.S'//.s/. of Surg., vol. iii. p. 738), in a foot-note, 
 writes: "I have often thought that, in cases of irreducible dislocation 
 attended with much pain, the removal of the head of the bone might 
 be justifiable, but have not met with any case in which the operation 
 has been performed." In the Syd. Hoc. Bienn. Retr. for 1861 is a very 
 brief extract of an American case in which excision was performed 
 for an old dislocation on to the dorsum of the scapula. The result is 
 not given. Sir J. Lister {Ed. Med.. Jovrn., March, 1873) excised the 
 head of the humerus after securing a rujjture of the axillary artery, 
 which vessel had given way in an attempt to reduce a dislocation of 
 seven weeks' standing. The patient sank quickly. Considering the 
 frequenc}' with which this accident has taken place in attempting to 
 reduce old dislocations of the shoulder, it would be wiser, in these days 
 of antiseptic surgery, to attempt to improve the condition of things by 
 excising the displaced head. (While these sheets are passing through 
 the press, Mr. Sheild has published a most successful case.) 
 
 V. Perhaps in a few cases of growth connected with the upper extrem- 
 ity of the humerus. Whilst the priceless value of the hand fully jus- 
 tifies the attempt in some instances, such cases admitting of excision 
 must be extremely rare. 
 
 Perhaps it is owing to this rarity that this matter has received so 
 little attention. 
 
 The best reported English case with which I am acquainted is one 
 in which Mr. Mitchell Banks* endeavored to save the upper extremity 
 of a patient by excising the upper end of the humerus, the site of 
 enchondroma ; 
 
 " S. D. was a spare, placid man of fifty-six, a chapel-keeper. So far 
 back as the summer of 1865 he was seized with violent pain near the 
 right shoulder, and after that came a hardness and swelling at the top 
 of the humerus, which very slowly increase<l. As it gave him no great 
 inconvenience, he did not heed it much for many years, but )>y 1878 
 it had grown to be as big as a cocoanut, so that, on attempting to raise 
 the arm, it became locked against the acromion, limiting movement, 
 while pain of a severe character set in. In June, 1878, the tumor was 
 
 * Clinlral Notes upon Two Yearx' Surgical Work in the Lim-pool Royal Lijiniuiry, p. 6. 
 It is much to be desired that this original and rao.st instructive writer would give to the 
 profession, wilh equal vigor and terseness, some more of his experience. See also a 
 successful case of resection for a central sarcoma, Southam, Med. Chron., .January, 1887. 
 
EXCISION OF THE SHOULDER- JOINT. 129 
 
 removed by cutting down upon it, and dissecting off the tissues from 
 over it. As it grew from the outer surface of the upper third of the 
 humerus, this was effected without difficulty. Then with a mallet and 
 chisel it was cut cleanly away from the bone, and the surface from 
 which it sprang was thoroughly scraped — a pretty broad surface, by- 
 the-way. I left no cartilaginous remains that could be seen. The 
 patient rapidly recovered, but in the tract of the wound a sinus or two 
 persistently remained, leading down to the bone. After the lapse of 
 about two years it became clear that the tumor was returning, and by 
 the summer of 1881 — three years after the first operation — it had attained 
 an immense size, having taken a fit of growing during the last few 
 months. It clearly arose from the same site as before, but now it filled 
 up the axilla, and had even "got beneath the great pectoral. Pain and 
 rapidity of growth demanded its speedy removal. But removal of a 
 whole right arm at the shoulder-joint seemed such a dreadful thing, 
 that one was anxious to save a hand and forearm by carrying away, 
 if possible, the tumor and upper part of the humerus, even although 
 the upper arm might remain useless. The joatient being made well 
 aware that, in case of the failure of this project, there was nothing left 
 but amputation, I attempted it. The incisions necessary to lay bare 
 the tumor were very extensive, the chief one reaching from above the 
 acromion, half way down the outer side of the upper arm. With 
 much trouble, and after the loss of a great deal of blood, the outer and 
 upper surfaces of the growth were exposed, and the humerus was dis- 
 articulated from the scapula. Then, sawing through the humerus, 
 about 1 inch below the deltoid insertion, I attempted to dissect away 
 the tumor from the brachial vessels and nerves. Here, however, 
 most serious difficulty was encountered, from their intimate incor- 
 poration with the growth, and at last, after a prolonged attempt, I was 
 reminded by my colleague, Mr. Harrison, that the patient had plainly 
 endured as much as he could, and that to make further effort might 
 only lead to collapse on the table. I was reluctantly compelled to ad- 
 mit this, and so rapidly swept the limb away at the shoulder. So 
 profound was the shock, that a short time after the operation the tem- 
 perature fell to 95°, and remained so for many hours. The operation 
 was conducted antiseptically, and the patient, in spite of the loss of 
 blood, made such a rapid recovery that on the twenty-third day he 
 left the infirmary quite well, and remains so now, two years after the 
 amputation. If the great vessels and nerves had not been so seriously 
 enveloped by the growth, the limb would have been saved, although 
 with the loss of the upper half of the humerus. But even a forearm 
 is better than no arm at all. The case also shows that chiselling off 
 cartilaginous tumors is not by any means a certain removal. The 
 surface that was left upon the humerus, after the first removal of the 
 
 9 
 
130 OPERATIONS ON THE UPPER EXTREMITY. 
 
 tumor, looked perfectly healthy to the naked eye, but there must 
 have been cartilage cells deep down in the tissue of the bone."* 
 
 Mr. J. Hutchinson has recordedf a case of resection of the upper 
 part of the humerus for a large myeloid growth. The following is a 
 summary of the case : Supposed fracture of the neck of the humerus 
 in a woman, aged twenty-seven. Permanent loss of movement and 
 gradual enlargement above the part. Amputation at the shoulder- 
 joint advised fourteen months after the accident, on account of a large 
 tumor which formed — refused by the patient. Arrest of the growth 
 for four years. Subsequent rapid growth and enlargement of glands. 
 Resection of the upper third of the humerus, and removal of the dis- 
 eased glands. Recovery, with a useful arm, but rapid reproduction of 
 the disease in four different parts. Death, five months after the resec- 
 tion, from an enormous mass, with sloughing and bleeding. Second- 
 ary growths connected with the bone, axilla, cervical glands, and 
 lung. 
 
 The operation of resection was only performed because amputation 
 was again refused. The account is suVjjoined : " Two long incisions 
 having been made, meeting at an apex a little below the insertion of 
 the deltoid, the flap of skin, which was triangular, and had a broad 
 base over the shoulder, was dissected up. This flap consisted merely 
 of skin, for the deltoid was found inseparably involved in the growth, 
 excepting at its borders. At the posterior part the skin also adhered 
 to the growth, and a second curved incision, including a crescentic 
 portion of it, was accordingly made adjoining into the outer side of 
 the triangle above and at its apex. This done, the upper surface of 
 the growth was well exposed, and the next step consisted in sawing 
 through the shaft of the humerus at the commencement of its middle 
 third, which was accomplished by means of a Hey's saw, the soft 
 parts being held away by retractors. The lateral connections of the 
 mass were next freed — a dissection requiring much care, as the vessels 
 and nerves were embedded in a deep furrow, formed by projecting 
 nodosities of the growth. Before accomplishing the disarticulation, it 
 was found necessary to saw away the acromion and the coracoid pro- 
 cess, and even then it was not done without much difficulty, on ac- 
 count of the tumor, in its growth upwards, having embraced the artic- 
 ular head of the scapula, which was firmly lodged in a cup at least 1 
 inch in depth. Only one vessel required ligature (the posterior cir- 
 cumflex) ; it was of large size, and had been divided very near to the 
 main trunk. The bleeding had, throughout, been but slight, and the 
 patient, when returned to bed, was in very good condition. The large 
 
 * The other cases of enchondi-oma of the upper exlremity of the humerus treated by 
 excision of the joint are alluded to below, 
 t Path. Soc. Trana., vol. viii. p. 346. 
 
EXCISION OF THE SHOULDER- JOINT. 131 
 
 mass of glands from the infra-axillary space had been removed hy a 
 second incision, which did not join that for the resection of the bone. 
 A length amounting to about one-third of that of the shaft of the hu- 
 merus having been removed, the arm was greatly shortened. There 
 was no difficulty, however, in lifting the elbow up, so that the upper 
 part of the humerus, where sawn across, came nearly in contact with 
 the glenoid cavity, and in this position it was retained by a band- 
 age." 
 
 In the following case,* the growth being a more innocent one, re- 
 section was more successful : 
 
 A farmer had a swelling in the deltoid region, about the size of a 
 hen's egg, very hard, and considered to be an exostosis. In the course 
 of a year it grew rapidly, and the shoulder now measured 17 inches 
 in circumference. Excision of the head of the humerus was performed, 
 the bone being sawn through at the insertion of the deltoid, the mus- 
 cles severed, including the pectoralis major and latissimus dorsi, the 
 tendon of the biceps being preserved. Sixteen months later the pa- 
 tient could " plant corn as well as any man." There had been a slight 
 reproduction of bone up to within 2 inches of the glenoid cavity, a 
 narrow strip of periosteum having been preserved along the inner sur- 
 face of the bone almost up to its neck. The shortening of the limb 
 amounted to nearly li inch. The length of bone removed, including 
 the head, measured 3J inches. The growth was 13 inches in circum- 
 ference at its largest part, and proved to be an enchondroma.f 
 
 Methods.! 
 
 i. By a straight incision (Figs. 38 and 39). 
 
 ii. By a deltoid flap. 
 
 The first need only be referred to at any length here. The deltoid 
 flap gives more room, and thus facilitates the operation considerably, 
 but the larger scar, and far greater, in fact almost total impairment of 
 deltoid jaower, are such serious drawbacks! that it is nowadays hardly 
 
 * Dr. Bennett, Amer. Jour. Med. &i'., 1863, vol. ii. p. 385. He, qnoting from Hodge's 
 Excision of Joints', states tliat four oases of excision of tlie shoulder for growths are there 
 given. Three were cases of malignant disease, and were all nnsnccessfnl, the patient 
 either dying soon after the operation, or later on from i recurrence. The snccessful 
 case was one operated on by Mr. Bickersteth, for an exostosis which impeded the move- 
 ments of the joint. 
 
 t Fnrther information of this case would have been very valuable. In two of the 
 cases in which Prof. Syrae excised the scapula, he had previously excised the head of 
 the humerus. In one, the growth was fibro-cartilaginons, and recurrence did not take 
 place for a year and three months. In the other, the nature of the growth, a cystic 
 one, is not specified ; recurrence here also took place, about a year later 
 
 X Fourteen ditTerent methods are figured by M. P6an, he. infra eit. 
 
 I Prof. Longmore (loc. supra eit. p 9) says that at one time there were at Fort Pitt 
 two patients, in each of whom resection of the joint had been performed, in one by the 
 
132 
 
 OPERATIONS ON THE UPPER EXTREMITY. 
 
 ever used. If the head of the humerus is very much shattered, if the 
 soft parts are much matted and thickened, if there is any special 
 reason for completing the operation rapidly,* this method may, though 
 very rarely, be made use of. 
 
 The patient being rolled a little over, and the shoulder supported 
 by a pillow, the surgeon, standing at the shoulder facing the body, 
 with an assistant facing him, and another seated to manipulate the 
 limb, makes an incision, 3 inches long, commencing just outside the 
 
 Fig. 38. 
 
 Excision of .shoulder-joint by a straight incision placed just outside the coracoid process. As 
 only the anterior part of the deltoid is cut, the posterior circumflex and the circumflex nerve 
 are less damaged. (Piian.f) 
 
 coracoid process, and on a level with it, through skin and fascise ; the 
 deltoid is then divided for the same length, and, if the arm has been 
 rotated outwards, the bicipital groove will be seen lying at the bottom 
 of the wound. The condition of this important tendon will vary 
 much : (1) it may be normal ; (2) it may be surrounded with pulpy 
 
 longitudinal, in the other by the flap, incision. In the former case, the patient could 
 raise, without difBculty, | hundredweight with the arm in an extended position by his 
 side, and hold 14 pounds in his hand wlien the arm was flexed. In the latter case, all 
 the movements of the joint were very seriously impaired. The man could not, in any 
 degree whatever, move the arm from the side himself, nor could he flex the forearm 
 upon the upper arm without support from the other hand. 
 
 * Perhaps, too, in the rare cases of excision attempted for large growths, for the 
 sake of more complete exposure (p. 128). 
 
 f J. P^an, Be la Scapulalgie, el de la Resection scapulo-humerale (Paris, 1860.) 
 
EXCISION OF THE SHOULDER-JOINT. 
 
 133 
 
 material; (3) it may be frayed an;l adherent to the bone; (4) it may 
 be ulcerated or absent. Whenever it is possible to preserve it, it should 
 be carefully separated from its groove and drawn aside with a blunt 
 ^hook. The capsule is next to be freely opened, and, the arm being 
 strongly rotated outwards, the sub-scapularis is divided ; then, after 
 rotation inwards, the three muscles attached to the great tuberosity are 
 cut through, and the capsule still more freely opened. 
 
 The bone may be divided in two ways : (1) In situ (Fig. 39). A 
 blunt director is passed under the bone from within outwards, so as to 
 
 Fig. 39. 
 \ 
 
 i^ 
 
 Kn^\ 
 
 V 
 
 protect the soft parts ; the bone is sawn through with a narrow-bladed 
 or osteotomy saw, seized with lion-forceps, and twisted out, the lever- 
 ing movements of an elevator, or a few touches of the knife, aiding 
 this. (2) The head is first thrust out of the wound, and then sawn off. 
 This method is somewhat the easier, but disturbs the soft parts more.''^ 
 The former is perfectly safe, and inflicts less damage on the surround- 
 ing tissues ; finally, where ankylosis is present, it may be most diffi- 
 cult to thrust the head out.f Whichever is adopted, the soft parts 
 should be scrupulously protected. 
 
 * It must not be forgotten that these soft parts are largely made up of important 
 nerve cords. I have seen this operation followed by tetanns in a case in which the 
 surgeon was obliged to rely on most inadequate instrnments. 
 
 t In one of M. OUier's cases, as the head of the huraerns wag beingthrust outthrough 
 the wound, the bone, which was very fragile, was broken across just above the condyles. 
 This accident ultimately exercised no untoward influence on the result. 
 
134 OPERATIONS ON THE UPPER EXTREMITY. 
 
 Site of Section. — It being most important to leave the humerus as 
 long as possible, not an atom more than is needful should be removed. 
 The section should be made just below the articular surface in every 
 case where this will remove the whole of the disease, and where all the 
 head mast go. The advantages of sawing here over division through 
 the surgical neck are — (1) A longer humerus is left to be brought 
 against the glenoid cavity, and aid as a fulcrum the action of the del- 
 toid in elevating the arm. (2) The section is made within the capsule, 
 after, of course, freely opening this, but not damaging its attachments 
 to the neck of the bone. (3) The tendons in the bicipital groove are 
 less likely to be interfered with. 
 
 Mr. Davies Colley (Guy's Hosp. Reps., 3d series, vol. xx. p. 525) re- 
 lates a case of partial resection of the head of the humerus followed 
 by unimpaired movement of the joint. As at the time of the operation 
 a portion of the head of the humerus seemed healthy, and the disease 
 consisted chiefly of a carious erosion of the great tuberosity and the 
 adjacent 23ortion of the articular surface, these portions only were re- 
 moved, without dislocating the head of the bone. The part removed 
 was chiefly the articular surface above the greater tuberosity, together 
 with what remained of that process. The lesser tuberosity appeared 
 not to have been touched. About three-fifths of the articular surface 
 was left, being healthy. There was some erosion of the bone below 
 the epiphysial line, but the greater part of the disease was situated in 
 the epiphysis. The section of the bone was hard. Seven months later 
 the movement of the joint was " perfect in every direction. He swings 
 the arm round above his head, and rotates it, and performs every ac- 
 tion with as great freedom and rapidity as with the left shoulder-joint." 
 On this matter of partial excision of the head of the humerus, the re- 
 marks at pp. 133, 135, should be referred to. 
 
 If the disease extends lower down, gouging may be resorted to, or, 
 if needful, one or two further sections* may be made till healthy tis- 
 sue is reached, but, as in the case of the elbow, periosteal deposits or 
 roughenings, which will subside when the irritation is removed, must 
 not be mistaken for disease which calls for extirpation. 
 
 The glenoid cavity is then examined, and gouged if carious. Cases 
 where its complete removal is called for must be most rare. If really 
 called for, it may be effected by an osteotome, or by cutting bone-for- 
 ceps ; but taking away the glenoid cavity must interfere with the at- 
 
 * In cases of gunshot injury, splinters of head or shaft will have to be carefully re- 
 moved, and the point determined whether the shaft is extensively split towards the el- 
 bow. This is often very difficult to determine, because a longitudinally fractured shaft 
 may be maintained in an apparently nnfractured condition by the close apposition rf 
 the fragment* and by (he periosteum, etc. 
 
EXCISION OF THE SHOULDER JOINT. 135 
 
 tachments of the bicepp and triceps, and cause risk by the opening up 
 of additional cancellous tissue. 
 
 Any vessels which require it are then secured — e.g., branches of the 
 posterior circumfiex artery. Sinuses are then examined, pulpy tissue 
 scraped out with sharp spoons, drainage provided, and the upper 
 part of the wound closed. It is well, in inserting the drainage-tube, 
 to make a counter-jDuncture at the back of the upper arm, so tliat 
 the site of tlie operation may be well drained while the jDatient is 
 recumbent. 
 
 The patient for the first few days should have his shoulder supported 
 on a pillow, and wear a large pad, 5 to 6 inches thick at its base, in 
 his axilla. By the end of the first week he should be sitting up, still 
 wearing the pad, and after a fortnight, earlier if possible, passive 
 movement should be begun. The fingers and elbow should be gently 
 moved from the very first. Electricity, shampooing, encouraging the 
 patient (if in a hospital) to sweep with a short brush, carry weights, 
 constantly practice lifting the arm — anything, in short, which prac- 
 tices the patient in using the arm and new joint — should be persever- 
 ingly made use of. 
 
 Question or Sub-periosteal Resection. — As one of the chief draw- 
 backs of the ojjeration is the poor amount of abduction and elevation 
 which remains, owing in large measure to the humerus being too short 
 to be brought into the glenoid cavity when the deltoid acts, I think 
 that in this joint a trial of the sub-periosteal method should be care- 
 fully made, to insure as much reproduction of bone as possible. Mr. 
 Holmes (System of Surgery, vol. iii. p. 741), it is true, does not have a 
 high opinion of this method. " I do not find any clear proof, in the 
 recorded experience of operators who practice sub-periosteal excision, 
 that more extensive movement is obtained after that than after the 
 ordinary method. Nor does it seem probable that it should be so. 
 The power to elevate the arm above the horizontal line depends on the 
 rotation of the scapula, Avhich carries with it the humerus, the two 
 bones being for the moment consolidated in consequence of their 
 perfect apposition in the joint. When the joint is destroyed, and a 
 ligamentous connection between two irregular bony surfaces has been 
 substituted for it, such a consolidation is impossible, and the rotation 
 of the scapula will no longer elevate the humerus. Unless we could 
 believe that the globular head of the humerus were reproduced, we 
 could not expect that the power of elevation would be regained. M. 
 Oilier speaks as if this reproduction were the normal result of sub- 
 periosteal resection, but he refers to no dissection." Urging, as I 
 would very strongly, the importance of giving the sub-periosteal 
 method a full trial in this excision, I would point out that M. P^an 
 iloc. mpra cit. p. 51 et seq.) quotes Textor as finding, eleven years after 
 
136 OPEEATIONS ON THE UPPER EXTEEillTY. 
 
 an excision of the shoulder, " a new fibrous capsule. This, hard and, 
 as it were, fibro-cartilaginous, surrounded, by its inner surface, the up- 
 per fourth of the humerus, and embraced it so firmly as to be separa- 
 ted with difficulty ; by its outer face it was blended, by the intervention 
 of fibrous tissue, with the structures surrounding the joint, and par- 
 ticularly with the deep surface of the deltoid and the cicatrix in the 
 soft parts." Allusion has already (p. 69) been made to the complete- 
 ness of the capsule which may be met with after excision elsewhere. 
 V. Langenbeck (Arch. f. klin. Chir., 1874, vol. xvi.) gives more than one 
 case in which the arm could be raised vertically, and the movements 
 were excellent. While it is true that these were cases of resection for 
 gunshot injury, and therefore the patients probably healthy adults ; 
 on the other hand, preservation of the periosteum is not likely to be so 
 easily effected here as in those cases where it is softened by disease. 
 Even if the periosteum cannot be completely preserved, an additional 
 i inch or inch in length gained, an irregular knob or nodule-like mass 
 which may be moulded into a rudimentary head within the new cap- 
 sule, may make much difference in the future mobility and usefulness 
 of the limb. 
 
 In carrying out the sub-periosteal method, v. Langenbeck and Oilier 
 (Traite de la Regeneration dei On, et des Resections eles grandes Artictda- 
 tions ; 1867), after the deltoid has been divided longitudinally by an 
 incision very similar to that already given, and the edges of the mus- 
 cle retracted, raise the periosteum on the inner side of the bicijDital 
 groove up to the inner tuberosity, and then peel off the tendon of the 
 sub-scapularis, every care being taken to keep as intact as possible the 
 connections of this tendon with the periosteum and capsule. When 
 this has been done, and the bone denuded as far as possible on the 
 inner side, the outer side and outer tuberosity are treated in the same 
 way, and with the same precautions. To facilitate the above, the bi- 
 ceps tendon is drawn aside, and the humerus forcibly rotated, first out 
 and then inwards. 
 
 Amount op Bone that may be Removed. — This will mainly depend 
 upon the amount of damage done to the periosteum, the possibility of 
 retaining it entire, the age of the patient. Dr. ^laclaren (Lancet, June 
 7, 1873) removed the head and 31 inches of the upper end of the hu- 
 merus with an excellent result. 
 
 Langenbeck mentions a case in which the whole shaft of the hu- 
 merus necrosed, and was removed, the elbow joint being resected at 
 the same time, and yet the reproduction of bone was so complete that 
 the shortening was no more than If inch. The patient was young, 
 and growth went on, though the bone remained behind its fellow. 
 The new humerus broke several times, but the movements of the 
 
EXCISION OF THE SHOULDER-JOINT. 137 
 
 shoulder and elbow were very satisfactory, and the hand was capable 
 of most delicate movements. 
 
 Prof. Billroth ( 117^. Med. Bldtt, iMarch 20, 1884 ; Lond. Med. Rev., 
 1884, p. 197) gives the case of a patient, aged twenty, in whom the 
 whole of the right humerus was removed when he was twelve. Though 
 the periosteum was carefully left intact, the bone did not form again. 
 Yet the forearm was well developed, and, by means of an ingenious 
 splint and an artificial shoulder-joint, the patient could use his arm 
 and hand well. Cf. the remarks on excision in continuity of the shaft 
 of the humerus, p. 101. 
 
 Excision of Shoulder in Military Surgery. — The following 
 points of practical importance are taken mainly from the Med. mid 
 Surg. History of the War of the Rebellion, pt. ii. p. 519 et seq. Dr. Otis 
 here draws conclusions from the histories of 885 cases, 670 being for 
 direct injury, and 215 for fractures in near proximity to the joint or 
 for consecutive caries or necrosis. 
 
 Excision of the head of the humerus, together with portions of the 
 clavicle and scapula — e.g., acromion, spine, coracoid process, glenoid 
 cavity — was performed in forty-two cases. It is remarkable that the 
 mortality is less in this group than in that of simple removal. The 
 following remarks are quoted from Lcjeffler : Fracture of the glenoid 
 cavity is especially frequent in shot injuries of the shoulder. This 
 complication makes the jarognosis of excision more serious, but is not 
 a contraindication. If only fissures are present, the glenoid cavity 
 should not be removed. Tedious burrowing of pus is very likely in 
 these cases. 
 
 Partial excision of the head of the humerus was done in fourteen 
 cases. " The results do not prove that, when the head of the humerus 
 is grooved or grazed by a ball, it is safer to slice off the injured part 
 rather than to decapitate the bone. Ankylosis was too frequent 
 to permit much to be said in favor of partial excision in this 
 region." 
 
 Date of excision of shoulder. The primary cases were 273, the in- 
 termediate 55 in number, the results being far less satisfactory than in 
 the primary, '" and corroborating the general rule forbidding operations 
 during the inflammatory stage after injury, except under circum- 
 stances of exceptional urgency." The mortality was twice as great as 
 in the primary, and nearly 12 per cent, greater than in the following, 
 Secondary, twenty-six cases, with a mortality of 50 per cent. The 
 greater success of primary excision can well be understood. The con- 
 dition of the soft parts is much more favorable. There is no infiltration 
 or burrowing of pus, no softening of parts or degeneration of muscles, no 
 caries or ostitis — none, in fact, of those complications which, in sec- 
 
138 OPERATIONS ON THE UPPER EXTREMITY. 
 
 ondary excision, imperil the life and usefulness of the limb of the 
 patient.* 
 
 Excisions of the head and portions of the shaft of the humerus as 
 well, 293 cases, in 190 of which the precise length of bone excised was 
 specified. Thus, in twenty-three, 4 inches ; in eleven, 4i ; in seven, 5; 
 in two, 5J ; and in five, 7 or 8 inches were excised. While the arm 
 was shortened (there being very rarely any restoration of bone) and 
 feeble, the forearm and hand were usually most useful. Where the arm 
 was flexile and uncontrollable, an auxiliary apparatus, such as the 
 ingenious ones of Dr. Hudson .f brought about usually a great im- 
 provement. Dr. Otis (loc. sivpra cit. p. 611) states of shot-injury resec- 
 tions: "In the majority of cases that I have examined, motion in 
 flexion, extension, and abduction was tolerably well preserved. I 
 have met with no instance of true ankylosis. In a large proportion of 
 the cases, the functions of the forearm and hand were but slightly, and 
 in many not at all, impaired. Those who argue that the limb is use- 
 less after an excision at the shoulder because it dangles by the side 
 display a superficial appreciation of the considerations to be taken 
 into account. Apart from the inestimable value of even a partial use 
 of the hand, the mere weight of the limb, though its motor functions 
 be completely destroyed, is of advantage in preserving the equilibrium 
 of the body and avoiding the distressing deformity consequent on 
 ablation." 
 
 CHAPTER VII. 
 REMOVAL OP THE SCAPULA. 
 
 Indications. 
 
 1. New growths. 
 
 2. Necrosis. 
 
 3. Accidents — e.g., railway and machinery accidents. 
 
 * Dr. Otis quotes Riippreclit, one of the German authorities in the war of 1871, to 
 the s:\me effect : " The secondary operations were very much aggravated by deformi- 
 ties gradually appearing after the injury, through thicl<ening of the periosteum espe- 
 cially, and liy extensive cavities succeeding abscesses. Immediately after the operation 
 qven, healing was retarded by pus-formations, sometimes under the clavicle, in other 
 instances under the scapula, again on the anterior aspect of the arm. Aside from the 
 greater nmscular atrophy due to debility resulting from antecedent, tedious suppura- 
 tions, and to pain and loss of sleep; apart, also, from the abundant granulations at- 
 tending secondary operations, and resulting prejudicially in regard to the future use- 
 fulness of the limb, the disadvantages of secondary operations already adduced were of 
 sufficient importance to permit us to declare that primary resection of the ' houlder-joint 
 is preferable to the secondary operation." 
 
 f Loc. supra cit , Fig". 449, 453. 
 
REMOVAL OF THE SCAPULA. 139 
 
 As it is the first of the above which chiefly raise the question of re- 
 moval of the bone, and which present the greatest difliculties, it is to 
 removal of the scapula for new growths that most of the following re- 
 marks will apply. 
 
 Partial Removal of the Scapula.— In a very few cases (e.g., 
 
 for a simple exostosis, or where the surgeon is certain that he is deal- 
 ing with an unmixed enchondroma in an early stage) a more limited 
 operation may be sufficient. The chief essential points here are — (1) 
 to freely expose the growth by appropriate flaps, so that the limits 
 may be clearly defined ; (2) to be provided with reliable instruments 
 of keen temper, owing to the exceeding hardness which may be met 
 with here. 
 
 While some Continental writers* have given elaborate directions for 
 partial removal of the scapula, it is only in the above very few cases 
 that this operation is likely to be used by English surgeons. Mr, Pol- 
 lock, in his paperf on two cases of removal of the scapula, thus advises 
 on this matter : " If a portion of the scapula be removed, it should 
 only be the lower portion. But even if this be attempted, the loss of 
 blood would probably be much greater than if the whole bone were 
 removed; for the wound is more confined, and the wounded arteries 
 are more apt to retract behind the bone above, and offer great obsta- 
 cles to their being secured. However, should the lower angle be alone 
 the seat of the disease, the attempt to remove the lower portion only 
 is justifiable. It must, however, lie borne in mind that, when a bone 
 is once the seat of disease which requires removal, the disease is very 
 apt to recur in the portion left, and less liable to do so if the wliole 
 bone be removed. Such was not, however, the case in which Sir W. 
 FergussonJ operated, though the disease returned in Mr. Liston's§ 
 patient. As the removal of the whole bone is not a more formidable 
 operation than the removal of a portion of it, and as the patient has 
 less chance of a recurrence of his disease if the whole bone l)e taken 
 
 * E.g., M. A. Demandre, Des Tameurs de f Oinoptate (Paris, 1873). 
 
 t St. Georges Hasp. Report!:, vol. iv. |i. 236. 
 
 X Lectures on the Progress of Anatomy and Surgery, p. 45. Tlie mention of this is 
 extremely brief — namely, that the tumor was nearly the size of a fist, and involved the 
 lower angle of the scapula. Nothing is said as to its nature. It appears to me very 
 probable that this case is identical with another one of partial removal by SirW. Fer- 
 gnsson, mentioned below, in which recurrence did take place. 
 
 § Ed. M^ed. and Surg. Journ., vol. xvi. p. 6(5. Tlie tumor, in a boy aged sixteen, had 
 grown in tliree months from the size of a filbert to that of an orange, and subsequently 
 extended with great rapidity over the lower two-thirds of the scapula. On attempting 
 to separate its attachment to the spine, most jirofuse hfemorrliage occurred. The scap- 
 ula was sawn across so as to leave merely its upper portion on a level with about a 
 third of the spine. Recurrence took place within six weeks of the operation, and killed 
 the patient. 
 
140 OPERATIONS ON THE UPPER EXTREMITY. 
 
 awa}', it should be in a very exceptional case, and on some very pecu- 
 liar merits of its own, that the surgeon ought to undertake the removal 
 of a portion of the scapula." 
 
 The above remarks of Mr. Pollock are entirely borne out by the his- 
 tories of cases which have been watched after partial removal of the 
 scapula for any growth save an exostosis. 
 
 Thus, in January, 1865, Sir W. Fergusson* removed the Tower two- 
 thirds of the scapula for a sarcomatous growth. Recurrence took 
 place, and, in the following November, the rest of the scapula, the 
 greater part of the clavicle, and the upper extremity were taken 
 away. 
 
 Dr. Bird, of Stockport,t removed the lower two-thirds of the scap- 
 ula for a growth the size of an orange in the infra-spinous fossa, in a 
 child aged ten, the bone being sawn through behind the neck in aline 
 with the supra-scapular notch. A year and a half later the growth 
 recurred and grew quickly, the rest of the scapula being now taken 
 away together with the head of the humerus, which had become adhe- 
 rent to the scapula, and thus also required removal. A year and a half 
 later the child remained well, the use of the hand "in sewing and writ- 
 ing being verj^ little impaired." 
 
 Mr. Cock ;|; removed a myeloid tumor, the size of a foetal head, from 
 the scapula, the greater part of the spine being removed and the 
 acromial end of the clavicle. A recovery took place, but the history 
 is not carried on beyond a few months. 
 
 So, too, in a case of myxochondroma removed by Prof. Billroth, § 
 where the lower angle was left together with the teres major and 
 minor, the last note of the case is six weeks after the operation. 
 
 In the case of growths, removal of the scapula alone or together with 
 the upper extremity may be called for. 
 
 The malignancy of the growths, mostly sarcomata, which may call 
 for either of these steps is well known, togfther with their tendency to 
 involve surrounding parts and to creep into regions inaccessible to the 
 surgeon. Early operation is imperatively required. 
 
 In the case of operation, the prognosis will be best, however large 
 the growth, when the rate of progress has been slow, when the growth 
 is uniformly hard, or if only a certain amount of elasticity is combined 
 with the hardness (as in unmixed cnchondroma), when the outline is 
 distinct and well defined, and the mass movable upon the ribs.|| 
 
 * Lancet, 1865, vol. ii. p. 591. f Ibid,, p. 69ij. 
 
 X Gui/'s Hasp. Reports, 1856, p. 1. 
 
 'i Reported by Dr. Nedorpil, Lond. Med. Record, March 15, 1878; and Arch.f.klin. 
 C'hir., Bd. xxi. 
 
 II That this mobility is a matter of some importance is shown by the following case, 
 (pioted by M. St lillot at p. 550 of his Tra''te He Meiecine operatoire : " Nous refiisimes 
 
EEJEOVAl- OF THE SCAPULA. 141 
 
 On the other hand, the prognosis is less and less favorable in pro- 
 portion as the outline is uniform I'ather than nodulated or hossed, the 
 feel semi-elastic and obscurely fluctuating instead of hard, the prog- 
 ress rapid and attended with pain, the different parts of the scapula 
 much obscured* and its mobiUty much impaired, the outline of the 
 growth ill defined and lost indistinctly in the axilla. Pulsation and 
 bruit, enlarged glands, and tendency to infiltration of the skin are also, 
 of course, of evil omen. 
 
 A. Removal of the Entire Scapula by itself (e.g., cases 
 
 where the growth is primary from the scapula, and where there is no 
 extension to the humerus or into tlie axilla). — Preparations against 
 shock should be taken, the extremities being bandaged in cotton- 
 wool, the head kept low^, ether given, and subcutaneous injections of 
 ether and brandy being in readiness. The patient is placed at the 
 edge of the table and rolled over to the opposite side. If the groAvth 
 is very vascular, the patient weakly, pressure on the subclavian is of 
 importance, or if, from the extension of the growth, it is rendered diffi- 
 cult, this may be effected by making an incision down to and through 
 the deep fascia over the artery itself, in order to enable an assistant to 
 put the thumlj or finger directly upon it.f This may be done by a 
 separate incision, or by an extension of that bj' which the clavicle is 
 divided. 
 
 Flaps are freely turned back, usually by a T-shaped incision, one 
 limb running from the acromion process inwards to the superior angle 
 of the scapula, while the other and longer is made at right angles to 
 the first down to the angle of the scapula. In another case the sur- 
 geon may prefer to make an incision along the vertebral border of the 
 scapula, and the other at right angles to it across the centre of the 
 
 1111 jour d'o^i^rer iin jeiine honiuie atteint d'lin cancer 4inornie dii scapuhim, dont les 
 limites n'^taient pas iiettement fix^es, et nous duuies nous applaudir de notre absten- 
 tion en d&onvrant plus tard, a la n^cro| sie, que la tunieur avait pfen^trfe dans la poitrine 
 et envahi iin lobe pulmonaire." 
 
 * In a very large scapular sarcoma on which Mr. Pollock operated, it is stated that 
 " the mass extended over the upper portion of the scapula, which could not here be 
 traced, and over the outer part of the clavicle, which could not be felt ; and also so far 
 into the lower triangle of the neck that the subclavian artery could not be distinguished 
 or readied by the finger." The whole mass was removed, but the patient, aged forty- 
 seven, died on the sixth day, of chronic bronchitis. 
 
 t As adopted by Prof, fc-yme in performing the old operation in a case of axillary 
 aneurism, p. 111. If the clavicle is going to be removed, the subclavian can be com- 
 manded by cutting down on the clavicle, freeing it from its attacliments in its inner 
 third, passing a fiat director carefully beneath it, sawing through the bone here, and 
 removing a portion of it, the finger being thus placed directly on the subclavian ( Jeaf- 
 freson, Lcmcet, 1874, vol. i. p. 759). 
 
142 OPERATIONS ON THE UPPER EXTREMITY. 
 
 growth /i= Flaps thus shaped are dissected quickly back, care being 
 taken not to open the capsule of the tumor.f 
 
 AMien the whole mass is thoroughly exposed, the muscles on the 
 vertebral border are first severed. The subclavian being now firmly 
 •compressed, the trapezius, levator anguli, and the rhomboidei are cut 
 through, t the posterior scapular artery secured, and the serratus mag- 
 nus divided, being first made tense by lifting the scapula off the ribs 
 upwards and outwards. The muscles on the upper border are next§ 
 attacked— viz., the deltoid, the omo-hyoid, and the supra-spinatus— 
 and the supra-scapular artery secured. The acromio-clavicular joint 
 is next opened, or else the acromion or clavicle,|| according to the 
 extension of the growth in this direction, severed by bone-forceps or a 
 narrow saw. If the acromion can be safely left, the resulting deform- 
 ity — viz., dropping of the shoulder and entire loss of trapezius action 
 — ^will be lessened. 
 
 The lower angle and the latissimus dorsi (if involved) being freed, 
 the scapula can now be dragged away from the chest by slipping two 
 or three fingers over the upper or vertebral border. Thus, by tilting 
 the scapula outwards, the axillary border can be inspected, the teres 
 and infra-spinatus muscles severed, the position of the sub-scapular 
 artery defined by a finger passed beneath it, and this vessel secured, if 
 possible, before it is cut. The scapula being still farther pulled away 
 from the chest, the muscles attached to the coracoid process are next 
 severed, and the scapula removed by cutting into the shoulder-joint 
 and severing the capsular tendons and the biceps and triceps. The 
 coracoid process may become detached at this stage if partially eroded 
 
 * If tlie skin is involved or ulcerated, the flaps rnnst be so shaped as to isolate this. 
 
 t Polhick, St. George's Hasp. Reports, vol. iv. p. '-J37. 
 
 X It is a bad sign if any of the muscles severed are infiltrated with growtli. That 
 this, however, is not incompatible with a good recovery is shown by the second of Prof. 
 Synie's cases [Excision of tlie Scapula, p. 28), in which it is stated that "the tumor 
 weighed between 4 and o pounds ; it had a soft consistence and very suspicious aspect, 
 which was strengthened by microscopical examination, as the muscular substance that 
 was taken away along with the growth appeared to be loaded with the germs of future 
 disease; but fifteen months having elapsed since the operation was performed, without 
 the slightest appearance of relapse, it may be hoped that the recovery will prove per- 
 manent." 
 
 ^ If the upper border can be taken before the axillary one is dealt with, the subcla- 
 vian can be better controlled when the sub-scapular artery (a source of free liiemor- 
 rhage) is severed. 
 
 II Prof. Spence (EiI. Mrd.Journ., August, 1S72, p. 178) recommends that the clavicle 
 should be left, not sawn through, otherwise the head of the humerus tends to project 
 through the incision, there being nothing but skin left, the overhanging arch of bone 
 having been removed. On the other hand, sawing the clavicle, while it leaves a cut 
 surface of bone as a possible source of irritation, facilitates the operation somewhat, as 
 it exposes better the large vessels and the muscles attached to the coracoid process. 
 
REMOVAL OF THE SCAPULA. 143 
 
 by extension of growth * If this happen, it must be carefully dis- 
 sected out afterwards.f Every vessel must be thoroughly secured 
 when it is severed ; otherwise, oozing is very likely to take place a few 
 hours later.J If the anastomoses are free, double ligatures will be 
 required. 
 
 Hffimorrhage may be best avoided by attention to the following 
 points : (1) Adequate pressure on the subclavian, this being effected 
 by a special incision, if needful, to command the vessel. (2) Taking 
 care not to cut into' the tumor itself (3) Dealing with the axillary 
 border and sub-scapular artery last. (4) By some it is recommended 
 to make the incisions gradually, not larger than are required at the 
 time, as a means of minimizing the haemorrhage. It must be remem- 
 bered, with regard to this point, that small and cramped incisions 
 interfere with a free and rapid hand and sufficient exposure of the 
 parts, conditions which conduce to thorough dealing with bleeding 
 points, and thus facing one of the chief difficulties of this important 
 operation. 
 
 Adequate drainage is now provided, the flaps united, and the arm 
 secured to the side for a few days, after which it may be supported in 
 a sling if the head of the humerus does not tend to protrude. 
 
 Condition of the Limb after Removal of the Scapula.^A 
 limb thus preserved will be strong and useful. If the clavicle has not 
 been much interfered with, the clavicular fibres of the deltoid will 
 remain, and these, together with the latissimus dorsi and pectoralis 
 major, will probably confer a fair amount of motion on the limb. In 
 one of Prof Syme's cases, after removal of the scapula and the outer 
 third of the clavicle, and, by a previous operation, the head of the 
 humerus, the patient was able to lift heavy weights, and to fill the 
 appointment of provincial letter-carrier. 
 
 In a very successful case of Mr. Symonds' {Clin. Soc. Trans., vol. xx. 
 p. 24), in which the scapula was removed for osteo-sarcoma, the man 
 was in good health two years and a half after the operation- " He 
 
 * Especially if the patient be a young one, as in a ease of Mr. Pollock's. 
 
 t If the growth has involved the axillary vessels and nerves, this outlying portion 
 may be dealt with later on, after the main mass has been separated and removed If it 
 is desired to remove this extension of the disease now while in continnity with tlie 
 scapular growth itself, the surgeon will have both his hands free for what is a troub- 
 lesome dissection, by asking an assistant to drag the main mass strongly backwards. 
 To facilitate this step, Prof. Syme {loc. supra cit., p. 26) placed a piece of cord round the 
 divided extremity of the clavicle, for the assistant to pull upon. The greatest care 
 must be taken, when dealing with projections into the axilla, to keep tlie knife, or 
 blunt dissector, very close to the growth, for fear of opening the large vessels. 
 
 I In a case of this kind, Mr. Berkeley Hill transfused twice, but unsuccessfully, the 
 patient dying of shock and acute septicsemia in forty-flve honrs {Brit, Med. Journ., 
 1880, vol. i. p. 487). 
 
144 OPERATIONS ON THE UPPER EXTREMITY. 
 
 was able to do all the lighter work of a carpenter, including the use 
 of a plane. Overhead work he could not do." In this case the artic- 
 ular surface of the humerus had also been removed about a month 
 later, as it was thought to be the cause of prolonged suppuration sub- 
 sequent to the first operation. 
 
 B. Removal of the Scapula, together with the Upper 
 
 Extremity (Fig. 40).^ — This operation is required in cases where a 
 growth has involved the axilla and humerus as well as the scapula, and 
 
 Fig. 40.* 
 
 ' J/ 
 
 J., i'' 
 
 (After Heath.) 
 
 in a few cases of machinery accidents. In the former case it may be 
 performed on the following lines, modified to suit the case (Fig. 
 40). 
 
 The patient being prepared and placed as directed at p. 141, the sur- 
 geon commences his incision over the outer third of the clavicle, and 
 thus can now either proceed to secure the subclavian artery at once, 
 or enable an assistant to put his finger directly upon the vessel. In 
 the former case the soft parts must be separated with a raspatory, the 
 subclavius divided, and the vessels found beneath it. From the end 
 of this incision, over the acromio-clavicular joint, another is made 
 curving outwards over the shoulder and upper part of the arm, 
 and then sweeping back to the inferior angle of the scapula. This 
 curved oval flap is then raised towards the spine, the muscles on the 
 
 * This drawing is based upon one of a patient of Mr. Heath's {Brit. Med. Jown., 
 18S6, vol. i. p. 66). The outline of the flaps has here been brought somewhat too low 
 down upon the arm. 
 
EEMOVAL OF SCAPULA AND UPPER EXTREMITY. 145 
 
 vertebral and upper borders of the scapula divided, and the iiosterior 
 and supra-scapular vessels secured. Tlie scapula, with the arm, is 
 next carried boldly forwards towards the axilla,* and the sub-scapular 
 vessels secured and divided, together with the muscles in the axillary 
 border. A second incision, the extremities of which meet the first, is 
 then made over the front of the shoulder and arm, curving liack across 
 the axilla. When the anterior flap, thus marked out, has been suffi- 
 ciently dissected up, the large vessels, if not already dealt with, are 
 found and secured before their division, and the limb and scapula 
 removed. 
 
 All hfemorrhage being securely arrested, the flaps are next submit- 
 ted to careful scrutiny for any suspicious infiltration, and the axilla 
 examined for any enlarged glands or outlying masses of growtli. If, 
 owing to the necessarily prolonged operation or for fear of shock, no 
 sprayt has been used, the flaps should be sponged over with zinc-chlo- 
 ride solution (gr. xx-§j) before being adjusted, due drainage being 
 also provided. 
 
 Age of the Patient. — It may be not uninteresting to some to know 
 that the scapula has been successfully removed for growth at ages 
 varying between "about seventy " and " about eight." The former 
 was a patient of Prof. Syme,I wlio died about two months after the 
 operation, apparently of internal deposits. The latter case occurred in 
 India,§ the upper extremity being removed at the same time. 
 
 Dangers of the Operation and Causes of Death. — These are 
 chiefiy — 
 
 1. Hffimorrhage. 
 
 2. Shock. 
 
 3. Septicasmia. 
 
 4. Entrance of air into veins. This very nearly jDroved fatal in a 
 case in which Mr. Jessop, some years ago, removed the scapula, outer 
 half of the clavicle, and the upper extremity (Brit. Med. Journ., 1874, 
 vol. i. p. 12). In this case the scapula seems to have been removed 
 owing " to considerable deficiency of cover " after removal of an upper 
 limb much damaged by a machinery accident. " Whilst cutting 
 through the last attachments of the scapula, two distinct loud whiffs 
 were heard, caused by the rush of air into the subclavian vein." The 
 
 * During these or other necessary manipuhitions, the humerus, if much invaded by 
 growth, may give way. 
 
 t If possible, a very efficient substitute for this may be used by irrigating, occasion^ 
 ally, the wound as made, with a lotion of mercui-y perchloride, glycerine, and water. 
 
 + Loc. supra eit. 
 
 § A very brief mention of this case is given in a letter, Lancet, 1874, vol. i. p. 819'.. 
 It is not stated whether the patient was a native or no. 
 
 10 
 
146 OPERATIONS OS THE UPPER EXTREMITY. 
 
 operation was completed while artificial respiration was being per- 
 formed, and the lad recovered. 
 
 5. Recurrence. This takes place usually within six or twelve 
 months. In a case of Mr. Heath's (foe. supra cit.), recurrence took 
 place seven months after extirpation of arm and scapula in a lad aged 
 sixteen, with two years' history of the growth, an " osteo-sarcoma." 
 The recurrent growth was removed, but two years and a half after the 
 original operation recurrence again took place, and was dealt with 
 about five months later. A rapid recovery took place, and at the time 
 of this the latest operation, no signs of extension to the internal organs 
 could be detected, and the patient was in robust health. 
 
 Removal of the scapula for caries* needs no especial mention. The 
 parts being sufficiently exposed, the operation will be conducted, as 
 far as possible, sub-periosteally, by means of appropriate blunt dis- 
 sectors or periosteal elevators. 
 
 CHAPTER VIII. 
 OPERATIONS ON THE CLAVICLE. 
 
 REMOVAL OP THE CLAVICLE. 
 
 Removal may be required for new growths or necrosis. In either 
 case it is very rarely called for. That for necrosis differs in no way, 
 save for the importance of surrounding parts, from the same operation 
 elsewhere. 
 
 Removal of Clavicle for New Grov^ths. — Xo better idea of 
 the kind of operation required, and the difficulties likely to be encoun- 
 tered, can be gained than from the accovmt of Prof. Mott's celebrated 
 case.f 
 
 A youth, aged nineteen, consulted Prof Mott in 1828 for a tumor 
 about 4 inches in diameter, very hard, firmly attached to the clavicle, 
 which had been noticed about four months, and which was fungating 
 owing to irritation by escharotics, etc. 
 
 An incision, begun over the sterno-clavicular joint, was carried, in a 
 semicircular direction, as close to the fungating part as was safe, to 
 near the acromio-clavicular joint. In dividing the pectoralis major, 
 
 * A good case of this kind is recorded by Sir. W. Fergusson [Med. Chir. Trans., vol. 
 xxxi. p. 310). An exquisite drawing of the scapula — one of the very best by the hands 
 of the Baggs — will be found in the same author's Practical Surgery, 4th ed. p. 309, Fig. 
 144. 
 
 f Amer. Journ. Med. Sci. (O S.), vol. iii. p. 100. 
 
REMOVAL OF THE CLAVICLE. 147 
 
 arteries sprang in every direction ; a, number of large venons branches, 
 under the muscle, also required ligature. Care was taken to avoid 
 the cephalic vein, which was drawn outwards. Finding it injpussiljle, 
 from the size of the tumor and its close proximity to the coraeoid pro- 
 cess, to get under the clavicle in this direction, an incision was made 
 from the outer edge of the external jugular, over the tumdr, to the tojo 
 of the shoulder. After dividing the skin, platysma, and part of the 
 trapezius, a sound part of the clavicle was exposed nearer to the acro- 
 mion than the coraeoid process. A steel director, verj- much curved, 
 was now cautiously passed under the bone from above, great care being 
 taken to keep the instrument in close contact with the bone. The 
 great depth of the clavicle from the surface rendered it somewhat diffi- 
 cult to accomplish this safely ; an ej^ed probe, similarly curved, con- 
 veyed along the groove of the director a chain saw, which, when moved, 
 showed that nothing intervened between it and the bone ; the clavicle 
 was then readily sawn through. 
 
 The first rib being next exposed under the sternal end of the clavi- 
 cle, below the pectoralis major, the rhomboid ligament was divided 
 and the joint opened. This gave great and encouraging mobility to 
 the diseased mass. 
 
 The sawn end of the clavicle being a little elevated and the parts 
 around it- loosened, the surgeon tried to discover the subclavius mus- 
 cle, but it could not be seen, being incorporated with the diseased 
 mass. Had this muscle been found, the separation of the tumor 
 would have been much less difficult and tedious, as, by keeping above 
 it, the subclavian vein is, of course, protected. The origin of this mus- 
 cle was seen and divided, but it was almost' immediately afterwards 
 obliterated in the tumor. 
 
 The omo-hyoid was found under the sterno-mastoid, and traced to 
 its origin on the scapula. In separating the tumor from the cellular 
 and fatty tissue between the omo-h3'oid and the subclavian vessels, a 
 number of large arteries were divided, which bled freely, parti-cularly 
 a large branch from the inferior thyroid. 
 
 The anterior part of the upper incision was now made from the 
 sternal end of the <-lavicle, and carried over the tumor, until it met the 
 other at the external jugular vein. This vein was then cut between 
 two fine ligatures. 
 
 The clavicular part of the sterno-mastoid was next cut about 3 
 inches above the clavicle, and the anterior scalene exposed by careful 
 dissection. 
 
 The subclavian vein from the edge of the scalenus to the coraeoid 
 process was so firmly adherent to the tumor as to lead the operator at 
 one moment to believe that the coats of the vein were so intimately 
 involved in the diseased structure as to render complete removal 
 
148 OPERATIOXS ON THE UPPER EXTREMITY. 
 
 utterly impracticable. By the most .cautious proceeding, however, 
 alternately with the handle and blade of the knife, he finally succeeded 
 in detaching the tumor without the least injury to the vein. This 
 part of the operation was attended with peculiar difficulty and danger. 
 
 At every cut an artery or vein would spring and deluge the parts 
 until secured by ligatures. The external jugular was so situated in 
 the midst of the bony mass as to require division again here between 
 two move ligatures, near to the subclavian. Near the sternal end of 
 the clavicle, a lai'ge arter;^ and vein required ligature; they were con- 
 sidered branches of the inferior thyroid. 
 
 From having cut through the clavicular portion of the sterno-mas- 
 toid, it was possible, by turning the tumor down, to detach it from the 
 situation of the internal jugular and left subclavian without the least 
 injury to these important parts. 
 
 To reach the lower part of the tumor as it extended upon the thorax, 
 it was necessary to separate the pectoralis major in a line with the 
 fourth ril). The incision upon the neck extended from the sterno- 
 clavicular joint, in a semicircular direction, to within 1 inch of the 
 thyroid cartilage and base of the lower jaw, and 2 inches from the 
 lobe of the ear, and terminated near the acromio-clavicular joint. 
 
 The discharge of blood was so free at every step of the operation 
 that about forty ligatures were applied. It was estimated that the 
 patient lost from 16 to 20 ounces of blood. Prof Mott stated that the 
 operation far surpassed in tediousness, difficulty, and danger anything 
 which he had ever witnessed or performed. 
 
 The tumor was an osteo-sarcoma, about the size of two adult fists. 
 
 The patient made a good recovery, and died fifty-four years after the 
 oijeration from causes unconnected with this disease. The use of the 
 arm is said to have been complete. Post-mortem examination showed 
 that 5 inch of the acromial end of the clavicle was left, the rest of the 
 bone l)eing occupied by an adventitious ligamentous band.* 
 
 Strict observance of antisejitic details is esjDecially needed in such 
 operations, owing to the great risk of diffuse cellulitis in this region. 
 
 ^[r. Wheeler, of Dublin, recordsf a case of complete removal of the 
 clavicle for osteo-sarcoma. The patient was forty-three, and the 
 growth extendeil all over the clavicle, save at the extreme ends. 
 
 A curved incision was made downwards from the sternal to the 
 acromial extremity of the clavicle. The sterno-mastoid and other 
 muscles l)eing divided, the acromio-clavicular joint was opened and 
 the clavicle dragged up with lion-forceps. The coraco-clavicular and 
 other ligaments were then divided, and the subclavius detached. The 
 
 * tinier. Journ. Med. Sci., vol. Ixxxv. p. 546. 
 t Dab. Journ. Med. Si-i., Miiy 1, 1885. 
 
UNUNITED FRACTURE OF THE CLAVICLE. 149 
 
 subclavian vessels were exposed, an<l, with the thoracic duct (the oper- 
 ation was on the left side), carefully avoided. A vertical incision 
 was required upwards into the posterior triangle. Fourteen lii^atures 
 were needed. 
 
 The patient made a good recovery, and when seen, ten years later, 
 had, to an ordinary observer, every power as if the clavicle had not 
 been touched. 
 
 Mr. Holmes* draws attention to the fact that one case is on record 
 in which Mussey,t of Cincinnati, removed the whole clavicle and 
 scapula for a tumor recurring after amputation at the shoulder-joint. 
 The patient was heard of in perfect health thirty-four years after- 
 wards, at the age of seventy-one. IMussey commenced from the inner 
 side, so as to tie the subclavian early in the operation ; and this would 
 probably be the best course if the state of the parts would allow of 
 it. Mr. Holmes followed the same course in a similar case. The 
 patient recovered rapidly, but died from a recurrence. Mussey nearly 
 lost his patient from the passage of air into the subclavian vein. 
 
 UNUNITED FRACTURE OF THE CLAVICLE. 
 
 While this condition is extremely rare, it is of such importance as 
 to claim some notice here. 
 
 An excellent instance, most successfully treated, has been recorded 
 by Mr. Barker.]: A boy, aged twelve, was noticed soon after birth to 
 have a fracture of the right clavicle, the cause of this being uncertain. 
 Up to nine years of age the child had no inconvenience. He was then 
 gradually more and more troubled with pressure on the brachial 
 plexus, pain down the arm, and a tendency of the fingers to become 
 stiff and fixed in a flexed position in writing, this condition soon 
 amounting to one of painful spasm, rendering the writing quite 
 illegible. 
 
 With a view of resecting the false joint, lifting the inner end of the 
 outer fragment off the brachial plexus, and wiring it to the inner frag- 
 ment, Mr. Barker operated as follows : 
 
 " Observing all the details of the Listerian method of antisepsis, I 
 made a semilunar incision, about 3 inches long, with its two ends on 
 the clavicle, and its convexity downwards. This corresponded to the 
 middle of the bone, having the false joint above its centre. The flap 
 of skin so formed was turned upwards off the bone, and with it I dis- 
 sected up some fibres of the pectoralis with the object of securing that 
 the nutrition of the skin should not be disturbed by dividing its 
 
 * Stjsiem of iSurgery, vol. iii. p. 743. 
 f Amer. Journ. Med. Sci., vol. xxi. 
 J Clin. Soc. Trans., vol. xix. p. 104. 
 
150 OPERATIONS OX THE UPPEU EXTREMITY. 
 
 deeper vessels. The bone being thus exposed, a false joint was found 
 between the Ijroken ends, which were united by fibrous tissue. I now 
 divided the outer end of the inner fragment obliquely in a plane run- 
 ning from within outwards, and from before backwards. The section 
 was made with Gowan's osteotome, and was done very cautiously, so 
 as to disturb the periosteum and soft parts as little as possible, and 
 obviate all risks to the vessels running beneath the clavicle. I then 
 placed the osteotome on the inner end of the outer fragment, and 
 divided it in a plane corresponding to that of the section of the inner 
 fragment. Here my first cut was too oblique, and I withdrew the 
 blade of the saw ; but the second was accurately placed and sacrificed 
 less bone. I now lifted the inner end of the outer fragment of the 
 brachial plexus, and placed its cut surface resting upon that of the 
 inner ]jortion of the bone. A silver wire was then passed through 
 both ends from before backwards, and twisted firmly. This seemed 
 to secure sufficient fixation of the two portions, and the ends of the 
 wire were cut, and the twisted portion bent level with the bone. The 
 skin was then united with ordinary carbolized catgut, the edges of the 
 pectoral muscle having been first brought together with stitches of 
 the same. A strand of catgut was also inserted between the lips of 
 the wound for drainage. No blood to any amount was lost, and the 
 wound was a dry one. I therefore dressed it with powdered iodoform 
 and salicylic wool, considering the latter more elastic than gauze. 
 Plenty of ordinary wool was added for padding, and over all a plaster- 
 of-Paris bandage was laid on. This was applied over a webbed vest 
 precisely as for spinal caries, and completely immobilized the arm and 
 shoulder for the month during which it was worn. To this perfect 
 fixation of the parts concerned, quite as much as to the accurate ap- 
 position of the cut surfaces of the bone, the good result of the operation 
 is, in my opinion, to be ascribed." 
 
 The dressings were not disturbed for fourteen days, when the wound 
 was found united by first intention, except at one point where the cat- 
 gut drain was still unabsorbed. There was not a drop of pus any- 
 where. A similar dressing was applied, and not removed for fourteen' 
 days, when all healing was complete. The plaster corset was then 
 removed, and a mass of callus could be felt at the seat of operation. 
 A week later the power of writing was found to be much inproved, 
 and the arm became perfect in all its functions. 
 
PART [I. 
 
 THE HEAD AND NECK. 
 
 CHAPTER I. 
 
 OPERA.TIONS ON THE SCALP. 
 
 But few — viz., those for large fibro-cellular tumors, and the vascular 
 tumors known as aneurisms by anastomosis, etc. — will require men- 
 tion in a work like this. 
 
 FIBRO-CELLULAR TUMORS, OR MOLLUSOUM 
 FIBROSUM. 
 
 These rare growths occasionally require removal, on account of their 
 hideous deformity.* The chief points of importance in such opera- 
 tions are — (1) The haemorrhage. This may be terrific,t copious, and 
 weeping from every part, owing to the huge size of the growth and the 
 vascularity of the parts. It is best met by an ingenious precaution of 
 Mr. Hutchinson's, J who prevented all arterial haemorrhage during an 
 
 * A goo(^ illustration of these growths is given by Mr. Hutchinson {Land. Hasp. Re- 
 ports, vol. ii frontispiece), and another by Mr. Erichsen (Surg., vol. ii. p. 533 . The 
 drawing in this case is said to be taken from a patient of Sir W. Stokes. This surgeon 
 figures an excellent one [Dub. Journ. Med. Sci., vol. Ixi. (N.S ), frontispiece). 
 
 t It is so described by Sir W. Stokes (loc. supra cit.}. The patient, a man aged 
 thirty-three, in good condition, almost died on the table, Nfelaton's method of invert- 
 ing the head being made use of with excellent results. 
 
 t Loc. supra cit., p. 118. The piece of scalp removed here was twice as large as the 
 palm of the hand. Owing to the precautions taken, there was no arterial hsemorrhage. 
 In Sir W. Stokes's case, the base of the growth was very wide, reaching from above and 
 in front of the right ear to the left of the occipital protuberance, upwards as high as 
 the vertex, and hanging down as low as the shoulder. In such a case, Mr. Hutchin- 
 son's plan might be made use of by applying the tourniquet carefully round the lower 
 jaw and nape of the neck if it could not be applied from the latter point obliquely up- 
 wards on to the forehead, the strap being kept low in position, if needful, by loops of 
 bandage pa.ssed under it on either side, and drawn downwards by assistants. 
 
152 OPERATIONS ON THE HEAD AND NECK. 
 
 extensive operation of this kind by applying round the head, just 
 above the ears, a Petit's tourniquet with a narrow strap. In a smaller 
 case, strong india-rubber bands, with pads over the chief arteries, may 
 perhaps be useful. (2) The need of maintaining strict asepsis. As 
 nearly the whole thickness of the scalp affected must usuallj' be sacri- 
 ficed, the pericranium may be damaged and the bone necessarily ex- 
 posed, especially during the tedious process of granulation by which 
 the extensive wound must usually heal. The risk of septic ostitis and 
 then phlebitis of the veins of the diploe is well known, with the inevi- 
 table result of pyeemia. 
 
 ANEURISM BY ANASTOMOSIS. 
 
 The trea.tment of these most difficult cases is given under the head of 
 Ligature of the External Carotid. 
 
 QUESTION OF OPERATIVE INTERFERENCE IN 
 GROWTHS OP THE CRANIAL BONES AND DURA 
 MATER. 
 
 Under this heading are included malignant growths, usually sarco- 
 matous, springing from the diploe or the dura mater, and having in 
 common the features of steadj^ progress, penetration of the skull, and 
 pulsation. It remains to be seen what operative attacks, aided by 
 antiseptic surgery, may avail in these cases, but for the present, unless 
 an opportunity arise for attacking such growths quite early — e.g., 
 while tliejr are only of the size of a small nut — it will be wiser not to 
 interfere.* 
 
 The following case is a good instance of these growths, though it re- 
 mains uncertain as to its exact origin. The question of operation, as 
 mentioned below, was repeatedly discussed here. 
 
 D. E., aged twenty-eight, a Welsh miner, was sent to me, in 1885, by 
 Dr. Evans, of the Rhondda Valley. Three years ago he had noticed a 
 swelling, the size of a pigeon's egg, in the centre of the right parietal 
 
 * Further carefully recorded cnses, with post-niorleiu record?, yiaying especial atten- 
 tion to the possibility of removal, are niucli needed here. An interesting cane is pub- 
 lished by Mr. Morris (Path Sue. Trims , vol. x.^txi. p 259). The disease here certainly 
 took six years in running its course ; otlier deposits were present. The patient died 
 away from London. The growth is stated to have begun in the diplne, and to have 
 compressed, not involved, the brain. Mr. West (Lancet, 1876, vol. i. p. 4o7) records a 
 caseof fungus of the dura mater, which was explored. This case, however, from the 
 history, appears to have been syphilitic ; the growth was checked, and disappeared 
 under the influence of very moderate pressure. Fits occurred later, and proved fatal. 
 Deposits, thought to be scirrlious, were found in the liver. 
 
GROWTHS OF THE CRAXIUM AND DURA MATER. 153 
 
 bone ; for a year previous to this he had pains in the head. During 
 his worli in the mine, his head had received repeated blows, many 
 bluish characteristic scars being present. A month after the lump 
 appeared, fits began to occur nightly, and lasted thus for three months ; 
 then they gradually became fewer, and for the last year there had been 
 none at all. 
 
 At a spot 2 inches above the left ear was a large elevation of the 
 scalp, measuring nearly 5] inches in one diameter, and about 4f in the 
 other. There was no ulceration of the scalji tissues here, but unusu- 
 ally large vessels were to be felt over the area thus prominent. In the 
 centre the bones of the skull appeared to be deficient over a circular 
 spot the size of a shilling, as here the scalp could be deeply dimpled 
 by finger-pressure as if through a ring of penetrated cranial bone. 
 Over this central gaj), pulsation was strongly marked and rather heav- 
 ing; it was also present, to a less degree, over the rest of the swell- 
 ing. 
 
 At other parts of the area of the growth, especially at several spots 
 in the periphery, was a remarkable feeling as if of bony trabecular 
 structure. It was doubtful whether this was brought about by growth 
 gradually invading a flat cranial bone, or to calcification taking jjlace 
 in the periphery of a sarcomatous growth. 
 
 On a level with the left ear was an enlarged gland. 
 
 Mr. Targett, the surgical registrar, reported that double optic neuritis 
 was present, but no oculo-motor paralysis. The reflexes were normal, 
 and there was no loss of sensation or motion. 
 
 There were no urgent symptoms; the patient had occasional throb- 
 bing and pain in the swelling, but no obstinate headache and vomit- 
 ing; he was able, as yet, to work, and stipulated that no operation 
 involving risk to life should be performed. 
 
 For these reasons, and because, owing to the size, duration, and 
 characters of the growth, the risk of attacking it was undoubtedly 
 great, the patient left the hospital without anything being done. 
 
 Unless such a case can be seen very early (and this is just the stage 
 which does not come under the notice of the surgeon), the following 
 would appear to be amongst the difficulties and risks of an operation 
 in these cases : 
 
 The necessary difficulty and tediousness in isolating the affected 
 bone by sufficient trephine crowns, and joining these with a saw or 
 chisel.* In the above case at least four crowns must have been re- 
 moved at the difl"erent angles of the growth. It must be remembered 
 that the overlying soft parts were extremely vascular and perhaps 
 
 * The use of the dental engine in these cases is alluded to elsewhere (p. 165). 
 
154 OPERATIONS ON THE HEAD AND NECK. 
 
 (from the enlarged gland) already involved in the growth. In isolat- 
 ing and going wide of the affected bone, it was uncertain whether one 
 or more sutures would not have to be crossed, and sinuses, such as the 
 superior longitudinal, opened, thus leading to profuse hasmorrhage in 
 addition to that certain to be met with in dealing with the soft parts 
 and with the diploe around the affected bone. 
 
 Then, sup])osing the bone sufficiently removed wide of the growth, 
 in one or more pieces, if the growth were from the dura mater, this 
 membrane must certainly be dealt with, and the same would very 
 likely be the case if, originating in the diploe, the growth had crept 
 inwards. In further isolating the disease, if it had merely pressed 
 upon the brain and not involved it, most delicate work would be re- 
 quired : enlarged branches of the middle meningeal and, very likely, 
 dilated sinuses would require dealing with. If the disease had in- 
 volved, instead of merely displacing, the lirain, new and special risks 
 would have to be encountered just when the patient's condition, 
 after an already prolonged operation, was least fitted to bear 
 them. 
 
 Such are amongst the chief difficulties and dangers which appeared 
 to me very likely, if not certain, to be met with as I thought over the 
 question of operation in the case of the patient just given. They do 
 not appear to me to be exaggerated. 
 
 Moreover, in these and in any other prolonged operations which 
 deal with the brain and its membranes, the fact must never be lost 
 sight of that, what with the necessary interference with very vital 
 organs, and what with the aneesthetic, the margin left to the patient 
 between life and death may be a very narrow one.* 
 
 * Abonl four years ago I had occasion to explore and attem))! the removal of a gli- 
 oma, proved later to occupy almost the entire right frontal lobe of a patient at Gny's 
 Hospital. The pnlse failed so ominonsly with chloroform that, after removing one 
 crown, ether was given while the tiephine was applied again, and the two openings 
 thrown into one. The substitution of ibis annesthetic was followed by so much cyano- 
 sis and jerky, gasping, irregular breathing, witli a fixed chest (the patient wa-; a yonng 
 man, much emaciated by vomiting and headaclie, bnt free from any lung-tronble), 
 that it was decided to do no more that day. The patient never ''came to," and died 
 comatose a few hours later. In this case there had not been time to interfere with the 
 brain and its membranes. Another patient of mine, admitted for epileptic seizures 
 connected with iv huge cancellous exostosis of the frontal bone, which, as it proved, was 
 pressing inwards upon the brain and membranes, had been under observation for a 
 fortnight, his diet being strictly regulated. On the evening of Christmas Day, his diet 
 having been not unnaturally, but too suddenly, altered, a severe epileptic seizure came 
 on ; this was followed by coma, rapidly deepening into death. I have elsewhere ( p. 
 178) alluded to the suddenness with which respiration may fail in patients the snlijects 
 of middle meningeal hiemorrhage. 
 
GROWTHS OF THE CRANIUM AND DURA MATER. 155 
 
 An attenijited removal of a growth afterwards proved to spring from 
 the dura mater is thus recorded by Sir ^V. Ijawrence :* 
 
 In this ease, the patient and her friends were anxious for an opera- 
 tion, owing to their constant fear of haemorrhage on account of the 
 strong pulsation in the growth, from the result of previous incisions 
 into it, and also because of the constant headache. The growth, which 
 was a comparatively small one, measured 2 inches in diameter, and 
 was situated in the felt frontal region. Another swelling, probably 
 secondary, could be felt deep seated in the region of the left hip. 
 
 An incision, 4 inches long, was made around the posterior half of 
 the swelling, keeping clear of the growth by a considerable margin. 
 Most violent ho?morrhage at once took place from numerous vessels, 
 which could not be tied owing to the density of the surrounding 
 structures ; the bleeding was only partially arrested by pressure, and 
 was so severe that the patient seemed likely to sink under it. The 
 operation was completed by making a similar incision in front, and 
 by rapidly detaching the growth on a level with the bone. In doing 
 this, numerous long spicula were found in the base of the growth, and 
 it was now made out for the first time tJiat the growth passed into the 
 interior of the skull through an opening more than an inch in diame- 
 ter, at the bottom of which brain-pulsation could be felt. The appli- 
 cation of a iDad of lint with much firmness was required in order to 
 stojD the bleeding. The patient recovered from the operation, but fits 
 came on, and she died in about two months. 
 
 The growth proved to be a malignant one springing from the dura 
 mater. The bone around the opening in the frontal bone appeared to 
 be perfectly health 3^ The left anterior lobe was depressed, but other- 
 wise both the brain and its membranes were unaffected. There was a 
 small outgrowth in the left pterygo-maxillary fossa, and another in 
 the left lobe of the cerebellum, which perhaps accounted for the pain 
 which had been complained of in the back of the head. The right 
 humerus was fractured at the site of a secondary deposit ; the swelling 
 in the region of the left hip was not examined. 
 
 * 3Ied. Times and Gaz., 18o3, vol. ii. p. 129. 
 
156 OPERATIONS ON THE SKULL. 
 
 CHAPTER II. 
 
 TREPHINING* 
 
 OPERATIVE INTERFERENOEt IN IMMEDIATE OR 
 REOENTt FRACTURES OF THE SKULL. 
 
 Indications. — The chief of these are : 
 
 i. Compound Depressed Peactuhes.— Whether symptoms of com- 
 pression are present or no, these fractures should, as a rule, be ex- 
 plored by reflecting adequate flaps, then elevating any depressed 
 fragments, and removing any which are quite loose. At the same time 
 the surface of the dura mater, where exposed, should be carefully 
 scrutinized, and, together with the rest of the wound, thoroughly 
 cleansed. 
 
 Operative interference is indicated in these cases for two reasons : 
 (a) Even if no symptoms of compression are present at first, second- 
 ary inflammation is very likely to follow in a few days, it not having 
 been possible by expectant treatment to completely cleanse the wound. 
 If, now, some minute fragment of the brittle inner table has pricked 
 
 * I may take this opportunity of saying, once for all, that much of what is written 
 below is based upon a strong belief that trephining, if carried out by careful hands, 
 and with a strict attention to antiseptics, is, per se, an operation of very slight risk. 
 This opinion has been strongly held by Mr. Walsham in England, and Dr. Briggs, 
 Prof. Nancrede, Dr. Amidon in America, in yiapers referred to below. Another writer 
 on the same .side, Dr. J. B. Eoberts [Ann. of Surg., vol. ii No. 7, p. 8), appears to me 
 to weaken his case by saying that a trephining, properly done, is but little more risky 
 than amputation through a metacarpal bone. It is true that, in both, cancellous tissue 
 is opened ; but, in one, this contains large venous channels in intimate connection with 
 the sinuses, and so witli the general venous system. Moreover, in the one operation 
 the sawing is very simple ; in the other, for reasons given at p. 166, it i=, unless most 
 carefully done, very perilous. But while I cannot but think that Dr. Roberts has 
 overstated his qase, and thus rim the risk of leading inexperienced operators to think 
 too lightly of trephining, I would in no way seem to de]ireciate his most instructive 
 paper referred to above. Prof. Nancrede, stating that from his experience trephining 
 is not a dangerous operation, and that more patients die from complications, which 
 might have been prevented by a timely operation, than from the removal of a disk of 
 bone, gives the mortality of 10.69 per cent, as a probably fair estimate of the risk of 
 the operation per se. The above e'-tiniate appears to me to be much too high. 
 
 t This term is used to include the use of the elevator and dressing-forceps as well as 
 that of ihe trephine, a matter which is alluded to again below (p. 164). 
 
 X By these terms it is intended to make a distinction between those cases in which 
 operative interference is made use of within a few days of a fracture and those in which 
 it is only had recourse to a long time after the injury : see p. 185, Trephining for Trau- 
 matic Epilepsy. 
 
TREPHINING IN SIMPLE DEPRESSED FRAGTaRE. 157 
 
 e, 
 
 the dura mater, fatal septic meningitis i,, almost eertain. If, therefon, 
 the surgeon, in these eases, waits for evidence of compression as a 
 justifieation (if operative interference, he will too often wait till it is 
 too late. Evidence of the presence of dirt, (.'specially of dirt ground 
 down to, or into, the bone, is a reason for exploring tlie wound, even 
 if no symptoms of compression are present, {b) If the patient re- 
 cover from the immediate effects of the fracture, injury to the inner 
 table, insufficient to cause symptoms at the time, and not detectable 
 save by an operation, may be present all the time and cause much 
 future trouble. In the words of Prof. Nancrede :* " Undoubtedly, 
 many patients recover in whom the bone is not elevated, but in too 
 many epilepsy, insanity, chronic cerebral irritation, etc., render life a 
 burden, and operations arc then required which often pr(n'e useless.! 
 .... Operations for epilepsy sliow at times that, in the effort to 
 bridge across the irregular fragments, and from the constant irritation 
 due to the eercljral ])ulsation driving the dura mater against the bony 
 fragments, Nature throws out osteophytic growths, which eventually — 
 perhaj^s after years— set up serious trouble." 
 
 ii. Simple Depressed Fractures.— Where symptoms of compres- 
 sion are present, ojaerative interference is the only course open. But 
 where no such symptoms are present, the expectant treatment is by 
 most surgeons held to lie sufficient. We may perhaps come best to a 
 decision as to using operative interference in simple depressed fract- 
 ures, wdthout symptoms, liy dividing them into the three followin<^ 
 groups : 
 
 1. Where the depression extends over a consideraljle area, where it 
 is slight in degree — e.;/., not more than a sixth of an inch, especially if 
 the patient is young and the bones yielding — expectant treatment is 
 no doubt the best. 
 
 2. But, on the other hand, where the depression is limited and de- 
 fined, where the depressed fragment not only affects a small area, but 
 is turned down angularly or edgeways, operative interference should 
 be resorted to at once, even though no symptoms are present, and 
 whether there is a wound or nd, to prevent the onset (if dangers, imme- 
 diate and remote, fully alluded to later on. 
 
 * International Encyclnpmdia of Surgery, vol. v. p. 24. 
 
 t Dr. Gunn {Trans, Amcr. Surg. Assoc, vol. i, p. 89), speaking of later trephining; 
 for tlie relief of old depressed fractures, says : '' Althoiif,'h results of tlie.se secondary 
 operations do not show a flattering percentage of success, I think that the reason may 
 be looked for in the late period at wliich the operation is performed. It is rare that 
 the patient sulmiits to the dreaded operation till years have been wasted in tlie vain 
 endeavor to effect a cure by medication. In the meantime, the constant irritation has 
 beifotten a permanent impression upon the brain and nervous systeiu, which remains 
 after the offending point of irritation has been removed." 
 
158 OPERATIONS ON THE SKULL. 
 
 3. There is a large class of cases intermediate between the above, 
 where the fracture is a simple one, where symptoms are absent, and 
 where the depression is sufficient to cause anxiety, though not so 
 sharply defined as to call imperatively for operation. 
 
 In these cases, if the surgeon decide to wait for symptoms, he can 
 appeal to an array uf great names who concur in putting aside opera- 
 tive interference in these cases. But it is impossible to write on this 
 matter in 1887 without seeing that, owing to the introduction of anti- 
 septics and the lessening dread of oi)erations on the skull and brain, 
 the pendulum of opinion, which has for so many years swung in the 
 direction of non-interference, is now coming back towards the oppo- 
 site view. While it is much to be desired that, in this as in other 
 cases where modern surgery seems likely to reverse the weighty opin- 
 ion of those who have gone on before us, no change in practice shall 
 be made hastily, the following points are worthy of attention : 
 
 It is possible that the compound character of a fracture of the skull 
 has been too much made the determining touchstone in deciding 
 whether to operate or no. In other words, have not surgeons, while 
 rightly looking upon compound depressed fractures as foreshadowing 
 meningitis and ence^jhalitis, too much overlooked the fact that simple 
 fractures without symptoms may lead to future, though perhaps much 
 more distant, trouble by the gradual formation of irregularities, if not 
 of osteophytes, on the inner surface of the skull ? And with regard 
 to this point, has not the fact that, when both tables are injured, the 
 comminution and displacement of the internal is usually Ijy far the 
 worst,* been overlooked, or, at least, under-estimated ; a confusion 
 being perhaps made between this fact and another equally well 
 
 * The following remarks of Dr. Roberts [Ann. of Sarg., vol. ii. Xu. 7, p. 14) are well 
 worthy tiie attention of the practical surgeon. Having pointed out that both fatal en- 
 cephalitis, or, later on, epilepsy, mental impairment, etc., are often due to"spicnla- 
 tion " of the inner table, he goes on to say, " Hence it follows that exploratory perfora- 
 tion of the cranium is jnstitiable in all cases where the nature of the impinging force 
 or the appearance of the external table renders spiculation of the inner table probable : 
 provided that less danger to life and heiilth is inlierent in perforation than in the prob- 
 able speculation. ... 1 am driven to the cflnclusiou that exploratory [lerforation to 
 determine the absence or presence of internal spiculation is often demanded by the 
 uncertainty of the invisible condition. Withouta knowledgeof the true state of affairs 
 treatment is empirical ; and the risk to 8ubscc|ueut mental health or to life is too great 
 to permit reliance upon emjiirical treatment when a knowledge of the true condition is 
 obtainable with the slight danger that pertains to antiseptic trephining. Whenever 
 the fracture, whether originally an open one or so made by any incision, presents the 
 possibility of the inner (able heiui; detached and splintered more extensivelv tlian the 
 outer, I should be inclined to advise perforation. In other words, I would cut the scalp 
 to see the condition of the outer table, and I would cut the bone, to see the condition 
 of the inner table, in every case where the risk of obscure knowledge is greater than 
 the risk of divided scalp and perforated bone.'' 
 
TREPHINING IN SIMPLE DEPRESSED FRACTURE. 159 
 
 founded, that injury to the internal table alone is very rare. Perhaps, 
 too, surgeons, because little or no callus-material is found uniting 
 fractures of the base, have taken it as too much for granted that the 
 same takes place invariably in fractures of the vault. 
 
 However these questions may be decided, it will be agreed that all 
 surgeons departing from the time-honored rule of non-interference in 
 simple dei)ressed fractures without symptoms, must, by paying careful 
 attention to the following points, make certain of not bringing dis- 
 repute on trephining or elevation of bone : 
 
 1. That a freer use of the trephine in doulitful cases can be justified 
 alone by keeping the wound strictly aseptic throughout. 
 
 2. Any coexisting conditions which would contraindicate the 
 operation must be carefully looked for — viz., (^1) Severe and pro- 
 longed concussion; (2) Encephalitis; (3) Injury to the base. 
 
 Influence of Site. — It is often said that a depressed fracture, even if 
 distinctly marked, over the frontal sinuses, does not require ojjerative 
 interference, and that any such steps should be avoided for fear of 
 leaving a fistulous opening leading to passage of air and troublesome 
 emphysema. But it must be remembered that these sinuses do not 
 appear before the age of fifteen or sixteen, and that, even in adult 
 skulls, the extent of their development is most uncertain, the sinuses 
 being sometimes represented b_y a small unilateral cell instead of 
 fair-sized bilateral cavities.* Other sites, which it is well to avoid in 
 trephining, if possible, are the position of large sinuses,t that of the 
 
 * Hilton, Gay's Hasp. SepnrU, 2d series, vol. viii. p. 362. Notes on the Cranium, p. 
 8 et seq. 
 
 f It is worth while to bear in mind that if a large venous sinus is opened into, the 
 hiemorrhage is usually at once arrested hy xery moderate pressure applied at the right 
 spot. The pres.siire should be made by a carbolized finger or sponge, and kept up if 
 needful by a pad of dry aseptic gauze dusted with iodoform, left in situ for two or 
 three days if possible. Dr. Cameron (Lancet, 1884, vol. i. p. 931) was able to complete 
 a trephining while very slight pressure with lint controlled the bleeding from a 
 wound in the superior longitudinal sinus. He points oat tliat the imaginary fear of 
 fatal hfemorrhage from such a wound may at times deter from a necessary operation 
 with the trephine, and it is well that it should be dissipated. Dr. Hopkins (Ann. of 
 Surg., vol. ii. Xo. 7, p. 67), in a case of extensive compound fracture of the skull, 
 found that a small lint-compress, dusted with iodoform, lightly applied to ^ wound 
 in the superior longitudinal sinus exposed by elevation of fragments, readily arrested 
 the haemorrhage, which persevering eflbrts with tenaculum-forceps had failed to check 
 with a ligature. In other cases, a wound of this sinus has been closed by sutures of 
 catgut. Thus, Dr. Parkes {Ann. Anat. and Surg., vol. viii. p. 118), in treating a wound 
 caused by a fracture of the skull, arrested the terrific hsemorrhage first by pressure, 
 and then by introducing three fine catgut sutures. These entirely closed the rent and 
 controlled "all bleeding, and though the calibre of the sinus was reduced fully one- 
 third, and the sinus bulged inarkedly at the anterior extremity of the sutured wound 
 showing interference with the backward blood-flow, there was no evidence of cerebral 
 
160 OPERATIONS ON THE SKULL. 
 
 trunk and chief branches of the middle meningeal artery * and also 
 the lines of the sutures, apart from any subjacent sinuses, as here the 
 dura mater is firmly attached, unless it chanced to be loosened by a 
 violent blow. Age, too, must have i^roper weight attached to it, it 
 being well known that in the first few years of life a very considerable 
 depression may take place after an injury, and yet be followed by 
 absence of head-symptoms and by spontaneous recovery.! 
 
 iii. Punctured Fractueks.— Here, however slight is the injury to 
 the outer table, that inflicted upon the inner is certain to be much 
 more serious. And the more the diploe is present, the more extensive 
 will be the damage which driven-down fragments of this will inflict 
 upon the brittle inner table. It must be remembered that punctured 
 fractures, with all their serious results, may be caused by blunt, 
 though pointed, bodies, as well as by sharp ones. J Instances of these 
 are, blows with a pickaxe, fragments of brickbat, coal, stdnu, the 
 trigger of a clubbed gun, or falls on a fender-ornament. Immediate 
 operative interference — and here, owing to the limited injury to the 
 outer table, the trephine will Ije called for — is imperatively demanded 
 in all punctured fractures, however iusignificant is the damage to the 
 scalp and outer table. 
 
 iv. In some Cases of Fracture about the Inner Angle of the 
 Orbit. — The trejjhine should always be used (together with a small 
 gouge) in exploring those grave injuries which may be caused by 
 direct violence from thrust wounds at the inner angle of the orbit, or 
 root of the nose — e.g., with scissors, slate pencils, ferrules of walking- 
 sticks, etc. 
 
 The apparent slightness of these injuries, the trifling Avound, the 
 period of latency of symptoms, and the onset of fatal brain mischiefs 
 inevitable, though delayed, if let alone— are all well shown in the 
 folloAving case of Mr. Hulke's : § 
 
 disturbance due to this interference with so large a column of blood, the wonnd heal- 
 ing well with antiseptic precautions. Dr. Brinton (Phil. Med. Times, vol. xii. p. 577), 
 quoted by Dr. Roberts (loc. supra cit.). applied a lateral ligature successfully to the 
 lateral sinus. The strictest antiseptic precautions should be made use of in dealing 
 with wounds of these sinuses owing to the great risk of septic phlebitis and pya;mia. 
 
 * The treatment of ha;niorrhage from the middle meningeal artery is given at p. 
 ]83. 
 
 t Good instances of this are given by Mr. Le Gros Clark {Diuijnoxis of Visca-al 
 Lmons, p. 94) ; Mr. Bryant (Surnenj, 2d ed. vol. ii. ji. 3.57) ; Prof. Nelaton [Pathologie 
 C'hirnryicale, tome ii. p. H'J). Tlie two last are accompanied by illustrations. 
 
 t Prof. Nancredel/ocsH^ira cit., p. 18) points out that a punctured fracture caused 
 by a sharp instrument may consist of merely a splitting ofl' of a small scale of the 
 Inner table, but that a blunt-poinlcd body will comminute the inner table extensively 
 by breaking up tlie diploe. 
 
 I Syst. of Surg., vol. i. p. 586. As here pointed out, the injury is especiallv likely 
 to be overlooked if the instrument has slipped under the lid, and so reached the roof 
 
REMOVAL OF FOREIGN BODIES FROM THE SKULL. 161 
 
 " A little girl, aged six yoars, fallinn, with a piece of slate pencil 
 ill her hand, it pierced lier right eyehrow near its inner end, and 
 broke sliort off'. Admitted soon after into the iliddlesex Hospital, 
 the house surgeon took out of the wound several splinters composing, 
 he thought, the whole jiiccc, covered the wound witli a pad of lint, 
 and had the child placed in hed. Her general condition did not 
 betray the serious nature of the injury. She slept quietly through 
 the night, and next morning did not appear niucli worse for the 
 accident. In the afternoon, when I then first saw the child, I detected 
 with the probe another splinter of the pencil, and enlarging the little 
 puncture exposed a piece of pencil tightly plugging a hole in the 
 bone. Enough of this was cut away cautiously with a gouge to allow 
 the pencil to be grasped with a forceps. It proved to be shattered, 
 and splinters representing a cylinder three-quarters of an inch long 
 were removed. Intracranial inflammation (indicated by convulsions, 
 delirium, a high temperature— 10:]° — and rapid pulse) supervened. 
 On the ninth day after the injury the temperature fell to 1)7.5° (the 
 child had passed a quiet night, and took her food better), and from 
 this date it continued subnormal, or only slightly exceeded the nor- 
 mal average, until the sixteenth day, when it rose suddenly to 104°. 
 With this elevation of temperature were associated restlessness, 
 delirium, a flushed face, screaming, vomiting, convulsions, and coma. 
 Death occurred about twenty-four hours later. At the necropsy a 
 large abscess was found in the frontal lobe of the right hemisphere. 
 It inclosed a piece of pencil about one inch long, and it had evidently 
 quite recently burst into the anterior horn of the lateral ventricle. It 
 is a matter of regret that the trephine was not employed instead of 
 cutting away the bone around the pencil, which had the effect of 
 loosening the splinters, and contributed to the fatal mistake that the 
 whole piece of pencil had been removed." 
 
 V. Foe the Removal of Foreign Bodies Fissuring or Fracturing 
 THE Skull.— These are rare— e.^., penknife-blades, pieces of stone, 
 bullets, etc. To insure certainty of complete removal the trephine 
 will usually be required. 
 
 The following cases show how the gravest results may ultimately 
 follow on the overlooking of a small piece of knife-blade. The first 
 case is an instance of the long time which occasionally intervenes 
 between the injury and the onset of urgent symptoms due to abscess. 
 The second case is an excellent instance of the history of a cerebral 
 abscess, though here, too, the symptoms were delayed unusually long. 
 
 of the orbit and base of the skull, leavhig, it muy be, n.erely a patch nf ecchymosis on 
 the conjunctiva. 
 
 11 
 
162 OPERATIONS ON THE HEAD AND NECK. 
 
 The first case is given bv M. Dupuytren.^^ " H y a huit ou dix ans, 
 un ieune homme regut dans une querelle un coup de couteau sur le 
 sommet de la tete ; ce couteau se rompit dans la crane, apres 1 avoir 
 perfore Le chirurgien qui pansa le malade n'examina point avec 
 tout le soin dfeirable I'etat de la plaie ; il en rapprocha les bords, et 
 le malade gu6rit. Plusieurs ann(jes se passerent sans accidents; 
 seulenient, de tem])S en temps, le malade ressentait des douleurs dans 
 sa cicatrice. Au bout de (jueLiues annees, sans cause e(jnnue, il lui 
 eouvait un assoupissement treslort de la fievre ; il vint a I'Hotel-Dieu 
 et y fut regu. En examinant sa cicatrice, je sentis quelle etait soule- 
 vee et dessous die un corps etranger; j'incisai etfis Textraction d'une 
 portion pointue de lance de couteau, a I'aide du trypan. Les accidents 
 persisterent, il s'y joignit la paralysie du cote du corps oppose a celui 
 de la tete qui' etait blesse. J'incisai la dura mere, il ne sortit rien ; je 
 plongeai un bistouri avec precautions dans le cerveau, et il jaillit de 
 suite un flot de pus. Le soit meme de cette operation, tons les acci- 
 dents disparurent ; la fievre, la somnolence et le delire ; et le malade 
 guerit." 
 
 In the following case of Prof. Nancrede's,t the apparent slightness 
 of the injury, the long absence of symptoms, then their sudden onset, 
 the difficulties met with during trephining, the results of promptly 
 meeting them, and finally death brought about by hernia cerebri are 
 all deserving of most careful attention. 
 
 On March 6th, J. Y., aged nineteen, walked into the Episcopal Hos- 
 pital, complaining of a sore on the top of his head, the result of a blow 
 received two months previously. On examining the wound, in the 
 centre of au ulcer, located about the position of the left middle parie- 
 tal lobe, was found the broken edge of a knife-blade. On being told 
 of this he seemed thoroughly surprised. But little could be made out 
 as regards the incidents of the attack, except that a man had struck him 
 on the top of the head so forcibly that he had fallen on his hands and 
 knees, but had recovered himself almost immediately. He said that 
 he did not, at that time, or afterwards, lose consciousness, nor had he 
 had even a headache. All symptoms of brain injury were absent. 
 He did not complain of any pain or uncomfortalde sensation wdien the 
 knife-blade was removed, but in the afternoon of the same day he had 
 shght pains in the head. ]\Iarch 7th, had slept well. No headache, 
 temperature 100°. Slight retinal hyperiemia. March Sth, epilepti- 
 form sei'zuv(-s set in to-day, l>eginning wdtli twitching of the right arm, 
 but soon Ijecoming general. Prof. Nauerede trephined over the seat 
 of injury, tlie bono removed sliowing a slight depression of the inner 
 table. The jxisition which the lilade had occupied could be seen in 
 
 * Ijiriiiix Orules (/c Clin. CIdnirg., 2il ed., vol. vi. p. 146. 
 f Iiilcrii. Encyd, of iSanj., vol. v. p. 83. 
 
TREPHINING IN FRACTURED SKULL. 163 
 
 the dura liiater, there heing an opening surrounded with dense cica- 
 tricial tissue. The dura mater did not seem to be congested, and tliere 
 was evidently no pus or fluid heneath it. During the next three 
 weeks the fits apparently ceased, but symptoms indicating cerebral 
 abscess — viz., temperature often low, 97J°-98°, slow pulse, marked 
 mental dulness — set in. March 30th, temperature 99°, pulse 70°. 
 The patient was unconscious, with right-sided hemiplegia, and rapidly 
 sinking. Prof. Xancrede, on reflecting the fla}) covering the trephine 
 hole, found it filled by the tensely stretched dura mater, pulsating 
 strongly. A small incision was made through this, but nothing was 
 evacuated. The coma rapidly deejiening, an aspirator needle, con- 
 nected with a vacuum, was passed in at three or four different spots, 
 to the depth of i inch, but with no result. Feeling convinced that 
 pus was present, and from the symptoms that it was compressing the 
 ascending frontal and parietal convolutions, Prof Xancrede proceeded 
 to set a large-crowned trephine in front of and below the first open- 
 ing, which was slightly behind the fissure of Rolando. Before the 
 skull was half divided both pulse and respiration ceased. The opera- 
 tion being rapidly completed, the dura mater was incised without re- 
 sult. At this moment a large drop of pus oozed up through one of 
 the aspirator punctures. A knife being plunged into the brain sub- 
 stance, from one to two ounces of pus were evacuated. The patient 
 appeared to be quite dead, but vigorous and prolonged artificial res- 
 piration revived him. The next day a hernia cerebri as hxrge as a 
 walnut was protruding from the wound in the dura mater. This in- 
 creased in size, and broke down, the patient dying on April 4th. At 
 the autopsy the left parietal lobe formed an enormous abscess cavity, 
 the abscess being superficial, and destroying the greater portion of the 
 upper part of the left hemisphere. 
 
 TREPHINING* IN FRACTURED SKULL. 
 
 (Figs. 41 and 42.) 
 The scalp having been shaved and thoroughly cleansed (infra), 
 the patient brought under the influence of chloroform,t unless a con- 
 
 * It has been already stated that in many cases of depressed fractures, after exposure 
 of the fragments, a pair of dressing-forceps and an elevator may do all that is required. 
 That the trephine itself is not always needed sho.dd h^ clearly understood, as it is 
 probable that elevation of fragments might most wisely have often been performed if it 
 had not been for the absence of a special instrument, wrongly supposed to have been 
 essential, or for the dread of an operation of undoubted severity with its necessary 
 laceration of the vascular diploe, and requiring delicacy and skill also. _ 
 
 t I much prefer this anesthetic, if possible, in these cases of trepluning, on account 
 of the greater excitement and congestion which are usually associated with ether. But 
 whenever it is possible, and especially when the pulse and breathing are failing, anaes- 
 thetics should be dispensed with (p. 154). 
 
164 
 
 OPERATIOXS ON THE HEAD AJv'D NECK. 
 
 dition of unconsciousness renders this unnecessary, the head is sup- 
 ported on sand-bags at a convenient height. The fracture is next 
 exposed bj^ appropriate flaps, the old-fashioned crucial or T-shaped 
 incisions being as useful as any, or a semilunar incision which can 
 afterwards be converted into a Y, if it be needful to follow a line of 
 fracture.* The incisions should usuall}' go down to the bone itself, 
 and the pericranium should be raised, b_y the handle of the scalpel, 
 cleanly and regularly off the bone, together with the flaps. If it be 
 needful to operate through the tempoi-al muscle, its fibres must be suffi- 
 ciently severed and raised with the flaps, it being somewhat more 
 difficult to separate the periosteum here, on account of its thinness in 
 this region, and more intimate adhesion to the subjacent bones. f In 
 reflecting scalp-flaps, free haemorrhage is nearly always met with, espe- 
 
 FiG. 41. 
 
 [^, r^V^ 
 
 Compouud depressed fracture of gutter form. There being no comminution, the trephine has 
 been placed close to, and, in part, overhangs the fracture (Hutchinson). 
 
 daily in the case of the chief superficial trunks and the deep temporal 
 arteries, but this is promptly and easily arrested liy the use of Spen- 
 cer Wells's forceps, which act as most useful retractors, taking up but 
 little room, while at the same time they arrest the hannorrhage. If 
 bleeding continues from any crack in the bone which may now be 
 found, it will only cease on the elevation of the fragment, or on the 
 exposure of, and the dealing with, any subjacent clot. The fracture 
 being now in view, and it lieing found imiiossible to introduce an ele- 
 
 * On this subject, .see the phtn adopted by Prof. liorsley (infra). 
 t The greater thickness of the soft iiarts which will here form the cicatrix will, in a 
 measure, make up for the difficulty in preserving the periosteum. 
 
TREPHINING IN FRACTURED SKULL. 
 
 165 
 
 vator or pair of dressing-forceps, even after sawing oJ3F any projecting 
 angle of bone, the surgeon must decide where to place his trephine. 
 In doing so, he must choose a spot, if possible, clear of a sinus, or 
 large branch of the middle meningeal artery,* and one which will at 
 the same time support firmly the pressure needed in the working of 
 the trephine. Thus the pin and the greuter part of the trephine crown 
 are placed on sound bone (Fig. 41), while a small part of the trephine 
 
 Fig. 42. 
 
 Severe compound fracture of skull. The bone being much damaged by comminution, the tre- 
 phine has been placed at a little distance from the fracture, so as to be on sound skull. The 
 intervening bone would be readily clipped* away with bom- forceps. The flaps are retracted, 
 and cut vessels in them at the same time commanded by three pairs of torsion-forceps. 
 
 usually overhangs a depressed fragment. But if the surgeon fears 
 that the fragments are in contact with the dura mater, and perhaps 
 injuring it, and that the jarring movement of the trephine coming in 
 contact with one may be pernicious, he will so place his trephine that 
 it rests entirely on sound bone, any intervening bridge being easily 
 cut away (Fig. 42). A spot being thus chosen, a trephine of appropri- 
 ate size is taken,t with the centre-pin protruded for about a tenth of 
 
 * If it is really needful to trephine over one of these vessels, the remarks at pp. 159, 
 178, will show how the haemorrhage should be met. 
 
 f One J inch in diameter is usually ample. The conical tre|)hine is said by Ameri- 
 can surgeons {e.g., Nancrede, loc. supra cit. p. 96; Dr. Hopkins, Ann. of Surg., vol. ii. 
 No. 7, p. 69) to be safer than the ordinary one, it being almost impossible, owing to its 
 greater steadiness, to injure the brain with it, if, as the deeper part of the internal table 
 
166 OPEEATIONS OX THE HEAD AND XECK. 
 
 an inch, and firmly fixed in this position, the trephine being so 
 grasped in the hand, that the index finger steadies the centre-pin 
 screw when the hone is entered. The instrument is now firmly ap- 
 plied to the bone, the centre-pin being bored inwards, and as soon as 
 the teeth feel the bone, the trephine is worked from left to right and 
 then from right to left, care being taken to exert equal pressure in 
 both directions ; while the first groove is being cut, the movements of 
 the trephine must be light and quick, but without jerking, the ten- 
 dency of the instrument to slip being met with steady bearing on the 
 centre-pin, and by keeping the left forefinger at first on the bone, close 
 to the trephine. 
 
 As soon as a groove has been cut sufficient to keep the trephine 
 steady, the pin is drawn upwards, and so fixed. The rotary move- 
 ments alternating from sixle to side are now continued, care being 
 taken to bear as evenly as possible on every part of the circle, till the 
 diploe* (if this be present) is reached. This is known liy the easier 
 working of the instrument, and liy the softer sound. On the living 
 body at least, owing to the oozing from the vascular parts around, the 
 blood-staining of the bone-dust described as taking place at this stage 
 is liable to be fallacious. 
 
 Throughout the operation, but especially now as the thinner table 
 is being reached, every care must be taken to keep the circle of equal 
 
 depth — (1) by jjressing on the saw evenh' ; 
 (2) by making it bite in as equally from 
 right to left as from left to right ; (3) by re- 
 membering that, owing to the skull being 
 spheroidal in shape, it is impossible, with- 
 out the greatest carefulness, to keep the 
 groove of equal depth all round; (4) by 
 bearing in' mind that while the average 
 thickness of the adult skull is one-fifth of 
 an inch, the thickness varies so much that it is almost always greater 
 at one part of a trephine-circle than another f (Fig- -13). Thus at fre- 
 
 is divided, any undue pressure should be made. But if used with ordinary -.kill, the 
 old form of trepiiiue is perfectly safe. The modified biirr of the dental engine lias 
 been found to work accurately by some .•\merican surgeons — c.(/., Dr. Roberts (he. 
 TO/)ra cii), especially in removing large areas of bone. Hilherto, simpler, old-fash- 
 ioned instruments have held their place in England. 
 
 * Tiiis is absent in early life and in the aged. Again, over a large part of tlie 
 squamous b<]ne and in the occipital fossa?, diploe is never met with. Thus, in ca.ses 
 wliere tlie diploij is absent, esppcially in the thinned calvaria of an aged corpse, it is 
 quite possible, by using haste or force, to jam the crown of bone in upon tlie brain. 
 
 t Mr. Holden's word< ( Ldudmarks, p. o) are excelieu! : "In applying the trephine 
 this is not a bad rule — 'Think tiiat you are operating on the thinnest skull ever .seen, 
 and thinner in one-half of the circle than in the other.'" Sir A. Cooper (Swyery, 
 
TREPHINING IX FRACTURED SKULL. ]67 
 
 quent intervals the flat end of a trephine-probe, or a clean quill cut 
 pointed must be carefully introduced at different spots, and when 
 the circle is found to be deeper on one side (still more if it is perfo- 
 rated) the trephine must be so slanted that its teeth are only cutting on 
 that part of the groove which is still shallow. When the groove has 
 been made sufficiently deep, and careful examination finds one or 
 two points of penetration, the bone may be removed either Ijy tilting 
 it out in the trephine, by sharply rocking this from side to side, or by 
 inserting the elevator at the deepest part of the groove ami lifting up 
 the disk of bone by carefully making a fulcrum of the sound bone or 
 of a finger. 
 
 If profuse hajmorrhage occur on raising either the disk of bone or a 
 depressed fragment, it will probably come either from a branch of the 
 middle meningeal artery or from a sinus. The treatment of the former 
 is given at p. 178 ; in the latter case pressure should be at once applied 
 by means of a piece of sponge which has been kept in and wrung out 
 of a solution of carbolic acid, or mercury perchloride, and dusted 
 with iodoform powder; if this has to be tucked under an edge of 
 bone to control the bleeding, a ligature of carbolized silk should be 
 fastened on to it, to secure its withdrawal in about three davs' time 
 (p. 169). 
 
 In the case of a punctured fracture, a full-sized inch trephine should 
 be applied, so as to remove the outer table around the immediate 
 neighborhood of the puncture, and thus expose freely the damage to 
 the inner table. 
 
 If after removing a crown of bone more room is still required, this 
 may be obtained either by taking out a second crown close by and 
 joining the two, or by the use of a Hey's saw or Hoffman's forceps; 
 with the latter instrument, if of reliable temper, a considerable area 
 of bone can be quickly nibbled away. 
 
 Mr. Hutchinson* has drawn attention to the feasibility of obtaining 
 satisfactory access to depressed fragments, and of removing them, 
 after trephining through the external table only. Thus, at p. 188, loc. 
 infra cit., he writes : " With a small trephine I removed a circle of the 
 bone in front of the depression, not going deeper than just into the 
 diploe. This done, with a little trouble I got away the anterior frag- 
 ment, which acted as a buttress between the depressed fragments and 
 the other part, and would have entirely prevented its being elevated. 
 
 edited by Dr. A. Lee, vol. i. p. 188) thus speaks of the operation. "Some people say 
 that this is a trifling operation, not difBcult to perform, nor dangerons; bnt they 
 deceive you : it is one of the most dangerous operations in surgery ; whilst performing 
 it there is but a single step — a small network — between your patient and eternity." 
 * Clin. Sitrg., vol. i. p. 187 et seq. 
 
168 OPERATIONS ON THE HEAD AND KECK. 
 
 When this was removed, I easily got the point of an elevator into the 
 diploe of the depressed portion, and succeeded in lifting it into place." 
 
 ■\^'ith all due deference to Mr. Hutchinson, I cannot think that this 
 method of only removing the outer table should be generally adopted, 
 and for these reasons. In hands less experienced levering up a 
 depressed fragment by insinuating the point of an elevator into its 
 diploe, seems to be very likely to end in increasing the depression. 
 Again, every surgeon in whose hands the outer table has come away, 
 accidentally, by itself, knows how difficult this renders the completion 
 of the operation. A surgeon, then, who had done this purposely, and 
 then found himself unable to remove the depressed fragments lay the 
 method just given, would very likely find the completion of the tre- 
 phining and the getting out of the inner table a matter of embarrassing 
 difficulty. 
 
 Mr. West recommends that the periosteum, which has been care- 
 fully preserved, should be adjusted by catgut sutures, this precaution 
 tending to prevent any subsequent hernia cereliri. Sufficient drainage 
 must of course be provided. 
 
 With the same view, in order to diminish the subsequent gap, any 
 detached fragments of bone (which should have been kept in warm 
 carbolic acid solution) may be i^laced across the aperture in the skull, 
 it having been found by Dr. Macewen* that they will adhere and give 
 no further trouble. Sufficient drainage is then provided by fine tubes 
 or drains of horsehair or gut, sutures inserted and dressings applied. 
 
 The terse summing up of Dr. Amidon, of New York,t may here be 
 quoted : " Let the operation always be clone with antiseptic precau- 
 
 * On this subject I would refer the reader to a case of Dr. Macewen's (p. 102). Mr. 
 Clark (Lancet, 1886, vol. i. p 243) in a case of trephining for tranmatic epilepsy, in 
 which this operation was followed by ranch impi-ovenient, bnt not a complete cure, 
 replaced the cnjwn of bone— a piece of the frontal, and the seat of ostitis — after 
 bevelling off' the inner edge so as to prevent pressure upon the dura mater, and 
 after cutting a notch in the side of it (o serve for drainage. The restored crown 
 did not necrose but united satisfactorily. However right it may be to replace, in most 
 cases, bone which has been removed, especially in those cases where the removallias 
 been extensive, I doubt very much if this course is judicious in cases of trephining for 
 trauujatic epilepsy. Until this subject has been more thoroughly worked out, I 
 think it would be wiser to leave the small trepliine-gap not filled up, and thus provide 
 a safety-valve for the relief of varying tension. This course would be especially indi- 
 cated in cases of long-standing depressed fracture where trephining is resorted to late, 
 and though the source of irritation is thus renewed, the brain has taken an impression, 
 which, though perhaps latent, will remain permanent, and which will be prone to show 
 itself on very slight excitement. See foot-note f, P- lo7. 
 
 t Med. News, Philadelphia, June 21st, 1884; Ann. of Surg., No 3, vol. i. To this 
 second paper of Dr. Amidon, a very instructive and helpful statistical table of 115 
 cases is appended. 
 
PUS BETWEEN THE SKULL AND DURA MATER. 169 
 
 tions. Try and secure only proximate coaptation of the flaps. Pro- 
 vide the freest possible draiuat^e. Use crild antiseptic dressings, 
 without much compression. Enjoin the strictest quiet in a posture 
 facilitating drainage." 
 
 TREPHINING FOR PUS BETWEEN THE SKULL AND 
 
 DURA MATER. 
 
 While the mode of using the trephine here will in no way diiler 
 from that already given, a few practical remarks will be made on this 
 most important condition. 
 
 It is well known that operative interference here is now less frequent 
 than it would appear to have been a hundred years ago when ISIr. Pott 
 drew the attention of surgeons to the need of trephining when pus was 
 present immediately beneath the skull. For while Mr. Pott, in his day, 
 saved five out of eight of these cases in which he trephined, surgeons 
 of the present time, when they tre])hine, have been usually baffled by 
 the coexistence of pya?mia, or, if this ominous complication be absent, 
 by finding the collection of i)us not localized between the bone and 
 dura mater, or if so localized, combined with suppurative arachnitis 
 also. 
 
 Mr. Holmes (Treat, on Surf/., 1st ed. ]>. 130) brings forward the fol- 
 lowing weighty statements : " Some years ago I published* the expe- 
 rience of St. George's Hospital in this particular for seventeen years — 
 1841 to 1857 inclusive. Eight cases occurred in which the trei^hine 
 was applied for pus. The pus was found in every case, but all the 
 patients died. Seven were examined after death, and in six of these 
 unmistakable evidence of phlebitis in the sinuses of the brain and 
 veins of the skull and of general pyiemia was discovered. In the 
 seventh case the abscess reached the ventricles of the brain. There 
 were eight other cases in which the trephine was not used, and where 
 matter was found above the dura mater, but it was not limited to this 
 situation in any of these cases, nor would adequate exit have been 
 procured for it by the trephine. In nine other cases there had been 
 intra-cranial suppuration, but the matter was diffused among the 
 membranes or in the substance of the lu-ain, and lay entirely below 
 the dura mater." 
 
 The above most gloomy picture of what has been usually met with, 
 only serves, I think, to confirm the opinion given below that these 
 cases should be explored early, being treated, in short, more like cases 
 of acute periostitis and osteo-myelitis elsewhere, than has hitherto 
 been the case. 
 
 When it is remembered that pus does not form between the bone 
 
 * Brit. Med. Journ., October 16th, 1858. 
 
170 OPERATIONS ON THE HEAD AND XECK. 
 
 and ilura mater without a previous stage of traumatic ostitis arid 
 plilcljitis of tlie veins of the diploe, it will be readily understood liow 
 easily, if the wound be foul, septic osteo-inyelitis and septic phlebitis, 
 with the inevitable result of pysemia, will follow. 
 
 Indications of the Formation of Pus between tie Bone 
 and Dura Mater : Question of Trephining.— History of a head 
 injury with damage of some kind to the outer table. Thus there is 
 often a scalp wound exposing the pericranium, often opening this up 
 at one or two points, perhaps small and not seen at the time ; occa- 
 sionally the bone itself is laid bare by the injury. Either now or later 
 on the wound becomes septic. After a varying period, usually in the 
 course of the second week after the injury (during which period defi- 
 nite symptoms are often altsent), headaclic, fretfulness, nausea, or 
 vomiting set in, gradually followed by drowsiness, delirium, twitch- 
 ings, convulsions, paralysis, coma, and death. 
 
 This on-rush of symptoms about the eighth or tenth day may be 
 accompanied by evidence of pyiemia — viz., rigors followed Ijy sweating, 
 a jactitating temperature, progressive emaciation, and affections of 
 viscera and joints, amongst which pleuro-pneumonia is one of the 
 most frequent and grave. 
 
 The surgeon who is watching a case of this kind, and also is not 
 unmindful of what has happened and what is liable to be going on — 
 the injury to the pericranium and bone, the ostitis and osteo-myelitis 
 with plugging of the diploic veins, the extension to the inner table, 
 the formation between the bone and dura mater of lymph ready to 
 suppurate, this deep-seated inflammation being only too ready to 
 extend to the arachnoid and thus become a diffused meningitis — will 
 find it a matter of much difficulty to answer the question, How far 
 has the mischief gone? Is the case a hopeless one? If the intra- 
 cranial collection of pus be a localized one and uncomj^licated, well- 
 marked hemiplegia and the aliscnce of pya^mic symptoms will call 
 hopefully for trephining. On the other hand, paralysis, indistinct or 
 complete, epileptiform convulsions, extreme irritaljility, an aspect of 
 fever, and, es])ecially, any evidence of involvement of nerves at the 
 base, will all point to that form of meningitis which will show itself 
 as a diffuse layer of pus and lynipli over one side of the arachnoid. 
 
 Equally pointing to a fatal issue will be the symptoms of pyajmia 
 already alluded to, and needing no further mention here. 
 
 Wliat is to be done in these i-ises? Where the evidence of menin- 
 gitis is undoubted, of some days' standing, where the hemiplegia has 
 been little marked, or where it is replaced liy i>araplegia, general con- 
 vulsions, and other unfavoraljle signs, no surgeon will be wise in 
 tre]jliining. 
 
 Should evidence of coexisting pyjemia be looked upon as equally 
 
PUS BETWEEN- THE SKULL AND DURA MATER. 171 
 
 hopeless and equally negativing the use of the trejjhine? I scarcely 
 think so. Every surgeon knows that, although pya?mia is usually 
 fatal, it, very occasionally, ends favorably. Again, in treating pyicmia 
 resulting from periostitis and osteo-myelitis elsewhere, we are not 
 deterred from making free incisions and exploring the bone. 
 
 The real treatment of these cases must, of course, be really pre- 
 ventive — i.e., every scalp wound should be rendered aseptic and kept 
 so from the very first, however slight it seems to be. But, as this pre- 
 caution is not always taken, and is occasionally impossible, the con- 
 dition of the pericranium and bone should be explored earlier, at the 
 very first warning of danger. Instead of treating such a case as a 
 special result of head injury, and waiting for evidence of pus between 
 the bone and dura mater, we should, I think, deal with it as we do 
 periostitis and ostitis elsewhere; that is to say, that, in cases of this 
 kind where there is reason to believe that the bone has been injured, 
 especially if there is any doubt as to the condition of the wound 
 throughout, the surgeon should, on the first appearance of malaise, 
 irrital)ility, headache, nausea, chilliness, explore the wound. Any 
 granulations here present will very likely be at a standstill. A piece 
 of bone will probably be bare and perhaps soft, the pericranium infil- 
 trated and separating. The whole area of bone which is thus being 
 deprived of its pericranium should be explored, and drainage pro- 
 vided. But in nearly all cases, especially if the bone is softened at all, 
 it will be wiser to do more, and open the bone with a trephine to give 
 vent to any inflammatory material in the diploe, to prevent septic 
 phlebitis and its extension to the sinuses, and to save the inflammation 
 from reaching the inner table and dura mater. 
 
 The above depends on the fixed conviction that trephining, in 
 careful hands, and with due precautions, is not. in itself, a dangerous 
 operation (p. 156), and on the fact, which is beyond dispute, that, if 
 these cases are left till hemiplegia pronounces the existence of intra- 
 cranial pus, they will, too- often, be left too long, as this waiting will 
 give time for the onset of pyemic infection, and for the arachnoid to 
 be involved in the inflammation. 
 
 The operation of trephining here will in no way differ from that 
 already described. Pus welling up from the diploic cancelli, or a fetid 
 condition of these, is ominously suggestive of impending pytemia. If 
 such a condition be present, the bone should be freely removed, and 
 disinfected as far as possible; but, from the probable extension of 
 thrombi to the sinuses, the outlook is a very dark' one. If pus be 
 present between the bone and dura mater, it must be thoroughly 
 evacuated, and free drainage provided.* The condition of the dura 
 
 * In these case?, and, in fact, in any trephining cases where the discharges are fonl 
 and the scalp the seat of cellulitis or erysipelas, iced boracic acid (a saturated solution) 
 
172 OPERATIONS ON THE HEAD AND NECK. 
 
 mater should always be examined into, whether pus is found super- 
 ficial to it or no. If it pulsate freely and be natural in appearance 
 and devoid of lymph, nothing more need be done. If, on the other 
 hand, it bulge into the trephine-hole devoid of pulsation, it should be 
 punctured, this perhaps giving vent to a jet of purulent fluid from the 
 arachnoid cavity. If the arachnoid is seen to be covered with Ijanph, 
 this is of the gravest omen. The possibility of the existence of cere- 
 bral abscess must always be remembered in these cases, where nothing 
 else has been found to account for the head symptoms. The symptoms 
 and treatment are fully given at p. 183. 
 
 The following cases are good examples of this most dangerous con- 
 dition of ostitis of the cranium and its scquelfc and complications: 
 
 The first case, reported by Mr. Hutchinson,* show.^ pya?mia promi- 
 nent rather than arachnitis ; the second,! <ilso ]\Ir, Hutchinson's, shows 
 the reverse condition — much arachnitis and no general pvffimic infec- 
 tion. The third, one under my own care, shows both arachnitis and 
 pyaamia combined. In all pus was present between the lione and 
 dura mater. 
 
 J. W., aged ten, on Octolier 15th received a large lacerated scalp 
 wound from a dog bite, a triangular flap of all the tissues of the scalp 
 being torn up, from the left parietal bone. The pericranium was not 
 torn up excepting perhaps at a few points. 
 
 The boy was admitted into the London Hospital at once, the flap 
 of skin adjusted, and for some time all went on perfectly well, the boy 
 being only kept in bed for a day or two. 
 
 Oct. 28. He did not eat his dinner as well as usual. The wound 
 was looking a little pale. 
 
 Oct. 29. While up and at dinner he was noticed to be cold and 
 shivery. A very severe rigor followed. It was impossible to ascertain 
 whether he had headache for some days or not. In the wound the 
 granulations were pale and glassy, and a small piece of dry, bare bone 
 was exposed. 
 
 During the next few days there were repeated rigors and much 
 headache. 
 
 Nov. 1. He had now very decidedly the aspect of pneumonia, and 
 the breathing, temperature, [)ulse, and cough confirmed this. 
 
 Nov. 2. He seemed better than yesterday, the respiration being 
 more easy. There is not the slightest sound of paralytic weakness. 
 Doubts have been expressed as to whether this boy is or is not the 
 subject of pyaMnia. He looks eomfortalde, excepting for the blueness 
 
 lotion applied by means of lint freqnentl.v welled and renewed, tosetlier with a dust- 
 ing of iodoform, is preferable to dry dressings clianged less frequentU-. 
 
 * Cliu. Surg., vol. i. p. 97. 
 
 f Loc. supra cU., p. lO'J. 
 
PUS BETWEEN- THE SKUEL AND DURA MATER. 173 
 
 of the lips, which is less than yesterday. That he is suffering from 
 pneumonia all must admit, and that the pneumonia does not produce 
 the usual train of symptoms (no rust-colored sputum, no great dys- 
 pnoja, tongue almost clean, etc.). He has had a series of rigors of the 
 most marked character. If tliere had heen but a single rigor, it is 
 very possible that it might have been indicative only of pneumonia, 
 but their recurrence seems to me to denote pyiemia.' This diagnosis 
 is also favored by the fact of his ajjparcnt imi)rovement at times and 
 great variations in condition. 
 
 The wound was now secreting a very fair quantity of healthy pus. 
 Its granulations are much better than they were, and fairly florid. 
 
 During the next three days the thoracic symptoms increased. He 
 emaciated rapidly. Consciousness was perfect to the last, and he had 
 neither paralysis nor convulsions. All traces of granulations dis- 
 appeared from the wound. He died November 7. 
 
 There were very numerous pysemic deposits in the lungs, liver, and 
 spleen. Beneath the scalp wound was bare and greenish bone the 
 size of a crown-piece. The edges of the wound were thin and loose, 
 and the pericranium was also loose over a surface as large as the palm 
 of the hand, comprising, in fact, iiearly all the parietal bone. There 
 was a recent scar in the scalp, crossing the vertex transversely, just 
 above the lambdoid suture; the pericranium here was thickened and 
 inflamed, and the bone on both sides of the sagittal suture here was 
 green. On applying the trephine at this spot, dirty-green, fetid 
 pus was exuded on the inner surface of the bone. It must be observed 
 that this portion of inflamed bone extended on each side of the sagittal 
 suture, and that it was under, not an open wound, but a soundly 
 healed one. 
 
 E. S., aged ten, was admitted, July 21, into the London Hospital 
 Avith very extensive laceration of the scalp on the left side, laying 
 bare the parietal bone. During the first few days he took his food, 
 was ijerfectly conscious, and seemed to be doing well. 
 
 July 26. Bone as large as a crown-piece is exposed, white and dry,, 
 above the left ear. 
 
 July 29. A strong rigor. 
 
 July 30. Wound without granulations, looking glazed. 
 
 July 31. Very restless. Uses all his limbs at times, but the left 
 ones much better than the right. 
 
 Aug. 1. The skull was trephined in the middle of the exposed 
 bone two inches directly above the left ear. The dura mater w^as 
 covered with yellow lymph. It pulsated pretty freely. On cutting 
 through it, about a drachm of thin, purulent fluid jetted out. The 
 yisceral arachnoid was seen to be covered with lymph. 
 
 Aug. 2. He still uses his left arm, but never his right hand. When 
 the brain, which bulged, pulsating, into the wound was pressed back,. 
 
174 OPERATIONS ON THE HEAD . AND NECK. 
 
 thin pus ran out in considerable quantity from the arachnoid cavity. 
 His a.spect was that of a patient in the very last stage of fever. Death 
 took jilace on August 3. 
 
 The bone around the trephine-aperture was dry and green. Every- 
 where on the left side the parietal arachnoid was concealed by a thick 
 deposit of puro-lymph, whilst everywhere on the right side the mem- 
 branes were perfectly free from deposit, polished and glistening. The 
 superior longitudinal sinus contained puriform fluid. The skull at 
 the seat of injury was discolored over an extent almost as large as the 
 palm of the hand; adjacent to it were other patches, greenisli-yellow, 
 opaque, and non-vascular. There were no pyamic deposits in the 
 lungs or in the viscera of the abdomen. 
 
 E. S., aged forty, slipped while getting off an omnibus, January 22, 
 1877, and was admitted into Guy's Hospital under Mr. Howse's care 
 with a scalp wound four inches long exposing the right parietal bone. 
 
 Owing to some oversight the wound was not dressed at first anti- 
 septically,* the discharge became offensive, and erysipelas of the scalp 
 setting in she was transferred to my care on February 1. At this time 
 almost the entire right parietal bone was exposed, owing to sloughing 
 of the pericranium. 
 
 Incisions were made where needful, drainage tubes introduced, and 
 in a few days the erysipelas had subsided, and the wound was sweet. 
 
 Fel). 11. She had a rigor for the first time. 
 
 Feb. 13. There was some paralysis of the left side of the face and 
 the left limbs. The temperature was 104°. 
 
 Feb. 15. The hemiplegia becoming more marked, I trephined 
 through the exposed bone, about one inch above the right parietal 
 eminence. Pus was met with in the diploic cancelli. 
 
 On removing the crown of bone an ounce of thick, foul, greenish 
 pus welled up. The inner surface of the bone was very rough, the 
 dura mater which corresponded to it being covered with velvety 
 granulations. As the dura mater did not pulsate, it was punctured, 
 but without result. 
 
 The patient became more conscious after the operation, but soon 
 lapsed again into a semi-comatose state. Convulsive seizures of all 
 the limbs, with twitchings of l)oth sides of the face, then set in and 
 continued till the patient's death, on February 17. 
 
 The ])a,rietal bone was found to be dying for a considerable area, 
 the diploe Ijeing green and offensive. The pus seemed all removed 
 from the dura mater, liut thta-e was suppurative arachnitis over the 
 right hemisphere, reaching up to the falx in one direction and the 
 base in the other, Init stoiiping short of each. There were numerous 
 pyaraic abscesses in the lungs and liver. 
 
 A precaution on wliicli my colleague Imbituallv insists. 
 
MIDDLE MENINGEAL HiEMORRtlAGE 175 
 
 TREPHINING FOR MIDDLE MENINGEAL 
 HEMORRHAGE.* (Figs. 44, 45.) 
 
 Indications.— When a pcatient, after I'eceiving an injury to the 
 head, has sliown several of the symptoms given below. 
 
 It is noteworthy that tlie injury and amount of violence vary 
 extremely. While most frequently serious, as in falls on the head, 
 the violence may be extremely slight, as when a patient slips going 
 downstairs and strikes the liead against the wall, when a boy receives 
 a blow from a cricket-ball, or when a child has a fall of 2 feet 6 inches 
 out of a swing. From this the following conclusions follow naturally : 
 (a) That in the cases of severer violence, laceration or contusion of the 
 brain are, only too frequently, complications ; (h) where the violence 
 has been slighter, cither no fracture may l)e present, or, if one be 
 present, it is often only a mere fissure, and may involve the internal 
 table onl}^ 
 
 i. Iritenrd of Cdn.sciousness or L ciditi/.^This interval between the 
 stunning effects of the injury or concussion and the onset of com- 
 pression from the effused blood vai-ies, when present, in length from 
 a few minutes to several hours. In altout half the cases it is well 
 marked. In a second class it is but little marked, and may easily be 
 overlooked altogether. In a third and last set of cases this interval 
 is never present at all, owing to (1) The presence of a very large ha?m- 
 orrhage producing compression- symptoms ; (2) Coexisting depression 
 of bone; (3) Coexisting injury to the brain; (4) Drunkenness of the 
 patient. 
 
 ii. Condition of the Limbs as to Hemiplegia, Purab/sis, Rigidity, etc.— 
 Hemiplegia, though well marked in a large proportion of cases, must 
 not be looked upon as essential, and middle meningeal haemorrhage 
 must not be overlooked because hemiplegia is aljsent, ill-marked, or 
 replaced by some other condition of the limbs. At least, the following 
 seven conditions of the limbs niay be met with in middle meningeal 
 haemorrhage. 
 
 (a) Hemiplegia present and well marked, the leg or arm, and 
 usually both when taken up and let go, dropping like those of a 
 corpse. This condition is present in probably one-third of the cases. 
 It is noteworthy that occasionally the hemiplegia is on the same side 
 as that injnred, the extravasation taking place on the side opposite to 
 that struck. 
 
 (/?) Hemiplegia present, but little marked. In these cases, which 
 are not uncommon, the extravasation ma}^ be overlooked. They fall 
 into at least two divisions. In one the hemiplegia is little marked 
 
 * For fuller information on tliis most important subject, I may, perluips, refer 
 tlie reader to an article contributed to the Guy's Hasp. Repo-ls, 1886, p. 147. 
 
176 OPERATIONS ON THE HEAD AND NECK. 
 
 throughout, owing, perhajjs, to some power of accommodation on the 
 part of the brain, or to the circulation remaining feeble, owing to 
 coexisting shock from the time of the injury to the moment of death. 
 
 In another group of cases, the hemiplegia is ill marked because of 
 brief duration, coming on as it does in these cases towards the close, 
 together with coma, giving but little warning and leaving but short 
 time for interference. 
 
 When there is any doubt as to the existence or degree of hemi- 
 plegia, the following tests should he carefully made use of: whether 
 the patient resists on the surgeon attempting to move the limbs; the 
 power of the grasp, if any; the result of pricking ; whether the patient 
 moves either of his hands, or which of them, when the cornea is care- 
 fully touched or the cilia gently pulled. 
 
 (y) Hemiplegia present, but temporary. A very rare condition, 
 produced probably liy the brain being able to accommodate itself to 
 the blood. 
 
 (S) Monoplegia, or the paralysis more marked in one limb than the 
 other. A rare condition, as the haemorrhage generally makes pressure 
 ui^on all the motor area. 
 
 (e) General paralysis. Another rare condition, the existence of 
 which may be explained b}' a verj' large clot — e.g., on the left side, 
 rapidly effused and making pressure through the leftside of the Ijrain, 
 upon the right as well, or by coexisting extravasation into the brain 
 substance itself. 
 
 (C) Absence of any paralysis. A very rare condition, and one which 
 is, perhaps, due to the blood effused from the middle meningeal 
 artery, finding its way through a fracture in the skull, beneath the 
 scalp. 
 
 (t?) Limbs rigid, convulsed, or twitching. It is only too probable 
 here that, in addition to middle meningeal extravasation, contusion, 
 or laceration of the brain substance will be found at more spots than 
 one. 
 
 iii. Condition of the Piqyils. — Whilst this may be various, there are at 
 least three conditions which are most important. 
 
 («) If the pupils are natural as regards reaction to light, the com- 
 pression of the brain is probably recoverable if trephining is immedi- 
 ately performed. Furthermore, it is probal)ly a case of compression 
 only of the brain, without other injury. 
 
 (/3) If the pupils are insensitive, often at the same time dilated, the 
 compression is proljaljly extreme, and while trephining is urgently 
 called for, it is less probable that in these cases the brain will recover 
 itself after removal of the clot. 
 
 (7) If one pupil is found widely dilated, the other being natural or 
 contracted in size, and if the dilatation be present on the side injured. 
 
MIDDLE MENINGEAL H.'EM.IRRHAGE. 177 
 
 in other words, opposite to the side paralyzed, it is a most valuable 
 sign, the explanation of which we owe to Mr. Hutchinson* 
 
 Taken with other evidence of middle meningeal extravasation this 
 condition of the pupil points to a large clot, reaching down into the 
 base and pressing forwards upon the sphenoidal fissure, and thus com- 
 pressing the third nerve. 
 
 iv. The. Pulse. — This will varj' according as the case is one of well- 
 marked, uncomplicated extravasation, or complicated with contusion 
 or laceration of the brain ; and, if the concussion stage has been severe, 
 according to the degree to which the heart has recovered from this. 
 
 In well-marked uncomplicated compression, the pulse will be 
 slower than normal — e.g., 66, 52, and still falling, 42, and usually some- 
 what full and laboring. 
 
 V. Coma, or Unconsciousness. — With regard to this, the following 
 points should be borne in mind ; 
 
 (a) The degree of unconsciousness will vary with the size of the 
 branch injured, and the rapidity with which the blood is effused. 
 Where the effusion is rapid and the compression great, the coma may 
 be as deep and complete as in apoplexy. But, in other cases, it will 
 be found that though the coma is apparently deep, this is not really 
 so, thus the patient may moan constantly, or may move his limbs 
 feebly when disturbed. 
 
 (/3) The commencing coma may be taken for natural sleep, or 
 drunkenness, in which conditions the patient may be allowed to lie 
 till it is too late. 
 
 (r) In a few cases, the onset of the coma is deferred till late, its on- 
 set is here sudden, its course rapid, and it generally ends in death. 
 
 vi. Respiration. — This, in well-marked cases, is often stertorous and 
 somewhat slow. In cases where stertor has not supervened to call at- 
 tention to the existence of compression, other and still graver altera- 
 tions in the breathing may be present, alterations which are warnings 
 that the end is not far off, and that, in the case of intended trephining, 
 there is no time to lose— viz., catchy, short respirations, cyanosis, and 
 gasping, irregular breathing, ceasing for intervals of ten or fifteen sec- 
 onds, and then repeated. 
 
 vii. State of Scalp.— Wheu the history is deficient, or when the sigus 
 of compression are not well marked, ecchymosis or contusion of the 
 parietal and temporal regions giving rise to a pulpy or puffy feel are of 
 great value. This condition will be especially marked, when the 
 hasmorrhage from the middle meningeal artery is finding its way 
 through some fracture into the tissues of the scalp.f 
 
 * On Compression of ilie Brain : Land. Hasp. Reports, 1867, vol. iv. p. 29 
 t There is a good specimen of tliis in St. George's Hospital Museum, Series No. 4, 
 fi<M]red bv Mr. Holmes in his Treatise on Surgery, 4th ed. p. 140, Fig. 39. It shows the 
 ° ■ 12 
 
178 OPERATIONS ON THE HEAD AND NECK. 
 
 Treatment.— Early trephining should be performed as follows: 
 The scalp should be shaved widelj^, for the liberal application of ice, 
 later on, if needful. No anesthetic should be given if the patient is 
 unconscious or the respiration failing. The head being supported on 
 sand-bags or a firm pillow, the middle meningeal area on the side 
 which is bruised, and on the side opposite t(j the hemiplegia, is ex- 
 plored by turning up flaps with a free crucial incision, the centre of 
 which islHnch behind the external auditory meatus, and 1 inch 
 above the zygoma. The brisk hajmorrhage which now usually takes 
 place will be best arrested by applying Spencer .Wells's forceps to the 
 keeding points, the forceps thus not only arresting haemorrhage, but 
 acting as retractors also (Fig. 42). The pericranium is then carefully 
 separated, and any fissure or fracture looked for on the bone. Whether 
 one is found or no, a crown of bone is next removed with a full-sized 
 trephine. When this has exposed the clot, * hasmorrhage may be still 
 going on, warning of which will, perhaps, be given by the pulsation of 
 the clot. This being removed by a small lithotomy scoop, one of 
 Volkmann's spoons, or the handle of a small teaspoon, the haemor- 
 rhage may cease, or it may continue profusely, welling up from a 
 point quite out of reach. In such cases, the surgeon may, after saving 
 his patient from the dangers of compression, have to face those of 
 most serious hasmorrhage. In such a contingency, the following steps 
 may be made use of: (1) The use of cold, either in the shape of large 
 ice-bags over the side of the face, head, and neck (M. Beck), or, as a 
 freezing mixture, three parts of salt and two of ice (Howse) ; (2) Press- 
 ure, by suturing the edges of the wound,t or by digital pressure on 
 the common carotid ; (o) If the bleeding spot is found by the aid of a 
 pointed probe to lie in a distant bony canal, the ha?morrhage may, 
 perhaps, be arrested by plugging this canal with a tiny wooden peg ; J 
 
 parietal bone of a chilrl, a.seil five, in wliicli a gaping fissure crosses the eroove for the 
 middle meningeal artery, prodnoinp; considerable extravasation inside the skull, and 
 still more exiernally. 
 
 * Perhaps another crown of bone must be removed to do this Thns, in one case, 
 when trephining over the trunk of the middle meningeal, I came down on the pro- 
 longed tail-like extremity of a luige clot, reaching far away upwards and backwards, 
 and due to a branch being opened at some distance by a most extensive fissure. 
 
 t This can only be carried out under certain conditions, as when the edges of the 
 wound are clean cut, of the surgeon's own making, and also when the surgeon is able 
 to see his patient at short intervals, or to leave him in competent hands; otherwise, if 
 the haemorrhage persist, this additional precaution may increase the risk of that com- 
 pression which the operation had been intended to obviate. 
 
 t This was suggested by Mr. T, Smith, and used successfully by Mr. Willett and Mr. 
 H. Marsh, at St. Bartholomew's Hospital in cases of htemorrhage from the descending 
 palatine artery (Clin. Soc. Trans., vol. xi. p. 71). 
 
MIDDLE MEM>GEAL HAEMORRHAGE. 179 
 
 (4) The above means failing, which is unlikely, ligature of the external 
 carotid had better be resorted to * 
 
 Whether the surgeon should remain satisfied with a single trephin- 
 ing and partial removal of tlie clot, or, having exposed the clot, pro- 
 ceed to remove the skull, and then the blood, more extensively, is as 
 yet doubtful. For the present, and until a larger number of cases in 
 which trephining has been performed for this htcmorrhage have been 
 collected, that surgeon will probably be wiser who rests satisfied with 
 a simple trephining, using a full-sized instrument and trusting to the 
 "safety-valve action"! which this ensures for the brain. 
 
 Prognosis.— With reference to this point, I may quote the follow- 
 ing remarks from my paper in the Gm/s Hasp. llq,s., vol. xliii. : 
 
 " The chief points on which this depends are, whether the middle 
 meningeal extravasation is probably complicated with such injuries 
 _ as extensive fractures and brain injury, and secondly upon the date of 
 the trephining, and whether, at this time, the brain recovers itself 
 quickly or not. With regard to the former, or the existence of com- 
 plications, the surgeon Avill, if asked to state the probable result, base 
 his opinion on the history of the case, the severity of the violence, e.;/., 
 height of fall, whether any interval of lucidity has been present, and, 
 if so, for how long and how far this has been well marked, how far the 
 symptoms of compression, well-defined hemiplegia, the falling pulse, 
 the stertorous breathing, etc., are present or replaced by, or compli- 
 cated with, those symptoms which are believed to point rather to lacera- 
 tion or contusion of the brain and its membranes — viz., restlessness, 
 convulsive movements or twitchings, pulse quick and sharp, and other 
 evidence of pyrexia, which show that inflammation of the brain has 
 probably supervened upon the injury to its substance." 
 
 The seventy cases on which the above paper was based appeared to 
 fall into the three following groups : 
 
 A. The Mod Hopeful Cases for Trephining. — Violence comparativelv 
 slight ; laceration of middle meningeal artery or its branches ; fracture 
 of skull, if present, slight, and localized to side of skull, i.e., not impli- 
 cating base ; compression, but little or no contusion or laceration, of 
 brain. Twenty-seven cases. 
 
 B. Less Hopeful Cases. — Violence greater; laceration of middle 
 meningeal or its branches ; fracture implicating base, i.e., middle fossa; 
 some injury to brain, but this only trivial. Twenty cases. 
 
 * Ligature of the coaimon carotid, if preferred, is justified by a successful case re- 
 corded by Dr. Liddell (Amer. Journ. Med.Sci., vol. Ixxxi. p. 344), in wliicii secondary 
 haemorrhage from the middle meningeal artery, three weeks after a shell wound in the 
 temporal region, wassiiccessfidly arrested by ligature of the common carotid. The ad- 
 ditional special risks of this operation are, however, well known. 
 
 t Mr. Marcus Beck, 3Ied. Times and Gazette, 1S87, vol. ii. p. 199. 
 
180 OPEEATIOXS ON THE HEAD AND NECK. 
 
 C. Cases prohahh/ Hopeless from the First— Violence very great; 
 laceration of middie meningeal or its brandies ; fracture of skull very 
 
 Fig 44. 
 
 Middle meningeal hemorrhage with extensive fracture of the skull. Prep. 1593", Guy's Hos- 
 pital Museum. From the severity of the fracture which involves vault and base such a ease 
 gives very little hope. 
 
 extensive, perhnps implicating several bones and sutures, both in vault 
 and base ; injury to brain very severe. Twenty-three cases. 
 
 TREPHINING AND EXPLORATION OP CEREBRAL 
 ABSCESS DUE TO INJURY. 
 
 Indications for Exploring; Symptoms and Diagnosis of 
 Traumatic Cerebral Abscess. — Many of these are given at some- 
 what fuller length when that form of cereliral abscess which is one of 
 the results of otitis media is discussed at p. l!3o. To begin with, there 
 is the history of an injury* with primary brain symptoms, e.g., con- 
 
 * This may have been a stab with a knife, p. 1G2, a graze of head with momentary 
 concussion, a fracture, a blow with a stone, a glancing bullet, etc. But the belp in the 
 case which the history of an injury gives is not always present, and (his is an indica- 
 tion for always examining for any wound or scar and exploring it, liowever unim- 
 portant it may seem to be, in these cases. Thus, in the following case (Hulke, Sysi. 
 of Svrg., vol. i. p. li'Jd), the necrosis might have been overlooked, and the fit and 
 rigidity put down to another cause. A middle-aged woman, having fallen down in a 
 fit in a neighboring street, w;is brought to the Middlesex Hospital. She was uncon- 
 scious, and her left arm and leg were rigidly flexed. On her right tem[ile was a small 
 
TRAUMATIC CEREBRAL ABSCESS. 181 
 
 cussion lasting a variable time, but usually brief. If no such injury 
 as fracture and depression of the skull exists, and if no laceration, etc., 
 of the brain has occurred, there now often follows a latent period 
 devoid of brain symptoms, which may last from a iew—i:rj., four- 
 days to three or four weeks or much longer.* This latent period is 
 succeeded by brain symptoms increasing in severity and going on to 
 those of compression— viz., headache felt over the side injured, Imt not 
 necessarily most intense at the injured spot; nausea or vomiting; 
 some pyrexia, but the temperature usually rises slowly, if it rises 
 above normal at all.f 
 
 Other symptoms are mental dulness, the answers long delayed but 
 intelligent when they come, a slow pulse, perhaps rigors, progressive 
 emaciation, perhaps accompanied by vomiting. Whether local nerve 
 symptoms— e.j^., disturbances of sensation and motion— are present 
 must depend on the position of the abscess. If the injury has been 
 over the motor area (Fig. 48), nerve symptoms may be clearly marked ; 
 but if over the anterior part of the frontal, or tempero-sphenoidalj 
 
 festering wound, leading to necrosed bone. On perforating tliis with a trephine, several 
 drachms of pns were forcibly ejected to some distance tlirough a slongliy hole in the 
 dura mater. Tlie spastic rigidity of the left arm and leg immediately disappeared, bnt 
 the patient soon died. At the examination of the body, the empty cavity of a large 
 abscess was found in the anterior lobe of the right cerebral hemisphere. 
 
 * As in M. Dupnytren's and Prof, Nancrede's cases at p. 162; so, too, in a case 
 of Mr. Hnlke'.s, alluded to in a font note, p. 182, the patient, an errand boy, continued 
 to work for seven weeks after tlie injury, more or less headache being present all the 
 time; retching and hemiplegia then coming on, 
 
 t On this point I would refer my readers to p, 196. Dr. Nancrede {loc. supra cit., 
 p. 95) writes tluis: "I believe that an abscess involving the cerebral tissues alone will 
 be accompanied, in most cases, by a subnormal, or, at least, a normal temperature. 
 Where a high temperature is noted, either the pus collection is simply a localized 
 suppurative arachnitis limited by adhesions, or there is a meningitis in addition to the 
 abscess,'' Dr. Kancrede quotes briefly a case recorded by Dr. H. L Brown [Bost. Med. 
 and Sunj. Journ., December 29th, 1881, p. 610) in which the temperature was 97° 
 for eleven days. Mr. Hulke {Synt. of Stirg., vol. iii. p 627, 628) gives two cases of 
 cerebral absce.ss, in which he trephined successfully ; tlie temperature was subnormal 
 in both. More rarelv, tlie temperature shows considerable fluctuations, as in a case of 
 Dr. Burney Yeo (Bnt. Med. Journ., 1879, vol. ii. p. 84) in which most remarkable 
 temperatures ranged during the last twelve days of the patient's life, from 94° to 105°, 
 these being, as Dr. Yeo points out, roughly divisible into a period of high temperature 
 and a period of low temperature. During the former, there were no brain symptoms 
 proper, and during the latter, there were brain symptoms. More rarely still, the tem- 
 perature continues high throughout, so that the case may be mistaken for one of con- 
 tinued fever. 
 
 X With regard to this part of the brain, in which, comparatively speaking, large 
 collections of pus are often found, Dr. Yeo (loc. svpra cit., p. 885) quotes the following 
 remark from Hugenin (Ziemssen's Cyelopcedia, vol. xii.): "Tlie difficulty of diagnosis 
 is increased by the circumstance that no bands of fibres, which are direct conductors of 
 
182 OPERATIONS ON THE HEAD AND NECK. 
 
 lobes, they may be entirely absent. Thus hemiplegia * a paralysis 
 limited— r.(/., of upper limb, and, later on, gradually increasing— epi- 
 leptic seizures, spasms, spastic rigidity, all have been met with, but 
 must by no means be relied upon, and even wlien paralysis is present 
 it may escape observation, as when there is slight i)aralysis of the 
 muscles of the lower half of the left side of the face, and some loss of 
 power in the left liand and arm, but only tem})orary.t 
 
 Finally, the surgeon, who is watching what he believes to be -a 
 cerebral abscess, must always remember that after a period of latency, 
 which may last weeks or more, acute symptoms may set in suddenly 
 and quickly close in death. 
 
 Such a case is given by Dr. Fagge {Medicine, vol. i. p. ')51). In 1876, 
 a girl, aged eighteen, was admitted aljout 5 p.m. into Clinical Ward, 
 Guy's Hospital. She had for six days been suffering from sickness 
 and diarrhoea, witli severe headache, so that she was said by the med- 
 ical man who attended her to have typhoid fever. She then spoke 
 rationally, and answered questions put to her, l)ut seemed odd in her 
 manner. At 8 p.m. she suddenly made a great noise, then became 
 jjartially insensiljle, but capable of being roused. She seemed to have 
 left hemiplegia. An hour later she all at once ceased to breathe.]; In 
 
 sensibility, or motion," |iass through tliis lol)e; and, therefore, an alisce-^s here " miiy 
 attain a considerable size, and may cause general symptomi of compression before any 
 distinct sympluni of local disease arouses the suspicion of a localized aflTection of the 
 brain." 
 
 * Mr. Hulke, in relating the case of a boy whicli he brought before the Medico- 
 Chirurgical Society, Marcli 1 1th, liS79, laid stress on the fact that hemiplegia occurring 
 some time after an injury to the head was significant of disease in the brain itself 
 rather than of arachnitis. 
 
 f The value of accurately noting symptoms which, though of but brief duration, may 
 be very important guides in treatment, is well shown by a case of Dr. Macewen'g 
 (Lancet, ISSl, vol. ii. p. 582). A boy, aged eleven, was admitted into the Glasgow 
 Royal Infirmary, two weeUs after a fall upon his head, with a partially healed wound 
 and bare bone over the left eyebrow. A week afier admission he had a rigor wliich 
 was considered to indiciite the luobable formation of pus. Five days later, or tweiitv- 
 six days after the injury, the patient had a convulsion confined to the right side; 
 when this had passed oftj he was distinctly aphasic. The scat of the abscess now seemed 
 to be the third left fi'ontal convolution, and trephining was proposed. The friends, 
 however, refused to permit this, as tlie patient had recovered consciousness, though they 
 were warned that the improvement would be only temporary. Tliirtv hours later, the 
 convulsions of the riglit side recurred, the temperature rose quickly from 101° to 104°, 
 and the patient died before the operation could be performed. The e.xistence and 
 situation of the abscess were verified after death. 
 
 I This sudden alteration in, or cessation of, brealbing in cerebral cases is again 
 noticed at pp. 15-1, 177. So, too, in a case whicli Mr. Gamgee brought before the 
 Medico-Chirurgical S,jciety, June 14th, IS7'.). A boy, who had been trephined for 
 suspected cerebral abscess, the pus not being found, suddenly ceased breathing the day 
 after the operation. The patient, though apparently dead, being partly revived by 
 
TRAUMATIC CEREBRAL ABSCESS. 183 
 
 this case four or five abscesses were found in the posterior and middle 
 lobes of tlie right hemisphere. A case wliere tliis sudden cessation 
 of breathmo- took place, and life was temporarily restored by openino- 
 the cerebral abscess, is given below. " 
 
 Operation of Trephining for Traumatic Cerebral Abscess. 
 —As the fatality of cerebral abscess, if left to itself, is so high— 90 to 
 100 per cent.— trephining is abundantly justified, but it must be con- 
 ducted aseptically for fear of setting up supi)urative meningitis and 
 brain softening. The chief difficulty is, of course, hitting off the seat 
 of the abscess, especially in cases where there are no definite nerve 
 symptoms to guide, and where the history of the part of the head 
 injured is indefinite also. To obviate the necessity of multiple tre- 
 phining Dr. Fenger and Dr. Lee, of Cliicago, have recommended,* as 
 easier and safer, exploratory puncture and aspiration. This must be 
 done methodically with a fine needle, 4 inclns long, set in a large-sized 
 hypodermic syringe. The needle, •^^■ell disinfected, is pushed, through 
 a trephine hole, straight in in a definite direction for ] or 1 inch ; the 
 piston is then withdrawn a little, and, if no pus follows, the needle is 
 pushed J inch further, and the piston again withdrawn. The depth 
 to which it will be permissible finally to push the needle will, of 
 course, vary with the position of the trephinc-opening and the direction 
 of the puncture, the surgeon being guided by the anatomy of the 
 brain. The punctures are to be repeated at intervals of I inch or 1 
 inch, the utmost care being taken to push the needle in straight, and 
 to avoid all lateral movements. If, after a reasonalile number of 
 punctures no jris is withdrawn, the operator may feel convinced that 
 no pus is present. An abscess in the brain is usually as large as a 
 walnut, often much larger. 
 
 Puncturing healthy brain tissue with a fine perfectly aseptic needle 
 can do but little mischief 
 
 When the abscess is found it is best opened, not l.iya cutting instru- 
 ment, but by dressing-forceiDS, which can be i)Uslicd along the needle 
 as a guide. The abscess-cavity is then washed out and drained in the 
 manner pointed out at p. 197. 
 
 The following cases of cerebral abscess, in addition to those given 
 at p. 161, and in the footnotes to p. 182, are good instances of the 
 disease and also of its successful treatment : 
 
 artificial respiration, the dura mater and brain were now incised — a step wliicli liad 
 not been taken before, as tlie former structure lool<ed healthy, and did not bulge 
 into the trephine hole — pus welled \ip, and the child survived for a week. Post- 
 morleni: an abscess 2 inches lonp;, and still containing an ounce of pnrnleut fluid, 
 was found in the right frontal lobe: the abscess had burst externally, causing purulent 
 meningitis. 
 * Trans. Amer. Surg. Assoc, vol. ii. p. 78. 
 
184 OPERATIONS OX THE HEAD AND NECK. 
 
 A laborer * aged sixty, was admitted into the Middlesex Hospital, 
 under the care of Mr. Hulke, a fortnight after being struck a glancing 
 blow on the right temple by a falling ladder, which stunned him for 
 a few minutes and caused a considerable bruise. He continued, 
 nevertheless, to work as usual until the middle of the third day, when 
 headache, which he had had from the time of the accident, became 
 very severe— so severe that his wife feared he would go out of his 
 mind. When taken into the hospital the pulse was 56, and the tem- 
 perature slightly below the normal. His mind was unclouded. 
 About one week later, in the night, he became insensible, and in the 
 morning the right upper and lower limbs were found absolutely pal- 
 sied as regards motion, and nearly so as regards sensation. When the 
 arm or thigh were severely pinched, he gave scarce any sign of con- 
 sciousness of it, but shrank slightly when the left limbs were pinched 
 similarly. Two days later spastic rigidity of the left arm supervened. 
 A small disk of bone cut out beneath the bruised bone on the right 
 temple appeared uninjured. The dura mater bulged up so tensely 
 that pulsation could neither be seen nor felt; its exposed surface 
 appeared healthy. A needle connected with an exhausting syringe 
 was pushed through it to a depth of li inch. A brownish turbid fluid 
 rose up into the receiver, and continued to flow after the needle was 
 withdrawn. The minute opening was enlarged with a scalpel, and a 
 considerable quantity of fluid escaped. The flaps, which had been 
 reflected, wei'e replaced, and the wound was very lightly dressed with 
 a little boric charpie. An hour later he asked for food. Next morn- 
 ing the spastic rigidity of the left arm had gone. On the second day 
 slight return of power was noticed in the right limbs, and before the 
 end of a week their palsy had disappeared. For a very few days after 
 the operation the charpie was wetted and discolored l)v the fluid 
 which continued to ooze, but the wound soon healed, and two months 
 after the operation the patient ajDpeared quite well. 
 
 It is interesting to note in the follow^ing casef that the hemiplegia 
 which followed the operation was only transitory. It also shows that 
 grave symptoms may be latent for as long as five months if a skull 
 wound remains unhealed. 
 
 A child, aged four and a half, had sustained a severe compound 
 fra,cture of the right frontal bone. Tlie removal of some necrosed 
 portions of l)()ne led subse(]uently to some slight hernia cerebri. A 
 sinus persisted, but the child seemed well in other respects, until 
 about five months after the accident, when left-sided convulsions 
 (cluefly of the muscles of face and arm) came on, and an alarming 
 
 * Hulke, Syst. of Sary , vol. i. p. 6-28. 
 
 t Briefly reported from the Australian Mfcdical Gazette in the Ann. of Surg., Febru- 
 ary, 1887, p. 143. 
 
TRAUMATIC EPILEPSY. 185 
 
 condition rapidly developed. The sinus was opened up and a director 
 passed for a distance of 1 inch into the right frontal lobe downwards 
 and backwards. A free flow of fetid pus occurred, and alter the 
 cavity had been washed out with carbolic solution (1 in 40}, a drain- 
 age tube was inserted. The latter was removed at the end of a fortnight. 
 Left hemiplegia followed the operation, but it passed off some twenty- 
 four hours subsequently. Recovery was rapid and complete. 
 
 TREPHINING FOR EPILEPSY AND OTHER LATER 
 RESULTS OF A CRANIAL INJURY.* 
 
 Indications.— The surgeon who is interested in this matter will 
 find much information in an excellent paper by Mr. Walsham (.SI 
 Barth. Hosp. Rep., vol. xix. p. 127), from which the following five 
 headings are taken : 
 
 i. Local indications calling for trephining.— In forty-four out of 
 eighty-two cases the scar or spot was painful, tender and sensitive. 
 Pressure in some cases caused vertigo, convulsive fits, rigidity, or 
 spasmodic twitchings of some group of muscles. In eight there was 
 a fistula leading down to bare bone. In three a fissure existed. 
 
 ii. Cause, nature and situation of the head-lesion to which the 
 epilepsy was ascribed. — In seventy-two out of eighty-two cases there 
 was a distinct history of some lesion to the head. In fortj'-six out of 
 the seventy-two there was a fracture, which in twenty-six of tlie forty- 
 six was compound and depressed.! The exact seat of the lesion is 
 not given accurately in a large majority of the cases. In forty-five 
 it was over one or other parietal, in fourteen over the frontal, in three 
 over the occipital area. 
 
 iii. Time of onset, duration and character of symptoms. — The time 
 at which the epilepsy followed the injury varied greatly. In the 
 majority this took place after a variable period, even as much as 
 thirteen years. The shortest i^eriod was within a few hours. 
 
 The duration of the ejiilepsy, after it had become established, varied 
 
 * Under tliis head are included, amongst others, convulsive movements, paralysis, 
 aphasia, idiocy, mania, and strange alterations in character and temper. The char- 
 acter of the fit, the frequency with wliich such accidents as tongue-biting occur, the 
 tendency of the fit to be brought on l)y eating, and thus to cause choking, must be 
 taken into due account when the need of an oiieration is being considered. 
 
 t In a case of Mr. West's, brought before the Medico-Chirnrgical Society {Lancet, 
 1879, vol. ii. p. 798), in wliich epileptic fits followed on a fracture of the skull, com- 
 plete relief was given by trephining, though the fracture was found to involve only 
 the outer table; the child, who before was fatuous, aphasic, and passing her excreta 
 involuntarily, is stated to have recovered entirely. Here tlie epilepsy must have been 
 due to reflex irritation, following a fracture of the outer table, and not to any direct 
 pressure on the brain or its membranes. 
 
186 OPERATIONS ON THE HEAD AND NECK. 
 
 from a few days to twenty years. In nearly all the long-standing 
 cases the fits increased in severity, the intervals growing less. 
 
 In a large majority of cases other symptoms presented themselves 
 in addition to the fits— viz., loss of memory, moroseness, delusions, 
 even utter imbecility, or violent madness, constant headache, paralj^sis. 
 
 iv. Condition of the parts found at the operation.— In two-thirds 
 of the cases the bone was found either depressed or variously altered 
 or diseased. Thus it was thickened, spongy, carious, necrosed, a 
 fistula often coexisting in the two latter. Depression, when present, 
 often took the shape of a spiculum.* 
 
 The dura mater in the greater number of cases was healthy, but in 
 some congested, thickened, vascular, or adherent.f 
 
 In sixteen cases nothing was found at the time of the operation to 
 
 * The term exostosis is sometimes applied to the depressed bone, this, when circum- 
 scribed and osteophytic, is easily dealt with. An allied condition, rarer, and one 
 much more difficult to deal with, is described by Dr. Echeverria {Arch. Gen. de Med., 
 1878, t. ii. p. 533) The cause of the epilepsy was here found to be a conical, irregu- 
 lar projection of bone, measuring 2 X 22 inches, compressing the dura mater and brain, 
 and situated very close to the superior longitudinal sinus, just to the left of the 
 occipital protuberance, lu trephining, the crown entered into this exostosis, and the 
 removal of the rest of it was most laborious, the operation lasting three and a half 
 hours. The recovery was ultimately -i good one. 
 
 f A rare condition (Echeverria, loc. supra at., p. 535) was as follows: The patient, 
 aged twenty-two, had, ten years before, fractured his riglit parietal bone. Epileptic 
 fits began six months after the injury, and their increasing frequency was associated 
 with an extreme degree of idiocy, tlie patient being, on admission, a mere automaton, 
 without intelligence or memory. On the seat of fracture being explored, a kind of 
 pouch was found embracing an old blood clot. When this was turned out, the hsem- 
 orrhage was so free as to require the actual cautery. The intellectual faculties were 
 largely restored by the operation, and the fits were also much reduced in frequencv. 
 The deatli of the patient took place, nearly nine months later, from meningitis, ajipar- 
 ently due to exposure to the sun. An autopsy showed that the clot-containing cavity 
 %Tas in connection with the brain-membranes, and apparently continuous with one of 
 the branches of the middle meningeal artery. The brain at this spot was adherent to 
 the membranes, and the right supra-marginal gyrus, and the right parietal convolu- 
 tions were much atrophied. In some cases a cyst may underlie tlie seat of injury, and 
 be the cause of the mischief. Thus (Ann. of Surg., vol. iii. No. 6, p. -522 ; Amer. Journ. 
 Med. Sci., April, 1886), there is the case of a pistol-shot woimd of the skull, about f 
 inch from the middle line, and 1| inch from the hairy scalp, followed by aberra- 
 tion culminating in marked insanity. The depression in the forehead being explored 
 by a crucial incision, an opening in the skull was discovered closed by fibrous, not 
 bony, material. In the expectation of finding an abscess cavity, the needle of a 
 hypodermic syringe was thrust through this tissue in several directions until the 
 barrel was found to be filling with a serous fluid, all of which was withdrawn to 
 the extent of about two draclims. On emerging from the auii^sihetic, the patient 
 was found to have fully regained his mental equilibrium, in which condition he 
 remained five months later, the wound having promptly healed. 
 
TRAUMATIC EPILEPSY. 187 
 
 account for the epilepsy * Ten of these sixteen recovered, and seven 
 were cured of their epilepsy. It is difficult to say how tlie trephining 
 cured in these cases, the symptoms had lasted many years, and yet 
 ceased after the operation. It is noteworthy that in one case, though 
 nothing was found at the time of the operation, a spiculum was found 
 at the post-mortem examination not far from the trephine-holc, thus 
 pointing to the advisability of sweeping a probe, carefully and with 
 aseptic precautions, around the circumference of the trephine opening, 
 and at some distance from it. 
 
 v. Results of operation.— These are eminently satisfactory. Out of 
 eighty-two, forty-eight were completely cured, and thirteen relieved. 
 Of the latter, some have been quite cured after a longer interval, and, 
 on the other hand, some of the former may have relapsed. 
 
 Operation .t— To begin with, a painful cicatrix J may be freely 
 excised. This may be done with good hope that nothing further in 
 the way of operation will be required in cases where the scar is con- 
 stantly painful, tender, or hot ; where it corresponds to the course of 
 some known nerve, and in any case where the original wound wns 
 lacerated, or contused, and slow in healing, and where there is any 
 chance of a splinter of wood or metal being embedded in the scar.§ 
 
 If it be necessarj', as it usually is, to remove a crown of bone, 
 appropriate flaps of one of the different forms mentioned at p. 164, 
 must be reflected with the aseptic and other precautions already given. 
 Hemorrhage being arrested, and the flaps retracted by Spencer Wells's 
 forceps, the pericranium is carefully divided and turned off the bone,|| 
 and its condition noted as to thickening and other evidence of old 
 inflammation. The bone being thoroughly exposed, the surgeon must 
 be prepared for the following conditions — viz., the line of an old 
 
 * In two of them nothing was found, even after a po-it nuirtern examination. 
 
 t It is worth while lo point ont tliat, during tliis, the surgeon must be on liis guard 
 for the sudden supervention of epileptic seizures or convulsive inovements of one liu)h 
 — e.ij., when lie is raising a crown of bone much thickened and alherent to the dura 
 mater. 
 
 I Prof. Briggs, of Nashville (Trcms. Amer. Sing. Assoc, vol. ii. p. 116), in a most 
 excellent paper, in which large personal experience throws much light upon the sub- 
 ject, speaks of having had Hve cases of this character. After thorough removal of the 
 scar, tlie w(Uind was left to heal by granidation ; in all the attacks were arrested. In 
 one of Dr. Echeverria's cases he supra cil.), convulsion-^, vertigo, etc., were cured by 
 the removal of a small fibroma adherent to the frontal periosteum and supra-orbital 
 nerve. 
 
 I Dr. Johnson {Clin. Soc. Trans., vol, vi. p. 35) records a case where trismus, facial 
 neuralgia, and paralysis, with a recurrence of epilepsy (the patient, aged forty-four, 
 had been free from fits for twelve years), were caused by a sharp, angular piece of flint, 
 embedded in a painful cicatrix of the cheek, the removal of which was foUovped by 
 com|i]ete recovery. 
 
 II Or this structure may be raised together with the flaps. 
 
188 OPERATIONS OX THE HEAP AND XECK. 
 
 fracture, necrosis (indicated by a sinus with prominent granulations), 
 hypertrophic sclerosis amounting, in some cases, to eburnation, and, 
 on the under surface, depressed fragments of the internal table, spurs, 
 or nodules of bone. Any sequestrum will of course be removed. If 
 the surgeon finds it needful to resort to trephining, he will do so with 
 the precautions given at p. 166, remembering that here he is especially 
 likely to be dealing with a crown of bone of varying density at different 
 points of its circumference.* It must be elevated with particular 
 caution, as a spicule may have nude its way through the dura, mater 
 and be pressing on the brain. f 
 
 If the first crown shows nothing abnormal, a probe should be gently 
 inserted between the bone and dura mater and carefully swept around, 
 so as to give information of the condition of the inner surface of the 
 surrounding bone. If the first crown show changes which are, how- 
 ever, not localized to it, the trephine must be applied again till all 
 thickened bone capable of exerting pressure on the brain and its 
 membranes is removed. | 
 
 If no change can be found in the crown removed, or in the sur- 
 rounding bone, what more should be done on this occasion?- If there 
 be reason to suspect abscess in the brain, because the symptoms of this 
 condition (pp. 180, 195) are present, or because the dura mater bulges 
 up without pulsation into the trephine-hole, the treatment should be 
 as directed at p. 183. 
 
 Prof. Horsley, in one of his brilliant cases lately published, § has 
 shown how much it may be possible to do in cases of epilepsy where 
 the bone has already been removed, and where the mischief lies deeper 
 down. 
 
 A patient, aged seven, was run over by a cab and sustained a 
 depressed, comminuted fracture, with loss of brain-substance in the 
 situation mentioned below. The fragments of bone were removed, 
 and the wound ultimately healed, although it suppurated freely, and 
 hernia cerebri occurred. The patient was hemiplegic for some time, 
 
 * Free and most emhurrassing luemorrliage may be met with in sawing tlirongh 
 altered diploe traversed by large sinus-like venous channels, requiring sponge-pressure 
 before and after the operation. 
 
 f In one case Prof. Briggs (Inc. swpra cit., p. 106), on elevating the bone, found that 
 a spicule of bone from its under suiface had penetrated the superior longitudinal sinus. 
 The ha?morrhage was arrested by sponge pressure, and the patient made a good recov- 
 ery. In such a case, the sponge should be carefully disinfected and dusted with iodo- 
 form (p. 159). 
 
 I Prof. Briggs (?oc. mpra cit, p. IIS), speaking of one case in his practice, says that 
 six large crowns of the trephine wore found necessary to surround and separate the 
 thickened and roughened hone, which, after the angles were rounded off with a Hey's 
 saw, left an opening as large as the palm of the hand. The patient was cured. 
 
 i Brit. Mid .Town., lHS(i, vol. ii. [i. G7'.>. 
 
TRAUMATIC EPILEPSY. 189 
 
 but gradually (in seven weeks) the jiaralysis disappeared. When aged 
 fifteen, the patient began having fits, which were very intermittent. 
 When aged twenty-two, he was admitted into the National Hospital 
 for Paralysis and Epilepsy ; he now had an enormous number of fits, 
 and for some days was in the status epilepticus. On the left side of 
 the vertex (the exact site, as determined liy measurement, being the 
 centre of the upper third of the ascending frontal convolution — that 
 is, posterior to the hinder end of the superior frontal sulcus) there was 
 a quadradiate scar, opposite to the centre of wliich the bone could bo 
 felt to be wanting, so as to form an oval opiening in the skull, the long 
 diameter of which was about an inch, and parallel to the sigittal suture. 
 Pressure on this scar alway.s gave pain, which was very greatly in- 
 creased when the jaatient was suffering from one of his paroxysms of 
 fits. 
 
 The fits, which occurred in batches (at this time the patient had 
 3000 in a fortnight), were almost always of the same character, usu- 
 ally commencing in the rij^ht lower limb, sometimes in both the right 
 limbs simultaneously. An example of a fit of the first category is as 
 follows: 
 
 The right lower limb was tonically extended, and the seat of clonic 
 spasm. The right upper limb w^as then slowly extended at right angles 
 to the body, the wrist and fingers being flexed ; the fingers next became 
 extended, and clonic spasms of flexion and extension affected the 
 whole limb, the elbow being gradually flexed. By this time, spasms 
 in the lower limb having ceased, but those in the upper limb continuing 
 vigorously, spasm gradually afiected the right angle of the mouth, 
 spreading over the right side of the face, and followed by turnin'j of 
 the head and eyes to the right. 
 
 To sum up : The focus of discharge was situated around the poste- 
 rior end of the superior frontal sulcus, this point coinciding, as men- 
 tioned above, witli that found by actual measurement. Before going 
 on to describe the surgical treatment, it is important to mention that 
 the patient was distinctlv hemiplegic, even ten days after the last fit, 
 but he could perform all the movements of the right limbs, though 
 about half as strongly as on the left side; there was no affection of 
 sensation on the right side, while the reflexes, superficial and deep, 
 were exaggerated in both the right limbs. 
 
 The bone around the old opening was freely removed, the dura 
 mater, arachnoid, and skin being found to form a homogeneous mass 
 of fibrous tissue, the former being raised with the flap. Ihe scar in 
 the brain was found to be highly vascular, of a deep red color, and 
 about 3 centimetres long and 2 broad. The membrane covering 
 the brain around appeared to be very opaque, and ^h^ ^ram of a 
 slightly yellower tinge than usual. The scar and about * centimetre 
 
190 OPERATIONS OX THE HEAD AND NEPK. 
 
 of surrounding brain substance was excised to the depth of two centi- 
 metres. It was then found that the scar penetrated a few millimetres 
 farther into the corona radiata fibres of the marginal convolution. 
 This portion was then removed, and the wound closed. In the 
 removal of the mass, three fair-sized veins, coming directly from the 
 middle of the area of the upper limb, had to be ligatured, since they 
 passed directly into the scar. The wound completely healed in a 
 week. The tension of serum was twice relieved. 
 
 The most interesting point now to be recorded is, that, after the 
 operation, the patient was at first cumpletely paralyzed in the digits 
 of the right upper limb; and for further flexion of the wrist and 
 supination of the forearm. Coupled with this motor paralysis, there 
 was loss of tactile sensibility over the dorsum of the two distal pha- 
 langes of the fingers. He could not localize the touch anywhere below 
 the wrist within the distance of one internode ; finally, he could not 
 tell the position of any of the joints of the digits. We have here, 
 apparently, a distinct instance of loss of tactile sensibility and mus- 
 cular sense, coupled with motor paralysis, all due to lesion* of the 
 cortex. This condition of motor and sensory paralysis gradually <lis- 
 appeared in the course of the next two months. Up to the time of 
 Prof Horsley reading his paper in August, ISSlj, the patient had 
 no fits. 
 
 jMost strict antiseptic precautions (infni) should be made use of 
 before and during the operation, sufficient drainage should be pro- 
 vided, and, in bringing the flaps together, the drainage-tube must not 
 be pressed upon or closed. (4reat care must be taken to keep the 
 wound sweet later on, putrefraction leading to septic softening and 
 hernia of the brain. 
 
 Causes of Failure after Trephinicg for Traumatic Epilepsy. 
 
 — Amongst these are : 
 
 1. Not hitting off the right spot. — It has already been mentioned 
 that, in one case at least, a bony spiculum, not detected at the time 
 of the operation, has been found, post-mortem, not far from the tre- 
 phine hole (p. 1<S7). To prevent any such condition being overlooked, 
 it has been advised to sweep a probe carefully round the circumference 
 of the trephine hole, and at some distance from it. 
 
 2. Owing to the long continuance or to the amount of the irritation, 
 the brain may be permanently affected. Thus, in words already 
 quoted,t there are ciises of deiiressed fracture in which "the constant 
 
 * By this, Prof. Ilorsley means the distiu-b.inco in the area for the upper limb pro- 
 duceii by the liffatiire of the veins coming from it. Me points out, liowever, that 
 It IS very possible that .some of the fibres coming from the gyrus fornicatns in tlie 
 corona radiata may have been injnjed 
 
 t Dr. Gnnn, loc. siipnt ell., p. 89. 
 
TRAUMATIC EPILEPSY. 191 
 
 irritation has begotten a permanent impression upon the brain and 
 nervous system which remains after the offending point of bone has 
 been removed." 
 
 3. Idiocy or mental weakness persisting. — From alterations in 
 the membranes or brain itself, permanent and too extensive for re- 
 moval. 
 
 •4. Neglect of after-treatment both medical and surgical, but chiefly 
 the former. — As bearing on this matter, the following words of Prof 
 Nancrede* are well worthy of remembrance: " The operation, indeed, 
 removes the most important cause of the epilepsy, but only one cause. 
 The disturbed circulation in the nervous centres, and the excessive 
 mobility of the nervous system, can only disappear with time, and if 
 all other sources of peripheral irritation are not most carefully guarded 
 against, the patient may be sliglitly, if at all, benefited, whereas judi- 
 cious after-treatment will sometimes relieve an apparent operative 
 failure." 
 
 5. Trephining for fits not epileptic in character.— Mr. Hulkef gives 
 a most interesting account of a case in which he trephined for " anom- 
 alous " convulsive attacks su]>ervening several months after a head 
 injury. The operation, while it did no harm, was useless. Bromide 
 and iodide of potassium having been tried in vain, a full trial of val- 
 erianate of zinc was made, the fits subsiding under this treatment. 
 This fact, the way in which the fits came on, the slight degree of un- 
 consciousness, its gradual onset, and the fact that occasionally the first 
 convulsion had the aspect of purposive movement, supported the view 
 that the fits were not epilei)tic, but hysterical, induced by the shock 
 of an accident in a person of unstable nervous system. On the other 
 hand, the traumatic origin, the headache, the darting pain on touch- 
 ing the part injured, were all suggestive of some chronic irritative pro- 
 cess, and justified the operation of trephining. 
 
 6. Accidents during the operation, perhaps the fault of the surgeon 
 — viz.,(l) middle meningeal hfemorrhage, (2) hemorrhage from an 
 
 opened sinus (p. 159). 
 
 7 A septic condition of the wound, almost invariably the fault ot 
 the surgeon, and bringing about (1) meningitis, (2) hernia cerebri, (3) 
 cerebral abscess. 
 
 * Loc. supra cit., p. 102. . , , j 
 
 t Med. Time..and Gaz., 1881, vol. ii. p. 85. It is noteworthy that the bone removed 
 and the d.ra mater in this case being normal, an aspirator-needle »as pushed through 
 the latter to the depth of an incl>, and then withdrawn, as nothing escaped through 
 it. For a few minutes, owing to the high inlra-cranial pressure, cerebro-sp.nal fluid 
 spirted in a slender stream for the distance of nearly a foot, and continued to leak 
 away for several hours. 
 
192 OPERATIONS OX THE HEAD AKD >'ECK. 
 
 TREPHINING FOR MASTOID ABSCESS AND CEREBRAL 
 ABSCESS, THE RESULTS OF OTITIS MEDIA. 
 
 (Figs. 45 and 46.) 
 
 Points on Practical Importan*;!: to the Surgeon in the Anat- 
 omy OF THE Parts concerned.* 
 
 I. Tympanum. — (a) Roof always tliin, not more than a line and a 
 half in thickness, often thinner.f Through this inflammation in otitis 
 media readily reaches the brain, causiii,^- meningitis, subdural or cere- 
 bral abscess. (6) Parts of the brain and cerebellum which are in con- 
 tact wi:h middle ear. These are the middle and back part of the 
 temporo-sphenoidal lobe, and the outer and front j^art of the lateral 
 lobe of the cerebellum. With regard to this latter site of abscess, !Mr. 
 Toynbee'J: held that the greater freciuency in adults of cerebellar ab- 
 scess and, with this, thromliosis of the lateral sinus, were due to the 
 development of the mastoid cells backwards, (c) The mucous mem- 
 brane and the endosteum lining the tympanum are in most intimate 
 contact; hence, in otitis media, caries and necrosis readily occur, es- 
 pecially if the blood-supply to the tympanum from the dura mater is 
 cut off. (d) The skin of the external auditory meatus is continuous 
 with the membrana tympani, and thus otitis media may be set up 
 from without, as well as by mischief reaching the tympanum through 
 (e) the Eustachian tube, which enters in front, and makes the mucous 
 membrane of the throat continuous with that of the tympanum. (/) 
 The outlets of the mastoid cells and of the tympanum are inadequate 
 for drainage in otorrhoea, as many of the mastoid cells lie l)elow the 
 level of their opening into the tympanum, and the floor of. the tympa- 
 num is, in part, below the orifice of the Eustachian tube. The results 
 are thus favoralile to decomposition. 
 
 II. MoHtdid Cells. — ((/) Their development varies with age. In 
 adults, if well marked, they may measure 11 inch horizontally, 2 inches 
 vertically, and reach quite up to, and even around, the lateral sinus 
 (Fig. 4.5). In these, septic thrombosis and pyaemia is must likely to 
 take place. (5) Two groups of cells are present : (1) The horizontal, 
 which are closely adjacent to the back of the tympanum, and commu- 
 nicate with it. This group constitutes " the antrum, and is present 
 both in early and late life. Their size is that of a good-sized round 
 ])ca. The antrum is bounded externally by that part of the squamous 
 bone which is immediately behind and aljove the external meatus. 
 
 * These should be studied together with a skull and one or two sections of a tem- 
 poral bone, somewhat similar to that shown in Fig. 45. 
 t The bony roof is occasionally absent. 
 t See Fig. 4.5, 
 
MASTOID ABSCESS. 
 
 193 
 
 Through this bone, extremely thin in early life, pus from the tympa- 
 num may make its way externally. After the second year it becomes 
 much thicker, and this mode of exit is cut off. It is through this bone 
 that the trephine or drill should be directed in opening up the mastoid 
 cells. (2) The vertical. These are not developed in earlier life ; later 
 on their presence brings pus nearer the lateral sinus and cerebellum 
 {xnde svpra). (c) The contents of the cells vary a good deal, being in 
 some air, in. others marrow. In yet a third class the cells are largely 
 obliterated by old sclerosing ostitis, (d) The passage of veins from 
 the tympanum and niastoid cells. These fall into three chief groups: 
 (1) those opening into the lateral sinus ; (2) those passing through the 
 mastoid foramen into the occipital vein and the soft parts outside the 
 skull; (3) those running through the petro-squamosal suture to the 
 
 Fig. 45. 
 
 A section of a temporal bone showing the mastoid cells, both horizontal and vertical, 
 with the close proximity of the lateral sinus. (Toynbee.) 
 
 dura mater. All these veins carry sheaths of connective tissue, and 
 thus inflammatory products may reach (a) the lateral sinus, causing 
 septic phlebitis ; (6) the soft parts outside, causing periostitis, celluli- 
 tis, etc. ; Cfi) the dura mater and brain, causing meningitis and abscess. 
 
 Four Results of Otitis Media which may come under the 
 Notice of the Surgeon.— (i.) Acute inflammation of mastoid cells : 
 mastoid abscess; (ii.) abscess in brain or cerebellum; (in ) aseptic 
 thrombosis of sinuses and pyemia; (iv.) meningitis. ^.B-ihe 
 above four often coexist, and thus the symptoms may be much blended 
 together and confusing. 
 
 (i) Acute Inflammation of Mastoid Cells: Mastoid Abscess.- 
 Symptoms.-TheBe vary much. There are two quite distinct conditions 
 to remember. The more the periosteum over the mastoid process is 
 involved, the more clear are the symptoms and the more certain will 
 
 13 
 
194 OPERATIONS ON THE HEAD AND NECK. 
 
 be the relief from a sufHcient incision. The less the jjeriosteum and 
 the soft parts are involved, or the more altered the bone by old scle- 
 rosing ostitis due to prolonged irritation, the less evident and decided 
 are the symptoms, and the less likely is an incision to relieve. 
 
 Indiciitions for interfering by Incision or Trephining. — History of old 
 otitis media, with long-continued discliarge and deafness. Pain in 
 and behind the ear, over the temple or occiput, unrelieved Ijy ice, 
 leeches, fomentations, etc. Mastoid tenderness, swellirig, redness, 
 cedema. N.B. — The last three are by no means always present in 
 mastoid aljscess. Discharge fetid, and unrelieved by washing out 
 with lotions, e.g., mercury perchloride (1 in 2000), saturated Ijoracic 
 acid, etc., followed by the insufflation of powders, e.g., boracic acid 
 finely powdered, 3 parts, iodoform 1 part. Drowsiness, torpor, but 
 absence of the graver symptoms, pointing to cerebral abscess, p3-aemia, 
 or meningitis (vide infra, pp. 196, 197). 
 
 llVr/r'-s Incision. — The parts being shaved and cleansed, and an 
 ancesthetic cautiously given, a free incision is made with a strong- 
 backed scalpel down to the bone from the base to the apex of the 
 mastoid process, i inch behind the auricle. The condition of the 
 periosteum is then noted; if it is not much softened, if there is no 
 marked escape of pus, etc., the bone must be investigated. If any 
 soft, carious, or bare, spot is found, the cells must be opened up with 
 a drill, brad-awl, gouge, or trephine. All caseous pus and foul granu- 
 lation-material must be removed with a sharp spoon, syringing, etc. 
 A short drainage-tube is then inserted, or one passed between the 
 antrum and external auditory meatus, if possible. 
 
 Trephining Mastoid Cells.— If on exploration the bone is not altered, 
 or if the above incision does not relieve, the cells must be freely 
 opened up by trephining. The above incision, if present, is converted 
 into a T above, or a crucial one made, and a small trephine applied 
 immediately behind the auricle (Fig. 46), on a level with the external 
 auditory meatus, and directed forwards and inwards, especially in 
 children, owing to the close proximity of the lateral sinus. After 
 sawing for i or J inch, the crown removed will be found to have 
 penetrated the cells. These are then to be freely opened up with a 
 gouge, cleansed as far as possible, and disinfected as explained above. 
 As good a dressing as any to apply afterwards is lint wrung out of 
 saturated boracic-acid lotion, kept moist, and frequently renewed, 
 iodoform being dusted on occasionally, and the middle ear frequently 
 syringed out. The bowels should be freely opened, and limited, light 
 diet given at first. 
 
 I much prefer, for opening up the mastoid cells, a small trephine 
 (with I -inch crown) to any of the various drills. Save in early life, 
 
ABSCESS IN BRAIN OR CEREBELLUM. 195 
 
 the cells are somewhat complicated, their contents often most fetid, 
 and a thorough opening up is urgently required. This, it seems to 
 
 Fig. 46. 
 
 ^ 
 
 1 
 
 .*. 
 
 •I 
 
 '. • V \ 
 
 V 
 
 > 
 
 Trephining tlie mastoid cells. The auricle is drawn forwards. The direction of the trephine 
 is too much upwards. Above is shown the under surface of the disk of bone removed, with the 
 cells opened. 
 
 me, is most thoroughly and speedily done by a small trephine applied 
 and directed as advised. 
 
 Heemorrhage during and after the operation* is occasionally trouble- 
 some, especially when the tissues are soft and almost rotten, and' 
 ligatures difficult to apply. Such ha?morrhage is best met Ijy forcible 
 pressure, made use of with Spencer ^Vells's forceps. Thus, in one case 
 where, after successful opening of the mastoid cells, in a patient 
 admitted with erysipelas of the scalp and mastoid abscess, secondary 
 hsemorrhage took place a few days later from the posterior auricular 
 artery. The tissues from their condition not holding a ligature, and 
 breaking away with torsion, I applied a pair of the above-named 
 forceps. When they came away on the fifth day no further hsemor- 
 rhage had taken place, and the case made a good recovery. 
 
 (ii.) Abscess in Brain or Cerebellum. — (A) When in the brain 
 the collection of pus is usually in the middle and back part of the 
 temporo-sphenoidal lobe; (B) when in the cerebellum, in the front 
 and outer part of the lateral lobe. 
 
 Symptoms.— These are often rather negative, no special nerve symp- 
 toms being called out in the above regions, as is the- case with an 
 abscess in the motor area. There is a history, perhaps, of mastoid 
 
 * If the lateral sinus has been accklentally opened, the treatment must be that 
 given at p. 159. This complication is, however, a very serious one here, owing to 
 the difficulty of keeping the wound sweet, and thus of preventing septic phlebitis. 
 
196 OPERATIONS ON THE HEAD AND NECK. 
 
 suppurati.on, with the symptoms given above, unrelieved by treatment. 
 Amongst the most important symptoms are drowsiness, deepening 
 into coma ; while power of speech remains the answers are unwillingly 
 given, delayed, but intelligent ; " sluggish but perfect cerebration " 
 (Barker*) ; vomiting (this is occasional, or ceases after a day or two), 
 not constant and incessant ; one or two rigors may occur at the com- 
 mencement of the abscess-formation, but they are not commonly 
 repeated; the temperature is subnormal, e.g., 97°, and falling; the 
 pulse slow, e.g., 65-50 ; optic neuritis ; t progressive emaciation ; obsti- 
 nate constipation. Special symptoms of nervous disturbance — e.g., 
 hemiplegia, paralysis of face, ptosis, alteration of pupil — are either 
 absent or present only later on. The following symptoms are most 
 grave, and point to a fatal termination being not long delayed — viz., 
 iividity, irregular pulse, tracheal rales, pulmonary crepitation, incon- 
 tinence of excreta, tremors, and cervical swelling along the internal 
 jugular vein, and, of course, evidence of pyaemia or meningitis, these 
 conditions often coexisting. 
 
 Treatment. — Early aseptic trephining : sites (A) In the Brain. — Mr. 
 BarkerJ thinks that nine-tenths of abscesses in the brain lie within a 
 circle with a f-inch radius, whose centre lies 1\ inch above, and the 
 same distance behind, the centre of the bony meatus. This corre- 
 sponds to the posterior inferior angle of the parietal bone, and the 
 lower and back part of the temporo-sphenoidal lobe. Dr. Macewen 
 .found a cerebral abscess, and dealt with it successfully by trephining 
 at a point i inch above and J inch behind the centre of the meatus. 
 Mr. Hulke found an abscess by applying the trephine over the squa- 
 mous bone, 1 centimetre above the external auditory meatus. 
 
 B. In the Cerebellum. — Mr. Hulke § found a cerebellar abscess by 
 trephining just below the inferior curved line, 2 centimetres behind 
 the mastoid process. 
 
 Steps of the operation of trephining for brain abscess in connection 
 with otitis media. — The tympanum and mastoid cells being rendered 
 as aseptic as possible, the head is shaved, and an an;T?sthetic cautiously 
 given (p. 178). 
 
 Appropriate flaps being turned up, and htemorrhage arrested by 
 applying Spencer Wells's forceps, a ^-inch trephine is applied over the 
 spot selected (according as the pus is believed to be in the temporo- 
 sphenoidal lobe, or in the cerebellum), and worked cautiously, owing 
 to the thinness of the bone in these regions. The crown removed 
 
 * Lanref, 1887, vol. i. p. 1177. 
 
 t This is present also in mastoid inflammation without cerebral abscess,and persists 
 for some time after the case has been relieved by opening up the cells. 
 t BHt. Med. Journ., December 11, 1886. Man. of Surg. Operations,fp. 400. 
 § Lancet, July 3, 1886. 
 
PHLEBITIS OF SINUSES. 197 
 
 should not show any of the groove for the lateral sinns, nor, if pos- 
 sible, any middle meningeal branch. If the latter is in the way, 
 crossing the dura mater, it should be secured with two ligatures, or 
 the opening in the bone enlarged. The dura mater being next 
 divided, a little arachnoid fluid may escape, and the brain which 
 bulges forwards, without pulsation, may show lymph upon its surface, 
 and yet the case end successfully if the pus is evacuated. A fine 
 trocar or aspirator needle (without making any vacuum), is next 
 slowly inserted either straight in, or in a direction downwards, for- 
 wards, and inwards towards the apex of the petrous bone. If the 
 abscess is struck, bubbling of foul gas, or a few drachms of foul pus 
 will escape, when the needle has entered to a depth of i or f of an 
 inch. The puncture is then enlarged with a director and dressing- 
 forceps, and the abscess-cavity syringed out with boracic-acid lotion. 
 A short drainage tube should be inserted into this cavity, and the flaps 
 so arranged as not to interfere with free drainage.* The wound is 
 then dusted with iodoform, and sal alembroth gauze or other aseptic 
 dressings applied. The drainage-tube should be retained as long as 
 any cavity exists, probably for two or three weeks, being shortened 
 very gradually. The treatment should be rigidly aseptic, in order to 
 secure early healing, and to prevent the risk of softening and hernia 
 cerebri. 
 
 The two following complications of otitis media do not admit of 
 surgical interference, save in the case of the abscesses of pyaemia, but 
 as they often coexist with mastoid suppuration and cerebral abscess, 
 and thus are liable to render the diagnosis obscure, and the prognosis 
 difficult, they are briefly given here. 
 
 (i.) Phlebitis of Sinuses, usually Septic, and producing Pyiemia.— Symp- 
 toms.— Uepesited rigors; sweating; oscillation of temperature; sweet 
 " ferment breath " ; and a cord-like feel along internal jugular, with, 
 perhaps, tenderness here. Treatment— This is usually fruitless.! 
 Three main indications must be fulfilled. (1) To get tympanum and 
 mastoid cells clean ; (2) To support the strength ; (3) To meet com- 
 plications— c.^r. , pleuro-pneumonia and abscesses. 
 
 (ii.) iMeningitis.— The history of old otitis media will be obtainable. 
 
 * Part of these should be cut away, if needful, for this purpose. 
 
 t Prof. Horsley {Clin. Soc. Trans., vol. xix. p. 290), recording a case in which he 
 trephined for mastoid suppuration, and in which recovery took place, though throm- 
 bosis of the right lateral sinus was believed to exist, leading to septic embolism of the 
 heart and left lung, suggests that, as soon as the first indication of embolism appears, 
 the internal jugular vein should be tied in the middle of the neck, though, as he points 
 out, a serious argument against the performance of this operation " lies in the, at pres- 
 ent impossible, task of discovering how much thrombosis there is, and, further, what 
 risk there is of "embolism from the same." 
 
198 OPERATIONS ON THE HEAD AND NECK. 
 
 /Symptoms.— Amongst these are, the intense headache, tantamount to 
 agony, the sudden cries, the high temperature, and perhaps rigidity 
 of the neck. Treatment.— Probably altogether hopeless. Iced towels 
 or iced irrigation,* opium and calomel, morphia. 
 
 OPERATIVE INTERFERENCE IN THE CASE OF 
 FOREIGN BODIES IN THE BRAIN. 
 
 Under the above heading such bodies as bullets, knife-points, etc., 
 are included. Depressed and isolated fragments of bone may come 
 within the meaning of foreign bodies, but have already been consid- 
 ered (p. 156). 
 
 A. BuHds.— The following sites,t being those in which a hospital 
 surgeon is usually called upon to treat bullet wounds, may be briefly 
 alluded to : 
 
 i. The mouth. — This may be passed by at once as the bullet usually 
 so damages the base of the skull as to cause rapid death. It is just 
 worth while to mention a possible cause of fallacy here, and that is, 
 that a small revolver bullet, leaving an almost impenetrable track in 
 the soft parts which have closed over it, may lodge in the upper cer- 
 vical vertebra, becoming, as it were, encapsuled, and lead to no future 
 harm. 
 
 ii. The forehead. — From the presence. of sinuses more or less devel- 
 oped, and of two tables, the progress of the bullet may be quickly ar- 
 rested. The well-known fact that patients frequently recover after 
 very severe injury to, and loss of substance of, the frontal lobes should 
 also be remembered. 
 
 iii. The side of the head.— The thinness of parts of the skull here, 
 especially the squamous bone, the subjacent motor area, the possibil- 
 ity of middle meningeal haemorrhage, either at the time, or when the 
 wound is explored, may be all points of importance. 
 
 The following questions will suggest themselves to the surgeon 
 when he is called upon to examine a case of penetrating bullet wound 
 of the skull : 
 
 1. Has the bullet penetrated the skidl at all? Thus it may have 
 lodged, rebounded, or fallen out, or 
 
 * Mr. Keetley ('_'/;». Sor. Trans, vol.xii. p. 145) records aca.-ie of severe traumatic 
 meningiti.s, treMted successliiUy in the stage of coma, by tlie cold douclie, continued for 
 two and a lialf liours. This mode of treatment deseivfS a more energetic trial at the 
 hands of surgeons in llieir treatment of meningitis. 
 
 t Mr Barwell (OUn. Sue. Trans, vol. xviii. \i. iHi) makes the following observation 
 which is of importance if it is found to be constant — viz , that, thongh the weapon may 
 be held very close, there will be neither scorching nor powder-tattooing, if the bullet 
 be driven by one of the modern fulminates, contained in the same cap with the pro- 
 jectile. 
 
rOEEIG>r BODIES IN THE BRAIN. IfiQ 
 
 2. It may have passed between the bone and dura mater, without 
 penetrating the latter, and reached a spot quite out of sight. ' In such 
 cases Sir T. Longmore advises the use of a curved probe, and extrac- 
 tion of the bullet " with suitable instruments," if it can be felt. Prob- 
 ably in most hands a second application of the trephine, if needful 
 at some distance from the wound, so as to extract the loullet here' 
 would be preferable to attempts at removing it from the original 
 wound. 
 
 3. Has the ball split into two or more pieces ? Balls elongated as 
 well as round are liable to split when impinging on sharp angles of 
 bone. Thus, when the ball splits upon the outer table, part may pass 
 beneath the scalp, while the rest may drive on before it some of the 
 internal table, causing pressure on the dura mater, or even reach the 
 brain. 
 
 4. Has the bullet penetrated the brain? If so, where does it He? 
 Ought any further exploration to be performed, and if so, ought this 
 to be done through the original wound only, or at some counterpoint 
 as well ? 
 
 Before attempting to answer these last questions it may be well to 
 try and give an answer to the question which will be sure to arise in 
 the surgeon's mind when called to a bullet-wound of the skull— viz., 
 Shall I explore this or treat it expectantly ? 
 
 The following appears to me to decide in favor of exploring in all 
 cases in which it is clear that the injury is not going to be quickly 
 fatal : 
 
 a. The fact that only by exploring will the surgeon be able to an- 
 swer the question certain to be put to him by the friends whether the 
 brain is injured or no. 
 
 b. Whether the bullet has split, whether the internal table is shat- 
 tered, and, if so, how far it resembles a punctured"^ fracture, are also 
 points which can alone be cleared up by trephining. 
 
 c. Good drainage, disinfection of the wound, are almost hopeless 
 unless this is opened up and explored by trephining if needful. 
 
 The following case is not only a good instance of the kind of gun- 
 shot injury to the head which may be met with in civil practice, but 
 it shows how slight may be the injury which actually originates the 
 fatal mischief. It was brought before the Clinical Society by my col- 
 league Mr. Lucas. t 
 
 * Excellent instances of how closely some gun-shot fractures may resemble theclas- 
 Pieal " punctured" fractures, not only in the greater damage to the internal table co- 
 existing with but slight mischief externally, but also in the onset of grave symptoms 
 inevitably fatal unless trephining has been performed early, are shown in Figs. 79 to 
 88, Med. and Sarg. Hist, of the. War of the Rebellion, pt. i. pp. 168, 169. 
 
 t Vol. xii. p. 5. 
 
200 OPERATIONS ON THE HEAD AND NECK. 
 
 The patient, aged twenty-one, had shot himself with a small revol- 
 ver. " He was brought to the hospital about half-past eleven in the 
 evening in a semi-conscious state. Almost in the centre of his fore- 
 head were two small circular holes, with slightly inverted edges. 
 The skin surrounding the bullet-holes was raised into a rounded emi- 
 nence. There was some bleeding from the nose as well as from the 
 wounds. Chloroform was administered, and a crucial incision made 
 over the wound. On turning back the flaps, a blackened cavity was 
 opened beneath the skin, formed by the expansion of the powder 
 after it had penetrated the integument. At the bottom of this cavity 
 a somewhat cruciform aperture was seen in the bone, and lying upon 
 the internal table were two flattened bullets. The internal table was 
 driven back so as to give the appearance of a sinus, in which the bul- 
 lets were lying loose; and at the time, we were under the impression 
 that the man had very large frontal sinuses, which had been opened 
 by the bullets. After removing numerous fragments belonging to the 
 external table and diploe, the splintered internal table forming the pos- 
 terior wall of the cavity was also removed. This came away in large, 
 sharp-edged angular fragments, two of which were grooved by the 
 longitudinal sinus. When the internal table had been removed the 
 dura mater was seen at the bottom of the wound, and pulsating. The 
 membrane was entire except at one spot, where there was a small 
 aperture just such as might be made by stabbing the point of a pen- 
 knife into a sheet of paper. But for that small puncture it is not im- 
 probable that he would have recovered." Septic meningitis came on 
 in about forty-eight hours, followed bv death early on the sixth day. 
 
 Exploration, with or without trephining, in these cases should be 
 conducted on the lines already laid down (p. 164). The chief differ- 
 ences are only in degree — viz., the greater care with which all frag- 
 ments should be removed. Occasionally, portions of the bullet are 
 found embedded with very great firmness in the diploe, these are best 
 removed by careful use of gouge or chisel. If the dura mater is found 
 to be injured, every attempt should be made to disinfect this from the 
 first, and so obviate the otherwise inevitably fatal arachnitis. With 
 blunt-pointed scissors, the aperture, if small, should be opened up, 
 and a little iodoform, or equal parts of this and finely powdered bo- 
 racic acid, dusted within the cavity of the arachnoid ; or with a camel 's- 
 hair brush the parts may be carefully wiped over with a solution of 
 mercury perchloride (1 in 500 or 800), and the above powder dusted 
 on. An adequate-sized drainage-tube should be carried quite up into 
 the skull opening, and retained in position here by strips of gauze 
 carefully packed around. No sutures should be used, as a rule, in 
 these wounds where swelling of the scalp (it being impossible to ren- 
 der the parts rigidly aseptic) is sure to follow, and is very likely to in- 
 
REMOVAL OF BULLETS FROM THE BRAIN. 201 
 
 terfere with the escape of discharges, and where primary union cannot 
 be expected. 
 
 If, after exploring, the surgeon is certain that the bullet has pene- 
 trated the brain, another question arises as to the wisdom of further 
 exploration and attempts at removal. As a rule, if the bullet is not 
 found within one or two inches of the skull injury, nothing more 
 should be done now, especially if the patient's condition is not good, 
 or the anesthetic's influence not well maintained. It is needless to 
 say that in exploring the track in the brain the utmost gentleness is 
 essential. As with fine metal probes, owing to the pecuUar consistence 
 of the brain, it is very easy to lose the track, and thus, at the same 
 time, inflict fresh mischief, it will be wiser to make the gentlest pos- 
 sible use of a. bougie (those with a double-silk web are the most suit- 
 able) after placing it for a few minutes in a solution of carbolic acid 
 or mercury perchloride. If the bullet is found within one or two 
 inches of the skull wound, it should be removed with a fine-pointed 
 pair of dressing-forceps. It will be wise, if the track in the brain is 
 much lacerated, to treat it like an abscess, and introduce a soft drain- 
 age-tube, to be gradually shortened. 
 
 The following points may be adduced for and against the attempt 
 to remove bullets which have lodged in the brain ; 
 
 The surgeon who decides to abide by the expectant treatment in 
 these cases both immediately after the injury and later on, can justify 
 his course by a sufficient number of cases. Of these, one or two may 
 be usefully referred to. 
 
 Dr. Brunton* brought before the Medical Society the case of a 
 patient who had lived twenty-nine years after a gunshot wound of the 
 brain. He had fired a pistol at his forehead, but the recovery was 
 eventually so satisfactory, that it was believed that the bullet had 
 glanced off, or that the pistol had contained a blank charge. The 
 patient carried on his business as a corn-merchant for twenty-nine 
 years, married, and had children. He was said to be excitable in tem- 
 perament, but his intellect was clear. Death eventually taking jjlace 
 from sciatica and bladder trouble, it was found that the bullet had 
 entered the left frontal bone at the inner part of the frontal sinus, and 
 lodged in the inner table, projecting through it, and pressing on the 
 membranes, destroying them in situ and also a portion of the second 
 and third convolutions of the left frontal lobe. There was no pus or 
 artificial membrane present, simply thickening of the membranes. 
 
 This can scarcely be considered as a case of a bullet lodging in the 
 brain. It will be noticed that the velocity of the bullet was probably 
 delayed by its passing through the frontal sinuses, and that the part 
 
 * Lancet, February 12, 188 L 
 
202 OPERATIONS ON THE HEAD AND NECK 
 
 of the brain injured is one which is notorious for its power of recovery 
 (_cf. Mr. T. Smith's case, Lancet, May 3, 1879). In such cases, for the 
 .future, it would be always interesting to know something of the bore 
 of the pistol and size of the bullet. 
 
 In the next case, the recovery seems to have only taken place after 
 the patient had had a very narrow escape. 
 
 Dr. Barton reports a case of recovery after lodgment of a bullet inside 
 the cranium. The bullet, weighin- 34 grains, fired from a small 
 Remington pistol, had entered the skull 2 inches above a horizontal 
 line drawn just above the eyebrow, and about i of an inch to the left 
 of the middle line. 
 
 At first there appeared only a puncture, then ecchymosis around the 
 wound. On the fourth day a globular pulsating swelling of the scalp 
 appeared here, and a probe could be passed straight backwards into the 
 cranial cavity, being only stopped by the fingers. A drachm of cerebro- 
 spinal fluid now escaped, and symptoms of compression which were 
 present (e.g., a pulse of 44) were relieved. Carbolic-oil dressings were 
 applied. The patient now made a good recovery up to the fortieth day, 
 when suddenly violent pain, rigors, delirium and convulsions set in. 
 Calomel and opium were given, and the patient made a good recovery, 
 being perfectly well, in all respects, five months after the accident. The 
 history is not carried beyond this date.* 
 
 The following casef is noteworthy as showing the course of a bullet 
 which had traversed so great a thickness of soft parts that, though it 
 entered the skull, it did not penetrate the brain. 
 
 The patient had shot himself with a pistol. Just behind the angle 
 of the jaw was a small dark inverted wound immediately in front of 
 the carotid vessels. On the left temple, just behind the external 
 angular process of the frontal, was a puffy swelling; when this was 
 incised, a large fissure was found in the skull, i an inch behind the 
 above process, extending down behind the zygoma. The edges of this 
 were rough, and bulged slightly outwards as if by some force from 
 within. At the widest part of the fissure the finger could feel the dura 
 mater — the bullet lying lietween it and the bone. On extraction of the 
 
 * In the Lancet, August 14, 1886, is the abstract of a case reported to the Society 
 of Surgery, at Paris, by jM Prengiieber. The patient had fired a revolver at the middle 
 of his temporal fossa, the bnllet lodging in his lirain. For the three days following 
 the accident the surgeon abstained from interference, as the only symptoms were gen- 
 eral prostration witli lowering of the temperatm-e. Epileptiform attacks having 
 occin-red on the fourth and fifth day, the wound was ex|iiised and several bony spicula 
 removeil, which had penetrated the brain. A stilet having failed to detect the bnllet, 
 though piissed along its course to a depth of five centimetres, nothing else was done. 
 The epile[itiforni seizures did not recur, and the patient left the hospital at the end of 
 a month, without any cerebral complication. 
 
 t Loud. Med. Times and Guz., August 16, 1856. 
 
REMOVAL OP BULLETS FROM THE BRAIN. 203 
 
 bullet with dressing-forceps, the dura mater, though much detached 
 was found to be uninjured. ' 
 
 From the symptoms which followed, and from examination with a 
 probe, the course of the bullet was probably as follows: Entering 
 behind the angle of the jaw, it passed through the pharynx, then cleft 
 the palate, and- ascending through the great wing of the sphenoid 
 external to the external i^terygoid plate, coursed at first upwards 
 between the dura mater and the bone, and then dropped, spent, into 
 the lower angle of the fissure. 
 
 On the other hand, no one, in my opinion, would blame the surgeon 
 who, preferring exploratory to expectant treatment, endeavors to 
 remove the bullet from the brain. 
 
 For while the cases of recovery after expectant treatment are few, 
 it is probable that out of these, few as they are, a considerable pro- 
 portion, if watched, would he found to be incomplete recoveries. Thus 
 Dr. Otis* writes of balls lodged within the cranial cavity: "Many 
 instances were reported of patients who had survived the lodgment of 
 missiies within the skull, but few or none resembling the eases reported 
 by Larrey, of balls encysted in the brain and giving no inconvenience 
 for years. It is, indeed, reported that some patients went to duty with 
 balls lodged in the cerebrum; but the diagnostic details accompanying 
 the history of these cases are not sufficiently precise to invite the fullest 
 confidence. In most of the cases in which the evidence that the ball 
 remained within the skull was conclusive, either fistulous sinuses 
 existed, or there was much cerebral disorder,! or the position of the 
 missile was discovered after the patient's death at a period remote from 
 the injury." 
 
 The evil results of allowing a foreign body to remain in the brain 
 are usually manifested sooner or later, even as long as thirteen years 
 after the injury. Inflammation, slow or rapid, sometimes involving 
 large portions of the brain-tissue, or yellow softening are apt to be set 
 up around the foreign substance, either spontaneously, so to say, or 
 from the most trivial exciting causes. The usual termination is cere- 
 
 * Sfed. and Surg. Hist of the War of the Rebellion, pt. i. p. 193. 
 
 t Dr. Nancrede {Intern. Encycl. of Surg., vol. v. p. 72) gives the following important 
 abstract of a most careful paper by Dr. Wbai-ton [Phiia. Med. Times, 1879) in which 
 316 cases of foreign bodies lodged in the brain are analyzed. Of these, 100 recovered, 
 while 156 proved fatal. The influence upon recovery of the removal or retention of the 
 foreign body vpas most marked. The foreign body was removed in 106 cases, 72 
 recovering, while only 34 died. In the remaining 210 no attempt at removal was 
 made, and only 88 recovered, 122 dying. A further analysis shows that amongst those 
 cases classed as recoveries, death ultimately took place in ten at periods varying from 
 three to ten years, and that many of the patients suffered from such after-effects as 
 vertigo, incapacity for physical exertion, loss of sight or 'hearing, epilepsy, and dete- 
 riorated mental powers. 
 
20i OPERATIONS ON THE HEAD AND NECK. 
 
 bral abscess, this condition having been found in fifty-three cases, in 
 which a post-mortem examination was obtained. Apoplexy is an 
 occasional cause of death, as is pressure of the foreign body on the 
 venous trunks inducing ventricular eifusion and consequent com- 
 pression of the cranial nerves. The probable explanation of those 
 cases in which no symptoms have been present for long periods, but 
 in which death has rapidly followed upon the sudden development 
 of brain symptoms, is that quoted by Wharton from Flourens. This 
 observer found that bullets introduced into different portions of the 
 upper parts of the hemispheres and the cerebellum gradually pene- 
 trated the brain substance, ultimately reaching the basis cranii, the 
 bullet tracks healing after them (Nancrede, from AVharton). 
 
 As to the fatality of wounds of the different portions of the brain, 
 58 deaths took place out of 132 cases where the foreign body entered 
 through the frontal bone ; 58 wounds of the parietal showed 27 deaths 
 and 31 recoveries. The occipital bone was penetrated 23 times, with 
 16 deaths and 7 recoveries; the temporal bones 31 times, with 12 
 deaths and 19 recoveries (Nancrede, from Wharton). 
 
 The following are interesting instances of successful operations for 
 the removal of bullets penetrating the brain, the one being performed 
 a few hours after, and the other not till over three months had elapsed 
 since the injury : 
 
 The patient,* aged nineteen, shot himself with a pistol held in con- 
 tact with his forehead. About twelve hours afterwards, when seen by 
 the surgeon, he was semi-conscious, aphasic, with complete loss of 
 motion, without loss of sensation on the right side below the head. 
 Left side hypereesthetic. Pupils equally dilated. P. 100, T. 101.4°. 
 Ether was given, and under the protection of copious irrigations of 
 corrosive sublimate solution (1 in 1000), the wound of entrance, nearly 
 in the centre of the forehead, was enlarged, including also the wound 
 in the skull. This procedure was complicated by hfemorrhage from 
 a branch of the cerebral f artery, which was finally controlled by small 
 comjDression-forceps left in situ. The track of the ball through the 
 brain was then probed by a bulb-pointed X copper probe, and the point 
 on the scalp noted at which the probe would emerge if projected 
 through the head. At this point the cranium was exposed and tre- 
 
 * This case was under the care of Dr. FUihrer [Neio York Med. Joiirn., March 28, 
 1885 ; Ann. of Surg., vol. i. No. 6, p. 573). It is from the latter that the above account 
 is taken. It is to be regretted that the site of the posterior opening, and the way in 
 which the drainage-tube was passed across the brain, are not mentioned. 
 
 f Probably this word should be " meningeal"? 
 
 X Owing to the great facility with which an ordinary probe leaves the track of a 
 foreign body, and enters healthy brain substance, a bougie slightly softened and made 
 aseptic is likely to do less damage, if a bulb-pointed probe is not at hand. 
 
EEMOVAL OF BULLETS FROM THE BRAIN. 205 
 
 phined. The trephine-hole was enlarged towards the assumed openin<^ 
 of emergence of the bullet, and the dura mater slit in the same direc° 
 tion. Some eflfused blood and disintegrated brain matter appearing 
 more of the skull was cut away, and the slit in the dura mater pro- 
 longed, until a gush of brain matter, and a rent in the pia mater 
 demonstrated the point of impact of the bullet. The probe was intro- 
 duced through the opening in the pia, and passed downwards towards 
 a point where a feeling of resistance had previously been felt with the 
 tip of a finger applied on the surface. At the distance of an inch the 
 bullet was detected, and then extracted with slender-bladed forceps. 
 It weighed 42 grains. A small-sized rubber drainage-tube was then 
 introduced along the track of the ball through the brain, and the pro- 
 jecting ends cut off to within 1* inch of the skull. Iodoform dress- 
 ings, with an external protective layer of borated cotton, were applied. 
 The after-history was one of gradual but progressive amendment. On 
 the sixth day the drainage-tube was withdrawn, and replaced by a 
 drain made of four strands of catgut and ten of horsehair. On the 
 eighth day the compression-forceps were found to be loose. On the 
 thirteenth the catgut had become absorbed, and four strands of 
 horsehair were withdrawn. Considerable cerebral irritation followed 
 this proceeding, and as it seemed that the presence of the remaining 
 hairs were exciting further disturbance, they were all withdrawn on 
 the fifteenth day. A hernia cerebri had developed at both cranial 
 openings. On the twenty-fifth day. the patient was entirely free from 
 pain, and his temperature, respiration, and pulse were all normal. 
 After the thirtieth day, the hernife, which up to this time had been 
 simply protected from irritation, were subjected to a slight continuous 
 pressure. They gradually shrank, and by the end of three weeks more 
 had disappeared. By the end of the second month after the operation 
 the posterior wound was completely cicatrized. Three weeks later the 
 anterior wound also was healed. After leaving the hospital the 
 patient returned to work, a slight impairment of memory being the 
 only apparent consequence of his wound. A severe blow accidental!}' 
 made upon the anterior scar some months after returning to work, 
 determined a violent convulsive attack, which recurred at the end of 
 three weeks. Bromides wei'e freely given, and no further recurrence 
 had taken place when the report was made six months later. 
 
 A Prussian sergeant* was wounded at Spicheren, August 6, 1870, 
 by a chassepSt bullet on the left side of the head. He was rendered 
 insensible, and remained so until August 23, when he recovered con- 
 sciousness. The right side of his body was paralyzed. On September 
 
 * Sir F. Longmore {Syst. of Snrg., vol. i. p. 507). No reference is given to tljis 
 most interesting case. Tlie fragments of the bullet, with a piece of bone fixed in the 
 larger portion, are in the Netley Museum, No. 562. 
 
206 OPEUATIOXS ox THE HEAD AXD NECK. 
 
 4, he had an epileptiform fit. A further examination of the wound 
 was then made, and a piece of bone and three small fragments of ^ead 
 were discovered in the brain near its surface and removed. The fits 
 continued several times daily, liut at the end of September they les- 
 sened in frequency and the jiaralysis began to decrease. On October 
 2, Dr. Junker took cliargc of the patient. He was still hemiplegie, 
 but able to move his fingers ; was giddy and faint on trying to raise 
 his head, semi-comatose, and had almost daily epileptiform fits. His 
 memory was nearly lost. The appetite was good. A sinus led from, 
 the wound, and a moderate discharire of thin pus came through a 
 drainage-tube inserted into it. On November 22, an elastic bougie 
 was passed by Dr. Junker into the opening, and a narrow canal was 
 found leading to the base of the left ventricle. An electric probe being 
 introduced showed that metal was lying at the bottom, and eventually 
 two pieces of lead were separately extracted, together weighing 275 
 grains. No more fits occurred, and the paralysis rapidly disappeared. 
 He now regained strength, but became excitalde and intolerant of 
 society to which he had been previously indifferent. The wound 
 gradually healed by granulation, the drainage-tube being dispensed 
 with in February, 1871. By September he was able to walk with a 
 stick, and to read large j^rint. He was then discharged from hos- 
 pital. He was seen in September, 1876, six years after his wound. 
 He had married in June of that year, and was able to keep the books 
 of a large business. Sexual desire was defective. He had a peculiar 
 gait in walking, tottering unless looking at his feet, recalling the 
 appearance of locomotor ataxy. The motor and sensory powers of 
 the legs were, however, perfect, and the muscles well developed. 
 The above cases seem to admit of the following deductions: 
 The surgeon having decided that the ball has entered, and that the 
 patient's condition admits of immediate exploration, opens up the 
 wound both in the scaljj and skull freely. He then tries to make out 
 whether the bullet has broken into fragments, and if it is between the 
 bone and dura mater in the neighliorhood of the wound. If the dura 
 mater is merely punctured by the bullet or by a fragment of bone, the 
 puncture should be enlarged to allow of cleaning and, as far as pos- 
 sible, draining this spot of injury to the arachnoid. If it is decided 
 to explore the brain, this must Ije done with the utmost carefulness 
 with a bougie or bullet-pointed prol)e rendered aseptic. If the use of 
 such instruments, the depth they have passed, and perhaps the con- 
 dition of the scalp at another part of the head, indicate that the bullet 
 has almost traversed the brain, a counterspot should be chosen for 
 trephining. The whole length of the wound in the brain should be 
 drained, if possible, and drainage should be dispensed with slowly. 
 
EEMOVAL OF BULl.KTS FEOM THE BKAIN. 207 
 
 Strict attention should be paid to keepint;- the wound as sweet as pos- 
 sible. Any hernia cereljri which may appear should be submitted to 
 early gentle compression with pads of aseptic dressings. 
 
 B. Other foreign bodies besides bullets which may penetrate the 
 brain arc knife-points. These, with their tendency to form cerebral 
 abscess, have already been alluded to, p. 161. 
 
 C. Another class of body which may be met with by the surgeon in 
 civil practice, is shown in the following case of Mr. Couper's.* A 
 house-])ainter fell twelve feet from a ladder, impaling the right side 
 of his skull on the spike of an iron palisade. When brought into the 
 hospital there was a clean cut wound three-quarters of an inch long, 
 immediately under the right ear, partly overlapped by its lobule. In 
 this the end of a large rough piece of metal, corresponding to a freshly 
 broken spike, co\ild be felt, and its direction could be inferred to be 
 upwards, inwards, and a little forwards from the outer wound, which 
 was situated half an inch under the external meatus between the mas- 
 toid process and the ramus of the jaw. There was some bleeding from 
 the right ear, but no facial or other paratysis. The patient being under 
 chloroform, Mr. Couper succeeded, after much forcible wrenching, in 
 extracting the iron, the head being as far as possible steadied by three 
 students and the operator's hand. During these efforts three or four 
 ounces of blood oozed from the wound ; this haemorrhage ceased as 
 soon as the iron was out, but a small quantity of semi-fluid brain 
 substance flowed. Right facial i^aralysis came on two days after the 
 injury, then delirium, restlessness, and on the seventh day left hemi- 
 plegia, followed by convulsive attacks, affecting the right limbs and 
 right half of the face. Two days later, or nine days after the accident, 
 the patient died. 
 
 Post-mortem.— No pus between dura mater and bone, dura mater 
 healthy, save for congestion. On opening it the surface of the right 
 hemisphere showed well-marked sub-arachnoid meningitis. The pos- 
 terior part of the right middlecerebral lobe had been deeply wounded, 
 the. brain substance at this point softened, and streaked with pus, was 
 healthy everywhere else. The spike had entered just under the apex 
 of the mastoid process, traversed the internal ear, and driven several 
 irregular masses of petrous bone through the dura mater. 
 
 Probably, in a similar case, the careful use of chisel or gouge might 
 loosen the foreign body, while the opening up of the wound would 
 facilitate drainage, and cleansing the parts damaged, even as far as 
 the brain itself. 
 
 * Lund. Bosp. Eeports, vol. ii. Hutchinson's Clin. Surg., vol. i. p. 91, pl- xvii. 
 
208 OPEEATIONS ON THE HEAD AND NECK. 
 
 TREPHINING FRONTAL SINUSES. 
 
 Prof Ogston* has advised the use of the trephine in cases of reten- 
 tion of secretion and chronic inflammation of the lining membrane' of 
 
 these sinuses. 
 
 Indications.— Uneasiness, pain over forehead and tenderness on 
 firm pressure, with occasional escape from the nose of thick pus, the 
 appearance of which is not to be otherwise accounted for. 
 
 The above are due to retention analogous to that causing empyema 
 of the antrum. As no probe can be passed from below, when all 
 other treatment fails, the sinuses should be opened above, and their 
 communication with the nose dilated. 
 
 Opsration.— A single vertical incision is made down to the bone, 
 commencing at the root of the nose, and extending upwards for an 
 inch and a half over the nasal eminence of the frontal bone. The 
 periosteum havmg been divided and carefully cleared back, a tre- 
 phine, the size of a sixpence, is applied to the middle line. 
 
 When the trephine has been found to enter a cavity which the 
 point of a quill or a probe shows to lie rather at the lower part of the 
 crown, the disk is removed. If the sinuses are large, this is readily 
 effected, but if they are small, the disk must be removed piecemeal, 
 with a mallet and chisel, until the sinuses are laid bare. The bleeding 
 is slight. 
 
 The object which now meets the eye is the livid mucous membrane 
 lining the sinuses. On opening it, it is found thickened, and to con- 
 tain mucus or muco-pus. This being sponged away, the orifice in 
 the nose is found f with a probe or a fine gum-elastic catheter, a 
 drainage-tube, about the size of a crow-quill, should be slid down into 
 the nose, and its upper end left in the sinus, and the skin united over 
 it, to secure union by first intention.^ 
 
 If, however, owing to great thickening of the mucous membrane, 
 foul caseous pus, etc., it is necessary to use the sharp spoon, and to 
 disinfect the recesses of the sinuses by syringing out, insufilation w^ith 
 aseptic powder, or brushing over with zinc chloride or silver nitrate 
 solutions, it will be wiser to run the risk of more tedious closure of 
 the opening, and to bring the upper end of the drainage-tube out on 
 to the forehead, only partly closing the wound around. 
 
 In 1886 I performed a similar operation in a case of syphilitic 
 necrosis affecting the upper turbinated bones, ethmoid, and nasal 
 spine of the frontal bone. The frontal sinuses being freely opened 
 
 * Med. Chron., vol. i. No. 3, p. 1. 
 
 f If the opening lie too small, Prof. Ogston advises that it should be enlarged by 
 thrusting down a trocar or any stout instrument. 
 
 X In one of Prof. Ogston's cases a small fistula persisted for some time. 
 
CEREBRAL LOCALIZATION. 209 
 
 up, the necrosed bone was removed from above and below, and a large 
 drainage-tube brought out by the forehead and nose. A condition of 
 foetor and nuisance soon became one of cleanliness and comfort, and 
 an excellent recovery ultimately took place with very little deformity. 
 
 It is probable that analogous operations would be found useful in 
 very obstinate cases of oza;na, in which there is evidence of the mis- 
 chief having extended to the frontal sinuses, and in which, there- 
 fore, other treatment, including Rouge's operation (infra), will be 
 insufficient. 
 
 Every attention should be paid to keeping the wounds as aseptic as 
 possible, and to preventing erysipelas. A dressing of boracic acid 
 lint, wrung out of a saturated solution of boracic acid, iced if needful, 
 frequently renewed, or kept wetted, will be found efficient. 
 
 CHAPTER III. 
 
 CEREBRAL LOCALIZATION IN REFERENCE TO 
 
 OPERATIONS. 
 
 OPERATIONS ON THE BRAIN. 
 
 CEREBRAL LOCALIZATION IN REFERENCE TO 
 OPERATIONS (Figs. 47, 48, 49j. 
 
 Sufficient cases are now recorded in which, by attention being 
 paid to the cerebral motor centres, a lesion has been diagnosed and 
 localized, and an operation has saved or relieved the patient. It only 
 requires more close watching of head cases, more careful weighing of 
 signs and symptoms, for such instances to be largely increased. 
 
 Motor Area. — The motor area, or that part of the cortex in which 
 lesions cause interference with the functions, especially paralysis of 
 the limbs on the opposite side of the body, lies beneath the anterior 
 half of the parietal bone. It may be said to be in form a parallelo- 
 gram, about an inch wide, with its centre traversed obliquely by the 
 fissure of Rolando. 
 
 Speaking succinctly, but perhaps with sufficient accuracy for 
 practical purposes, the centre of speech lies (on the left side) at the 
 lower and anterior angle, or a little below and in front of the area. 
 Paralvsis or convulsions limited to one lower extremity need the tre- 
 phine at the upper end of the opposite motor area. Paralysis of the 
 arm at the middle third, paralysis of the face at the lower third 
 Three applications of a trephine with chipping away of bone will 
 expose it for thorough examination ; if the paralysis is distinct and 
 
 14 
 
210 
 
 OPKEATIONS ON THE HEAD AND NECK. 
 
 limited, one or two applications will probably suffice to find the 
 lesion. Where lesions are combined (footnote, p. 214), points inter- 
 mediate between the respective centres must be exposed. 
 
 The following aids in finding the above most important fissure will 
 be found useful: 
 
 i. The upper end of the fissure is found about i inch behind a point 
 midway between the roof of the nose and the external occipital pro- 
 tuberance, the lower end is about 1 inch behind the bifurcation of the 
 
 Fig. 47. 
 
 + Most prominent pan of parietal eminence. /. E. Fissure of Rolando. .Si/./. Sylvian fissure. 
 Sy. h.f. Horizontal line of Sylvian fissure. The ascending limb would start two inches behind 
 and a little above the external angular process, running straight up for an inch between the 
 letters a and/at Sj/.u./. 1 and ■2/i-./. First and second frontal Assures. l,2,3.fr. c. First, second, 
 and third frontal convolutions. 1 and 2 (. s.f. First and second temporo-sphenoidal fissures. 
 1, 2, 3 1. s. c. First, second, and third temporo-sphenoidal convolutions. (After Reid.) 
 
 Sylvian fissure. This bifurcation corresponds to a point li inch 
 behind and i inch above the level of the external angular process of 
 the frontal bone.* 
 
 Mr. Godlee, in a most interesting case f of trephining for cerebral 
 tumor, used the following simple method of exposing the fissure of 
 Rolando in its middle third : 
 
 * Ericlisen's Surgery, vol. i. p. 731. 
 
 f An abstract of this most helpful case is given at p. 216. 
 
CEKEBEAL LOCALIZATION. 211 
 
 (1.) A line was drawn between the frontal and occipital pro- 
 tuberance. 
 
 (2.) At a right angle to this a line was drawn vertically downwards 
 through the front of the external auditory meatus. 
 
 (3.) Parallel to the last a line was drawn vertically upwards at the 
 level of the posterior border of the mastoid process, reaching the 
 longitudinal line (1) about 2 inches behind the second. 
 
 (4.) From the junction of the lines 1 and 3, one was drawn diagon- 
 ally downwards, reaching the second about 2 inches above the ex- 
 ternal auditory meatus. This was believed to represent the direction 
 of the fissure of Rolando. 
 
 ii. Dr. Reid* gives the following directions for finding the fissure of 
 Rolando (Fig. 47) : A line is first drawn from the root of the nose to 
 the external occipital protuberance, the horizontal limb of the fissure 
 of Sylviusf is next marked out, then, from a base-line running 
 through the lowest part of the infra-orbital margin and the centre of 
 the external auditory meatus, draw two perpendicular lines to the 
 top of the cranium, one from the depression in front of the external 
 auditory meatus, and another from the posterior border of the mas- 
 toid process. There is then described on the surface of the head a 
 four-sided figure bounded above and below by the lines for the lon- 
 gitudinal fissure and horizontal limb of the fissure of Sylvius re- 
 spectively, and in front and behind by the two perpendicular lines. 
 If a diagonal line is now drawn from the posterior superior to the 
 anterior inferior angle of this space, the line will lie over the fissure 
 of Rolando. 
 
 Position of the Chief Sutures (Figs. 48 and 49).— After con- 
 sidering the most important part of the brain, the motor area, which 
 hes under the parietal Done, ii; will be well to recall the landmarks of 
 the chief sutures which are met with in that region. The coronal 
 suture, the anterior limit of the parietal bone, may thus be traced. 
 The point where it leaves the sagittal suture, the bregma, may be 
 found by drawing a line from a point just in front of the external 
 auditory meatus straight upwards on to the vertex ; from this point 
 the coronal suture runs downwards and forwards, speaking roughly, 
 to the middle of the zygomatic arch, or, more exactly, to join the 
 
 * Lancet, September 27, 1884. From tlils paper Fig. 47, slightly altered, has been 
 taken. 
 
 t The fissure of Sylvius (Figs. 47, 48, 49) is found by drawing a line from a point 
 IJ inch behind the external angular process of tlie frontal bone to a point J inch be- 
 low the most prominent part of t)ie parietal eminence. Measuring from before back- 
 wards, the first f inch of this line will re|.resent the main fissure, and the rest its 
 horizontal limb. The ascending limb will start two inches behind and slightly above 
 tlie e-xternal angular pi-ocess, and rims vertically upwards for about an inch. 
 
212 
 
 OPERATIONS ON THE HEAD AND NECK. 
 
 temporal part of the great wing of the sphenoid, which it meets an 
 inch and a half above the zygoma, and not quite an inch behind the 
 external angular process of the frontal bone * 
 
 Under this suture lie the posterior extremity of the three frontal 
 convolutions (Fig. 48), for the frontal lobe lies not only under the 
 
 Fig. 48.+ 
 
 The above view of the brain innitn sliows the relations of the surface convolutions to the re- 
 gions of the skull. R, Fissure of Rolando, separating tlie parietal from the frontal lobe. PO, 
 Parieto-occipital Assure between the parietal and occipital lobes. S, S, Fissure of Sylvius, separ- 
 ating the temporo-sphenoidal from the frontal and paiietal lobes. SF, MF, IF, The superior, 
 middle, and inferior frontal convolutions. Asc.F, Ascending frontal convolution. .A.SC.P, As- 
 cending parietal convolution. The outlines of the coronal, squamoso-parietal, and lambdoidal 
 sutures are also seen. {After Turner.) 
 
 frontal bone, but extends backwards under the anterior part of the 
 parietal, the fissure of Rolando, which forms the posterior boundary 
 of the frontal lobe, lying from IJ to 2 inches behind the coronal 
 suture. 
 
 The occi'pito-parietal or lambdoidal suture, the posterior limit of the 
 parietal bone, will be marked out by a line which starts from a point 
 2i inches above the external occipital protuberance, and runs for- 
 wards and downwards to its termination, which will be found on a 
 level with the zygoma, 1 1 inches behind the fissure. 
 
 As the occipital lobe is not limited to the upper portion of the oc- 
 cipital bone, but extends forwards under cover of the posterior part 
 
 * I liave pointed out — "Middle Meningeal Hoemorrlias^e," Oiiy? Hospital Reports, 
 vol. xliii. p. 1.52, pi. iv. Fig. 3 — how thin the bone is in the vicinity of the coronal 
 suture. 
 
 f The above woodcut is taken, slightly altered, from Prof. Turner's Introduction to 
 Human Anatomy, part i. p. 266. 
 
CEREBRAL LOCALIZATION. 
 
 213 
 
 of the parietal, the parieto-occipital fissure lies about J inch in front 
 of the apex of the lambdoid suture (Fig. 48). 
 
 The squamous or squamoso-parictdl suture is not so easy to mark out 
 owing to the irregularity of its curve and variations. Its highest point 
 is usually If inch above the zygoma (Fig. 49). 
 
 The Sylvian fissure, which separates the temporo-sphenoidal from 
 the parietal lobe, passes from below obliquely upwards and backwards 
 across the line of this suture near its middle (Fig. 49), the temporo- 
 
 FiG. 49.* 
 
 FlSS. BOLAND 
 
 Call 
 
 illTERPARIE' 
 
 S^p Fhpn-dsl 
 
 Inf. Frontal 
 
 The chief convolutions and fi'^sares on the outer surface of the brain, together with the out- 
 lines of the sutures and bones beneath which they lie. Diagrammatic. (After Roberts, of Phila 
 delphia.) 
 
 sphenoidal lobe not only lying under the squamous and great wing 
 of the sphenoid, but passing upwards under cover of the lower part 
 of the parietal. 
 The following practical points are given by Prof Nancrede : f 
 (1.) Monoplegia or spasms limited to one member, or a portion of 
 one member, indicate hmited lesions. If the lower limb be affected, 
 the upper portion of the ascending parietal (Fig. 49), with perhaps 
 also the corresponding part of the ascending frontal, is involved. A 
 trephine-crown must then be applied about the upper part of the 
 Rolandic line. 
 
 * The above woodcut is taken from Dr. Roberts's paper on the "Operative Surgery 
 of the Human Brain," Annals of Surgery, August, 1885, p. 119. 
 f Internal. Encycl. Surg., vol. v. p. 90. 
 
214 OPERATIONS ON THE HEAD AND NECK. 
 
 (2.) With paralysis of tlie arm and leg, the lesion probably in- 
 volves the upper two-thirds of the ascending convolutions with the 
 paracentral lobule. The trephine should then be placed at the upper 
 part of the line, a little lower than in the former case. It may per- 
 haps be necessary to enlarge the opening by cutting out a circle lower 
 
 down. 
 
 (3.) Paralysis of the upper extremity alone probably indicates injury 
 to the middle third of the ascending frontal convolution, and the 
 trepiiine should be applied a little in front of the middle third of the 
 fissure of Rolando. 
 
 (4.) Paralysis of the lower part of the face points to a lesion of the 
 inferior third of the ascending convolutions, or of the foot of the 
 second frontal. 
 
 (5.) In sin-iple aphasia the trephine-crown should be placed lower 
 down still, in front of and below the lower extremity of the fissure of 
 Rolando. 
 
 (6.) In most cases many centres are affected,* and consequently 
 the surface to be explored is much larger. Thus : 
 
 With paralysis of both lower extremities, the summit of the line 
 and the contiguous superior portion of the cranium must be removed. 
 ^Mth paralysis of one upper and one lower extremity (hemiplegia) 
 the operation must be performed at tlie middle and upper portion of 
 the line ; in paralysis of the arm with facial palsy, at the inferior third 
 of the line, and a little in front ; in palsy of the upper extremity with 
 aphasia, the opening should lie made lielow and in front of the line ; 
 with facial paralysis and aphasia, the bone should be removed in 
 front of the left line, and lielow its inferior extremities. 
 
 The aliove statements from Dr. Xancrede, following ]M. Lucas- 
 Championniere,t are liable to revision with advancing knowledge. 
 
 The following location of the chief cerel:iral centres is thus given 
 ])y jM. Lucas-Championnerc. Lower extremity. — Summit of the ascend- 
 ing parietal convolution. Upper and lower extremity. — Summit of the 
 ascending parietal and frontal convolution. Upper extremity. — Middle 
 portion of tlie ascending frontal convolution. Upper extremity and 
 aphasia. — Lower third of the ascending frontal and foot of the third 
 frontal convolution. Facial jxiredysis. — Lower third of the ascending 
 frontal and foot of the second frontal. Aphasia. — Foot of the third 
 left frontal. 
 
 * Tlie fiillowing combinations are those usually met with (Naucrede, loc. supra cit., 
 p. 89) : Paralysis of face and aphasia; aphasia and paralysis of the arm ; paralysis 
 of arm and face; paralysis of the upper and lower extremities. 
 
 ^ La TrepaudlioiKjuklee par les Localisatiom cerebrates. Paris: 1878. These state- 
 ments will be found to differ somewhat from those taught by Dr. Ferrier, p. 218. 
 
CEREBRAL LOCALIZATION. 215 
 
 Contralndi.catiuHS to Trephining in Lesions of the above Cerebral Cen- 
 tre* — Evidence of base-lesions, e.g., paralysis of one or more cranial 
 nerves, neuro-retinitis, Cheyne-Stokes' respiration. Also hemiplegia 
 accompanied by marked anaesthesia, contraindicates operation, as the 
 latter symptom i)oints to lesions which implicate other portions of the 
 encephalon than the motor area, and which are too deeply seated to 
 be accessible to operative interference. 
 
 Cerebral Localization in Injury to the Head.— A typical 
 case, in which localization may help tlie surgeon in trephining, 
 would be one in which the injury is limited to the cranium, and is 
 followed immediately by paralysis. Secondary or tardy paralysis 
 may be the result of later intlammatorv processes.* 
 
 M. Lucas-Championniere gives this interesting case : 
 
 A man was found in the street with sliglit paralysis of the right arm, 
 but sensibility perfect. There was a slight superficial cut i inch long 
 over the left jjarietal eminence. Five or six days later the patient be- 
 came stupid and unable to swallow, and convulsions increasing in 
 violence, and involving all the body, save the riijht forearm and hand, 
 set in. Suspecting a fracture of the inner table, M. Lucas Champion- 
 niere trephined at the site of the wound, and found a fine fissure just 
 in front of this, there was slight depression of the fragments, which 
 were wedged tightly together. After tlie operation the convulsions 
 ceased, and a good recovery took place, with use of the right arm. 
 
 The fracture was proved b}' measurements to be over the middle 
 and lower part of the fissure of Rolando, considerably in front of the 
 scalp wound. 
 
 This case would seem to show that in trephining for what is believed 
 to be a fracture, it is better to apply the instrument over the centres 
 corresponding to the affected muscles, rather than at the site of injury, 
 e.g., a scalp wound. 
 
 Convulsions in themselves are only an indication for interference 
 when they are localized and persist, and especially if they alternate 
 with paralysis of the same muscles. 
 
 In other cases the reverse course is indicated, and the surgeon must 
 be guided by the seat of injury, and not by any cortical lesion. Thus, 
 in Mr. West's case, alluded to in the footnote, p. 185, the patient had 
 right hemiplegia and aphasia, in addition to the epileptiform seiz- 
 ures, which, increasing in number and severity, reduced the girl almost 
 to a state of idiocy. Here, on the doctrine of localization, the trephine 
 should have been applied near the lower end of the left fissure of Ro- 
 lando ; Mr. West, however, followed the old rule of trepliining over 
 the site of injury, which was in the frontal region. In this case 
 
 Nancrede, fcc. supra cit., p. PI. 
 
216 OPERATIOXS ON THE HEAD AND NECK. 
 
 though the symptoms were much relieved, this relief was not due to 
 removal of depressed bone, for the depression involved only the outer 
 table. Dr. Doaglas Powell's explanation seems here to be the correct 
 one — viz., that the epileptic attacks were not due to a direct lesion of 
 the brain at the seat of injury, but rather of a reflex nature, the 
 injured part exciting the convulsions, just as a carious tooth might 
 do so. 
 
 Cerebral Localization in the Diagnosis and Removal of 
 Cerebral Tumors. — Amongst the cases which have been published 
 there have been none to surpass in helpfulness, from the completeness 
 of the details, and the accuracy of its reasoning, one of the earliest of 
 the cases submitted to modern surgery — viz., that trephined by Mr. 
 Godlee* for Dr. Hughes Bennett, in 1884, an abstract of which is given 
 below. 
 
 A man, aged twenty-five, had, four years before, suffered from slight 
 concussion from a blow on the left f side of the head. A year later 
 first set in twitchings in the left side of the mouth and tongue, par- 
 oxysmal and irregular in occurrence. Some months later fits began, 
 with loss of consciousness and general convulsions. This condition 
 lasted two and a half years ; and six months before admission, twitch- 
 ings of left hand, followed shortlj' by weakness of the left fingers, 
 hand, and forearm, were noticed. For three months these had jjre- 
 vented his using his tools. During this last period there had been 
 twitchings of the left leg, which had also been getting weak. There 
 was nothing abnormal in the skull or scalp. Vision was normal, but 
 optic neuritis was present on both sides, most marked on the right. 
 Hearing was less acute in the right. There was more complete paral- 
 ysis of the left fingers, thumb, and hand, the elbow movements were 
 very limited, those of the shoulder impaired. There was no rigidity, 
 or wasting of muscles. The toes of the left leg did not clear the ground 
 in walking. There was persistent vomiting and retching, with attacks 
 of lancinating headache, rendering life intolerable. Large doses of 
 the iodides were fruitless. 
 
 An operation being decided on, the motor area and the diagonal 
 line representing the fissures of Rolando, was mapped out by the pro- 
 ceedings already given at p. 210. Theoretically, in order to hit the 
 middle of the fissure of Rolando, the centre of the trephine should 
 have been placed about 2^ inch behind the diagonal hue, and about li 
 inch from the median longitudinal line. As, however, there was a 
 tender spot on the scalp 2 inches anterior to this, the first opening 
 
 3Ial. Chir. Tram., vol. Ixviii. p. 244. 
 t Whether the glioma on the right side of the brain was due to a blow on the left 
 
 Ififi mnct Via iin^j-.t<tr> 1 » 
 
 side must be uncertain. 
 
TUMORS OF THE BRAIN. 217 
 
 was made (with a trephine 1 inch in diameter) between the two * 
 The dura mater was normal; after a crucial incision was made in it 
 the brain was thought to bulge abnormally, and to be rather more 
 yellow than usual, otherwise it was healthy. A second crown was cut 
 away, overlapping the first, external to and slightly in front of it, and 
 the angles of bone rounded off with a chisel and hammer, the brain 
 being protected with a copper spatula. These two openings were then 
 joined by one posterior to them, and the edges being chipped away, a 
 triangular aperture was left measuring 2 by 13 inch. The dura mater 
 was opened and a surface of brain exposed nearly equal in size to 
 that of the skull-opening. Occupying most of this space and crossing 
 it obliquely from above and behind, downwards and forwards, was a 
 convolution. Into the centre of this convolution an incision about! 
 inch in length was made with a scalpel. From 1 to J inch below the 
 surface lay a transparent, lobulated, solid tumor, thinly encapsuled, 
 but quite isolated from the surrounding brain substance. The inci- 
 sion into the cortex being prolonged, the sides of the growth were 
 easily separated by a spatula of steel, readily bent into any shape. 
 The superficial surface of the growth being thus isolated, this portion 
 was removed with the finger ; as part now broke away, the deeper 
 parts were enucleated with a sharp spoon, the scraping being contin- 
 ued till apparently only healthy brain matter remained. This caused 
 rapid welling up of blood into the cavity, which would have held a 
 pigeon's egg. Sponge-pressure failing, the hemorrhage was finally 
 arrested with the electro-cautery. The dura mater was drawn together 
 with sutures, and a drainage-tube inserted beneath it. Elsewhere the 
 skin was brought accurately together. Antiseptic precautions, includ- 
 ing the spray, were used throughout. The ana'sthetic, chloroform, was 
 taken well. 
 
 The wound was not dressed till the third day, when the discharge 
 had a distinctly putrefactive smell : the scalp near the wound was 
 somewhat osdematous. The next day wet boracic-acid dressings were 
 applied, there was hardly any trace of smell, but a hernia cerebri as 
 large as half an orange was protruding through the lips of the wound. 
 There were no twitchings of limbs or face, no headache. The patient 
 was bright and cheerful, with good appetite. The hernia cerebri how- 
 ever increased, and on the eighth day, having reached the size of half 
 a cricket-ball, was snipped away with scissors, the parts removed con- 
 sisting chiefly of granular matter and clot, with, apparently, little 
 true cerebral" stricture. The cut surface was treated with a strong 
 solution of zinc chloride and iodoform, and a cap of block-tin applied. 
 The hernia cerebri again increased somewhat, but all seemed to be 
 
 * The centre of the opening was li inch from the middle line and J incli beliind a 
 line drawn vertically upwards from the meatus of the ear. 
 
218 OPERATIONS ON THE HEAD AND NECK. 
 
 doing well, when, on the twenty-first day, a rigor appeared, headache 
 followed and vomiting, then restlessness, sleeplessness, and gradual 
 sinking ahout four weeks after the operation. 
 
 At the post-mortem examination extensive arachnitis was found. 
 The parietal area appeared to have fallen in ; in its centre. and occu- 
 pying the position of the fissure of Rolando was the wound in the 
 brain. The destruction of the cerebral cortex involved nearly all the 
 ascending parietal convolution, the upper part of the ascending fron- 
 tal, and the anterior third of the supra-marginal gyrus. The extent of 
 softening around was not great, but it was difficult to tell this accu- 
 rately, as the brain had undergone the process of hardening. The 
 original growth was a glioma, of the size of a walnut. 
 
 In commenting on the case, most interesting remarks are grouped 
 under the following heads: (1) Diagnosis. (2) Surgical treatment. 
 (3) Clinical phenomena after the operation. (4) Revelation of the 
 autopsy jihysiologically and pathologically considered. 
 
 These will well repay most careful perusal: only the chief points 
 can be given here. 
 
 (1) Diagnosis. — A brain growth on tlie right side was diagnosed in 
 this case on the following grounds : Slow progress, uncontrollable 
 vomiting. Violent pains. Double optic neuritis. It was thought to 
 occupy the cortex because certain motor tracts were implicated in 
 definite order, because paralysis was present without Joss of sensibility, 
 and above all because of certain paroxysmal seizures of local convul- 
 sions occurring without loss of consciousness, eminently suggestive of 
 irritation of the gray matter. 
 
 The special seat of the lesion was believed to be in the middle part 
 of the right fissure of Rolando. Following Prof. Ferrier, the motor 
 centres which govern the voluntary movements of the lijis and tongue 
 are situated in the lower portions of the ascending parietal and frontal 
 convolutions. Higher up, in the same gyri, are the motor centres for 
 the face-muscles. Occupying the middle and nearly all the ascending 
 parietal convolution are the centres of the fingers and hands. In the 
 middle of the ascending frontal convolution are the centres for move- 
 ments of the arm and upper arm, including flexion, pronation and 
 supination of the forearm. At the upper and back part of the 
 ascending parietal convolution is the centre for the lower extremity, 
 and at the upper and anterior portions of the ascending frontal con- 
 volution are the centres for complex movements of both the upper and 
 lower limbs. 
 
 In this case there was complete paralysis of the fingers and hand, 
 witli inability to pronatc' and supinate the forearm, there was partial 
 paresis of the movements of the elbow, and weakness of those of the 
 shoulder-joint. There was also slight paresis of the leg and one side 
 
TUMOES OF THE HEAIX. 219 
 
 of the face. Accompanying all these there were paroxysmal convul- 
 sions in all these regions, occurring either singly or in definite order 
 one after the other. These phunomeua were to be accounted for by an 
 extensive but not absolutely complete destruction of the motor centres 
 of the fingers, hand and forearm, with slight encroachment on and 
 irritation of those of the face, upper arm, and leg. A very definite 
 localization was thus permitted, and the tumor was pronounced to 
 have occupied the whole thickness of the middle two-fourths of the 
 ascending parietal convolution, and a portion of the adjoining upper 
 half of the ascending frontal convolution. 
 
 The growth was proved to be limited by the fact that the centres of 
 the leg above, of the face and tongue below, of sight behind, and of 
 the movement of the eyeballs in front, were not seriously involved. 
 It could not have exceeded 2 inches in diameter, and proved to be a 
 ghoma, of about the size of a walnut, lying obliquely in the fissure of 
 Rolando. As to the probable nature of the tumor, the age of the 
 patient, the absence of syphilis, and the slow progress, suggested 
 glioma. 
 
 (2) The Operation. — In this the advantages of the chisel and hammer 
 over Hey's saw were exemplified. JMr. Godlee considers that the use 
 of a larger trephine might be advisable in similar cases. One convo- 
 lution only being exposed during the operation, there was at the time 
 some question as to whether it was the ascending frontal or parietal. 
 This doubt arose from the circumstance that in the attempt to approach 
 the tender spot the theoretical i3osition had been slightly departed 
 from. After death, however, it was apparent that the convolution 
 which had been incised was that in which from the first the disease. 
 had been diagnosed to exist — viz., the ascending jjarietal. There was 
 no external appearance of disease about this part except that it seemed 
 swollen, less glossy, and less vascular than natural. An incision into 
 this showed the morbid growth to be immediately under the surface, 
 and almost completely involving the entire thickness of the cortex. 
 In clearing away the superficial parts of the growth a small spatula, 
 neither sharp nor blunt, and so tempered that it would keep any shape 
 given to it, was found most serviceal^le, and much preferable to the use 
 of the cautery, as this so chars the parts as to prevent a differentiation 
 between healthy and diseased tissues. It may be questioned whether 
 it was advisable to arrest the hemorrhage from the interior of the 
 wound by means of the galvano-cautery, as the bleeding was not 
 severe and would no doubt have become arrested by natural means. 
 The use of this instrument appears to have brought about the putre- 
 faction which was the cause of the inflammation and consequent 
 hernia cerebri. It may be doubted if the putrefaction was ever com- 
 pletely subdued ; the fact of the meningitis occurring at last, and that 
 
220 OPERATIONS OX THE HEAD AND NECK. 
 
 of smell having again become apparent after the attempt at removal 
 of the second protrusion, point probably to a continued septic infec- 
 tion. As to the hernia cerebri, it was remarkable in the first place 
 that the discharge continued for so long to be so copious and so watery 
 as to suggest the idea of its being cerebro-spinal fluid * Secondly, there 
 was a difficulty in shaving it off", owing to the enormous size of its base 
 and the danger of serious hajmorrhage. 
 
 (3) Clinical Phenomena follu wing the Operation.— The patient lost his 
 headache, vomitings, and violent twitchings in the limbs ; even the 
 double optic neuritis markedly diminished. The only change which 
 followed the operation was completion of the paresis of the upper ex- 
 tremity, evidently due to the unavoidable destruction of the remaining 
 arm-centres in the removal of the tumor. Coincident also with the 
 formation of the hernia cerebri came fresh symptoms, in the shape of 
 paresis of the left leg and partial anesthesia of one-half ef the body. 
 These were probably due to the effects of simple pressure, and pos- 
 sibly to the subsequent secondary softening of the conducting fibres 
 caused by it. On the twenty-first day the patient was seized with a 
 rigor, followed by fever, and all the symptoms of meningitis, from 
 which he died a week later. 
 
 (4) Revelations of the Autopsy.— The brain was practically everywhere 
 healthy, except over the area injured by the operation, and in the 
 membranes in the immediate neighborhood. The meningitis was due 
 to irritating matter from the interior of the wound flowing downwards 
 between the layers of the arachnoid, and accumulating at the base 
 of the brain. The local inflammation of the wound had opened out 
 the parts, and separated the adhesions so as to allow the discharge to 
 percolate into the cranial cavity, but not till three weeks after the 
 operation. 
 
 The al)ove most valuable paper, based upon the work of practical 
 physiologists, having served a pioneering purpose, and proved the 
 practicability of dealing Avith brain-growths, has been followed up by 
 other surgeons. Amongst these Prof Horsley's work has been pre- 
 eminent. His three successful cases brought before the Section of Sur- 
 gery at the Brighton meeting of the British jNIedical Association,! ^^ 
 which, guided by cerebral localization, he methodically planned and 
 carried out attacks upon the human brain, will repay the most careful 
 study. All three patients suffered from epileptic seizures, which in two 
 were due to old depressed fractures received fifteen and eleven years 
 
 * Wlieiher the lateral veriti'icle had been opened into, the post-mortem examination 
 did not prove conclusively. There was no colleclinn of foreign matter in its interior; 
 at the same time the softening had extended close to it. 
 
 t Jlril. Med. Journ., October 9th, ISSG. A second paper will be fonnd in the same 
 periodical for April 'iSd, 1887. 
 
TUMORS OF THE BRAIN. 221 
 
 before respectively ; in the third a tubercular tumor was the cause, and 
 this case, on account of the exceeding rarity of successful interference 
 in such cerebral cases, is much the most interesting of the three. 
 
 A man, aged twenty, began, in January, 1884, to have cramps in the 
 left thumb and forefinger, these consisting of clonic opposition of the 
 above-named digits, occurring about twice a day for three months. 
 The first severe fit occurred March, 1884; the second in January, 1885. 
 Then followed a series of remissions of the twitchings, until in August, 
 1885, commenced a series of fits occurring once or twice a week until 
 admission in December, 1885. The character of the fits was nearly 
 always the same. They began by clonic spasmodic opposition of the 
 left thumb and forefinger, the wrist next, and then the elbow and 
 shoulder were flexed clonically, then the face twitched and the 
 patient lost consciousness. The hand and eyes then turned to the left, 
 and the left lower limb was drawn up. The right lower limb was next' 
 attacked, and finally the right upper limb. At frequent intervals every 
 day the patient's thumb would commence twitching, but the progress 
 of the convulsion could often be arrested by stretching the thumb or 
 applying a ligature. Sensation was not affected. Tliere was frequently 
 severe headache, beginning at the occiput and shooting forward, espe- 
 cially to the right parietal region. The optic disks were normal. It was 
 decided to explore the junction of the middle and lower thirds of the 
 ascending frontal and parietal convolutions, a spot at which Prof 
 Horslcy and Dr. Beevor had shown that the movement of opposition 
 of the thumb and finger could be elicited. 
 
 On June 22, 1886, the seat of the lesion being determined by 
 measurement, the two-inch trephine was applied, and on removing the 
 dura mater a tumor came into view. By further removal of bone the 
 mass to which the dura mater was adherent was completely exposed. 
 It stood out about i inch from the surface of the brain, and was much 
 denser than the brain substance. It appeared to be only i inch broad, 
 but as the brain substance all around it for more than i inch appeared 
 dusky and livid, the part apparently diseased was all freely removed. 
 This was fully justified, since the growth spread widely under the 
 cortex. Before closing the wound the centre of the thumb-area was 
 removed by a free incision.* Numerous vessels were ligatured. The 
 wound healed, and within two months the patient had regained 
 everything, except that the grasp of the left hand was not quite so good 
 as before.t There had been no fits since the operation. The tumor 
 
 * This detail Dr. Hiighlings Jackson and Prof. Hor.sley had resolved to carry ont 
 in the possible event of there being no obvious gross, organic disease, in order to pre- 
 vent, as far as possible, recurrence of the epilepsy. 
 
 t Dr Huo-hlings Jack.son, in the discussion on Prof. Horsley's paper, said that it 
 was proved That the " thumb-centre "-i.e., that part of the cortex in which the most 
 
•222 
 
 OPERATIONS ON THE HEAD AND NECK. 
 
 was composed of dense fibrous tissue, with two caseated foci, micro- 
 scopical examination proving it to be tubercular. 
 
 In two recent papers on cerebral tumors,* Dr. Hale White draws 
 attention to the following points which will be of interest to the sur- 
 geon : 
 
 In a certain number of cases of tumor of the brain the bones of the 
 skull will be found, as the result of increased pressure, very light, thin, 
 roughened like sand-paper on the inner surface, but without any soft- 
 ening. If this observation is confirmed, it is obvious that it incul- 
 cates the need of extra care in trephining, while it points to the value 
 of inspecting carefully the inner surface of the crown removed. 
 
 Of a hundred cases of cerebral tumor the proportions were as fol- 
 lows : 
 
 Tubercle, 
 Glioma, . 
 Glio-sarcoma, 
 Sarcoma, . 
 Carcinoma, 
 Lymphoma, 
 Myxoma, . 
 Cyst, . . 
 Gumma, . 
 Doubtful, . 
 
 4o 
 24 
 
 o 
 
 10 
 
 
 
 1 
 1 
 4 
 5 
 3 
 
 100 
 
 Of the forty-five cases of tubercle, the cerebrum was affected in 
 twenty-two, the cerebellum in twenty cases. The growth was mul- 
 tiple in nineteen, and single in twenty-four cases. In all the forty- 
 five cases one or more other structures than the brain were affected. 
 Dr. White concludes that not more than three tubercular cases were 
 likely to be benefited by operation, and even in them the other organs 
 were tubercular. 
 
 Of the twenty-four cases of glioma, of ten only could it be said that 
 they were not infiltrating. The cerebruni was the seat of the disease 
 in thirteen cases, the cerebellum in four. In one case tliere wei'e mul- 
 tiple gliomata in the brain, and in two otliers there were growths in 
 other ])arts of the body. 
 
 special movements of the thumb are repiisenled — had been cut out, by the i'uct that 
 while the patient could move his thimib lie had lost tlie most delicate movements of 
 it. Even if the fils recuned, the patient was well rid of his tumor; if they did recur 
 Dr. Hughlings Jackson woiiJd advise removal of moreo'' ihe corle.'c, believing it better 
 to have some permanent [.aralysis than to be subject to tits becoming universal. 
 
 '•- Guy's Ihixpital J epmtss, ISSII: "On the Condition of the Bones of the SUull and 
 the Dura Mater in Cases of Tumor of the Brain ;" " One Hundred Cases of (,'erebral 
 Tumor, with reference to Operative Treatment, etc." 
 
TUMOES OF THE BRAIN. 
 
 223 
 
 Of the ten cnses of sarcomata several afFectcd the dura mater in 
 inaccessible positions; of the five cases which attacked the brain only 
 one alone could have been removed with any prospect of success Of 
 the remaining tumors none of the carcinomata or Kho-sarcomata were 
 amenable to treatment. Of the four cases of cyst one could certainly 
 and another possibly, liave been operated upon ; the myxoma was and 
 the lymphoma was not, amenal^lc to operation, and of tlie three 
 doubtful cases, two could have been operated on. Dr. White's sum- 
 ming u]3 is as follows : " Thus we see that out of one hundred cases 
 of tumor of the brain, ten might certainly have been operated upon, 
 and four additional ones might possibly have been, so that in 10 per 
 cent, of our cases we can hold out some hope of operative relief to our 
 patients, provided that a correct diagnosis of the position of the growth 
 be made, even so late as shortly before their death, whilst of course 
 earlier in their histories many others might have been operated upon 
 with a good prospect of success." 
 
 As bearing upon the subject of infiltrating brain-tumors alluded to 
 above, attention may be drawn to the following cases :* 
 
 In a patient, aged thirty-two, headache, vertigo, vomiting, unilateral 
 paralysis, and atrophy of the optic nerve pointed to a growth within 
 the cranium ; the epileptic and epileptiform seizures occurring without 
 loss of consciousness, pointed to a cortical seat for the growth ; it was 
 evident that the motor centres about the right fissure of Rolando must 
 be the seat, and from the fact that the face, arm and leg centres 
 apparently were affected, the middle portion was supposed with cer- 
 tainty to be involved ; it having been found that the seat of sensation 
 exists in the parietal lobes, the ana>sthesia of the left half of the face 
 indicated that the growth was located in the middle of the gyrus post- 
 centralis. Syphilis being excluded by history and treatment, three 
 buttons of bone were removed with the trephine, and under the dura 
 mater was found a glioma, which protruded about } inch, and was 
 removed in part, it being difficult to separate it entirely from the 
 healthy brain tissue. The symptoms were slightly improved by the 
 operation, but the patient died seven days later. The author attriliutes 
 the unfavorable result to the fact that the soft glioma was continuous 
 with the adjoining brain tissue, so that its com2Dlete separation was 
 impossible without the destruction of a large portion of the cerebrum. 
 Had it been a hard tumor that could have been readily isolated, it is 
 very probable that the patient W(juld have recovered. 
 
 In a patient of Dr. Fraser's.f seized, soon after a severe blow on the 
 left side of the forehead, with aphasia, vertigo, and later on with in- 
 
 * Dr. Hirschfelder: Annals of Sargery, vol. iv. Xo. 2, p. 171 ; Pacific Med. and Surg. 
 Journ., April, J 886. 
 
 t Lancet, 1886, vol. i. p. 398. 
 
224 OPERATIONS OX THE HEAD AND NECK. 
 
 creasing headache, and then right hemiplegia, Prof. Chiene trephined 
 over the left inferior frontal convolution. There was free haemorrhage 
 from the middle meningeal artery, which ceased when the disk of bone 
 was removed. On opening the dura mater nothing abnormal could 
 be seen. On the chance of there being deep-seated suppuration, a very 
 fine cataract-knife was introduced into the brain in three directions, 
 but no pus found. Death took place two days later. 
 
 The left tempero-sphenoidal lobe was swollen and decidedly larger 
 than the right. On section immediately through the centre of the 
 trephine-hole, the whole of the temporo-sphenoidal lobe was seen to be 
 occupied by a large glioma and surrounding softening, the tumor ex- 
 tending backwards as a uniform infiltration as far as the limit of the 
 posterior horn of the lateral ventricle. It had invaded Broca's convo- 
 lution and the adjacent parts of the ascending frontal and parietal 
 convolutions. A small nodule of similar tumor, about the size of a 
 cherry, was situated in the middle third of the ascending parietal con- 
 volution on the right side. 
 
 The following case* is of great interest from the size of the growth, 
 its less usual site, and the complication of haemorrhage, eventually 
 fatal. 
 
 The patient was affected with cerebral symptoms extending over 
 eighteen months, consisting of left hemianopsia, whicli could only be 
 accounted for by a destructive lesion in the neighborhood of the gyrus 
 cuneus of the right occipital lobe, and locomotory disturbances, which 
 appeared to be due to the pressure-effects of a tumor on structures 
 below the tentorium, and implied a growth of considerable size. Oper- 
 ation having been decided upon, a U-shaped flap was raised, and a 
 1-inch trephine apphed at 1 inch above the occipital protuberance, 
 and the same distance from the middle line, beyond the limits of both 
 the longitudinal and lateral sinuses, and the bone removed until an 
 oval opening 21 by 2J inches was made, exposing a dura mater of a 
 deeper hue than normal ; section of this exposed the tumor, the out- 
 lying edges and base of which could not be reached in spite of further 
 removal of the cranium ; it was therefore incised and some of its soft- 
 ened, granular and fatty-looking contents forced out^ Its size was 
 now somewhat diminished, and the forefinger could be i3assed between 
 the cranium and tumor, and by its aid the delicate cellular attach- 
 ments that held the mass in place were felt to yield easily ; enucleation 
 now became possible, and the base was finally reached ; by next 
 drawing the finger gently but firmly towards the cranial opening, the 
 tumor was torn nearly completely in two and its outer half lifted out ; 
 
 * " Eemoval of a Large Sarcoma, causing Hemianopsia, from the Occipital Lobe of 
 the Brain," by Dr. Birdsall and Dr. Wefr : JSeiv York Med. News, April 16, 1887; 
 Annals of Surgery, vol. vi. No. 2, p. 149. 
 
TUMORS OF THE BRAIX. 225 
 
 then the inner part was separated from the falx with the help of the 
 finger-nail and withdrawn. Inspection of the mass showed that the 
 tumor had been entirely removed, and that its probable attachment 
 had been towards the posterior border of the falx ; the tumor was a 
 spindle-celled sarcoma, weighing 51 ounces, measuring 3i inches long, 
 by 2i inches wide, and being 8i inches at its greater circumference. 
 The falx was crowded over towards the left, and the tentorium de- 
 pressed ; two bleeding points were observed, one being in the region 
 of the straight sinus, although not free enough for that vein, and 
 probably belonging to the pedicle of the growth, while the other was 
 apparently arterial. It being found that the ha-morrhage could be 
 checked by direct pressure, the cavity was packed with 5 per cent, 
 iodoform gauze, not too tightly, as it was assumed that the released 
 brain would contribute additional pressure, and the ends of the strips 
 were allowed, for easy extraction, to protrude from the lower angle of 
 the scalp wound ; the dura was partly united over the gauze by several 
 loose sutures instead of being brought closely together, and the scalp 
 wound closed with catgut sutures, a rubber drainage-tube being intro- 
 duced under the skin up to the skull opening, and over these subli- 
 mated and iodoform peat bags were secured with gauze bandages. 
 The patient soon showed symptoms of hesmorrhage, which could not 
 be controlled by further packing, and death ensued thirteen hours 
 later. Dr. Weir, in another case, would favor the application of 
 hffimostatic forceps to the bleeding points, retaining them in place for 
 twenty-four or forty-eight hours. 
 
 Chief Diflaculties and Dangers in Operations for the Re- 
 moval of Cerebral Tumors.— Amongst these are: 
 
 1. Sufficient exposure of the growth. 
 
 Not only may much bone require removal (as in the case recorded, 
 p. 224), but the patient's condition, from a tendency to coma, faihng 
 pulse, and respiration, aided by the effects of the ana?sthetic (p. 154), 
 may seriously embarrass the surgeon by cutting short the time need- 
 ful for sufficient removal of the cranial bones. 
 
 2. Hfemorrhage. 
 
 This may be met with on division of the dura mater from sinuses 
 or branches of the middle meningeal artery which cannot be avoided. 
 The means of treating such hesmorrhage have already been given at 
 pp. 159, 178. Far graver hemorrhage may have to be encountered 
 on removing the tumor itself, as occurred in the cases at pp. 217, 224.. 
 The best means of arresting this is probably, first, firm pressure with. 
 an aseptic sponge, followed by careful packing of the cavity with, 
 strips of sal alembroth or iodoform gauze, the ends being left long for 
 removal, then uniting, as closely as possible, the dura mater with 
 chromic gut sutures, and the scalp with silver sutures over the gauze,, 
 
 15 
 
226 OPERATIONS ON THE HEAD AND NECK. 
 
 a drainage tube of adequate size having first been adjusted, with its 
 distal end quite up into the cavity. These means faihng, Dr. Weir's 
 suggestion to leave Spencer Wells's forceps /)). situ should be tried, but 
 the frailness of the tissues on which they hold, and the need of keep- 
 ing the patient's head alisolutely still as long as these forceps are in 
 position, are points which will not be lost sight of. 
 
 3. Difficulty in detecting the growth.* 
 This may arise from several causes. 
 
 (ffl.) The Avant of distinctness in the growth— in other words, its 
 close resemblance to brain substance. f 
 
 (b.) By the growth being overLiid by normal brain substance (p. 
 
 217). 
 
 (c.) By change in the growth— viz., hemorrhage from its thin- 
 walled vessels, and later on caseation of the coagula, these conditions 
 being lilvely to puzzle the operator. 
 
 4. Difficulty in isolating the growth. 
 
 (1.) This may be due to the absence of a capsule, and thus to the 
 infiltration of the surrounding parts. Now that ghomata. owing to the 
 operative attacks which will be made upon them, are of such practi- 
 cal importance from a new point of view, this question of a capsule is 
 a very weighty one. It seems to be a disputed point. Thus, in Dr. 
 Bennett's and" Mr. Godlee's case the glioma w;is found to be "thinly 
 encapsuled, but quite isolated from the surrounding brain substance." 
 Not so, however, in the cases at pp. 223, 224. Indeed, the chief 
 pathologists speak decisively on this point. Dr. Fagge Qoc. sujiracit.) 
 wrote: The substance of glioma "is always continuous with that of 
 the surrounding cerebral tissue, for there is never a capsule,^ as with 
 some sarcomata. Indeed, it often assumes the form of the part in 
 which it grows, so that one might imagine tlie corpus striatum or the 
 thalamus, or some particular convolution, to liave become swollen to 
 three or four times its usual size." 
 
 (2.) Another source of doubt in telling when a glioma not encapsu- 
 lated has been isolated, arises from the fact that, as pointed out by Dr. 
 Fagge {he. sujira cit.), these growths, in common with all the less cir- 
 cumscribed form of cerebral tumors, are apt to set up morbid changes 
 in their immediate vicinity, usually of tlie nature of softening, partly 
 inflammatory, partly oedematous. 
 
 * I have confined myself here to glioniatn, the commonest of cerebral tumors. 
 
 t '' A glioma may be of a pinkish-red color, or it may look so exactly like the nor- 
 mal brain-snbstance that a microscoi^ie is required to demonstrate its presence." — Dr. 
 Fagge, Medicine, vol. i. p. 523. 
 
 X The glioma "is distinguished by having no capsnle, but merging indefinitely into 
 the tissue around. It is firm and tough, otherwise very like brain-tissue, but more 
 pellucid."— Dr. Wilks and Dr. Moxon, Path. Anal., p. 239. 
 
HOESLEY ON OPERATIONS ON THE BRAIN. 227 
 
 PROP. HORSLEY S METHOD OF OPERATING ON 
 THE BRAIN. 
 
 Prof. Horsley, in one of the papery already referred to * described 
 in detail his method of operating on the brain, of which the chief 
 points are here given in abstract.: 
 
 Preparation of the Patient. — The day Ijefore the operation the patient's 
 head is shaved, washed witli soft soap and then ether; next, the posi- 
 tion of the lesion is ascertained by measurement, and marked on the 
 scalp. The head is then covered wi*h lint soaked in carbolic acid so- 
 lution (one in twenty), oil silk and cotton wool, being thus thorouuhly 
 carbolized for at least twelve hours Ix-fore the operation. Finally, the 
 patient has the usual purgative administered the evening before, fol- 
 lowed by an enema on the morning of the operation. 
 
 Ansesthetic. — A hypodermic injection of a quarter of a grain of mor- 
 phinet is given, and then chlofroform is administered. The object of 
 giving the morphine is twofold, in the first place it allows of the jjer- 
 formance of a prolonged operation, without the necessity of giving a 
 large amount of chloroform, the amount actuallv used in an operation 
 lasting two hours being very smaU. 
 
 The second reason is perhaps the more important, that this drug 
 causes well-marked contraction of the arterioles -of the central nervous 
 system, and that consequently an incision into the brain is accom- 
 panied by very little oozing, if the patient be under its influence. 
 Prof. Horsley has not used ether in men, fearing that it would pro- 
 duce cerebral excitement; chloroform, on the contrary, producing 
 well-marked depre-sion. If there existed any heart complications,, 
 the above theoretical considerations would be disregarded in favor of 
 the safer ansesthetic.J 
 
 Treatment of the Wovncl—The high morttdity accompanying tre- 
 phining being largely due to septic meningitis, strict antiseptic pre- 
 cautions, including the spray, will alone give safety. 
 
 Line of Incision.— V vol Horsley disapproves of the ordinary crucial 
 inc'ision as inconvenient at the time, as the four flaps have to be held 
 out of the way, and later on their point of meeting, a weak spot, prov- 
 ing the formation of a hernia cerebri. If, on the contrary, a semi- 
 lunar flap be raised, it can be simply thrown back and requires no 
 
 * Brit. Med. Journ., October 9, 1886, and April 23, 1887. 
 
 t In one case, a child of four, one-twentietli of a grain was found amply sufficient. 
 
 I Attention is also called to the startling rapidity with which u. patient, who has 
 roused up in the middle of one of these prolonged operations, can be sent of?' again, in 
 a moment, with only a few whifTs of the drug, and that thus it is very easy to give too 
 much in a brief space of time. Prof. Horsley expresses a strong opinion that this 
 sensitiveness to the action of the anesthetic is more marked wlien the dura mater is 
 opened. 
 
228 OPERATIONS ON THE HEAD AND NECK. 
 
 more liolding ; later on, the advantage of raising such a large flap, 
 which can be laid down like the lid of a box, will be obvious since, 
 being continuous throughout, it offers plentj- of resistance to the 
 upward-pushing brain, which the point of meeting of four cross-cuts 
 can never do; this, indeed, on the contrary, favoring the very thing 
 one wishes to avoid. The following details with reference to raising 
 the flap Avill not be out of place here : (1) All the parts superficial to 
 the periosteum must be raised with the flaps. (2) The curve must be 
 a shallow arc to avoid cutting collateral vessels. (3) It must be so 
 drawn as not to divide the main arterial branches supplying that 
 part of the scalp. The periosteum should be reflected by a crucial 
 incision from an area corresponding to the first trephine hole, and 
 subsequently as more brme is cut away. 
 
 Rciiiiinil of the Bone. — Where exploration has to be made, the more 
 rapid way is to make a couple of holes with a 2-inch trephine at the 
 opposite extremities of the area to be removed, then to cut half 
 through the sides of such an area with a Hey's saw, and, finally, to 
 complete the division with a p(jwerful 1jone-forceps.* Where it is 
 pjossible to preserve the dura mater intact, the portions of bone re- 
 moved should be preserved in warm aseptic sponges, and, at the end 
 of the operation, placed l)etween the skin and dura mater, having 
 been previously divided into small fragments as advised by Dr. 
 Macewen.f 
 
 Treatment of the Dura Mater. — This should be incised round four-fifths 
 of the circumference of the area exposed at i inch distance from the 
 edge of the bone, so as to render it possible to stitch the edges together 
 afterwards. The dura mater is best opened first by incision with the 
 scalpel, and then by blunt-pointed curved scissors, great care being 
 taken not to wound the parts l)eneath. The main branches of the 
 middle meningeal are Ijest secureil by ligature before they are divided. 
 
 Treatment of the Brain.X — If this, after incision of the dura mater, 
 
 * In his second paper {Brit. Mrd. Journ , April 23, 1887), Prof. Hoi-sley recommends, 
 as the most rapid method, first, talcing out an inch disk with a trephine, and cutting 
 out a piece of the size required with a circular saw, mounted on a Bonwill's surgical 
 engine (Mayer & Meltzer), the separation being completed with very powerful bone- 
 forceps. 
 
 t For the details of Dr. Macewen's method the reader is referred to p. 102 of this 
 book. Thongli tlie vitality of the fragments lias invariably been perfectly preserved, 
 Prof, llorsley has not, so far, observed much ossification of the cicatrix. Where a 
 large area of bone has been removed, a perforated celluloid cap, light, but very strong, 
 is recommended. 
 
 X Any of the dura mater which is adherent to the tumor is usually much altered. 
 If the mischief is recent, the membrane will be simply highly vascular. In advanced 
 cases it may be yellowish, and in some instances, on separating it from the growth 
 beneath, it is fonud to be of a dirty-reddish color. In all cases where it is adherent 
 the dura mater must be freelv excised. 
 
HOESLEY ON OPERATIONS ON THE BRAIN. 229 
 
 bulges very prominently into the wound, it indicates pathological 
 intracranial tension, and probably a tumor.* The next point is' the 
 color of the brain. Prof. Horsley believes that the existence of a 
 sHghtly yellowish tinge, or, possibly, the contrary condition— viz., 
 lividity— will indicate a tumor beneath the cortex in the corona 
 radiata. The condition of the vessels and of the peri-vascular lym- 
 phatics should next be investigated, and particular note taken of any 
 yellowish-white patches in the walls of the latter, indicating old mis- 
 chief. Alterations in the density of the brain must next be observed, 
 but it must be remembered that cerel)ral tumors, situated beneath the 
 cortex, are scarcely to be detected, save by exploratory incision. 
 
 In removing a portion of the brain, or a tumor, the bleeding which 
 has been so much dreaded will permanently cease if the wound be 
 plugged for a few minutes with a piece of sponge. The value of a 
 preliminary injection of morphine has already been alluded to, and 
 Prof Horsley further points out that, owing to the fact of the main 
 vessels remaining in the pia mater they can be raised from the brain, 
 and especially out of the sulci, so as to allow of the subjacent brain 
 being removed. In incising the brain the cuts in the cortex must be 
 made exactly vertical to the surface, and directed into the corona 
 radiata where necessary, in such a manner as to avoid damage to the 
 fibres coming from the portions of cortex, and surrounding the seat 
 of operation. If possible, portions of each centre should always be 
 left, so that the representation of its movements may never be totally 
 destroyed. A portion of brain removed does not leave, as might have 
 been supposed, a i^ermanent gap with vertical sides, for in a very 
 
 * Dr. K. F. Weir, of New York, has piiblislied {Annals of Surgery, June, 1887, p. 
 506) a case of trephining for a brain-sarcoma, in which abundant evidence of intra- 
 cranial tension was fonnd, but no tumor. The patient liad been operated on fonr 
 times for the removal of a cervical sarcoma. For abont six weeks cramps in the calf 
 of the left leg, with failure of power in the limb, had been noticed, and later, cramps 
 and numbness in the left band, and frontal headache. As the paralvsis increased, and 
 stupor rapidly set in, the skull was trephined at the site of the upper part of the right 
 fissure of Bolando. On dividing the dura mater, which was verv tense and bulging, 
 deeply congested brain-substance projected above the level of the skull. A piece, half 
 as large as a hen's egg, was excised, its substance being deei>ly pigmented and very 
 vascular. The following signs of improvement following on theoperation were attrib- 
 uted to the diminished cerebral tension — viz., disappearance and non-recurrence of the 
 headache and cessation of the spasms of the limbs. The portion of brain excised 
 suggested from its gross appearance the possibility of its being infiltrated with a soft, 
 sarcomatous growth, but the microscope showed nothing abnormal. About three 
 weeks after the operation paresis and analgesia appeared more clearly on both sides, 
 and deatli took place two and a half months after the operation. No growth was 
 found in the brain itself, but a mixed-cell sarcoma, apparently originating in the pia 
 mater, sprang from the lower surface of the left cerebellar lobe, displacing the medulla 
 forwards to the right, and invading the fourth ventricle. 
 
230 OPEEATIONS ON THE HEAD AND NECK. 
 
 short time the corona radiata forming the floor of the pit bulges almost 
 to a level with the surrounding cortex. 
 
 Closure of the Wound. — All bleeding having stopped, the flap is 
 secured with medium-sized silk and horsehair sutures. Prof. Horsley 
 removes the drainage-tube, which is to be inserted at the most 
 dependent part of the incision (as the patient lies in bed), at the end 
 of twenty-four liours, and makes firm but gentle pressure over the 
 centre of the flap. The tube serves to remove the steady oozing of 
 blood and serum from the cut surfaces, which takes place during the 
 first twenty-four hours, and its removal at the end of this time is 
 advised,, in order to allow of a certain amount of tension of wound 
 exudation to occur within the cavity, this tension not interfering with 
 primary union if kept within proper bounds, while it secures pressure 
 on. the brain which is tending to extrude, and serves, when the wound 
 is finally healed, to separate the skin flap from the brain beneath by 
 a cushion of soft connective tissue. If, after the removal of the tube, 
 there is much pain and throbbing in the wound, and the union threat- 
 ens to break down, the edges must be sufficiently separtited with a 
 probe, gently used, in the track o-f the drainage-tube. 
 
 CHAPTER IV. 
 OPERATIONS ON THE FACE. 
 
 OPERATIONS ON THE FIFTH NERVE. 
 
 Qndee this heading will be given the operative treatment of facial 
 neuralgia, including neurotomy, neurectomy and nerve-stretching. 
 While the results in none of the three are really permanent, in the 
 first they are certainly the shortest-lived. It is, perhaps, too early to 
 estimate precisely the res})ective value of neurectomy and nerve- 
 stretching of the fifth nerve. In the first place, no comparison can be 
 made between stretching a nerve like the sciatic (one from which most 
 of our experience in the operation has been derived) and the fifth 
 nerve. In the sciatic, stretching alone is available, as the nerve is a 
 mixed one. Again, the course of the two nerves is widely different. 
 The sciatic runs amongst soft parts, and is readily reached and 
 stretched. The fifth nerve would he readily ruptured by anything 
 like the force which is usually applied to the sciatic ; furthermore, it 
 runs in its passage from the skull through bony foramina, and, in the 
 case of two of its divisions, through bony canals as well. In the sec- 
 ond place, in nerve-stretching, even more than in neurectomy, the 
 
OPERATIONS ON THE FIFTH NERVE. 231 
 
 published results seem to me to be unreliable, cases having here been 
 much too often published without sufficiently prolonged watching. 
 At present, I think the respective value may bo summed up in some 
 such way as this. It would appear from Wagner's * laborious collec- 
 tion of i:].5 cases of neurectomy, that 18 remained cured after as long 
 a period as three years. I am unable to find any case of nerve- 
 stretching reported as cured after a longer period of watching than 
 eight months.t As the relief after either operation is usually not per- 
 manent, the surgeon would be abundantly justified who first submitted 
 his patient to nerve-stretching, and after a rehipse gave him another 
 period of relief by the major operation of a thoroughly performed 
 neurectomy. 
 
 First Division of Fifth Nerve : Neurotomy and Neu- 
 rectomy.— These two operations may be considered together. 
 
 Neurectomy.— Here the incision may be made above or below 
 the eyebrow. The latter is preferable as leading to less scar. The 
 supra-orbital notch being made out J by firm pressure when the 
 patient is under the infiuence of an anesthetic, the eyebrow is drawn 
 up and the eyelid down, and an incision an inch and a half long is 
 made along the supra orbital margin, with its centre opposite to the 
 notch. The skin, occipito frontalis, and palpebral ligament being 
 divided, the cellular tissue is separated, the nerve found in the notch, 
 set free, drawn np with a strabismus hook and a full inch removed. 
 
 NeurOLOmy, — This may be performed subcutaneously or, as 
 above, by an open wound, with antiseptic precautions. Neither are 
 comparable with neurectomy, owing to the rapid union of the nerve. 
 The open method needs no further description. The subcutaneous 
 method may be thus briefly described. The position of the supra- 
 orbital foramen being made certain of by firm pressure, a narrow 
 tenotomy knife is entered to the inner side of the nerve, and then 
 passed outwards horizontally beneath the skin, till its point has passed 
 beyond the nerve. Its edge is then turned towards the bone, and the 
 
 * Arch f. Chir., Bd. xi. 
 
 t For a reference to the statistics of Halin, of Berlin, quoted by Dr. Chandler in liis 
 tabulation of cases (Neio York Med Record) and for Dr. Gray's tables (Joura. of Neu- 
 rology and Psychiatry, May, 1882), I am indebted to a paper by Dr. O. K. Fowler, 
 (Annrds of Surcjery, vol iii. No. 4, p. 269), which for its fulness and impartiality is well 
 worthy of reference. 
 
 X The following hints of Mr. Holden {Landmarks, 3hdical and Surgical, p. 6) will 
 be found useful: "'The supra-orbital notch or foramen can be felt about the junction 
 of the inner with the middle third of the supra-orbital margin. From this point a 
 perpendicular line, drawn with a slight inclination outwards, so as to cross the interval 
 between the two bicuspid teeth in both jaws, passes over the infra-orbital and the 
 mental foramina. The direction of these two lower foramina looks towards the angle 
 of the nose." 
 
232 OPERATIONS ON THE HEAD AND NECK. 
 
 nerve divided as the knife is withdrawn. This means of performing 
 neurotomy is said to be preferable to that by open wound, inasmuch 
 as it leaves less scar. Neurectomy, however, should reiDlace neurot- 
 omv, whether Ijv the subcutaneous or open method. 
 
 Second Division of Fifth Nerve : Neurotomy, Neurec- 
 tomy and Nerve-Stretching.— Of these, neurectomy wdll alone 
 be described in detail. In deciding between the only two operations 
 which are of value, the surgeon is referred to the remarks on neurec- 
 tomy and nerve-stretching at p. 231. 
 
 Neurectomy.— Cases justifying : epileptiform neuralgia resisting 
 all drugs and other treatment, rjj., extraction of teeth, the continuous 
 current, etc. Cases in which life is a burden, where, owing to the fre- 
 quent recurrence from the slightest touch, from a draught of air, eating 
 or drinking,* the patient is incapacitated for work, sleepless and 
 emaciating, and perhaps liecoming a morphia-habitue. 
 
 Doubtful Crt.'?f.s\— Cases in which the neuralgia is ascending— viz., 
 attacking first the inferior dental, then the superior maxillary, and so 
 on, in spite of operation. X\ic does not, if other conditions are favor- 
 able, necessarily prohibit the operation.f 
 
 Operation. — This, often known as Carnochan's, has the advantage 
 of removing the whole of the second division of the fifth, together with 
 the spheno-palatine ganglion as far back as the foramen rotundum, 
 the nerve forming the guide to the surgeon from the surface 
 backwards. 
 
 Carnochan (Amer. Juvrii. Med. Sri, 1858, p. 136) looked upon the 
 removal of Meckel's ganglion as the key of the operation. Whether 
 his view was right or no that this body could be likened to a galvanic 
 battery, keeping up a continuous supply of " morbid nervous sensi- 
 bility," there is no doubt that removal of the nerve beyond the ganglion 
 is strongly advisable, as by this step the spheno-palatine branches to 
 the gums are also removed. As pointed out by Dr. Clia vasse (Med. Cli ir. 
 Traiif!.. vol. Ixvii. p. 151) and Mr. Clutton (St. Thomo^'^ Hdsji. Bcpt-^., vol. 
 XV. p. 213) removal of the nerve beyond Meckel's ganglion ensures the 
 
 * In a patient of Dr. Fowler's (.Innnh of Surgery, vol. iii. No. 4, p. 800) "every 
 attempt to receive food on tliat side of tlie moiitii wa."? followed by exacerbations of 
 pain of the most frightful character. It was only by lying npon the opposite side, and 
 having a funnel passed back to the pbaryn.t, so as to guide tiie stream away from tlie 
 diseased side, that lie was enabled to taUe fond at all, and that ot a liquid character." 
 
 t Dr. Jliiclean, of Detroit, in a discussion on "A Case of Excision of the Inferior 
 Dental Nerve by Dr. Mears" (Trans Amrr. Siirt/. A.isnc, vol. ii. p. 485), mentioned 
 two oases of men, aged seventy-two and sixty-nine, in the first of whom he excised the 
 infra-orbital and inferior dental ; and in tlie second, the supra- and infra-orbital nerves 
 successfully, the good result having lasted six years in the tirst case. 
 
OPERATIONS ON THE FIFTH NERVE. 233 
 
 disconnection of the posterior dental nerve* from the brain, which is 
 probably the explanation of the success which follows the operation. 
 
 An anesthetic being given, and the parts shaved f and cleansed, a 
 T-incision is made with the horizontal portion reaching from canthus 
 to canthus just below the orbit, and the vertical one running down 
 close to the angle of the mouth. The flaps thus marked out being 
 reflected and all hsemorrhage stopped, the infra-orbital nerve is defined 
 by a little dissection, cut as long as possible, and a i)iece of silk tied 
 round it to make it serve as a guide. 
 
 A J-inch trephine is then applied just below, a,nd including, the 
 infra-orbital foramen, so as to remove the anterior wall of the antrum ; 
 next, the same sized or a i-inch trephine is applied to the posterior 
 wall of this cavity so as to expose the spheno-maxillary fossa. Free 
 and troublesome ha-morrhage must be expected from the first appli- 
 cation of the trephine, partly from the vascular facial bone, J partly 
 from the mucous membrane of the antrum, and in the fossa itself, 
 where the bleeding is always copious, from the terminal branches of 
 the internal maxillary. Pressure with small sponges in holders may 
 be relied upon. The next step is to open up the infra-orbital canal 
 with a small chisel or strong scissors — these last, or fine-cutting pliers, 
 being used to enlarge the wound whenever useful. 
 
 During the operation, if daylight be insufficient, a laryngeal mirror 
 and artificial light, or, better, an electric light, will greatly help the 
 surgeon. 
 
 The nerve being now brought into the posterior trephine-aperture, 
 it is traced into the spheno-maxillary fossa, which it enters through 
 the foramen rotundum. Being kept on the stretch by means of the 
 piece of silk, it is severed with long, delicate, curved scissors as far back 
 and as near the foramen as possible. If it is still held by filaments 
 passing downwards (spheno-palatine branches), these should be also 
 divided with scissors. Mr. Glutton considers that the total length of 
 nerve removed from the infra-orbital foramen to the foramen rotuudum 
 should be at least If inch, without including any of its branches. 
 Iodoform should be dusted in at once, and the wound plugged tempo- 
 rarily with carbolized sponges sprinkled with iodoform. When all 
 
 * In both of Dr. Chavasse's eases the commencement of the pain was invariably 
 referred to the periphery of the posterior dental branches, and it appeared very doiibt- 
 fnl if stretching would have had any eti'ect on slender branches at some distance from 
 the extension point. Both of Dr. Chavasse's cases remained practically well two years, 
 and a year and a lialf, after the operation. 
 
 t In one of Mr. Clntton's cases this conld not have been borne before. Recnrrence, 
 slight and relieved by quinine, ensne<l in both of Mr. Clntton's cases within the year. 
 
 X The superficial hajmorrhage will be all the freer in proportion as the part has 
 been recentlv submitted to bli.-tering, liniments, etc. 
 
2'Si OPERATIOKS ON THE HEAD AND NECK. 
 
 htemorrhage has stopped these are removed, and the spheno-maxillary 
 fossa and antrum are lightly plugged with aseptic gauze, or boric lint 
 and iodoform. The flaps are partially adjusted with a few points of 
 suture, leaving room for drainage and the removal of the plugs,* iodo- 
 form dusted on, and boraeic-acid lint wrung out of the same lotion 
 iced, applied constantly and renewed frequently for the first few days. 
 Difficulties which may be Met with During the Operation. 
 
 1. Ha3morrhage. 
 
 2. The nerve breaking, or being divided prematurely. 
 
 3. A deep wound, difficult to illuminate, especially if the antrum is 
 deep lietween the two trephine wounds. 
 
 Of other methods the following need only be alluded to here: 
 
 Prof Liicke of Strasburgf has operated three times with satisfactory 
 results by the following method : An incision is made from above the 
 external canthus along the zygoma, the masseter divided, and the 
 zygomatic arch then sawn through in front, and fractured posteriorly. 
 This is then turned up with the temporal fascia. By these means the 
 spheno-maxillary fossa is reached, and the nerve cut at its exit from 
 the skull. The zygoma is then replaced, and the masseter stitched 
 to it. 
 
 Prof. Lossen of Heidelberg J has modified the above by dividing the 
 temporal fascia along the upi)er ).iorder of the zygoma, then, after fract- 
 uring the bone, turning it back with the masseter left intact. After 
 replacing the bone, the temporal fascia is stitched to it, and the masseter 
 is unable to draw the fragment down. 
 
 Braun {Cciitr.f. Cliir., April 22, 1882) records five cases of intractable 
 neuralgia operated on successfully by the above method. 
 
 The objections to the aliove seem to be the resulting fixity of the jaw 
 from deep cicatrices, the risks of burrowing suppuration and necrosis, 
 while, as Mr. Glutton {loc. su2Jra cit.') points out, tlie coronoid process 
 and the temporal muscle are very much in the way, and even when 
 the muscle is drawn on one side the foramen is still hidden behind the 
 base of the pterygoid process. 
 
 Prof. Pancoast elevates the' masseter by raising a square-shaped flap 
 over the ramus of the jaw. The coronoid process being resected, the 
 internal maxillary artery is ligatured, and the heads of origin of the 
 external pterygoid separated, thus exposing the foramen ovale and the 
 spheno-maxillary fissure. At the former the inferior dental can be 
 divided, and after being expt)sed at the mental foramen which is en- 
 larged with a dental burr, the whole nerve can be withdrawn. The 
 
 * To be reniovc'd in twentv-foiir or forty-eight hours according to tlie aiuoiint of 
 Haemorrhage met witli during the operation. 
 t Chavasse, loc. supra cit., ]>. 152. 
 J Loc, supra cit. 
 
OPERATIONS ON THE FIFTH NERVE. 235 
 
 infra-orbital nerve can be hooked down as it crosses the sphcno-maxil- 
 lary fissure, and released at its exit on the face in the same way as the 
 inferior dental has been at the mental foramen. 
 
 This operation would seem likely to have many of those objections 
 already given. 
 
 After any of these operations on the fifth nerve the patient should 
 be strictly cautioned to avoid exposure to any of the causes of a return 
 of his enemy. The chief are i;iven l)elow (p. 2o!)). 
 
 Operations on Third Division of Fifth Nerve. 
 
 Neurectomy. — American surgions aided, perhaps, by the per- 
 fection of their mechanical dentistry, have, in this operation also, led 
 the way. The following case gives well most of the points of the 
 operation : 
 
 Dr. Mears* removed three inches of the inferior dental nerve, 
 including all that part of it contained in the canal and part of it 
 beyond the mental foramen. The outer surface of the jaw was exposed 
 by reflecting a flap raised liy an incision which reached from the 
 middle of the posterior border of the ramus along tlie horizontal ramus 
 to a point ))eyiind the position of the mental foramen. A ^-inch tre- 
 phine was applied over the position of the inferior dental foramen, and 
 a disk of the outer table removed. The mental nerve was dissected 
 to the distance of i inch beyond its point of exit from the foramen 
 and divided. A dental burr attached to the surgical engine was now 
 used to enlarge the mental foramen and release the nerve. Traction 
 was made upon the nerve at the point where it was exposed by the 
 trephine, and it was drawn entire from the canal. Before dividing it 
 posteriorly it was drawn down so that the division might be made as 
 high up as possible. The artery, which was torn, was twisted, no 
 hajmorrhage followed. The nerve, while in the canal, was found to be 
 swollen and reddened, and the artery seemed compressed and flattened. 
 The wound healed in six days. The patient, save for one or two spasms, 
 remained free from pain for nine months, up to date. 
 
 Microscopic examination of the nerve removed showed evidence of 
 a parenchymatous neuritis— viz., degeneration of the nerve fibres, and 
 thickening of the connective tissue. 
 
 Nerve-Stretching.— Mr. Pittsf gives two cases of stretching of the 
 inferior dental nerve for neuralgia. For more than a year after the 
 operation these cases were free from the slightest return of pain, then 
 relapses took place, but mildly, and the condition of the patients still 
 remained much improved. The inferior dental nerve was found by a 
 vertical incision within the mouth, along the innerj border of the as- 
 
 * Trans. Amer. Sarg. Assoc, vol. ii. p. 469. 
 t St. Thomas's Hasp. Reports, vol. xv., p. 207. 
 X Anterior? 
 
236 OPERATIONS ON THE HEAD AND NECK. 
 
 cending ramus. The soft parts being separated from the bone with 
 an elevator, and the position of entrance of the nerve being recognized 
 with the finger, the nerve was stretched with a blunt hook, this being 
 passed close to the bone. While it was thus easy to take up the nerve 
 it was difficult not to include the artery as well, and this in one case 
 caused free hasmorrhage, which was arrested by clamp-forceps left on 
 for twenty-four hours. Both patients suffered from swelling of the 
 throat and neck, as might be expected from the necessary bruising of 
 soft parts, and the impossibility of satisfactory drainage. Several 
 months elapsed before complete mobility of the jaw was regained. 
 The amount of pull required was not great, and it is advised to 
 stretch the nerve by a " number of small efforts rather than by one 
 jerk." 
 
 Intra-buccal Division.— The following case* is of interest as 
 showing with what facility the complication of hemorrhage noticed 
 in the last operation may occur. 
 
 The patient being etherized, and the mouth held open by a gag, an 
 incision was made, extending from the uj)per to the lower jaw, along 
 the inner edge of the latter. The spine of Spix was exposed, and the 
 nerve seized with a strong slender forceps at the point at which it 
 enters the dental canal, and divided with scissors above and below the 
 forceps. The small mass removed, however, did not plainly show 
 nerve tissue, whereupon a blunt hook with a short curve was intro- 
 duced two or three times, until finally, when passed well back and 
 drawn forward, it seized a cord which was supposed to be the nerve. 
 This was divided with scissors, when quite a severe haemorrhage took 
 place, which could only be controlled by rapidly packing the wound 
 Avith iodoform gauze. The hfemorrhage recurred the same evening, 
 several ounces more being lost, but it was checked by additional com- 
 pression, the jaws being firmlj' bound together so as to force the com- 
 press against the wound. The gauze Avas removed from the wound 
 piecemeal, the last being taken away by the tenth day. 
 
 STRETCHING THE FACIAL NERVE.f 
 
 As will be seen from the remarks made below (p. 238), it is ex- 
 tremely doubtful if anything more than temporary relief, of a variable 
 duration, can l<e promised by it. 
 
 Operation. — The following account is taken from Mr. Godlee's 
 
 * Dr. R. F. Weir, of New York {Annals of Surf/erii, .Tune 3, 1887, p. 504). Dr. Weir 
 is inclined to tliink that this hsemorrhage arose from the internal maxillary. 
 
 t The operation given below, that of Banm, is not, accurately speaking, une quite 
 on the face. It may, however, be conveniently considered here. 
 
STRETCHING THE FACIAL NERVE. 237 
 
 paper (Clin. Soc. Trnns., vol. xiv, p, 45), the method is that of Baum.* 
 An incision begun behind the ear, aliout opposite to the meatus, was 
 carried downwards and forwards to a point immediately below the 
 lobule, and then prolont^ed almost perpendicularly, but slanting a lit- 
 tle forwards, nearly to the angle of the jaw. A small transverse inci- 
 sion was also made below the pinna. After exposing the edge of the 
 sterno-mastoid and parotid, these structures were separated deeply 
 and pulled respectively backwards and forwards. As soon as the 
 edge of the digastric appeared, the knife was discarded, and the struct- 
 ures immediately alnjve and parallel with the upper border of the 
 muscle were one after the other pulled up with a blunt hook or for- 
 ceps and cleaned with a steel director. When the nerve was reached 
 and raised on the hook the twitching at first increased, a somewhat 
 firmer pull averted it for a time, but it liegan again on relaxing the 
 tension, a still firmer pull not onlj^ stop]>ed the twitching but caused 
 the right side of the face to pass into a state of complete paralysis. 
 One or two further pulls were given, and the wound closed. f The 
 operation was antiseptic throughout. Healing was comj)lete about 
 the ninth day. J 
 
 The performance of this operation is easy in thin patients, in stout 
 and muscular ones it would be decidedly difficult. In different ex- 
 periments on the dead subject the amount of tension which thfe nerve 
 would bear difi'ered very much : in some cases it resisted for an appre- 
 ciable time the strongest possible pull, in others it snapped across 
 with the greatest readiness. 
 
 The line for the nerve is exactly parallel with the upper border of 
 the digastric, and it will be found aliout half-way down that part of 
 the mastoid process which is exposed in the wound— viz., the free 
 anterior border. The great auricular nerve will be in part divided, 
 but as long as the operator keeps in the same plane as the digastric he 
 can scarcely wound any vessel of importance. The deep parts of the 
 
 * The other metliod is that (if Iluelei— by an incision 2 inches long in front of the 
 ei.r, its centre being opposite to tlie npper part of the lobnle. Dr. Keen (Annals of 
 Surgery, July, 1886, p. 13) gives the following reasons for preferring that of Baum : (1) 
 The scar is "hidden behind the ear, a point of nmcb importance in women in whom 
 this affection is not iincomnion ; (2) it is less bleody ; (3) it inHicts less damage on the 
 parotid ; (4) it reaches the nerve directly at its emergence from the stylo-mastoid fora- 
 men, before it has given off any branches excei-t, perhaps, the posterior auricular. 
 Thus there is no risk, as in Hueter's method, of the branches to the occipito frontalis 
 and orbicularis escaping. The above advantages outweigh the greater ease of Hueter s 
 
 operation. 
 
 t Adequate drainage by a tube or gut and horsehair will, of course, be provided.^ 
 J The surgeon must be prepared for what took place in Mr. Godlee's case— viz., 
 some troublesome conjunctivitis from the gaping of the lids, which was relieved by 
 mildly astringent coUyria and holding up the lower lid with plaster. 
 
238 OPERATIONS ON THE HEAD AND NECK. 
 
 wound are in close proximity to the internal jugular vein. The only- 
 vessels which should be met with are, the posterior auricular vein 
 superficially, and its artery more deeply, but a good deal of hsemor- 
 rhage may arise from glandular branches, and Mr. Godlee's advice to 
 keep the wound in a good light, well opened out with retractors and 
 carefully sponged dry, should be remembered. 
 
 Points which Deserve Attention.— ( 1) Finding the nerve. To 
 avoid needless injury and to shorten the operation. Dr. Keen* found 
 the use of a weak faradic current very useful. A wet sponge was held 
 on the cheek, and a fine wire at the other end was applied to various 
 points in the wound till the nerve was found. 
 
 (2) Mode of stretching the nerve. Dr. Keen advises stretching 
 from the periphery towards the centre. The amount of force to be 
 used he estimates at four to five pounds, and that this can best be 
 achieved empirically, by attempting to lift the head (six to seven 
 pounds), and abandoning the attempt the moment any fibres give 
 way. In other words the stretchings should be as severe as the integ- 
 rity of the nerve will allow. f 
 
 (3) Results of the operation. It appears that while many cases 
 have been, temporarily, very much relieved, as a certain rule, when 
 the nerve recovers itself the sj)asms return. Dr. Keen in the table at 
 the ena of his paper gives two cases in which the cure lasted much 
 longer, if indeed it may not be called permanent, viz., Southam's,J: in 
 which there was absolute relief for five years, and one under tlie care 
 of Jesas§ in which tlie cure had lasted two years and eight months. 
 Dr. Keen's concluding words are as follows: '' It would seem therefore 
 that, whether viewed from the point of palliation or of cure, the opera- 
 tion is, with our present knowledge, to be looked upon favorably. 
 Further observations may show its inutility, but when we consider 
 the utter hopelessness of improvement, much less recovery, from any 
 other means, relief by this operation, even if temporar3', is had at a 
 very trivial cost, and would be welcomed liy any sufferer, while per- 
 manent cure is not impossible." 
 
 * Loc. supra t-.it., p. 13. In the moist condition of the wound a strong current will 
 produce muscular spasm at once, but»a very weak current will only do so when the 
 nerve is touched. 
 
 t Two cases are quoted — those of Eulenberg and Schiissler — in the first of which 
 the nerve was " physically disorganized" by the stretching, while in tlie second the 
 nerve lay in a small Ioo|i in the cavily of the wound ; yet in each the paralysis gradu- 
 ally disappeared and the spasms partially returned. 
 
 X Liiwei, August 27, 18X1 ; Ibid., April 10, 18S6. 
 
 § Wien.Med. Woch., No. 2, 1SS4, and No. 27, 1SS7. It is an interesting fact that 
 no paralysis followed in this case. 
 
EESTOEATION OF STEN'O's DUCT. 239 
 
 Mr. Godlee in a second paper* in which he published tlie result of 
 his first case— after remaining for nine months practically well the 
 convulsions suddenly returned after a severe nervous shock, and 
 gradually increased until they regained all their former intensity- 
 sums up somewhat less favorably : " In discussing the question of 
 recommending the operation to a patient, we must not forget that the 
 risk, with due care, is almost nil ; that a certain immunity from the 
 trouble may be safely promised for a time, and that this period may 
 be very considerably prolonged, and while Southam's remarkable case 
 remains completely well, there is always the hope that the relief may 
 be permanent. Were it not for this, however, I am afraid that the 
 general verdict would be that the time has come when this small chap- 
 ter of surgical therapeutics .... must be closed." 
 
 It is of course to be understood that no patient would be advised to 
 submit to the operation without a thorough trial of other remedies 
 short of nerve-stretching. 
 
 And after submitting to stretching of the nerve, patients sliould be 
 most careful to avoid any exciting and predisposing causes of a return 
 of their trouble— viz., exposure to cold chills, sudden bright lights, 
 nervous disorder, mental worry, and living low. 
 
 RESTORATION OF STENO'S DUCT. 
 
 Where after burns, stabs, ulcerations, sloughing, operations for re- 
 moval of growths, a most annoying salivary fistula persists, the patient 
 suffering from disagreeable hot dryness of the mouth, and from con- 
 stant irritation and inflammation of the soft parts from the dribbling 
 of saliva, where previous measures — e.g., collodion and lieated wire, 
 paring the edges — have failed, the surgeon may adopt one of the fol- 
 lowing measures : 
 
 (i.) The following will often succeed in a recent case : 
 The opening into the mouth is first found, or one in its position 
 made, by passing a fine silver jirobe from the fistula into the mouth. f 
 As soon as the oral opening is found or established, the probe is passed 
 from the mouth along the duct, beyond the fistula, ujj to the gland 
 itself. The other end of the probe is then brought out of the angle of 
 the mouth, curved, and secured by strapping on the cheek, while the 
 
 * Both Mr, Godlee's second paper (Clin. Soe. Trans., vol. xvi. p. 220) and Dr. Keen's 
 {loc. supra cit.) contain table?, the former giving thirteen, the latter twenty-one cases. 
 Mr. Godlee's case was unwilling to purchase relief fronri her complaint by snbmitting to 
 permanent paralysis of tlie affected side of her face, owing to a dislike of the very ob- 
 vious nature of the deformity. 
 
 t Close to the projection of the raucous membrane, which usually denotes the posi- 
 tion of the orifice of the duct, opposite to the second upper molar tooth. 
 
240 OPERATIONS ON THE HEAD AND NECK. 
 
 fistula is kept as drj^ as possible, and covered with collodion, in the 
 hope that it will close,* now that the oral opening is re-established. 
 
 Mr. H. Morris (Clin. Soc. Trans., vol. xiii. p. 144) has recorded a case 
 which he successfully treated on the same lines, but with a fine cat- 
 gut bougie, which is much more easily worn than a probe. He also 
 suggests that it would be well if, during any operation on the face for 
 removal of a new growth, it be found necessary to divide the duct, a 
 bougie should be passed at once, and the patency of the duct secured. 
 
 (ii.) In cases of longer standing, where the duct is more obliterated, 
 especially at its narrow oral end, and the restoration is not so easy, 
 some such operation as Dessault's must be performed. A fine trocar 
 and cannula is pushed through the cheek from the fistula forwards 
 and inwards into the mouth, following, as far as possible, the course 
 of the duct. The trocar being withdrawn, a small silk seton is passed 
 along the cannula ; this is then taken out and the two ends of the 
 seton, the one projecting from the mouth and the other from the fis- 
 tula, are tied together; at about the end of three weeks (according to 
 the amount of inflammation) the seton is witlidrawn, and the sinus 
 established by it is kept open by prolje or Ijougie, as already described. 
 
 When the patency of the new <hict is thoroughly established,! the 
 external aperture may Ije closed by collodion painting, the cautery, or 
 paring the edges, according to its size. 
 
 OPERATIVE TREATMENT OF LUPUS.t 
 
 We owe to German surgeons our knowledge that, from the infecting 
 power of lupus growth, it is impossible, when once it is established, to 
 cure it by constitutional treatment. A further step has been the 
 gradual replacing of local treatment with caustics, or the cautery, by 
 the erasion method of Volkmann of Halle.§ 
 
 Lupus is so frequently met with in this country, the deformities 
 which it produces are so odious, and it is so readily arrested by local 
 treatment vigorously applied and energetically repeated if needful, 
 that a few practical remarks will be made here on the two chief 
 methods of using it — viz., erasion and scarification. 
 
 Mr. J. Hutchinson thus compares tlie three methods of local treat- 
 ment (Brit. Med. Jouni., May 1, 1880): "All are very good, but I 
 unhesitatingly prefer the last. If caustics are used, tliey must be used 
 
 * If Ihis fails, .i plastic operation of paring the edges and uniting them with nnmer- 
 ons fishing-gnt sntures will probably be required. 
 
 t Mr. Erichsen {Surg., vol. ii. p. 557) suggests the passage of a piece of larainaria 
 tent if tlie sinus shows mnch tendency to close. 
 
 I The above account, while introduced here from the greater frequency of lupns in 
 the face, is, of course, applicable to the disease elsewhere. 
 
 i Germ. Clin. Lect., Syd. Soc. Tr„nsl., p. 97. 
 
OPEHATIVE TREATMENT OF LUPUS. 241 
 
 very freely. I have repeatedly seen a patch wholly cured by a single 
 dressing with chloride of zinc or acid nitrate of mercury. As a rule, 
 these remedies are used too timidly or without sufficient painstaking. 
 They give more pain than the actual cautery, but their sores granu- 
 late better and heal more quickly. The actual cautery is compara- 
 tively painless, can be easily limited, and at the same time made to 
 act deeply. It is very efficient, but its burns are somewhat slow to 
 heal. The erasion treatment ai)pears to give less pain, to be very 
 efficient, and to leave a sore which heals rapidly and soundly." 
 
 Before speaking in detail of these methods it will be well to say a 
 few words about the chief forms of lupus, and to which of these 
 erasion or scarification is best suited. 
 
 I think that for the purpose of treatment the surgeon should keep 
 two great types before his mind. In one of these the lupus deposit 
 takes the shape of more or less localized nodules, tubercles, or nests, 
 reddish or yellowish pink, often quasi-gelatinous, and prone to attack 
 the cheeks near the junction of the ala3 and the upper hp. In the 
 other the lupus deposit is much more difiused, usually, too, more super- 
 ficial and less inclined to form nodules or nests. This type is met 
 with both on cheeks and nose, but is best seen on the latter. It is, in 
 my experience, much the most frequently met with form in the sur- 
 gical wards of a London hospital, and is the one most frequently 
 responsible for marring the above important feature in young patients, 
 usually girls. This is the lupus seborrhagicus of Prof. Volkmann,* 
 the seborrhoea being of secondary importance, the essential point being 
 the fine-cell lupus infiltration of the cutis, which develops most freely 
 in the neighborhood of the sebaceous glands, in which the cheeks and 
 nose are so rich, and gives rise to an increased secretion on their part. 
 
 Erasion. — This is most strongly indicated in both the above forms 
 of lupus, whether localized or diffused. The best instruments are 
 sharp spoons, with oval ends of varying size, or hoes ; whatever instru- 
 ment is used should be of steel, the silver scoops supplied in dressing- 
 cases being inefficient. Where the lupus deposit is of any size it 
 
 ■* Pr<if. Volkmann [loc. supra cit., p. 105) gives the following life-like description of 
 this foi'ni: Irregular, reddish-looking patclies n'et with on the cheeks and nose, often 
 covered with " dirty-looking thin crusts, which are distinctly fatty to the touch. They 
 consist, in fact, of nothing further than an e.xcessive secretion from the sehaceous 
 glands of the skin mixed with epidermis cells. When we have succeeded, with great 
 difficulty, in scraping off' this fatty layer with the knife, the underlying skin appears 
 red, sore, and as if studded with fine warts. But if you examine these warty points 
 more closely with a glass, you see that it is by no means a question of papillary eleva- 
 tions, but of a large number of fine holes, which, being closely adjacent to each other, 
 produce the warty appearance. These holes are the enlarged openings of the seba- 
 ceous ducts, and you can also see on peeling off' single fatty crusts how a fine prolon- 
 gation of the latter becomes detached from each small opening." 
 
 16 
 
242 OPERATIONS OS THE HEAD AND NECK. 
 
 should be deliberately and thoroughly scraped out, the instrument 
 being carried most painstakingly both over the surface and around 
 the edges. Where the deposits are more minute they must be as 
 carefully picked out. The surgeon need not fear removing too much, 
 as long as he keeps to parts which yield to a scoop which will never 
 remove sound, and only with difficulty, partly sound, tissues.* 
 
 Scarification.— This is only useful in the more diffuse forms, and 
 is to be employed in two ways, (a) Linear. With a fine and very 
 sharp scalpel the surgeon makes scores of fine delicate cuts, parallel 
 with each other, through the diffuse lupoid deposit, crossing these 
 again with similar delicate incisions at a right angle to the first.f All 
 these must be made quickly and with a hght hand, and care must be 
 taken, as far as possible, not to let them run into each other. The 
 bleeding is extremely free, but is readily arrested by carefully main- 
 tained pressure. 
 
 (6) Punctiform. Here hundreds, may be, of punctures are made 
 in. the diffused lupoid deposit, a delicate hand being again required, 
 and a fine sharp scalpel point or a large needle being used. In this 
 case, also, every pains must be taken to place the punctures equi- 
 distantly. After arresting the bleeding the surgeon looks carefully 
 over the patch ; if at any spots his incisions or punctures are crowded 
 together with intervening places but little touched, he again goes over 
 his ground carefully. 
 
 If, after the completion of these operations, the. tissues appear tal- 
 lowy, or whitish, there need be no fear of gangrene, the parts being 
 far too well supplied with blood. Prof. Volkmann, after using the 
 above methods, wipes the parts over with a stick of silver nitrate and 
 applies dry lint. I prefer to use iodoform gauze at first to the bleed- 
 ing surface, the gauze being washed off with warm water in about 
 forty-eight hours, when iodoform ointment or lead lotion may be 
 made use of. 
 
 An anaesthetic should always be given, as the pain involved is not 
 slight.;!: Repetitions may be, and often are, required in severe cases, 
 
 * Ai^ pointed out by Prof. Volkmann {loc. supra cit., p. 114) in cases of lupoid ulcer- 
 ations of longer standing, an almost filiroid tissue becomes exposed after tbe diseased 
 parts have been scraped off, a condition which is to be regarded as the expression of 
 reaction in the neighborhood. 
 
 f No scarring need be feared from either form of scarification. After three weeks 
 have elapsed the above incisions, however numerous, if done with proper delicscy, 
 can only be detected by looking for them very closely. In three months it usually 
 requires a lens to find them. 
 
 X Dr. Balmaiino Squire recommends (/>/■;!(. il/crf. Joiirn., May 1, 1880) the freezing 
 the skin with elher spray. This so entirely alters the feel of parts that I have not 
 used it. Cocaine may perhaps be useful in the lighter cases. For rendering scarifica- 
 tion expeditious and precise, Dr. Squire has devised a multiple linear scarifier. This 
 
OPERATIVE TREATMENT OF RODENT ULCER. 243 
 
 two or three times, at intervals of three weeks or more, or whenever 
 minute reddish specks appear and grow around the original disease, 
 or when the scar, though not again ulcerating, remains obstinately 
 dark bluish-red. 
 
 The object of scarification is, of course, to obliterate the lupoid 
 tissue by the formation of scar tissue. 
 
 Where the nose is affected, the inner aspect of the orifices should be 
 examined in case the mucous membrane is invaded. 
 
 OPERATIVE TREATMENT OP RODENT ULCER. 
 
 Owing to the great frequency of this disease on the face^ the follow- 
 ing remarks are inserted here : 
 
 Some Points of Practical Importance. 
 
 i. Propriety of Operation. — In this form of malignant disease, 
 owing to its extremely slow progress, its very long connection with 
 some well-known flat-topped wart, patients sometimes keep on defer- 
 ring the operation till their age and the extent of the ulcer cause some 
 difKculty in urging or advising an operation. 
 
 The following may help in forming a decision: (1) The extent, 
 depth, and site of the ulcer. A case of moderate severity— say of the 
 size of half a crown — may nearly always be submitted to operation. 
 But the difficulty of deciding will be much greater in cases which in- 
 volve extensively the nose, orbit, and eye as well, perhaps, especially 
 if the bones on the delicate inner wall are much involved ; in the 
 rarer cases in which orbit, nose, and mouth are thrown into one 
 hideous chasm,* and those cases, also rare, in which the ulceration 
 extends very widely, though superficially, over the side of the head 
 and face, involving forehead, temple, and parotid region. t (2) In all 
 cases of severity the following should be carefully considered— viz., 
 the real agej of the patient — i.e., the age not reckoned by years alone 
 
 instrument (Weiss) is most useful in port-wine stains, though I prefer fine, very keen 
 scalpels, which will suffice both for linear and punctiform searification. 
 
 * As in Figs. 2 to 6 at the end of Mr. Moore's work on Rodent Ulcer. 
 
 t Mr. Moore (loc. supra cit, Fig. 9) shows one of the'^e superficial but vast rodent 
 ulcers; and his cases vi. and vii show the exceeding ditficulty, if not impos-iibility, of 
 completely curing them, even in hands as experienced a,s his. He thought (p. 58) that 
 the firmness of the skull presented a mechanical obstacle to the complete healing of 
 these large sores. Mr. Hutchinson {Clin. Surg., vol. ii. pi. 6.j) points out that this ex- 
 tensive form may be very superficial for a long time, may even cicatrize with tolerable 
 soundness, but that, sooner or later, a stage o'.' deep growth and rapid progress is almost 
 certain. 
 
 X Sir James Paget's words on the risks of operations in old people (Clin. Led., p. 
 6) may be quoted here: " They that are fat and bloated, pale, with soft textures, flab- 
 bid, torpid, wheezy, incapable of exercise, looking older than their years, are very bad. 
 They that are fat, florid, and plethoric, firm-skinned, and with good muscular power. 
 
244 OPERATIOXS ox THE HEAD AND NECK. 
 
 —his habits, how long he probably has before him if no operation is 
 performed ; whether the disfigurement seriously interferes with the 
 following of an active life ; whether there have been any brain symp- 
 toms referable to the growth ; the condition of the viscera; any lia- 
 bility to erysipelas; finally, each case being considered by itself, 
 certain conditions will justify operations in otherwise doubtful cases, 
 as when a rodent ulcer, having destroyed the sight of one eye, is creep- 
 ing across the nose and threatening the opposite one. 
 
 ii. The Operation Itself. — In these days of aseptic surgery, the 
 combined operation by knife and caustics, or cautery, will be pre- 
 ferred to one by caustics alone, on account of its greater precision, and 
 more rapid and more painless healing, from the absence of fetid 
 sloughs, and the diminished liability to erysipelas, etc. The follow- 
 ing hints may be found useful in an extensive operation for rodent 
 ulcer : 
 
 (1.) To diminish the risks of erysipelas in these patients the ulcer 
 and the surrounding parts should be carefully cleansed and kept as 
 aseptic as possible by means of precautions similar to those given at 
 p. 227. 
 
 (2. ) Steps of the operation itself and the application of caustics. — 
 The surgeon first makes a groove-like incision* around the whole, or, 
 in a very extensive case, around part of the growth, and well wide of 
 it, and-arre&ts the bleeding by ligature, leaving on Spencer Wells's for- 
 ceps, or by sponge-pressure. The next step — that of removing the 
 affected soft parts — is often difficult, owing to their proneness to break 
 away, and thus giving no firm hold to forceps ; a sharp spoon is often 
 verj' useful here, but scraping alone is not to be trusted to. Having 
 scraped away the growth down to tissues apparently healthy, the sur- 
 geon scrutinizes these most carefully, picking out every atom of 
 yellow-gray granulation-like material, and then again repeating the 
 scraping with careful thoroughness. Where the bones themselves 
 appear eaten into, scraping will not be sufficient, and it will be wiser 
 
 cleai-lieii(ie(l, and willing to work like younger men, are not, indeed, very good snb- 
 jectsfor iiperations, yet lliey are scarcely bad. The old people that are thin and drv 
 and longh, clear-voiced and bright-eyed, with good stomaclis and strong wills, muscu- 
 lar and active, are not bad ; they bear all but the largest operations very well. But 
 very bad are they who, looking somewhat like these, are feeble and soft-skinned, with 
 little pulses, bad appetites, and weak digestive power, so that tbey cannot, in an 
 emergency, be well nourished." Sir Jaraes goes on to speak of their inability to bear 
 loss of blood, the lazy healing of large wounds, the liability of their stomachs to refuse 
 food, their prolonged convalescence, their getting "all but well," and the need of 
 meeting thesespecial dangers with special cares. 
 
 * A pair of sharp, blunt-pointed scissors may be fomid useful when the lids have to 
 be cut through. 
 
OPERATIVE TREATMENT OF RODENT ULCER. 245 
 
 to go over the worm-eaten surface with a fine gouge or chisel.* In 
 one region especially these must be used with the utmost caution— 
 i.e., where the paper-like bones on the inner wall of the orbit are in- 
 volved ; in this place, if the surgeon is not satisfied with the limited 
 use of the gouge or chisel— which is alone permissible here -he must 
 be content with finally applying Paquelin's therm<>cautery, unless 
 removal of the eye, at the same time, has allowed of the use of zinc 
 chloride paste. In other places this most valuable caustic may be 
 used fearlessly, as long as precautions are taken to use it in a concen- 
 trated form, and to apply it as firmly and as thinly as possible, so that 
 the discharges from the wound shall not allow it to liquefy and run 
 either towards the eye or nose or throat. 
 
 ^ (3.) Advisability of preserving the eye in cases where the conjunc- 
 tiva is involved. As a rule, in these cases, consent should be asked 
 to remove the eye if needful. Cases clearly requiiiiig this step will 
 be those where («) the eye is already useless, or so distinctly deteri- 
 orated that it cannot improve; (,?) where the Hds have shrunk off 
 away from it and left it irritable and painful from exposure ; (y) 
 where the disease cannot otherwise be removed, and where caustic* 
 cannot otherwise be made use of. 
 
 As a rule, if the conjunctiva is much involved, the necessary re- 
 moval of this will cause sloughing. Occasionally, this only threatens,, 
 and then passes away. Thus, some months ago a patient of Drs. T, 
 and J. B. Howell, at Wandsworth, came under my care for extensive 
 rodent ulcer. Both lids of the right eye, the conjunctiva largely, the 
 inner part of the orbit, root and right side of the nose, and upper part 
 of right cheek were involved. Operation had been advised ten 
 years before, the disease being of much longer duration stilL After 
 removal of the soft parts involved by the growth, it was found that 
 the lachrymal and ethmoid had been especially involved, being very 
 vascular and worm-eaten. Repeated applications of the sharp spoon 
 and a small gouge were made use of, and finally Paquelin's thermo- 
 cautery was applied. The inner half of the conjunctiva was involved, 
 and removed freely, the internal rectus being largely exposed. The 
 cornea became cloudy and discolored, and though on the third day 
 the pupil was visible and the patient could distinguish between the 
 medical men at his bedside, the cornea ultimately sloughed, and I 
 removed the eyeball a few weeks later.f 
 
 * Mr. Moore (toe. supra cit., p. 51 ) speaks decisively on this point : " The liiine itself 
 mnst be taken away to a depth exceeding tliat vvliich has yielded to the disease. Re- 
 cnrrence is olhervvise inevitable." Mr. Moore seems to have nsed ciittinfr bone-pliers 
 for this purpose. 
 
 t It would certainly have been wiser to have removed the eye at the first operation, 
 a step which would have facilitated the use of zinc chloride paste. The palient, how- 
 
246 OPERATION'S ON THE HEAD AND NECK, 
 
 iii. The After-Treatment. — (1) The chief object here is to keep 
 the wound scrupulously sweet. I prefer for this gently packing the 
 wound with iodoform gauze, or, in cases where erysipelas may be ex- 
 pected, dusting with iodoform, and dressing with boracic acid lint 
 soaked in a saturated solution of the acid, and changed at regular in- 
 tervals. Sufficient morphia should be given for the first day or two, 
 and the bowels kept regularly open. If zinc chloride paste has been 
 used, attention must be paid, as already advised, that it does not melt 
 and run into parts like the eye, nose, or mouth, and for this pur- 
 pose the position of the patient's head must be looked to. (2) If it 
 has been found needful to attack vigorously the bones of the skull, or 
 even to apply some of the caustic to diseased dura mater, and if dur- 
 ing the first ten days of the disease fits make their appearance, it does 
 not necessarily follow that cerebral inflammation is setting in. Ac- 
 cording to Mr. Moore* the fits maybe slight and the unconsciousness of 
 brief duration, or the fits even severe and attended with coma, but, as 
 a rule, they are recovered from. (3) Secondary hfemorrhage. This 
 is rare after the use of zinc chloride, which forms a deep, black slough, 
 and also seems to me to prevent the risk of iiytemia. But if the 
 cautery only has been used, the amount of fcetor is much greater, and 
 in parts so vascular that secondary hfemorrhage may easily occur, if 
 the wound is foul. (4) Recurrence. The patient must always be 
 most carefully watched, and, in the case of extensive and deep disease, 
 any suspicious granulations that appear must be attacked at once. 
 (5) When after a severe operation a plastic ojjeration cannot be per- 
 formed, very much may be done by a well-made vulcanite mask.f 
 
 REMOVAL OF PAROTID GROWTHS. 
 
 The question of operation arises here under three somewhat differ- 
 ent conditions — viz. : 
 
 (i.) In the case of the ordinary parotid tumor. 
 
 (ii.) In that of a sarcoma of the parotid, which has often started in 
 the growth just menti(.)ned. 
 
 (iii.) In carcinoma of the parotid. 
 
 (i.) Removal of an Ordinary Parotid Tumor.— These well- 
 known growths, containing a mi.xture usually of fibro cartilaginous, 
 myxomatous, and imperfect glandular tissue, require no especial allu- 
 sion here, beyond the need of— (1) Ex]iosing them sufliciently, (2) 
 Paying strict attention to the facial nerve, and (3) Removing the cap- 
 
 ever, had so ranch difficnlty in making np his mind to be operated on, that it was 
 thought best to attempt to do without tlie additional mutilation if possible. 
 
 * Loc. supra cit , p. 54. 
 
 t As is shown in Figs. 6 and 7 in Mr, Moore's book, loc. supra cit. 
 
REMOVAL OF PAROTID TUMORS. 247 
 
 sule itself, after the growth has heen shelled out, in any cases of clou1 it 
 — viz., soft consistency, rapid growth.* 
 
 (.ii.) Operation in Sarcoma of the Parotid.— This most fre- 
 quently originates in one of the growths just mentioned. This and 
 the next group may, as far as oi)er:itive steps go, be considered 
 together, it being remembered that there is this wide difference 
 between them, that carcinomata are here far more malignant, as a 
 rule, than sarcomata .f 
 
 (iii.) Operation in Carcinoma of the Parotid.— The question 
 of the advisability of interfering at all witli really malignant growths 
 of the parotid, especially carcinomata, has been much disputed, but 
 ■ as each case must be decided by itself, and as no hard-and-fast line 
 can be laid down here, some practical points which will be found 
 useful may be mentioned. On_ the one hand, attention must be 
 strongly drawn to the fact that reports of operations here are often 
 brief, and that too often they are published as soon as the patient 
 leaves his surgeon, and thus two-thirds of their value are lost; on the 
 other hand, I may perhaps venture to advise my younger readers that 
 a malignant tumor in this region is one in which, above most others, he 
 must not allow a wish to relieve a patient to overcome a decision 
 arrived at after careful examination, for there is scarcely any other 
 part of the body in which a malignant growth more quickly obtains 
 a firm hold on the surrounding structures— a fact which has even a 
 more grave bearing on the operation than the importance of these 
 structures themselves. 
 
 Practical Points in the Removal of Parotid Tumors. 
 
 Characters of the Tumor. — Amongst the most notable of these are — 
 (1) Mobility — viz., how far it can or cannot be lifted up by the fingers 
 from the subjacent parts. (2) Rapidity of growth. (3) Density — thus 
 a great hardness or evident softness will be, alilie, unfavoraljle, the 
 
 * In an article [Guy's Honp. SeDorts, v<jI. xxvi.) "On the Encliondromatri of the 
 Salivary (41an(ls," I ventured to say, with regard to the removal of these growths, ■■If 
 the wound be made too small in the Krst case for fear of a scar, the edges will only be 
 bruised and primary nnion be prevented. It is not uncommon for branches of tire 
 facial nerve to be in relation witli the capsule of the tumor, and if this has been much 
 handled, or treated by counter-irritation, they may very likely be firmly adherent. 
 In either case injury to the nerve may be best avoided by slitiing up the capsule and 
 shelling out the enchondroraa first. The capsule shoidd then be examined to see if 
 any nerve branches are adherent to it; after these have been separated, the capsule 
 itself should be removed. This should always be done to prevent any recurrence, as 
 the peripheral part of these enchondromata is often adherent to the capsule itself. 
 
 t Thus Mr. Bntlin (Oper. Surg, of MaUcj. Din., p. 117) si)eaks of carcinoma here as a 
 very dangerous and fatal disease, but of sarcoma as appearin^', whether in the pure Qt 
 mixed forms, to be a far more benign disease than sarcoma of most of the other pairts- 
 of the body. 
 
248 OPERATIONS ON THE HEAD AND NECK. 
 
 latter from the fact that such soft growths will break down during 
 attempts at removal, and leave parts behind. (4) Pressure symptoms. 
 Of these, dyspnoea, dysphagia, presence of outlying masses in the 
 fauces, and facial paralysis * are of evil omen. (5) Condition of the 
 overlying skin.f 
 
 Points in the Operation Itself.— Ho begin witli, the growth must be 
 sufficiently exposed by adequate incisions. Probably none will be 
 more generally suitable than a h- -shaped incision, the longitudinal 
 portion lying over the large vessels, and the transverse one exposing 
 the facial part of the growth. 
 
 If the skin is adherent at any spot this should be removed at the 
 same time. The growth being sufficiently exposed, the extirpation of 
 it had best be begun in front and above,| the posterior part being left 
 to the last, as here lies the most important relations, and as these can 
 be most readily dealt with when the growth has been freed elsewhere. 
 During the operation a blunt dissector should be used as much as 
 possible, aided by touches of a blunt-pointed bistoury, and by drag- 
 ging the growth in different directions. Every vessel, as soon as cut, 
 should be secured with Spencer Wells's forceps, and the free oozing 
 from the vascular skin and other parts arrested by sponge pressure 
 while the surgeon is engaged with some other part of the growth. 
 
 M. Malgaigne § advised that when the surgeon was working poste- 
 riorly and deeply he should have the rhouth widely opened, as this 
 movement, by removing the condjde from the meatus, enlarged the 
 space in which the instruments were working. 
 
 In addition to the free oozing, and the presence of important vessels, 
 other difficulties which may present themselves are the breaking down 
 of a soft growth, thus baffling attempts at complete extirpation, and 
 the strong processes of fibrous tissue which, passing normallv from 
 the parotid to some important adjacent structures — viz., the digastric, 
 
 * Prof. Billroth, quoted by Mr. B.itliii (he. supra cit., p. 118), considers that the 
 occurrence of facial paralysis from the pressure of a parotid tumor is to be regarded as 
 a sign tliat it is probably a carcinoma, for the sarcomata and other tumors rarely pro- 
 duce paralysis by pressure, altliougli paralysis frequently follows the operation for 
 their removal. 
 
 t The more adherent, discolored — viz., reddish purple— are the integuments, the 
 more unfavorable is the prognosis, 
 
 I M. Berard (Maladies de la Oland parotide, p. 2-10) advises that after the growth 
 has been freed in front, it should be ne.xt attacked from below upwards, and not from 
 above downwards, for these reasons — (1) Tlie blood Hows away from the wound, and 
 not over the instruments of the surgeon ; (2) the same vessels do not have to be tied 
 more tlian once; (3) if any large vessel has to be cut, it is .secured early, thus dimin- 
 ishing the ;imount of haemorrhage 
 
 I Opemlin- Surgery (translated by Dr. B.ittan), p. 349. 
 
REMOVAL OF PAROTID TUMORS. 249 
 
 the internal pterygoid, and the carotid sheath— are now liable to be 
 either increased in density or softened by extension of the growth. 
 
 Two points will require especial attention here— viz., the amount of 
 facial paralysis which may be expected,* and the question of haem- 
 orrhage. 
 
 Facial Paralysis.— While in the case of a smaller growth, if the 
 nerve has only been bruised, or, when divided, if the ends have been 
 placed in contiguity, union may take place, and the paralysis gradu- 
 ally disappear,t in the case of really malignant growths the question 
 of future deformity must be set aside, and the nerve divided as soon 
 as seen. 
 
 Best Modes of Meeting Haemorrhage.— The chief vessels 
 which will be met with are, the superficial temporal, transverse facial, 
 occipital, posterior auricular, the internal maxillary, and external 
 carotid. The external jugular vein, large communicating branches 
 between it and the internal jugular are sure to be cut, while the 
 internal jugular vein is almost certain to be seen in the bottom of the 
 wound. 
 
 It must be remembered that not only will all the above vessels be 
 liable to be much enlarged, but numerous other unnamed anastomoses 
 will be present. 
 
 The common carotid has several times been tied prior to this opera- 
 tion. With all due deference to those who have adopted this practice, 
 I would advise that this step should be dispensed with if possible, 
 and for these reasons — [1) It introduces certain grave additional risks 
 of its own. (2) It takes up time which will be wanted in the opera- 
 tion itself, especially if the projection downwards of the growth into 
 the neck overlaps and conceals the position of the vessel. (3) It is 
 by no means a certain jDreventive of hsemorrhage here, any more than 
 ligature of both Unguals can always be relied on to prevent haemor- 
 rhage during extirpation of the tongue. (4) This step, recommended 
 by many of the older surgeons, is not so needed now in these days of 
 anjesthetics, with an almost unlimited variety of forceps and ligatures 
 at hand. (5) Finally, it would appear better, because simpler and 
 equally efficient, to meet the htemorrhage from the large vessels before 
 they are cut, by taking them up with two pairs of Spencer Wells's 
 forceps, dividing the vessel between these, and tying or twisting both 
 ends. 
 
 * If the surgeon, especially in less serious cases, when making any deep incision 
 that is needCiil, can manage not to go above the level of a line drawn horizontally J 
 inch below the lobnle of the ear, he will avoid any serious interference with the trunk 
 of the facial nerve, and thus escape the risk of permanent paralysis. 
 
 f This gradual improvement in facial paralysis is alluded to, with a case in point, 
 in mv article, loc. mpra cit. Mr. Butlin [loc. supra eit , p. 120) suggests a trial of 
 nerve-snture here. 
 
250 OPERATIOXS 0>J THE HEAD AND NECK. 
 
 In dealing witli any large veins the risk of the entrance of air should 
 be prevented by making finger-pressure on the cardiac side, or by 
 securing them with double ligatures before they are cut. 
 
 If ligature of the common carotid is to be made use of here, it should, 
 in my opinion, be reserved for those cases in which the surgeon decides 
 to attack a very soft and vascular growth, as here the vessels may be 
 very numerous and difficult to isolate, and ligatures may be found not 
 to hold. In such a case, instead of tying the common carotid and thus 
 exposing the patient to the risks of brain mischief, it would be better 
 to pass a loop of chromic catgut ligature around the vessel, loosely 
 tied, and to ask an assistant to keej? up tension on this whenever much 
 bleeding takes place. This method seems to have been first made use 
 of by ]\I. Roux, and much more recently in this country by Mr. Riv- 
 ington * and Mr. Treves. f 
 
 If tlie wound has become foul — and sometimes in these oper.itions 
 near the mouth and nose it is impossible to keep the bandages from 
 shifting— the surgeon must always be prepared for the accident of sec- 
 ondary hajmorrhage. And on account of the same risk the actual 
 cautery should never be used at the bottom of a very deep wound near 
 to any suspicious tissues, if it can be possibly avoided. If some caustic 
 is required, zinc-chloride paste, used with the precautions given at p. 
 245, would, I think, be preferable from the absence of foetor with which 
 it works, and the dry black scabs it forms. 
 
 CHAPTER V. 
 
 EXCISION OP THE EYEBALL AND CLEARING 
 OUT OP THE ORBIT. 
 
 EXCISION OF EYEBALL.t 
 Indications. 
 
 i. New growths— e g., glioma of the retina, melanotic sarcoma of the 
 uveal tract. 
 
 ii. In the following cases of injury and its results : 
 (a) The eyeliall ruptured and collapsed after a blow. 
 ih) A large jagged foreign body in the eye— e.g., a bit of metal, 
 not removable without inevitable disorganization, 
 
 * Med.-Ghh. Trans, vol. Ixix. p. 72. 
 t Lancet, January 21, 1888. 
 
 t As the general surgeon may be called upon to perform this operation at any time 
 and as it should always be practiced on the dead body, it is included here. 
 
EXCISION OF EYEBALL. 251 
 
 (c) If (Nettleship's Diseases of the Eye, p. 142) the wound, lying 
 
 wholly or partly in the dangerous region * be so large and 
 so complicated with injury to deeper parts that no hope of 
 useful sight remains. 
 
 (d) If, though the wound be small, it lie in the dangerous region, 
 
 and have already set up irido-cyclitis. 
 
 (e) Where a small foreign body — e.g., a shot glancing in cover- 
 
 shooting, not removable by an electro-magnet, gradually sets 
 up inflammation and shrinking of the eye. 
 (/) AVhen there is a wound in the dangerous region complicated 
 
 with traumatic cataract. 
 (g) When traumatic cataract has been set up by a wound which 
 is wholly corneal, and therefore out of the dangerous area, 
 and yet severe iritis and pan-ophthalmitis come on in spite 
 of treatment, 
 iii. As part of an operation for rodent ulcer which has extensively 
 involved the conjunctiva (p. 245). 
 
 iv. As part of an operation for removal of orbital tumors— e.c/., a 
 glioma or sarcoma which has ruptured the sclerotic, rodent ulcer, 
 scirrhous, sarcomatous, congenital, bony growths, etc.f 
 
 Operation. — The chief object is to remove the globe alone, when- 
 ever this is possible, leaving the muscles to coalesce and form a stump 
 on which the artificial eye may be supported and be movable. As 
 much conjunctiva as possible should be left. 
 
 The surgeon, standing in front, having inserted a spring-speculum 
 between the lids, snips with blunt-pointed scissors through the ocular 
 conjunctiva close to the cornea and all round it, using toothed forceps 
 to lift the conjunctiva, and leaving enough at one side to hold on by 
 the forceps during the next step. This is to open freely Tenon's cap- 
 sule, and catching up each rectus tendon (beginning usually with the 
 external rectus), with a strabismus hook to divide them close to the 
 sclerotic, leaving the cut end of the external rectus long, in order to 
 draw the eyeball forcibly inwards. The superior and inferior rectus 
 are then out, and the speculum pressed back into the cavity of the 
 orbit so as to make the eye-ball start forwards. The scissors, blunt- 
 pointed and slightly curved, are now passed back to feel for the optic 
 nerve, which may be known by its toughness and thickness, and which 
 is now severed with one clean cut. The eye-ball being drawn forwards 
 with a finger, the oblique muscles and any remaining soft parts are to 
 be cut close to the globe. Sponge pressure is then to be applied firmly 
 for a few minutes, and for the first ten hours aseptic sponges and a 
 
 * A none nearly J inch wide surrounding the cornea. 
 
 t For an excellent account of these the reader is referred to Mr. Lawson's article, 
 Did. of Surg., vol. ii. p. 117 et seq. 
 
252 OPERATIONS ON THE HEAD AND NECK. 
 
 bandage should be worn to prevent temporary but troublesome 
 haemorrhage. 
 
 In the case of a new growth— e.p-., glioma— the optic nerve must be 
 divided as far back as possible. The scissors, slightly curved and long 
 enough to reach to the back of the orbit, are introduced on the inner 
 side, and the nerve either cut as far back as is possible before the globe 
 is removed, or, after this is done, the nerve is dissected out and a fresh 
 slice taken. 
 
 Where there is any suspicion of growth, as in a glioma of the optic 
 nerve, being left behind, zinc-chloride paste should be applied, as 
 at p. 245. 
 
 Owing to the early stage at which dissemination of intra-ocular sar- 
 comata takes place, and to the tendency of gliomata to creep back- 
 wards along the optic nerve towards the interior of the cranium, the 
 prognosis very largely depends upon the earliness of the extirpation. 
 On this account it should be remembered that the earliest symptoms of 
 these growths, viz., impairment of sight from partial detachment of 
 the retina by the pressure of the growth behind it— should be most 
 carefully tested in suspicious cases, this impairment of sight being not 
 usually noticed by the patient, save accidentally on closing the sound 
 eye, unless the growth originates near the yellow spot. If later evi- 
 dence is waited for, such as evidence of tension and pain, dissemina- 
 tion or recurrence is most probable, while the growth will very likely 
 have perforated the eye, and the severer operation of clearing out the 
 orbit will be required. 
 
 The following questions will very likely arise: If there is evidence 
 of general dissemination of the disease, is it expedient to remove the 
 eye, or, if this be insufficient, to clear out the orbit as well? In most 
 cases the answer will be in the affirmative, in order to save the patient 
 pain, and the misery of the protruding and ulcerating mass. 
 
 If the disease has recurred, is it any use to again attack it? Each 
 question here must be decided by itself. The answer will mainly 
 depend on the amount and depth of the recurrence, and on the com- 
 pleteness of the first operation. Thus, if the eye only was removed at 
 first, it may be wise to clear out the orbit thoroughly. 
 
 In a few most distressing cases in ctiildren it is well known that both 
 eyes are attacked. The question of operating on the second eye must 
 here be faced. Opinions here difler somewhat. Mr. Butlin* thinks 
 that it is better not to operate in such cases, '' although the operation 
 may be regarded as justifiable in order to prevent the occurrence of 
 fungous protrusion and the pain and misery which are associated with 
 it.'' Mr. Lawson,t on the other liand, holds that if both eyes are 
 
 * Loc. supra cit., p. 88. 
 
 t Diet, of Surg., vol. ii. p. 124. 
 
CLEARING OUT THE ORBIT. 253 
 
 affected, both should be excised, providing that the sight has ah-eady 
 been destroyed. He has, on many occasions, removed the second eye 
 to procure temporary relief from the excessive pain induced by the 
 over-distended globe, and when there has not been the slightest pros- 
 pect of arresting the disease. In each case the operation gave imme- 
 diate and perfect relief 
 
 OPERATION OF CLEARING OUT THE CONTENTS OP 
 
 THE ORBIT. 
 
 Indications —This operation will be briefly given here, as it is 
 required, though not frequently, in growths which, originating in the 
 eye, extend to, or recur, in the orbit ; in the case of sarcomatous (peri- 
 osteal) or scirrhous tumors of the orbit; and in rodent ulcer, in which 
 an operation has been long deferred by the patient, and the growth 
 has consequently attacked the conjunctiva and eye, and involved the 
 bones of the orbit as well. 
 
 Operation.— In most cases it will be well to enucleate the eye first, 
 and then to excise the growth, partly shelling it with a periosteal 
 elevator from the bones themselves, partly dividing the structures 
 behind with stout, short, curved scissors. 
 
 Mr. Butlin,* quoting from Arlt, advises that, to begin with, the outer 
 commissure of the lids be split, the lids raised off the growth by 
 dividing the uniting conjunctiva, and then turned back and fastened 
 out of the way. "If the periosteum is adherent to the tumor, and it • 
 is considered expedient to remove it, it must be incised at the margin 
 of the orbit, where it adheres firmly to the bone, with a sharp scalpel, 
 after which it is raised wp from the bone in the same way as the con- 
 tents of the orbit were separated, and removed either in whole or 
 part." 
 
 In working in the inner side the surgeon must remember the natural 
 thinness of the bones here when in a healthy state; both here and 
 elsewhere, as in the roof, the growth has very likely exerted a thin- 
 ning effect. 
 
 If any suspicious points remain, the surgeon goes over these again 
 with a sharp scoop, gouging out any suspicious patches in the bone, 
 and finally applying the thermo-cautery, or caustics, or both. Mr. 
 Lawson f gives the following method of applying the zinc-chloride 
 paste, so as to avoid the sloughing of the eye-lids from the caustic 
 extending to them : 
 
 After the eye and tumor have been excised, pressure is to be made 
 in the orbit until all bleeding has ceased. The mouth of the con- 
 
 * Loc. supra ciL, p. 80. 
 
 f Diet, of Surg., vol. ii. p. 118. 
 
254 OPERATIONS ON THE HEAD AND NECK. 
 
 junctival bag, from which the eye has been enucleated, is now to be 
 held open with two pairs of forceps, whilst the zinc-chloride paste, 
 spread on lint, is plastered round the sides of the orbit. A small piece 
 of cotton-wool is next introduced to keep the strips of lint in situ, and 
 the mouth of the conjunctival bag is closed over the whole by a single 
 continued suture. A layer of oiled lint is then placed over the con- 
 junctiva, and upon this the lids are closed and kept in position with 
 a compress of lint and a roller. 
 
 On the day following the operation the bandage may be removed, 
 or if there is much tension of the' lids from the stuffing within the 
 orbit, some of the cotton-wool may be gently drawn out. The remain- 
 der should be taken away on the second day, and a little fresh ab- 
 sorbent wool laid loosely within the orbit to absorb the discharges, as 
 soon as suppuration commences. 
 
 This should be repeated daily, but the pieces of lint on which the 
 zinc-chloride has been applied should not be removed until suppura- 
 tion has quite loosened them. After about ten or twelve days the 
 sloughs will separate from the orbit, and if any suspicious granulations 
 spring up they should be touched with the solid zinc-chloride or with 
 the potassa-cum-calce.* 
 
 CHAPTER VI. 
 
 OPERATIONS ON THE NOSE. 
 
 RHINOPLASTY OR PLASTIC OPERATIONS FOR THE 
 REPAIR OP THE NOSE— ROUGE'S OPERATION- 
 REMOVAL OF NASAL POLYPI. 
 
 PLASTIC OPERATIONS FOR THE REPAIR OF THE 
 
 NOSE (Figs. 50-57). 
 
 These operations may be divided into those for complete and par- 
 tial restoration. 
 
 Indications. — When the patient is healthy and fairly young, when 
 the cause of the destruction — viz., lupus, gunshot injury, syphilitic 
 ulceration — new growth necessitating removal is not only checked but 
 soundly healed. f 
 
 * Mr. Lawson lias three times seen epileptic convulsions follow within thirtv-six 
 hours after the operation, but they ceased after the removal of the zinc-chloride, the 
 patient in each ease making a good recovery (p. 246). If convulsions should occnr, 
 Mr. Lawson advises removing the zinc-chloride and syringing out the ca.vity with 
 dilute acetic acid (,^j — ^j). 
 
 t In Sir W. MacCormac's case, quoted below, the tip and alaj of the nose had 
 sloughed in infancy after the injection of a large nsevus with the liquor ferri perni- 
 tratis. 
 
REPAIR OF NOSE. 
 
 255 
 
 Thus, after lupus has been cured by scraping, and still more in the 
 case of syphilitic ulceration, it will be well to wait six months at least 
 after the disappearance of the disease. 
 
 A. Operations for Complete Restoration.— The following 
 
 will be found the most useful : 
 
 (1.) Verneuil's, by Super-imposed or Double Flaps from 
 Cheeks and Forehead (Figs. 60, 51). 
 
 (2.) Syme's, from the Cheeks (Figs. 52, 53). 
 
 (3.) The Indian or Frontal (Fig. 54). 
 
 (4.) The Italian or Tagliacotian. 
 
 Before deciding which operation he will make use of in restoring 
 the nose, the surgeon will investigate the following points : How far 
 is the bony framework of the nose destroyed ? If the cartilages, sep- 
 tum, vomer, ethmoid, and nasal bones are much removed, however 
 well made the frontal flap, and however skilfully it is adjusted, it will 
 
 Fig. 50. 
 
 Fig. 51. 
 
 <^ -' 
 
 Verneuil's incisions in rhinoplasty for 
 sunken nose. (Stimson.J 
 
 Verneuil's double flaps m situ. 
 
 Tbe frontal flap is also shown with 
 
 its raw surface. (Stimson.) 
 
 tend, after looking extremely well at first, to sink down to the level of 
 the cheeks. Verneuil's operation meets this partially by its double 
 layers or flaps. If he proposes to take flaps from the cheeks, the sur- 
 geon must inquire how far these are plentiful, and free from old scars. 
 So, too, if the forehead is to furnish the flaps, how far is it a capacious 
 one and free from hairs ? 
 
 The respective advantages of, and the indications for, the above 
 operations will be given in the description of each method. 
 
 (1.) VerneuiVs Operation (Figs. 50 and 51). — This operation, sug- 
 gested to M. Verneuil by M. Oilier, was employed successfully by him 
 in order to secure permanent elevation of a sunken nose, by super- 
 
256 OPERATIONS ON THE HEAD AND NEOK. 
 
 imposing two flaps and thereby doubling the thickness. The patient 
 had discharged a pistol into his mouth, causing the destruction of a 
 portion of the hard palate and septum, the nasal bones, part of the 
 nasal processes of the superior maxillary, the spine of the frontal, and 
 the anterior wall of the frontal sinuses. The ala3 and tip were unin- 
 jured, but much flattened; above them was a broad, deep groove, ex- 
 tending to the middle third of the forehead. The two principal 
 indications were to bring the lateral portions nearer the median Hne 
 and to rebuild the bridge of the nose. The latter could be perma- 
 nently accomplished only by filling in the great cavity which would 
 be left by raising the sunken parts. 
 
 Verneuil made an incision along the median line of the depression 
 and a transverse one at each end of the first, and dissected up the two 
 lateral flaps thus marked out. He then raised an oblong flap from 
 the middle of the forehead, leaving it adherent between the eyebrows, 
 and turned it directly downwards so that its raw surface was directed 
 outwards, its skin surface * looking towards the nasal foss;e. The two 
 lateral flaps were then placed upon it and united in the median line. 
 The raw surfaces united with each other, and the result was a nose 
 elevated i inch above the adjoining surface. The wound in the fore- 
 head was partly closed by a hare-hp pin and sutures, and later on 
 healed by skin-grafting. The pedicle of the frontal flap will require 
 dividing and trimming subsequently.! In addition to the advantage 
 which this operation possesses of rendering a sunken nose prominent, 
 it produces ultimately, from my experience of the case mentioned 
 below, but Httle scarring, the lateral incision-scars fading away gradu- 
 ally into the naso-labial sulci, and the folds beneath the eye. 
 
 (2.) Syme's, from the Cheeks (Figs. 52, 53).— This method is 
 described by its inventor in his Observations in Clinical Surgery, p. 56. 
 Besides doing away with a frontal scar, this method enables a nose 
 thus constructed to have its sensations in correspondence with the 
 part from which it was derived. 
 
 The following drawings. Figs. 52, 53, show the shape of the flaps, 
 and the manner of their adjustment. 
 
 New flaps of the shape given in Fig. 52 are marked out on the cheeks 
 with their conjoint pedicle above- at the root of the nose, between 
 the two inner canthi, extending sufficiently downwards and outwards 
 
 * Tliis should be refreslied. The above account is taken from Stinisun's Operative 
 Surgery, p. 2-14. 
 
 f I riKide use of this method in llie case of a Welsh miner, whose nose had been exten- 
 sively destroyed by Inpus, aided by « plaster and ointment which he had obtained 
 from a quack in Carnarvon for the payment of £5 7s. 6d. The bony parts were almost 
 intact, but the soft parts and cartilages widely destroyed. The resulting nose was 
 prominent and shapely, and the ultimate scarring very slight. 
 
REPAIR OF NOSE. 
 
 257 
 
 upon the cheek to secure sufficient amplcness for the new nose ac- 
 cording to careful measurements already taken.. The old nose being 
 got ready by careful paring, the flaps thus marked out are dissected 
 up and united in the middle line by three or four sutures, while the 
 outer margins are fixed on each side to the raw surface, at a proper 
 distance from the nasal orifice. Mr. Bell* advises that if any part of 
 the old septum remain, it should be made very useful as a fixed 
 point, a straight needle being thrust through one flap close to its 
 outer lower edge, then through the septum, and out at a correspond- 
 ing point of the other flap. The edges of the wounds left in the 
 cheeks can generally be partially united by sutures of silver or fishing- 
 
 FiG. 52. 
 
 Fig. 53. 
 
 (Bell.) 
 
 (Syme.) 
 
 gut, and the triangular portion, which must be left to heal by granu- 
 lation, proves an advantage, as by its depression it enhances the ap- 
 parent height and prominence of the new organ. The cavity of the 
 new nose may, for the first few days, be kept gently distended with 
 strips of iodoform or sal-alembroth gauze, and later on with small 
 pieces of Jacques' catheter on either side. 
 
 (3.) The Frontal or Indian Method.f— This method should be 
 used when the soft parts of the cheeks are insufficient, when they are 
 too cicatricial, or when an operation making use of them has failed. 
 Its chief objections are the large frontal scar, and the liability of the 
 single flap, though abundant^ and prominent at first, to shrink and 
 fall in later on. 
 
 A piece of gutta-percha or leather is so cut that, when folded, it is 
 of suitable shape and size for the new organ ; it is then laid, opened 
 out, upon the forehead, and the dimensions marked out with an ani- 
 line pencil or tincture of iodine. The flap thus drawn should be of 
 the shape in Fig. 54, and, owing to the retraction of the skin, should 
 
 * Jlanual of Surgical Operations {4th edition), p. 176. 
 f Introduced into European surgery by Mr. Carpue in 1816. 
 17 
 
258 
 
 OPERATIONS ON THE HEAD AND NECK. 
 
 measure i of an inch more than the model in every direction. The 
 average dimensions of the flap are thus given by Mr. Erichsen : * 
 
 Fig. 54. 
 
 Flaps from forehead. Also flaps from cheeks. (Skey.) 
 
 when the whole nose requires restoration, it is usually necessary to 
 make it about 21 to 3 inches long, and from 3 to 31 inches wide at its 
 broadest part. 
 
 For the frontal flap thus majjped out, a bed is now prepared by 
 paring the old nose into a raw, triangular surface ; in doing this the 
 knife must be used obliquely, cutting from without inwards towards 
 the middle line, so as to leave a grooved surface sloping inwards. The 
 warning of Erichsen {loc. supra cit, p. 609) should here be remembered, 
 not to remove the parts too widely, lest the cheeks later on retract and 
 flatten out the nose. The bleeding being arrested by sponge-pressure, 
 torsion, leaving on Spencer Wells's forceps (but not in this case by 
 ligature), and the raw surface covered over with lint wrung out of 
 warm boracic acid lotion, the frontal flap previously mrrked out may 
 now be raised. This is done by running a scalpel down to the perios- 
 teum, along the traced line, taking care that the pedicle should be 
 sufficiently long to bear a little twisting, and sufficiently broad and 
 thick to secure the presence of one if not both of the frontal arteries. 
 
 Surg., vol. ii. p. 603. 
 
REPAIR OF NOSE. 259 
 
 To avoid any risk of stoppage of its bloo(l-suppl_y and sl(juj;]iing, it is 
 well to place the incision for tiie pedicle a little obliquely, with one 
 side descending a little lower than the other — viz., on the side to 
 which the flap is to be twisted. Where the level of the hairy seal]) 
 admits of it, this flap should He a little obliquely, the tension l)eing 
 thus rendered a little less. Where necessary, the flap may be taken 
 transversely above one or other eyebrow, but the objection to this i.'*, 
 that the retraction of the scar upon the forehead draws the corre- 
 sponding eyebrow upwards.* The frontal flap, however placed, is 
 now raised from below upwards, so that the necessary haemorrhage is 
 rendered as little embarrassing as possible, and with as little handling 
 or pinching of the forceps as possible. The knife should be kept away 
 from the flap towards the periosteum, and used in the same plane 
 throughout, without any scoring whatever. The hajmorrhage, free at 
 first, is readily arrested by forcipressure (leaving on Sjjencer Wells's 
 forceps for a while), or by sponge-pressure. The flap, being sufficiently 
 raised to hang freely and without tension, is then twisted slightly to 
 one side (that on which the pedicle has l_>een cut longest), and brought 
 down and adjusted to the pared edges below by means of numerous 
 fine sutures of salmon-gut, fine silk, or wire, a few of chromic gut 
 being interspersed, and all introduced with very fine needles on a 
 holder. 
 
 If the condition of the forehead has admitted of taking a columella 
 from these, an appropriate groove must also have been cut in the 
 upper part of the median line of the lip, and the two carefully ad- 
 justed. If no columella can be taken from the forehead the upper 
 lip must furnish it, either now, if the patient's condition admits of it, 
 or later on, when the pedicle of the frontal flap is divided. If no 
 columella is made now, the flap, when attached, must be supported 
 by gently introducing strips of some antiseptic gauze, well coated 
 with eucalyptus and vaseline (.3j-5J) ointment. If a columella is 
 made, two bits of drainage-tube or Jacques' catheter are introduced. 
 The parts, being smeared with the above ointment, are well covered 
 in with aseptic gauze or salicylic wool, but in keeping these in posi- 
 tion no pressure must be made with bandages on the new nose. 
 
 The forehead wound, on which sponge-pressure has been made, is 
 now partially closed with one or two hare-lip pins and sutures, but in 
 introducing these great care must be taken not to constrict the pedicle 
 of the frontal flap. Later on, healing may be here promoted by skin- 
 grafting. 
 
 The chief points in the after-treatment are not to change the dress- 
 ings too frequently, and to use the utmost gentleness in doing so, to re- 
 
 * Slinison, loc. supra cit., p. 249. 
 
260 OPERATIONS OX THE HEAD AND NECK. 
 
 move the sutures gradually, and to be on guard to prevent the onset of 
 erysipelas, or of secondary haemorrhage. The former will be known 
 by a sudden rise of temperature, vomiting, or nausea, and is best 
 treated by warm boracic-acid lotion, aj^plied by a mask of boracic-acid 
 lint, and by a sharp purge. Ha-morrhage may occur, according to 
 Erichsen,* hs late as the ninth daj'. It must be met by careful plug- 
 ging with aseptic gauze, dusted with iodoform and tannic acid. 
 
 The flap remains for some time swollen, and oedematous, but if not 
 going to slough, it will found warm and sensitive. If too much swell- 
 ing persist, leeches or careful scarifications should be made use of 
 
 Separation of the root of the flap, 
 
 A month or six weeks after the first operation, when the blood sup- 
 ply to the flap in its new position is established, the pedicle is divided 
 with a narrow straight bistoury and cut somewhat wedge-shaped, 
 with the apex upwards, an appropriate resting-place being fashioned 
 for it in the skin beneath, which, up to this time, has not been touched. 
 The fine sutures already mentioned are then inserted. 
 
 If the patient's condition has been feeble, or if the tissues at the 
 sides are very cicatricial, and thus the new blood supply to the frontal 
 flap be insufficient, some sloughing may take place, but this is 
 rare. 
 
 Formation of a new coliimna. 
 
 If this was not made at the time of the first operation it should be 
 done at the same time that the pedicle is divided. It is rare that a 
 forehead is sufficiently high to obtain an adequate columna, and the 
 additional thickness and vascularity of the lip make it much more 
 desirable to take one from here. Two assistants, with a finger and 
 thumb at each angle of the mouth controlling the coronary arteries, 
 and at the same time making the parts tense, the surgeon, with a 
 straight, narrow bistoury, transfixes the root of the lip just to one 
 side of the middle line and cuts straight down through the free border 
 a similar incision is made on the opposite side of the middle line, and 
 a narrow strip, about 1 inch in width, is thus detached save above. 
 It is well, in a man, to shave off' the skin and hair follicles, and the 
 tip being pared, and the remains of the old columna appropriately 
 freshened, the fra^num is freely divided, and the new columna united 
 to the remains of tlie old and to the ahi: by one or two fine sutures. 
 The cut surfaces of the lip arc then brought most accurately into ap- 
 position with a silver wir(> suture oi)p(>site to the coronary arteries, 
 and several points of line silk and fishing gut. iV few more are next 
 inserted to further adjust the columna. 
 
 * Loa. nupra cit., p. Gil, is mentioned a Ciise of Lister's, in which hfemorrhage took 
 place on the niiitli day, the patient losing over a pint of blood. 
 
REPAIR OF XOSE. 261 
 
 (4.) Italian or Tagliacotian Method.— This is but very raidy 
 made use of in this country, owing* to the irksomeness which the 
 needful position entails, and the need of a complicated special ap- 
 paratus. 
 
 On the other hand, the absence of any additional scars on the 
 forehead and cheeks, and the abundant flap which can always be 
 obtained, are so important that it may be thought worth wliile to try 
 this method in female patients who have sufficient time and means, 
 and who will put up with the inconvenience of cramped restraint for 
 two or three weeks. 
 
 Sir W. MacCormac brought a case before the Clinical Societyf in 
 which this method had answered well in a girl aged sixteen. The 
 following account is taken from his paper. Means for keeping the 
 patient's arm. in the needful position for the requisite period were 
 thus provided : " A pair of ordinary stout well-fitting stays were first 
 procured, to which were attached two perinseal straps, to prevent dis- 
 placement upwards. A helmet, partly made of leather, was con- 
 nected with the stays by a leather band running up the centre of the 
 neck and back. A leather armpiece, strengtliened by a steel band, 
 was moulded so as to extend from the wrist to the shoulder, where it 
 was buckled to the stays. The wrist and hand were fastened to the 
 helmet by a gauntlet, while the elljow could be fixed steadily in any 
 required position by straps running from it to the stays, and to the 
 sides of the headpiece, so that there was nowhere any undue strain, 
 the pressure being so evenly distributed that each strap was almost 
 slack. This apparatus was next applied for some days beforehand, so 
 that any point of undue pressure might be remedied. The girl was 
 able to sleep soundly in it, and it gave promise of proving perfectly 
 efficient. 
 
 " Meanwhile I modelled on the deficient nose a gutta-percha sub- 
 stitute, and from this was able to project on a flat surface the extent 
 of the deficiency. 
 
 " The first part of the operation was performed thus : A flap was 
 marked out on the inner aspect of the left upper arm, more than 
 double the actual size of the estimated deficiency. The left arm was 
 the one chosen to supply the flap, and the right side of the nose the 
 one first operated on, the septum being fashioned at the same time. 
 The flap was left attached to the upper part of the arm by a broad 
 long pedicle, and so arranged that there should be no traction what- 
 
 * In cases where tlie destruction i.s very great, where otlier methods have failed, 
 where the skin available on the face is ninch scarred or of doubtful soundness, the 
 Tagliacotian method is especially indicated. 
 
 t Clin Soc. Trans., vo\. yi p.181. Three figures are given, of the patient before and 
 after the operation, and of the apparatus used. 
 
262 OPERATIONS ON THE HEAD AND NECK. 
 
 ever upon it, whilst the raw surface from which it was taken should 
 be accessible for daily dressing. With the flap I dissected up the 
 subcutaneous fat down to the muscular sheath. Immediate retract- 
 ion both of the flap and of the denuded part of the arm took place to 
 a large extent, so that the raw surface on the latter was almost co- 
 extensive with the whole inner surface of the girl's arm, the flap ap- 
 pearing quite small in comparison. 
 
 " I now made a slightly curved incision, nearly parallel to the free 
 border of the nose on the right side, and about three lines above it, 
 corresponding, in fact, to where the alar furrow should normally 
 exist. This incision was prolonged some little distance into the xiheek 
 in the line of the cheek furrow, whilst the remains of the septum were 
 split open in the median line. This nasal flap could now be turned 
 down so as to become horizontal, or rather a little depressed below 
 the horizontal line, to allow for retraction of the ingrafted piece. A 
 triangular gap, the apex pointing towards the cheek, was thus left 
 exposed on the right lateral aspect of the nose, and into this the trian- 
 gular-shai^ed piece from the arm was inserted, and accurately attached 
 by suture, the portion to form the septum being sutured in the groove 
 already formed by splitting the septum. In this way there was no 
 paring of edges, nor was a single particle of nose tissue sacrificed, 
 whilst by having so large a line of attachment, being almost sur- 
 rounded by living tissue, the new flap was much more likely to ad- 
 here satisfactorily in the first instance, and from its freer blood supply 
 less prone perhaps to subsequent contraction." Union took place in 
 great part by first intention, some suppuration setting in on the eighth 
 day, owing to the indifferent plastic power of the subcutaneous fat. 
 Healing was not complete for nearly three weeks. At this date the 
 operation was completed by detaching the flap from tlie arm, cutting 
 this so as to give it a triangular shape, and preparing the left side of 
 the nose to receive it in a manner precisely similar to the right. The 
 perfect vitality of the now comi)letely severed tissue of the arm was 
 made apparent by copious haemorrhage, and healing was complete in 
 a fortnight. 
 
 After the first forty-eight hours scarcely any inconvenience was 
 felt from the apparatus, save for a slight excoriation on one shoul- 
 der. 
 
 The result was good, but it was expected that further contraction 
 would much improve the asjiect of the nose, the new organ being fully 
 large. 
 
 Causes of failure after Complete Rhinoplasty. 
 
 1. Gangrene and sloughing. 
 
 2. Secondary hicmorrhage. 
 
 3. Erysipelas. 
 
REPAIR OF XOSK. 
 
 263 
 
 4. Destruction of the new nose by recurrence of the old disease. 
 
 5. Too large a nose. 
 
 6. Too small a nose. 
 
 B. Operations for Partial Eestoration of the Nose — 
 
 These are very numerous and have usually been designed for special 
 cases. A few only will be alluded to here. 
 
 (i) Two Lateral Flaps.— This method is indicated when the 
 lower third of the nose is left untouched and the central portion espe- 
 cially destroyed, (a) Small square flaps are raised and united in 
 the middle line (Fig. 55). (,?) Another method is shown in Fig. 54. 
 It was made use of by Mr. Skey * who thus describes it : " In cases in 
 which the ossa nasi are destroyed, the operation consists in bringing 
 to the mesial line two lateral flaps made from the side of the nose 
 upon the cheek. The calculations in this operation are nearly as im- 
 
 FlG. ."jO. 
 
 Fig. 56. 
 
 Fig. 57. 
 
 Rhinoplasty. Double square lateral 
 flaps. ;Stimson.) 
 
 Rhinoplasty. Single lateral flap. 
 (Stimson.) 
 
 Khinoplasty. Denonvilliers' 
 method. (Stimson.) 
 
 portant as inthe frontal method. An incision is commenced at the 
 root of the nose, as nearly as possible on the dorsum, and carried 
 down as close to the line of the former organ as the condition of the 
 skin will permit, and a second, commencing i inch on the outer side, 
 should extend downwards, curving at the same time a little outwards, 
 to avoid the orbicularis. The second incision should diverge from 
 the first towards the cheek-bone, and at its extremity, which should 
 correspond with the line formed by the base of the nostril, should be 
 distant more than a full inch from it." Mr. Skey advises that the 
 columella be made at the same time, attached to one of the flaps as 
 shown in Fig. 54. If this fail, the lip will still serve the surgeon's 
 purpose. 
 
 * Operative Surgery, p. 523. 
 
264 OPEEATIOXS ox THE HEAD AND NECK. 
 
 (ii.) Single Lateral Flap.— This may be taken in many different 
 ways : 
 
 (a) From the cheek, at the side of and below the nose (Fig. 56, a). 
 
 (/?) From the opposite side (Langenbeck). The apex of the flap is 
 left attached to the inner angle of the eye, on the same side as the 
 deficiency, while the base conies from the ala of the sound side (Fig. 
 56, b). 
 
 (y) M. Denonvilliers' method. A border that has already cicatrized 
 is made use of so as to prevent subsequent narrowing. A triangular 
 flap is marked out by incisions shown in Fig. 57, the pedicle being 
 internal. The flap, having been carefully raised with a strip of carti- 
 lage in its lower margin, is displaced downwards into position. 
 
 In all the above methods, if cartilage is not excluded in the free 
 border which is to form the new ala, the flaps should be cut long 
 enough to allow of turning this border upon itself and thus giving a 
 thicker and more natural appearance to it. 
 
 (5) M. Weber's method. The flap is taken from tlie upper lip : 
 on account of the hair follicles this plan is best suited to women. An 
 oval flap is taken, usually from the centre of the lip, with its pedicle 
 left attached close to the columna and its free margin reaching to the 
 prolabium. The flap, which consists only of part of the thickness of 
 the lip, is turned up, and stitched to the remains of the ala, which 
 have been refreshed. In three or four weeks this pedicle is divided, 
 and may be so united to the inner surface of the flap as to give it a 
 thicker and rounded margin.* 
 
 ROUGE'S OPERATION.f 
 
 Indications. — Whenever the surgeon desires to gain free access to 
 the nasal cavities, as in cases of — 
 
 1. Intractable ozEena.J Thus, when previous persevering treatment, 
 including Thudichum's douche, fails to cure cases of strumous ozsena, 
 with obstinate inspissated crusting of discharge under the turbinated 
 bones ; when dead bone is detected by a probe, or is believed to be 
 present in these cases, or, more commonly, in those of syphilitic 
 ozasna. 
 
 ' For the account of tliese hiieral flap ojierations and for Figs. 55, S6, 57, I am 
 indebted to Dr. Stinison's Operative Siirgcri/, ji. 240, 
 
 t Noiwelle Methode pour Ic Traitanait chirurgical de I'Ozbie, par le Dr. Rouge. Lau- 
 sanne : 1873. 
 
 X Mr. Hayward (Syst. of Surg., vol. ii. p. 644) believes that in a large number of 
 cases of oza;na the discharge is due to a carious surface being present on the base of 
 the skull. If this view is correct, it obviously points to not putting off this operation 
 too late. 
 
REMOVAL OF NASAL POLYPI. 265 
 
 2. In inveterately recurring nasal polypi, persisting after the steps 
 advised at p. 266. 
 
 3. In some cases of naso-pharyngeal polypi— viz., where the growth 
 is small, and where a scar is especially deprecated. 
 
 Operation. — An anaesthetic having been administered, the surgeon 
 must decide as to what steps he will take to jjrevent the blood from 
 getting down into the pharynx. This may be done either liy plugging 
 the posterior nares, or by performing laryngotomy and plugging the 
 faucfes with a sponge ihrfra). If the liicmorrhage is likely to be 
 troublesome, and the operation prolonged, I much prefer the latter 
 precaution, for I have found that when the nostrils are plugged it is 
 quite possible to sever the silk on one side, owing to its being hidden 
 by clots, and its whereabouts thus not seen. A preliminary laryngot- 
 omy followed by plugging the fauces does away with the trouble of 
 plugging the posterior nares and with the presence of silk ligatures in 
 the nostrils.* 
 
 The upper lip having been well raised and everted by an assistant 
 taking hold of it at the angles of the mouth, the surgeon frees it from 
 the upper jaw by an incision through the mucous membrane reaching 
 from the bicuspid teeth on one side to their fellows. In doing this 
 the knife should be kept close to the bones and parallel with them. 
 The cartilaginous septum is next detached from the anterior nasal 
 spine, and the lower lateral cartilages from the upper jaw, the adja- 
 cent parts of the cheek being also freed at the same time sufficiently 
 to admit of the nose and lips being lifted up sufficiently to explore 
 the nasal cavities. 
 
 After any dead bone has been removed, the sharp spoon applied, 
 and the nasal cavities thoroughly cleansed in cases of ozsena, or any 
 polypi dealt with, the jDarts are replaced (without sutures), and iced 
 boracic-acid lint applied for a day or two, till the pain and swelling 
 have subsided, and the risk of erysipelas has gone by. 
 
 Other operations on the nose — e.g., those of Lawrence and Oilier, 
 are given later on under the heading of Naso-pharyngeal Polypi, pp. 
 285, 286. 
 
 REMOVAL OF NASAL POLYPI. 
 
 Some six years ago I learnt from Mr. M. Banks his method of 
 clearing out the nose in the most troublesome cases. I have used it 
 since repeatedly with good results, and believe that in its thorough- 
 ness, the simplicity of the instruments required, it is far superior to 
 snare, injection with iron perchloride, etc., and the galvanic loop. 
 
 * Plugging the fiiuces after a laryngotomy has the further advantage of leaving the 
 posterior nares free for examination by a finger pa.s6ed from the month, a point of 
 importance in examining tliese parts, or in manipulations in the case of a polypus. 
 
266 OPERATIONS ON THE HEAD AND NECK. 
 
 Of the above, the first is an excellent means of getting rid of the larger 
 polypi which come down first, but it is, I think, tedious and inefficient 
 in the case of the crops of the smaller ones, often sessile, which make 
 their appearance later on. I have never found that the abundant 
 hsemorrhage causes any serious trouble, as long as the assistant who 
 administers the anaesthetic knows his business, and as long as the 
 patient's head is kept on one side, over the edge of a table or sofa. 
 
 Mr. Banks's method is given in his own words :* 
 
 "As to the most permanently curative operation for nasal mucous 
 polypi, I believe there is nothing equal to the use of the forceps prop- 
 erly managed. Where there are large isolated polypi with well- 
 marked stalks, the wire snare or Dr. Thudichum's process may do well 
 enough, and probably removes them with much less pain than the 
 forceps. But these are not the most common cases. On the contrary, 
 they are usually crojjs of small growths fringing the superior and 
 middle turbinated bones, which no snare can get hold of, and which 
 in due time make their appearance as large ones. Mr. Syme, after 
 great experience, used to say that the only way was to get one blade 
 of the forceps beneath the turbinated bone and the other on the 
 opposite side of it, and to carry away as much bone as possible. This 
 I always endeavor to do, and find that, along with the big ones, I 
 have brought away whole crops of minute polypi just commencing 
 their existence, which can only be removed by carrying away the bone 
 from which they grow. As to necrosis and all sorts of contingencies 
 which it is said 7nay occur as a result of such rough surgery, the 
 simple ans\TCr is. They don't occur. On the other hand, the patient 
 has a chance of getting rid of the source of his trouble, and does not 
 need to come every two or three years to have a fresl^ assault made 
 upon a fresh lot. Failure often results from using forceps which are 
 too big in the blades, and which are only toothed in the points instead 
 of all the way down. In not a few cases, where the patient has had 
 several operations performed previously by other surgeons, I have 
 simply smashed np the Avhole turbinated bone as widely as I could, 
 and so have settled the matter permanently. Now the pain and 
 dreadful sensations produced by this proceeding are more than mor- 
 tals can bear, and so the patients have had chloroform or ether, and 
 it M'ould be an excellent thing if this were resorted to more frequently. 
 Even a moderate assault with the forceps is a most horrid process, 
 and patients who have gone through it once or twice, will endure any 
 amount of chronic misery rather than face it again. But only a very 
 few surgeons seem inclined to give these unfortunates an anesthetic, 
 urging as tlieir reasons the danger of blood going down the throat and 
 
 Clin. Notes upon Two Years' Surgical Work in the Liverpool Royal Infirmary, p. 180. 
 
EEMOVAL OF UPPEU JAW. 267 
 
 choking the patient, and the fact that, owing to the patient being 
 insensible, he cannot blow down the nostrils so as to let it be known 
 whether they are clear or not. My plan is to have, the patient thor- 
 oughly anesthetized on a sofa. When fully insensible his head 
 should be brought over the edge so that the nostrils are dependent, 
 and then the surgeon, kneeling on the floor, passes up the forceps, 
 and pulls out everything he can till there is nothing more to pull. 
 Meantime, all the blood runs out of the nostrils, and none need go 
 down the throat at all, while the whole time necessary for a thorough 
 cleaning is about a minute for each nostril. I feel convinced that, for 
 certain cases, the only satisfactory cure is to pull away as much as 
 can be got of the superior and middle turbinated bones." 
 
 CHAPTER VII. 
 OPERATIONS ON THE JAWS. 
 
 OPERATIONS ON UPPER JAW. 
 
 These will include — • 
 
 i. Removal, partial or complete, for growths (Fig. 58). 
 
 ii. Operations for naso-pharjaigeal polypus (Figs. 59, 60, 61). 
 
 iii. Opening the antrum. 
 
 REMOVAL OF UPPER JAW, PARTIAL OR COMPLETE. 
 
 Indications. — These include the different growths to which the 
 upper jaw is liable, and opportunity will be taken here to give briefly 
 the chief practical points in- connection with these. 
 
 1. Epulis. — One of the most frequent new growths met with here. 
 Etymologically gum tumors, these growths vary a good deal. At first, 
 and most frequently, they are simply fibrous, tough and firm, springing 
 from the periosteum, the periodontal memlirane, and the endosteal 
 lining of an alveolus. Myeloid cells and small spicula of bone are not 
 uncommon. The longer they are left, the more they are irritated, 
 especially with imperfect attempts at removal, the more cellular and 
 allied to the sarcomata do they become. 
 
 Very rarely on drawing the tooth, to the alveolus of which the 
 growth is connected, the epulis comes away completely. Much more 
 frequently it is firmly connected to the periosteum and subjacent can- 
 cellous tissue, or the endosteal lining of one or more alveoli. Removal 
 should be early and complete. Shaving ofl' the growth and the gum 
 beneath, and then applying caustics to any suspicious granulations, 
 is most uncertain and unsatisfactory, especially if the presence of teeth 
 
268 OPERATIONS OS THE HEAD AND NECK. 
 
 is allowed to interfere with the complete removal of the growth, or if 
 this is connected with stumps, and thus dips deeply into an alveolus. 
 By far the best treatment is to draw a tooth in front and behind the 
 growth, and then with a nari'ow saw to notch the bone at these points 
 deeply through the alveoli; with cutting forceps a V-shaped or rect- 
 angular piece of the bone is then removed. The drawing of teeth not 
 only enables the surgeon thoroughly to eradicate the growth, but their 
 removal leads, as ])ointed out by Mr. Salter,* to wasting of the alveolus 
 and thus to non-recurrence of the growth. The teeth, if sound, should 
 be preserved, and, later on, when all is firmly healed, fitted to a plate 
 by a dentist. The deformity is thus rendered imperceptible. 
 
 In 1884, a captain in the koyal Navy whose ship was on the North 
 American station, came under my care with an epulis connected with 
 the lower incisors and contiguous alveolar margin. The teeth were 
 all preserved, and when the parts were soundly healed Mr. Moon 
 refitted them so skilfully that no trace whatever of an operation 
 could be noticed, and the use of a speaking-trumpet, which was most 
 essential in this case, was not interfered with. 
 
 If a patient refuse the only operation which is safe, the surgeon 
 must rest satisfied with shaving off the growth, gouging the subjacent 
 bone, and, if needful, applying caustics to any suspicious patches later 
 on. This course is not only much more tedious and painful, but is 
 uncertain to boot. 
 
 2. Fibroma. — These originate either in the periosteum or in the 
 endosteum of the antrum. At first firm, dense, and slow-growing, 
 they may, from the frequent irritation inseparable from their site, 
 become vascular, sloughy, and, taking on more rapid growth, tend to 
 invade the numerous fossse, fissures, and foramina in the neighborhood 
 of the bone. They should be attacked early, and while the surgeon 
 may need at this stage to remove only the periosteum and bone from 
 which the tumor springs, especially if it be alveolar in origin, or after 
 opening the antrum to shell out the fibroma completely, he must also 
 be prepared for more radical measures, especially if the growth is of 
 long standing, of late more rapid, if the patient is at all advanced in 
 years, and especially if the growth is recurrent. 
 
 3. Sarcoma. — These include the spindle, round and myeloid varie- 
 ties, the fibro-, chondro-, osteo-sarcomata, and the rarer form of alve- 
 olar sarcoma. While the more slowly growing ones simulate and may 
 be mistaken for more innocent growths, such as e])ulis, the more rapid 
 ones will tax the surgeon's judgment as to whether any operation is 
 
 * System of Surgery, vol. ii. p. 456. Mr. f^nlter also points out that where an epulis 
 forms on an apparently edentulous part of the jaw, the existence of stumps should 
 always be looked for. 
 
REMOVAI> OF UPPER JAW. 269 
 
 justifiable, and all his skill, if removal is attempted. On these subjects 
 the reader is referred to pp. 271, 272. 
 
 4. Carcinomata. — At the present time the softer growths which 
 attack the jaw, and were formerly called medullary cancers, are looked 
 upon as rapidly growing sarcomata. The only true carcinomata met 
 with here are cpitheliomata. These are usually of the squamous kind, 
 and commence in the alveolar border in ulceration, beginning in 
 syphilis or the irritation of an ill-fitting tooth-plate. They tend to 
 creep far back and to invade the palate and tonsil, on this account 
 they should be operated on early. \Mienever a sore in this position 
 is suspicious in its characters, and obstinate to treatment, whatever be 
 the age of the patient, the parts affected should be widely and freely 
 extirpated. If the growth has eaten into the antrum or has travelled 
 back so as to invade the pterygoid region, removal of the whole bone 
 is most likely to benefit the patient. More rarely a squamous epithe- 
 lioma attacks the jaw from the lip or face. This happens much 
 more often in the case of the lower javf. Another variety of epithe- 
 lioma met with here is the tubular* variety (cylindrical or adenoid 
 carcinoma), which begins in the mucous membrane of the antrum or 
 nose. It is marked by rapidity of growth and invasion of the sur- 
 rounding parts, and is thus of grave prognosis. 
 
 5. Dentigerous Cysts.— These are formed by a collection of serous 
 fluid taking place during the development of a tooth, nearly always a 
 permanent one, which has not come through.f 
 
 There are two varieties of these cysts ; one, the commonest, is cystic 
 only, consisting of an outer Ijony shell of varying thickness and an 
 inner membranous one. The tooth may be well formed or a small 
 shapeless calcified mass : its crown usually projects into the sac, ver- 
 tically or horizontally. 
 
 The following points are of practical importance. These cystic 
 swellings may be taken for solid growths, but this mistake may be 
 avoided by remembering that when such a swelling exists there is 
 usually a history of its having commenced in early fife, and that 
 though all the teeth may appear to be present, one will very likely be 
 
 * Mr. Heath {Did. of Sarg., vol. i. p. 8o7) quotes Rejlus as calling this form epi- 
 thelioma terebrwnl, from its boring or bnrrowing tendency. 
 
 t Mr. Salter (Syst. of Surg., vol. ii. p. 4S9) gives the following three circumstances 
 as capable of producing impaction of a tooth : (1) The tooth may be originally devel- 
 oped too deep in the body of the jaw— thus, though it grow in the right direction, it 
 will never reach the alveolar margin ; (2) while it may be sufficiently superficial, it 
 takes an oblique direction of growth, so that it lies covered more or less in the axis 
 of the bone; (3) the position of the tooth and its line of growth may be originally 
 normal, but from arrest of the development of the fang it may fail to reach the 
 alveolar edge. 
 
270 OPERATIONS ON THE HEAD AND NECK. 
 
 found to be a temporary one. Furthermore, there is the help derived 
 from puncture with a fine trocar.* 
 
 The treatment consists in exposing the surface of the cyst by turning 
 the lip up, or by making incisions through this as small as possible, 
 then in cutting away freely (with bone-forceps aided by a f-inch tre- 
 phine if needful) the walls of the cyst,t so as to examine its contents, 
 and then digging out the tooth, often the most difficult part of the 
 operation. The cavity is then carefully stuffed with strips of aseptic 
 gauze to encourage its granulating from the bottom. Later on, if any 
 swelling persist, keeping up deformity, pressure must be trusted to, 
 a Hainsljy's truss being here found useful. 
 
 In the other variety of dentigerous cysts, solid growth of a sarco- 
 matous nature is present in addition to the cj'stic. The surgeon here 
 must use his discretion as to opening the cyst, freely scraping out the 
 growth and then applying the cautery or zinc-chloride paste, or re- 
 moving the bone itself. If the case is of any duration, if the growth 
 is soft and making rapid progress, the latter course will be the wiser 
 one. 
 
 6. Enchondromata. — These are rare. They seem to commence in 
 adolescence, usually starting from the surface of the bone, e.g., the 
 nasal, or from the antrum. They should be removed early and com- 
 pletely, as they grow steadily, involving the nose, orbit, frontal sinuses, 
 and thinning the cranial bones. J 
 
 7. Osteomata. — These are rare also. Two forms occur: (1) of the 
 nature of an ordinary exostosis. These are usually cancellous, but 
 ivory ones arise from the superior maxilla as well as from the orbit 
 and frontal sinuses. Occasionally they are symmetrical.§ Their 
 growth is usually slow. If they occur in young subjects they should 
 be attacked while small. The ivory exostoses are occasionally found 
 loose on laying open the antrum, as is the case with those in the 
 frontal sinuses. (2) Diffuse osteomata. These are intermediate in 
 hardness between cancellous and ivory exostoses. They have often 
 broad, ill-defined bases, and are often multiple and symmetrical. As 
 
 * Mr. Fearn, of Derby, was candid enough to publish a case of tliis mistake in diag- 
 nosis in the case of the lower jaw, Brit Med. Journ., August 27, 18(i4. The specimen 
 is figured in Mr. Heath's Injuries and Diseases of the Jaws, p. 102, and shows well how 
 such a mista]<e might have arisen. 
 
 t A good illustration of lliis condition will be found in Mr. Bryant's Surgery vol i 
 Fig. 194. 
 
 X Good instances of what tliese enchondromata may come to are given by Mr. Mor- 
 gan's case. Gay's JI„-<p. Reps., 1842; j"\Ir. Heath's Diseases and Injurie.-: nf the Jaws, p. 
 237, with an excellent illustration. Fig. 1U7. 
 
 i In Mr. Hutcliinson's Clinical Surgery, vol. i. p. 11, Figs. 3, 4, will be found admi- 
 rable illustrations of symmetrical exostoses from the upper jaw. 
 
REMOVAL OF UPPER JAW. 271 
 
 they tend to produce hideous deformity, and, though slowly, most 
 distressingly, to destroy life, they should be attacked while small. Mr. 
 Pollock * quotes Mr. Stanley f as an authority for the fact that in cases 
 where the whole mass is beyond removal, a portion may be cut away 
 with present, if not permanent, benefit. This can only apply to osteo- 
 mata of purely hypertrophic nature. Where the bony growth is 
 tipped with cartilage every atom must be removed for the operation 
 to be of any benefit. Well-made osteotomes and drills worked by a 
 dentist's instrument may be of much service here, the great object 
 being to drill a number of holes in different directions through the 
 growth, and then to cut through the intervening bone with well-made 
 osteotomes and a mallet. One of the chief risks is that of intra-cranial 
 inflammation, especially if the growth has involved the interior of 
 the skull. 
 
 Questions arismg before Attempting Removal of the Upper Jaw. 
 
 (i.) Is the growth cystic or solid? 
 
 (ii.) What is the relation of the growth to the jaw? Did it begin on 
 one of the surfaces of the jaw, within the antrum, or behind the jaw? 
 
 (iii.) Is the growth one, whether malignant or not, that it is wise to 
 attempt its removal ? 
 
 (i.) Is the Growth Cystic or SoHd?— Cases already quoted 
 at p. 270, show that mistakes may arise here. Mr. Heath gives a case 
 under his own care in which caseous pus, after suppuration in the 
 antrum, was taken for a solid growth and the jaw removed. As the 
 diagnosis is evidently most difficult in .some cases, the surgeon should, 
 in all cases of doubt, explore with a trocar and cannula, a drill and 
 brad-awl, before he makes incisions which may be quite uncalled for. 
 
 (ii.) What is the Relation of the Growth to the Jaw ?— Did 
 it begin on one of the surfaces of the jaw, within the antrum, or behind 
 the jaw ? 
 
 In some cases it is quite impossible to be sure on this point up to 
 the time when the flaps are reflected, or till the jaw itself is removed. 
 
 The following points may be useful in aiding a decision as to the 
 relation of the groM^th to the jaw : 
 
 If the growth began on the surface of the jaw — e.g., the nasal or 
 malar process — there will prohably be a history of a lump noticed 
 here first, very likely after a blow, and any evidence of the antrum, 
 ,nose, palate, and orbit being involved will be deferred till late. On 
 lifting up the cheek, masses of growth will very probably be found 
 growing down between the cheek and gums, but not altering the line 
 
 * Syat. of Snrg., vol. ii. p. 535. 
 f Diseases of Bones, p. 5. 
 
272 OPERATIONS OX THE HEAD AND XECK. 
 
 or affecting the structure of the alveolus, unless it commenced in it or 
 just above it. 
 
 If the growth began in the antrum the cheek is more slowly swollen, 
 and the swelling is deeper and less defined. The different walls and 
 boundaries of the cavity— viz., the orbital, nasal, facial, and zygomatic 
 —are expanded steadily and with a varying rapidity ; while the pal- 
 ate is depressed and the alveolar border displaced and the teeth line 
 rendered irregular. 
 
 If the growth began behind the untram—e.f/., in the basilar process 
 of the sphenoid, or the pterygo-maxillary foss;e— in many cases a 
 history will be given of polypi removed from the nose or pharynx 
 some time before, perhaps recurring soon ; the upper jaw is pushed 
 forwards, and in some cases there is but little alteration in its outward 
 shape. But this is by no means constant. Not unfrequently the 
 upper jaw will be so altered by pressure, its processes— e.gr., the molar 
 — so thinned, flattened, and expanded that it may well be thought 
 that the disease began in the bone itself And this mistake is the 
 more excusable when it is remembered how easily a growth situated 
 behind the antrum may make its w.iy into this cavity either by 
 absorbing its walls or by entering it through the opening into the nose. 
 
 If the growth has begun behind the antrum, starting from the base 
 of the skull, symptoms pointing to blocking of the nose — viz., pain 
 here, in the orbit and brow ; epiphora from blocking of the nasal duct, 
 interference with nasal breathing, epistaxis, etc. — will most probably 
 be present, yet it must be remembered tliat m.any of these symptoms 
 will be brought about by a growth within the antrum increasing 
 rapidly. 
 
 It is only, I think, when the surgeon finds no evidence of the growth 
 beneath the skin, or of its originating on the surface of the bone, no 
 depression of the palate, and no irregularity of the alveolar margin, 
 or displacement of the teeth, that he can say that the growth is prob- 
 ably behind the antrum. 
 
 (iii.) Is the Growth one, whether Malignant or not, that 
 it is wise to Attempt its Removal ? — While every case must 
 be decided upon separately, and while it would be most absurd and 
 misleading to lay down hard-and-tast rules, the following are not 
 unwortliy of attention : 
 
 Favoriihlc C'tscs.— Growths with a duration of years, not months, 
 hard, well-defined, limited to the jaw, and the skin over the growth 
 perhaps thinned from pressure, and altered in color, Init still movable 
 over the jiarts beneath. 
 
 Uiifdrariihlc fw.srx. — History of a few months' duration ; growth soft, 
 vascular, ill-defined ; integuments involved and fixed ; naso-pharynx 
 invaded ; extension into orbit or temple — e.g., soft, semi-elastic swell- 
 
REMOVAL OF UPPER JAW. 273 
 
 ing noticed behind malar bone in temporal region ; extension to the 
 sub-maxillary and cervical glands ; origin of the growth behind the 
 jaw, rather than on it, or within the antrum. 
 
 Occasionally, a growth, unfavoral)le at first sight, from its large size, 
 will be found to have protruded on to the face without involving the 
 parts around, and especially those behind. 
 
 The history must be carefully examined into. If it be doubtful 
 where the growth began, whether it has invaded or only crept towards 
 the nostril, the surgeon will inquire as to the existence of deep-seated 
 pain, stuffiness in the back of the nose, loss of smell, interference 
 with nasal respiration, epistaxis, etc. Again, the existence of any 
 swelling near the inner canthus will point to extension towards the 
 ethmoid and base of the skull. 
 
 Complete Removal of Upper Jaw (Fig. 5s).— The patient 
 
 having been brought carefully * under an antcsthetic, and duly 
 propped up, the face shaved, and the head raised and turned over 
 towards the opposite side, the surgeon takes this opportunity of 
 examining more completely the attachments and limits of the growth, 
 and decides whether, owing to its vascularity, it will be wiser to pev- 
 forra a preliminary laryngotomy and plug the back of the 2:)harynx, 
 infra. 
 
 The incision, which goes by the name of Sir W. Fergusson,t is then 
 made through the centre of the lower lip (an assistant controlling 
 the opposite coronary while the one in the flap is commanded by the 
 surgeon himself), round the ala, and up along the side of the nose to 
 the inner canthus, and then outwards just below the margin of the 
 orbit, as far as the malar proininence. The flap thus marked out is 
 then reflected, and though no large vessels are cut, the hajmorrhage is 
 often free, especially in cases of ra])idly growing tumors which have 
 thinned the bone. Spencer \'\^ells's forceps are applied to the larger of 
 these, while the flap is Ijeing reflected these are secured, and an assist- 
 ant makes sponge-pressure if needful upon the flap to arrest oozing, 
 while the surgeon divides the bone in the following order, the ala of 
 
 * As ill excision of the tongue, the assistant to whom tlie anaesthetic is entrusted is 
 second only m importance to the surgeon. He should watch most carefnlly for the 
 first signs of flagging of the jinlse, and meet this by injections of ether or brandy. 
 Any evidence of blood going down the throat, dyspnoea (as shown by venous stasis of 
 the cheeks), lividity of the lips, or respiration shoit and fixed, must also be looked 
 out for. 
 
 t First recommended by DieflTenbach. Its advantages over such a one as Lister's are 
 very great — viz. (]) only the terminal branches of the facial nerve are divided ; (2) 
 only branches of the facial, not its trunk, are cut ; (3) the scar left is much less con- 
 Bpiciiou.s, as the incisions are placed in the natural feature-folds. 
 
 18 
 
274 
 
 OPERATIONS ON THE HEAD AND NECK. 
 
 the nose being first detached from the bony margin, and the perios- 
 teum of the floor of the orbit freed : 
 
 (1.) The junction of the jaw with the malar bone is divided. The 
 line for the saw is marked out with the knife upon the bone just in 
 front of the origin of the masseter. With a strong-backed saw (Fer- 
 gusson'b or Adams's osteotomy saw) this hue is converted into a deep 
 groove and the rest of the bone quickly severed with forceps, the left 
 forefinger placed upon the margin of the orbit steadying these instru- 
 ments and preventing any damage to the eye. This bone section is 
 practically in a line witli the spheno-maxillary fissure (at the lower 
 and outer part of the orbit), and should fall into it. 
 
 (2.) The nasal process of the superior maxilla is next severed by 
 cutting a saw-groove across it, and then phieing one blade of the for- 
 ceps inside the nostril and the other against the inner angle of the 
 orbit, the soft parts l.ieing first a little freed and carefully kept out of 
 the way with the left thumb-nail. 
 
 (3.) The central or a lateral incisor being next drawn, the mouth 
 
 is widely opened with a gag, and an incision is made with a stout 
 
 scalpel along the middle line of the hard palate up to the teeth, and 
 
 then another transversely outwards at the junction of the hard and 
 
 soft palate, towards the molar teeth on the side affected. The soft 
 
 „ ^o palate is then detached with a 
 
 Fig. 58. , , , , . , . 
 
 scaljiel or blunt-pomted scissors, 
 
 and thus preserved when the 
 bone and growth are wrenched 
 away. The hard palate is thei. 
 dee]>ly notched with the saw 
 introduced through the nose 
 opposite to the tooth which has 
 been drawn, and severed with 
 bone-f(.>rceits, one blade of which 
 is introduced within the nose, 
 the other into the mouth. If a 
 chisel or osteotome is now in- 
 serted into the different lines of 
 bone section, the bone is loosened 
 witli a series of quick and care- 
 ful levering movements, while 
 finally lion-forceps being made to bite firmly into tlie hard palate and 
 the malar aspect of the bone just below the infra-orbital foramen, the 
 bone is detached by a few wrenching, rocking movements uji wards 
 and downwards, and laterally, while the lelt forefinger detaches any 
 soft ]»arts which retain the bone, the superior maxillary nerve being 
 cut cleanly with scissors. 
 
 Removal of upper jaw. Reflection of 
 flap, and section of bones. 
 
REMOVAL OF UPPER JAW. 275 
 
 When the hone has been much invaded hy disease, or in the case 
 of an aged dead body, it is very likely to come away fragmentarily, 
 being unavoidably crushed down by the forceps. 
 
 On the removal of the bone, the pterygoid fossfe, the cavity of the 
 nose and the palate are examined, and the sharp spoon applied to 
 remove any remaining portions of disease, or Paqnelin's cautery 
 made use of to destroy any of these which cannot be otherwise 
 removed. 
 
 The bleeding is seldom free at this stage, save in rapidly growing 
 cases, as the branches of the internal maxillar}' are small before they 
 reach the tumor, and, as they are torn through, it is usually arrested 
 by firm sponge-pressure. 
 
 If there is an}' doubt about any of the growth being left behind, 
 some paste of zinc chloride, made up "with equal parts of flour, had 
 best be inserted on lint to which silk is attached, the threads being 
 brought out of the mouth through the palate, and so readily removed 
 in a few days. But if the bone has come away with all the growth, if 
 the surface of this is smooth ami encapsuled, not ragged or lacerated, 
 the surgeon will do best to insert nothing into the cavit}^ If oozing 
 is going on, or if there is reason to fear intermediary hremorrhage, 
 strips of iodoform or sal-alembroth gauze should be carefully packed 
 in, and removed later on l)y the mouth. But it is difficult to keep even 
 these sweet, and the surgeon will do best to dispense with any 
 plugging if possible, and to content himself with brushing over the 
 wound with a solution of zinc chloride (gr. xx-.5j ), or with a solution 
 of iodoform in ether. The edges of the wound are then brought 
 together with a few points of silver suture, one or two of these being 
 always inserted in the lip, and others of gut, or horse- hair, or carbol- 
 ized silk. Especial care should be paid to adjusting the red line. A 
 little iodoform is then dusted on and gauze dressings with salicylic 
 wool, or a pad of boracic-acid lint wrung out of the saturated lotion, 
 and kept constantly moist, applied. 
 
 During the after-treatment the patient should be kept well propped 
 up to facilitate the escape of discharges, which must be prevented 
 from collecting by frequent syringing, or, what is better, by the patient 
 himself often rinsing and gargling his mouth and wound with some 
 antiseptic solution. None of these are more readily used than the old- 
 fashioned potassium-permanganate lotion, and the wound should be 
 occasionally brushed over with iodoform in ether. 
 
 In those cases, rare nowadays, where the growth is of great size, 
 owing to the operation being deferred, the mouth may remain open 
 for some days after, but the power over the muscles which raise the 
 lower jaw is gradually regained. The lost sensation is usually restored, 
 
276 OPERATIONS ON THE PIEAD AND NECK. 
 
 and the resulting deformity is often very slight.* Later on, when 
 the parts are soundly healed, the skill of a dentist is called in to fit on 
 a tooth-plate,t and obturator if needful. 
 
 Partial Extirpation of the Upper Jaw.— Operations for 
 
 removal of an epulis with the alveolar border have been described at 
 p. 268, and one for opening up and exploring the antrum is given at 
 p. 292. 
 
 If the surgeon find that the lower part only of the upper jaw need 
 be removed, abundant room will be ,L;iven l)y dividing the upper lip 
 in the middle line, prolonging this round the colimiella into the nostril 
 on the diseased side. By detaching the nose and dissecting up the flap 
 of cheek the facial surface of the jaw can lie well exposed. 
 
 Again, if, after exposing the whole jaw l.iy .Sir ■\\'. Fergusson's inci- 
 sion, the surgeon finds that the orbital plate can ).>e spared, a horizontal 
 saw-cut is made just lielow the infra-orljital foramen and the bone cut 
 through with a chisel and a few taps of a mallet. J 
 
 When the orbital and nasal parts of the upper jaw are involved and 
 the lower alveolar j^ortions are sound, these latter may be thus pre- 
 served. A cheek flap bein.Li; reflected by an incision through the lip 
 and upwards to the inner canthus along the nose, the nasal and malar 
 processes ard divided while the eye is duly protected. A horizontal 
 saw-cut is then made above the alveolar process, outwards from the 
 nose, and another carried upwards from the outer end of this, to join 
 the incision through the malar process, being made either with the 
 saw or chisel. The piece of l.H)nc thus mapped out is loosened with a 
 chisel or elevator, and either prised out with the latter instrument, or 
 wrenched downwards and outwards with the lion-forceps. 
 
 Several other oiserations involving partial removal of the upper jaw 
 are given under the treatment of naso-pharyngeal polypus, p. 2S7. 
 
 DiflBculties and Dangers during the Operation. — These have 
 been already alluded to : the chief are — 
 
 1. Shock. 
 
 2. Haemorrhage. 
 
 * No skin is, of course, removeil, even if it a|ipe;irs to be very redundant; it rarely 
 slouglis, save when tlie stretching has been e.'ctreme, or when it has been needful to 
 apply the cautery to the flap. When the growth has invaded the skin over it, a hideous 
 fistula is left, which must be closed later on, if the patient survives, which he seldom 
 does in these cases. 
 
 f Mr. Butcher {loc. supra dt., p. '270) in one case preserved the last molar tooth and 
 part of tlie tiilierosity as a fixed point for a tooth-plate, intending to have removed 
 this if the disease recurred in it subsequently. 
 
 X The orbital plate sliould always be left if (lossible. As Mr. Butlin (toe. supra cit., 
 p. 13i) points out, when the floor of the orbit has been removed there often results not 
 only serious disfigurement, but much iwlonut of the lower lid, and an unhealthy con- 
 dition of the eye itself, which may be destroyed. 
 
REMOVAL OF UPPER JAW. 277 
 
 3. Breaking down of the bone in the lion-forceps. 
 
 4. Outlying pieces of growth either in the pterygoid or other fossa;, 
 or in the temporal region, or far back in the roof of the nose. 
 
 Possible Causes of Failure. 
 
 1. Prolonged shock. Inability to rally. Besides the usual applica- 
 tion of warmth and injections of ether and brandy, feeding by nutri- 
 ent enemata or by a tube passed by the mouth or by the opposite 
 nostril should be early resorted to, especially in the case of elderly 
 patients, or in those much let down. 
 
 2. Secondary hgemorrhage. If this is severe, resisting the use of ice, 
 etc., the wound must be opened up, and if no definite bleeding point 
 be found, firm plugging must be resorted to, either with carbolized 
 sponges dusted wdth iodoform and tannic acid, or strips of aseptic 
 gauze wrung out of turpentine. These steps, and pressure on the 
 common carotid, failing to arrest the hsemorrhage, ligature of this 
 vessel or of the external carotid must be employed. 
 
 3. Cellulitis and erysipelas. These grave complications are likely 
 to set in when the patient is aged or much broken down in health, 
 with impaired viscera, or when, owing to extensive removal of bone — 
 e.g., having to saw through the zygoma and loosen the outer wall of the 
 orbit, the surgeon opens up deep planes of cellular tissue, which cannot, 
 from the surroundings, be kept aseptic, most troublesome burrowing 
 in the neck probably following. To cut cellulitis short, free scarifica- 
 tion with small incisions should be made use of early so as to unload 
 the parts, and abscesses should be opened at once. 
 
 4. Lung trouble. Broncho-pneumonia from inhaling septic matter 
 is here, as after removal of the tongue, a decided risk. In this case, 
 also, the treatment is mainly preventive, by using every endeavor to 
 keep the wound sweet, by the means already given, p. 275. 
 
 5. Inflammation of the brain or its membranes. 
 
 6. Recurrence. 
 
 Mr. Butlin * has lately shown that the total mortality after removal 
 of the upper jaw is nearly 30 joer cent. — a very large mortality, equal 
 to that of amputation of the thigh in the upper half (for disease), or 
 perhaps exceeding it. He goes on to remark that, if we are to reduce 
 this mortality, " we must adopt two courses in the after-treatment, first, 
 such means as will render the w^ounds aseptic; second, regular and 
 sufficient administration of food." 
 
 With regard to the recurrence, Mr. Butlin considers the prospect as 
 very gloomy, only four cases out of sixty-four (in which the result is 
 recorded) being able to be considered successful — i.e., having remained 
 cured for three years. 
 
 * Oper. Surg, of Mai Dis., p. 130. 
 
278 
 
 OPERATIONS ON THE HEAD AND NECK. 
 
 OPERATIONS FOR NASO-PHARYNGEAL POLYPUS 
 
 (Figs. 59, 60, 61). 
 
 Attachments and Relations.— The surgeon should consider 
 these careful])' before deciding what operation he will adopt for one 
 of these most dangerous growths. 
 
 These will vary according to the duration of the polypus. The pri- 
 mary attachments of the growth start much more frequently from the 
 base of the skull, arising in the thick periosteum covered by mucous 
 membrane which covers in the roof of the nose and top of the pharynx, 
 especially the adjacent parts of the basi-splienoid and basi-occipital. 
 Less frequentljr they may arise in the pterygoid fossa and adjacent 
 
 Fig. 59.* 
 
 Naso-pharytiReal polypus springing from tlie hase of tlie slmll. In the sptienoidal sinus 
 is seen a smaller polypus. (Masse.) 
 
 plates, or from around the posterior nares. Dr. Sands f points out 
 that the region in which a naso-pharyngcal polypus can originate is 
 one of narrow limits, corresponding witli the margins of the posterior 
 nares and the summit of the pharynx. It is thus one that can be 
 
 * This wood-cut is taken from one of Dr. Robin Mass6's figures: Thlse clea Polypes 
 naso-pharyngiens. Paris, 1864. 
 
 t "On Naso-Pluiryngeal Polypi" ■ Dr. Brown-P^quard's Arch, of Sci. and Pract. 
 Med., No. 6. According to Dr. Sands, these polypi may also spring from the apex of 
 the petrous bone and the great wing of the sphenoid. 
 
NASO-PHAEYNGEAL POLYPUS. 279 
 
 satisfactorily explored with the finger, and by this means a polypus 
 should be detected in its early stage and removed safely while yet 
 small. 
 
 While the above are the most frequent primary attachments of the 
 growths, it should always be remembered that when one of these polypi 
 has existed for some time, when they are sloughy, when previous 
 attempts have been made to remove them — under these conditions 
 the growth is very lilcely to have taken on secondary attachments. A 
 common instance of these is seen when a growth springing from the 
 base of the skull forms adhesions to the pterygoid foss;e. 
 
 If secondary attachments are made out to exist, the next question 
 will be. How far are these intimate and close? How far is the growth 
 not only in contact with, but how far has it actually absorbed Ijones, 
 such as those of the nose ? How far has it got into the antrum and thus 
 come to resemble closely a growth of the upper jaw? It is obvious 
 that if the growth is mainly limited to the nose, if tlie bones of this 
 cavity are chiefly affected, it is through the nose that the polypus 
 should be attacked. Again, swelling of the cheek, with protrusion of 
 the eye, will point to an operation, osteoplastic or otherwise, on the 
 upper jaw. In the same way extension of the growth into the zygo- 
 matic and temporal fossa- will render the prognosis unfavorable. 
 Finally, any symptoms pointing to softening of the base of the skull 
 and implication of the membranes — c.r/., headache, tendency to coma, 
 convulsions, with evidence of pyrexia, will be conclusive against any 
 operation, even when most carefully performed. 
 
 Methods of Removal.— Amongst these are— 
 
 (i.) Avulsion. — In a few rare cases where the growth is small, 
 where the pedicle is distinct and narrow, and where it rises from a 
 point within reach, it may be torn away with suitably curved forceps 
 introduced either by the nose or by the mouth, aided in either case 
 by a finger passed behind the soft palate. 
 
 This method is onh^ suitable to the above cases, and in none is 
 without danger. Mr. Cooper Forster's interesting case * is a striking 
 instance of this. Attempts having failed to remove the polypus with 
 a wire loop, Mr. Forster introduced a pair of blunt-pointed strong 
 forceps, and twisted off several large pieces, enough to fill the palm of 
 the hand. These were very adherent, and required a great deal of 
 force to detach them. There was much hfemorrhage. Severe headache 
 quickly followed, then aj^hasia, restlessness, convulsions, and death on 
 the twelfth day. General arachnitis was found, with sloughy softening 
 of the brain, about Broca's convolutions. The growth occupied the 
 left side, filling the space between the greater and lesser wings of the 
 
 * Clin. Soc. Trans., vol. iv. p. 159. 
 
280 OPERATIONS OX THE HEAD AND NECK. 
 
 sphenoid, the orbital plate of the frontal, and the cribriform plate of 
 the ethmoid* From the nasal fossfe it had extended by the sphenoidal 
 fissure into the back of the orbit, but without damaging the optic nerve. 
 The cribriform plate of the ethmoid was broken, there being a small 
 opening at its back part from which a fracture extended forwards. It 
 seemed beyond doubt that this fracture had been effected while the 
 growth was being torn away. 
 
 The serious hsemorrliage,! and the proljable incompleteness of the 
 operation, are also strongly against making use of avulsion. 
 
 It is only right to state, while the subject of avulsion is under .con- 
 sideration, that Prof Syme was strongly in favor of this method for 
 naso-pharyngeal polypi. In three cases which he has briefly recorded J 
 he em^jloyed the ordinary forceps used for mucous polypi, introduced 
 through the nostril, assisting their action by the fore and middle fingers 
 of the left hand introduced Ijeliind the soft palate. He describes the 
 bleeding as being profuse, in one case "fearful" The after-result of 
 only one case is given, this being known to be successful for some 
 years after the operation. 
 
 The patient here had been under the care of Sir B. Brodie, Mr. 
 Travers, ^Ir. B. Cooper, and ^Ir. C. Hawkins, who all agreed as to the 
 impropriety' of attempting any operation. The size of the tumor is 
 not given. It is clear that Prof Lyme's method could only be success- 
 fully udtipted in cases in which there was a distinct pedicle, in which 
 the growth was one of moderate size, and free from secondary adhe- 
 sion, springing either from the base of the skull or the jjosterior nares, 
 and invading the naso-pharynx only. 
 
 While it is only riglit that these cases should be remembered, it is 
 much to be wished that the after-histories of two of them had beeix 
 more fully given. 
 
 (ii.) Ligature. — This again is only suitable to very few cases — e.g., 
 where the pedicle is distinct and fairly thin, and where the growth 
 has contracted no adhesion. In addition to the probability of return 
 in the pedicle, the IVetor which accompanies the sloughing process is 
 
 * It is notewortliy that thoiigli this liii-ge growth (Mr Forster describes it as ''an 
 enormous mass around which it was impossible I could get the wire") thus exten- 
 sively implicated the base of the skull, it only appeared externally as a firm, fleshy 
 polypus, filling up a large part of the left nostril, but apparently not pressing much 
 upon the right one. There was no dilatation of any part of the face, no fulness of the 
 palate, nor any projection in the tiiroat. 
 
 f According to Dr. Sands, Dupnytren lost a case from haemorrhage after an attempt 
 to remove a |)olypus liy forceps, in which he succeeded in removing only a few frag- 
 ments. If this method is ever made use of, it might be wise to first perform laryn- 
 gotomy, and plug the fauces with a sponge. 
 
 % Observ. in Gim. Surg., p. 130 et seq. 
 
XASO-PHARYNGEAL POLYPUS. 281 
 
 a most serious drawback* If the ligature were to be used at all, 
 every attempt should be made to get rid of the growth at the time by 
 attaching tlie ligature after it is placed round the pedicle to a suitable 
 ecrayeur, and so removing it. (.'are must be taken in such cases to 
 . prevent the growth, when the pedicle is divided, falling upon the 
 larynx. 
 
 (iii.) Galvanic Loop.— In the very few cases where ligature can 
 be tried, this modification would probably be the best. But even here 
 the pedicle would be left, unless the surgeon possesses special instru- 
 ments, such as the post-nasal galvano-cautery, and experience in 
 using it. 
 
 The following case, M'hich was under the care of two Italian sur- 
 geons, is thus reported in the Si/d. .s'or. Bieii. Rett:, 1871, 1872, p. 236. 
 Unfortunately, as is so often the case, the result is not given. 
 
 The tumor was round, very hard, smootli, and attached by a broad 
 pedicle to the pharynx, the upper part of which it occupied. A Bel- 
 loc's sound, introduced through the nostril, was passed between the 
 tumor and the uvula ; one end of a silk thread was, by means of the 
 sound, carried into the nose, and the two ends of a p'atinum wire, 
 about 2 feet long and 2-V inch thick, were fastened to the other end. 
 The silk thread was drawn through the nose, and by manipulating 
 the wire loop in the mouth, it was placed as high as possible on the 
 pedicle of the tumor. The ends of the wire were then placed in con- 
 nection with the battery ; the circuit kept closed for twenty seconds, 
 traction at the same time being made on the wire. The current was 
 now interru2oted, and the loop, wluch had cut into the tumor, was 
 placed more accurately on the i)cdiele. The circuit was again com- 
 . pleted, and the tumor was cut througli at its base, and removed 
 through the mouth by the fingers. It measured nearly 2 inches longi- 
 tudinally, and 1] transversely. The patient felt no sensation of heat 
 during the operation ; it was not followed by pain, haemorrhage, or 
 any discharge. 
 
 (iv.) Electrolysis. — This method is both most tedious and uncer- 
 tain. It can only be used as an auxiliary. Thus, Dr. Sands suggests 
 that after removal of the growth its pedicle might be successfully 
 treated by electrolysis. 
 
 Where patients are weakened by repeated bleeding, the htemorrhage 
 may be arrested by electrolysis, and the growth sufficiently reduced in 
 size to allow of its being removed through the natural passages. The 
 following casef was under the care of M. Ciniselli : 
 
 * Dr. Sands quotes otiier causes of deatli as not infrequent — viz., suffocation from 
 detachment of the growth, pvaemia, and oedema of the larynx. 
 
 t Syd. Soc. JBien. Retr., 1873-187 4, p. 291. M. Ciuinelli's wide experience with, the 
 galvano-cautery is well known. 
 
282 OPERATIONS OJf THE HEAD AND NECK. 
 
 The entire wall of the pharynx was found to be occupied by a fleshy 
 swelling which completely blocked up the left aperture of the nares 
 and pressed the epiglottis against the base of the tongue. The start- 
 ing-point of the tumor could not be discovered. The patient being 
 extremely emaciated and ana3mic, any operation involving loss of 
 blood was impossible, and therefore Ciniselli determined to apply the 
 galvanic cautery. On Nov. 20, 1869, he commenced with a small bat- 
 tery of eight elements. The reophores, of steel, were about 41 inches 
 long, and were covered with india-rubber to about 1 inch from the 
 ends. The needle of the negative pole was introduced through the 
 left nostril into tbe polypus, the other through the mouth into the 
 right side of the swelling, and the current was passed through the 
 tumor for fourteen minutes. On Nov. 29, there commenced a dis- 
 charge from the left nostril of a brownish-yellow fluid containing 
 shreds of destroyed connective tissue. On Dec. 8, respiration and de- 
 glutition were more easy. After twenty sittings, the tumor decreased 
 so much that in Oct., 1871, there was only a sbght indurated elevation 
 in the posterior inferior wall of the pharynx. 
 
 (v.) Excision by an Operation involving Removal of Bone, 
 Osteoplastic or otherwise.— These may be divided as follows-: 
 
 A. Those through which the attack is made by the mouth. 
 
 B. Those by which the attack is made through the nose. 
 
 C. Those by which the attack is made by removing the upper jaw, 
 partially or completely, or by resecting this bone osteo-plastically. 
 
 A. Operation for Naw-pliiiryvgenl Polypus through the Mouth (Fig. 61). 
 — This operation was strongly advocated by AI. Nelaton.* It consists 
 in slitting the uvula and soft palate exactly in the middle line from 
 before )iackwards,then prolonging this incision along the centre of the 
 posterior half of the hard palate, going here down to the bone; from 
 the end of this incision two others are made slightly obliquely out- 
 wards towards the teeth, also going down to the bone. The flaps, 
 together with the periosteum, are then detached, so as to form nearly 
 rectangular flaps.f Two large holes are then drilled through the 
 hard palate, each well to one side of the middle line, the intervening 
 bone is cut away by placing the ends of cutting-pliers in each of these 
 boles, and, by making lateral cuts back to the free border of the hard 
 palate, a rectangular portion of the posterior half of the bony vault is 
 removed. The mucous membrane and the periosteum on the upper 
 surface of the bone, which will now be found detached, are divided, 
 and, if needful to get more room, more or less of the vomer is cut 
 
 * Miiss^ '"c. supra cit., p. 53. 
 
 f This detachment is, as is well known in stapliyloraphy, difficnlt posteriorly at the 
 junction of the palates, and would best be effected by curved scissors. 
 
XASO-PHARYNGBAI. POLYPUS. 283 
 
 away. Room being thus obtained, the polypus is removed and its 
 pedicle dealt with. If all the growth is got away satisfactorily, the 
 palate flaps are united in the ordinary way : if further treatment is 
 required, staphyloraphy must be performed later. 
 
 The advantages of this operation, wlien contrasted with removal of 
 the upper jaw, are at first sight considerable. 
 
 (1) There is no deformity left on the face; (2) the parts cut through 
 are less important; (,;]) mastication is not interfered with by removal 
 of the teeth; (4) the operation is less difficult; (5) the liannorrhage is 
 less,* no large vessels being cut through ; (6) the growth is attacked 
 directly ; (7) through the gap thus left the surgeon can again attack 
 the growth, within a few days, if he has been unable to complete the 
 operation, or later on, if recurrence takes place; (8) the gap can 
 easily be dealt with later on by staphyloraphy, or by wearing an 
 obturator. 
 
 I am afraid that on closer examination the above will not bear the 
 only true test. The first three are no doubt of great value if the 
 growth can be entirely dealt with by this method ; otherwise, consid- 
 ering the malignancy of these growths, the inveterate way in which they 
 recur, if incompletely dealt with, neither surgeon nor patient would 
 be wise in running great risks for the sake of what one may call rather 
 aesthetic advantages.! There is no doubt that, in a few cases, to be 
 mentioned a little later, where the polypus is of moderate size, dis- 
 tinctly pedunculated, and attached low down, c.^f., about the posterior 
 nares, or well forward on the base of the skull, the operation will be 
 easier, the hemorrhage will be less, and the growth will be more 
 directly attacked. The advantage of a future staphyloraphy is, like 
 those given first, not of sufficient value to recommend this operation 
 if it is wanting in more important points. 
 
 Turning to the cases themselves. Dr. Robin Masse has collected X 
 twenty-six treated by this method, twelve having been under the 
 
 * Tliis is very doubtful. Dr. Sands (loc. supra cit ), in removing a polypus by this 
 method, had surronnded, witliout difficulty, the pedicle witli an fecraseiir-chain. This 
 breaking, the pedicle, which was stout and firm, was divided with scissors as close to 
 the skull as possible. Copious hpemorrhage followed, and much time was consumed in 
 unsuccessful attempts to secure a large artery which had retracted to the deepest part 
 of the wound, and which was inaccessible to the ligature. The bleeding finally ceased, 
 in consequence of the prostration of tlie patient, who had several alarming attacks of 
 syncope. The growtli recurring, it was removed by the method of Maisonneuve. 
 Though it was not thought prudent to attempt a small prolongation which ran into the 
 sphenoidal sinus, no recurrence hail apparently taken place nine months later. 
 
 t I may here draw attention to the great fre(|uency of these polypi in males, in 
 whom the growth of hair will largely conceal the facial deformity consequent on oper- 
 ations through the upper jaw. 
 
 X Thise, loc. supra cit. 
 
284 OPERATIO.VS ON THE HEAD AXD NECK. 
 
 hands of M. Nelaton himself. Of these twenty-six, thirteen are said 
 to have been successful, but it is not stated for how long they were 
 followed up. In one case, in which the after-history is given, a small 
 recurrence took place two years later from the pedicle, and was 
 destroyed. While suited to the cases mentioned above, it could 
 scarcely be made use of successfully in largo polypi, in the case of 
 those with secondary attachments or large sessile leases, or in the case 
 of those which have extended into the pterygoid fos.sic, or, in fact, 
 beyond the naso-pharynx. Save by French surgeons, it does not a,p- 
 pear to have been much used, from the belief that the space given is 
 too limited.* 
 
 Dr. Sands points outf that, in the majority of the cases in which 
 
 * Quite recently Mr. Stonliam i Lancet, January 7, 1X8S) lias recorded a case of naso- 
 pharyngeal jiolypus, in wliicl) " the soft palate was divided in the middle line, and an 
 attempt made to remove the growth tlirough the month ; bnt this plan failing to gi\e 
 sufficient room, the nasal cavity was opened up," and the growth thus successfully 
 removed. 
 
 I have no experience of this operation myself, but I should expect that the bleeding, 
 though from smaller vessels, might, owing to the confined space, and thus a more pro- 
 longed operation, almost ecpial that met with in operative attacks through the jaw, 
 while tlie vicinity of the larynx makes any hremorrhage here more embarrassing. 
 Again, in those patients with narrow, highly arched palates, this operation would be 
 accompanied with very great difficulty. 
 
 M. Guerin (Gaz. des Hop., 1865, p. .57.5; Syd. Sw. Bien. Edr., 1SG5-66, p. 241) re- 
 lated a case of polypus which he removed liy a modification of the above method. 
 The polypus was of enormous size; the boy i aged seventeen! could only breathe with 
 his moutli half open, and the velum palati was so displaced as to be turned down 
 towards the b;<se of tlie skull. Tlie attachment of the tumor appeared to be somewhere 
 near the posterior nares. The velum palati having been divided, a polypus as large as 
 a hen's e>;g was drawn into the mouth, and its pedicle severed without difficulty and 
 with little bleeding, tliough enough to be dangerous in the patients condition, which 
 was one of exhaustion from previous hseinorrhage- On examination it was found that 
 the bulk of the disease was left behind in the form of a large mass, round which the 
 finger could not be passed, and which appeared incarcerated in some way that could 
 not be made out. The finger was carried down behind the mass from the mouth, and 
 a rasp was pushed thmugh the nostril on to the base of the skull, and thus the mass was 
 detached from the cranium, together with what remained of the pedicle of the former 
 tumor, which was still bleeding. A large bony cavity was thus exposed, which seemed 
 to be the dilated sphen(]idal sin\is. The pedicle was now easily felt and detached, 
 partly with one blade of a pair of scissors, partly with a rasp. The bones were then 
 felt, rouuh, and devoid of periosteum There was little bleeding. Three days later 
 tlie galvano-cautery was applied to some inequalities felt near the pedicle of the 
 polypus, under the fear that this might be a new giowth. il. (iu^rin has found that, 
 in the case of large polyjii, the pharynx being accustomed to the presence of a foreign 
 body, the introduction of the finger is easier, and gives less annoyance than in healthy 
 persons. 
 
 t Loc. supra cil., p. 514. 
 
NASO-PnARY>'GEAI. POLYPUS. 285 
 
 surgeons have operated through the palate, they have had to leave the 
 wound open in order to remove the pedicle later. This step is hy no 
 means as easy as might be imagined, and in many cases the surgeon 
 has been driven later to make use of another operation when the 
 patient's condition is less satisfactory. Furthermore, the result of 
 repeated irritation in the shape of attempts at the destruction of the 
 pedicle with caustics, the cautery, etc., is too likely to take th<^ form 
 of rapid sarcomatous growth.* 
 
 B. Operation for A'aso-phnrynr/eal Polypus through the vYf^.sv'.— Uniler 
 this heading will be included : 
 
 1. Rouge's operation. 
 
 2. Lawrence s operation. 
 
 3. Langenbeck's operation. 
 
 4. Ollier's o]ieration. 
 
 These operations through the nose are only suited to cases in which 
 the bulk of the polypus is nasal rather than pharyngeal, and in which 
 its pedicle is attached to a point well within reach, as around the pos- 
 terior nares— for cases, in short, the rem(.>val of which might perhaps 
 be attempted, liy the use of force] >s, by the nose, but in which addi- 
 tional room is required. They may also be used in doubtful cases 
 for exploratory purposes. For other cases, the room which they give, 
 and the access which they afford to the tumor, will probaljly )je found 
 insufficient. Dr. Sands, in speaking of Langenbeck's operation (the 
 only one which he mentions), says that he has found that, after the 
 nasal bone and the nasal process of the sujjerior maxilla have been 
 removed, the distance of the basilar process of the occipital from the 
 anterior opening is nearly 3 inches,t and, although the boundaries of 
 the nasal fossas would, in any given case, probably l^e dilated by the 
 tumor, the space thus afforded would rarely be found sufficient for 
 satisfactory dealing with the pedicle. 
 
 (1) Rouge's operation. This has alreadj' been described at ]). 2(55. 
 
 (2) Lawrence's operation. J In this, the back of the nasal cavity is 
 exposed and got at by turning up the nose. 
 
 The integuments are first divided on each side of the nose l:iy an 
 incision beginning at a point just internal to the lachrymal sac, and 
 
 * Dr. Sands points out that the deep situation of the growth, and its position near 
 the larynx, render the use of caustics both difficult and dangerous. 
 
 t The experience of other surgeons is not in accord with this. Thus M. Hergott 
 (Gfiz. des Hop., 1867, p 97), in the case of a polypus recurrent after treatment by liga- 
 ture, tried rasping the point of implantation on the base of the skull. He found that 
 an instrument passed through the anterior nares impinged exactly upon this point; 
 the bone was easily denuded, and seven months afterwards no trace of reproduction 
 was visible. 
 
 t Med. Times and Gaz., 1862, vol, ii. p. 491. 
 
286 OPERATIONS ON THE HEAD AND NECK. 
 
 carried down to the junction of the ala and the lip. Next, the incision 
 is completed by cutting through the nasal bones and the nasal pro- 
 cess of the superior maxilla with bone-forceps. The septum being 
 now divided, the nose is turned up and the posterior part of the cavity 
 exposed. 
 
 (3) Langenbeck's operation through the nose* (Fig. 60). 
 
 In this the polypus is attacked through the upper part of the nose, 
 by the following osteoplastic operation : The soft parts were first 
 divided by an incision reaching from the centre of the root of the nose 
 obliquely downwards and outwards on one side of the nose on to the 
 cheek, and ending at a point external to the ala nasi. The soft parts 
 on the U])per lip of the wound being raised upwards and outwards, a 
 vertical incision was maile upwards through the nasal bone to the 
 nasal spine of the frontal, and a second outwards from the bony mar- 
 gin of the anterior nares to the margin of the orbit. The nasal bone 
 and the nasal process of the superior maxilla were then forcibly dis- 
 placed upwards, together with their periosteum, being still connected 
 with the frontal bone by skin, periosteum, and mucous membrane. 
 
 The polypus, which is stated to liave been of considerable size, was 
 then easily removed, the bones replaced, and the skin united with a 
 few points of suture. The patient made a good recover}-, a lachrymal 
 tistula which formed being closed after some small pieces of bone had 
 exfoliated. 
 
 This method has been used several times successfully. The cases 
 to which it appears to be suited have already been indicated (p. 1285). 
 
 (4) Ollier's operation through the nosef (Fig. 80). 
 
 In this method the nose is, by an incision somewhat like the last, 
 only bilateral, turned downwards. M. Oilier begins his incision at 
 the edge of the bone, close behind the ala of the nose, carries it up- 
 wards along its side to the highest j^art of the dei)vession between the 
 eyes, then across, down to the corresponding point on the other side. 
 The bone is sawn through in the line of the incision, the necessary 
 liberating incisions made in the septum and the sides, and the nose 
 turned down. The septum is pressed aside, the polypus extracted, its 
 base of implantation scraped, and the nose replaced. 
 
 A modification which is sometimes desirable on account of the size 
 of the polypus, or the distance of its nnplantation, is indicated in Fig. 
 79. The incision is made obliquely outwards upon the cheek, and a 
 transverse one is made from each end inwards to the ala of the nose. 
 The bone is divided in the direction of the skin incisions— in the ver- 
 tical one, as before described ; in the horizontal one, by passing a fine 
 
 * Deut. Klinili,4^; Gaz. Bebd., Janunvy 27 , 1800. 
 
 t I :mi indebted for the following bi-ief account of M. Ollier's operation to Dr. Stim- 
 son's Operatim Siirgerii, p. 185. 
 
NASO PHAEYXGEAL POLYPUS. 
 
 28/ 
 
 saw across the nostrils, through holes made between the hone and car- 
 tilages, and sawing outwards. This line of section must lie high 
 enough to avoid the roots of the teeth. 
 
 C. Operations for naso-phiirjjugeal polypus by removal of the vpper jaw : 
 (1) partially; (2) mmpktdy ; or (3) by osteoplastic operation on this bone. 
 
 (i.) Partial Removal of the Upper Jaiv. — These operations are very 
 numerous ; one or two will be given as spieimens. 
 
 (ii.) Complete Removal of the Upper Jaw. — This has already liccn fully 
 considered, p. 273. 
 
 a. Method of Maisonneuve* and Gu^rinf (Fig- 61). 
 
 Dr. Robin Masse {loc. supra cit., p. .51) states that the so-called oper- 
 ation of Maisonneuve is really that of Guerin, with only a modification 
 in the division of the soft parts. The essential point is to get room 
 
 Fig. go. 
 
 Fig. 01. 
 
 Fig. 60. — Langenbeck's operation through the nose, and Eerard's, through the upper part of 
 the jaws, for uaso-pharyngeal polypus. 
 
 Fig. 6]. — The dotted lines show Maisomieuve's operation, the two continuous ones that of Lan- 
 genbeck's osteoplastic operation on the jaw. On the hard palate are the lines of Nelaton's oper- 
 ation. Trephining the frontal sinuses is indicated above. 
 
 for attacking the polypus by removal of the lower part of the jaw. 
 This bone being sufficiently exposed by raising the soft parts over it 
 — and for this purpose the method of Sir W. Fergusson seems superior 
 to those given by the above French surgeons — the hard and soft palate 
 are then divided in the middle line, and the soft detached transversely 
 on the side to be operated upon. The hard palate is next divided in 
 the middle line by saw and bone-forceps, working from the nose into 
 the mouth. By a transverse section with a narrow-bladed saw intro- 
 
 * Oaz. desHop., 21 Aotit, 1860. 
 t Elem. Chir. Oper., 1858, 
 
283 OPERATIONS ON THE HEAD AND NECK. 
 
 duced into the nose, and made to cut horizontally outwards, the facial 
 aspect of the bone is divided as far as the maxillary tuberosity * The 
 lower part of the jaw is then strongly depressed, and thus detached, 
 consisting of the alveolar and palatine processes, a portion of the body, 
 and a varying amount of the pterygoid processes which usually conies 
 away with it. The polypus is then extirpated.f 
 
 b. JNIethod of M. Berard. 
 
 In this the upper, not the lower, part of the jaw is removed, so as to 
 preserve intact the teeth and alveolar process of the palate. The soft 
 parts being raised as before, the bone to l.)e removed is marked out by 
 the incisions shown in Fig. 60. 
 
 (iii.) Osteoplastic Operations on. the Upper Ja/r.—ln this the bone is 
 cut through by various incisions, turned in different directions on 
 some uncut attachments, as on a hinge, and then fitted down again 
 after the removal of the growth. 
 
 Method of Prof Langenlieck| (Fig. 61).— This is one of the best 
 known of the above operaticms. Its object is to get at the polypus, 
 especially one in the ptcrygo-maxillary fossa, without interfering with 
 the alveolar and palatine processes or with the orbital plate. Two 
 semilunar incisions, with their convexities downwards, are made across 
 the facial aspect of the upper jaw, the lower running from the ala of 
 the nose to the middle of the malar bone, the second starting from the 
 nasal process of the frontal and ])assing just below the orbit to meet 
 the first, where this ended. If needful, owing to the extension of 
 growths backwards, the meeting of these incisions may be carried back 
 along the zygoma. Each cut is made down to the bone, but the skin 
 is not reflected. At the outer end of the lower one the masseter is 
 detached from the zygoma, and if the growth has extended out into 
 the zygomatic fossiB it will now come into view on dividing the buccal 
 fascia. Prof. Langenljeclv found at this stage that by pressing the 
 growth to one side and depressing the lower jaw, he coidd pass his 
 finger through the pterygo-maxillarv fissure into the spheno-maxillary 
 fossa, and so on through tlic spheno-palatine foramen into the nose, 
 all these parts being enlarged liy tlie pressure of the growth. By 
 means of a narrow straight saw, introduced the same way, the upper 
 jaw was cut through hurizontally from behind forwards, while a fore- 
 finger jaassed by the mouth kept the tip of the saw fit)m striking 
 
 * This section slioiild piss al)o\'e tiio roots of tlie teeth and well below the infra- 
 orbital foramen. Acenrately speaking, it was mainly performed, in the hands of its 
 introducers, wiih Ijone-forceps. 
 
 f Dr. Sands appends to his paper a photograph of the patient on wliom he had 
 operated by this method, after failing to remose the polypus by the plan of M. N^la- 
 ton. Tlie deformity is very sliglit, the malar prominence and the fulness of the chee 
 being well preserved. 
 
 X Deals. Klin., IStil, p. 281 ; and Schmidt's Jahrb., vol. cxiii. p. 198. 
 
NASO-PHAEYKGEAL POLYPUS. 289 
 
 against the septum nasi. The saw was now applied along the upper 
 incision so as to divide the zygoma, the frontal process of the malar, 
 and the upper jaw, just below the orbit, up to the inner end of the in- 
 cision. The portion of the upper jaw thus marked out now only 
 remained attached, at its inner part, to the nasal bone and nasal pro- 
 cess of the frontal. Upon these connections, as upon a hinge, the 
 piece of bone was slowly raised by means of an elevator introduced 
 under the malar bone, upwards and inwards, until the malar bone was 
 nearly in the middle of the face. The growth was now completely 
 exposed. The operation took an hour, and was attended with much 
 haemorrhage, most of which stopped spontaneously. The wounds 
 healed well, a tendency of the bone to rise being met by pressure. 
 
 At the present time any surgeon making use of the above operation 
 would wire the bone when fitted down. I would suggest, too, that 
 the incisions through the bones might, perhaps, be more easily made 
 with an osteotome and mallet, especially in cases where, the deep 
 parts at the back of the jaw being not so much dilated as in Prof. 
 Langenbeck's case, it is difficult to manipulate a saw and to cut from 
 behind forward. 
 
 Prof Langenbeck's patient was a lad of fifteen. The growth could 
 be felt by the finger in the mouth, filling up the posterior nares on 
 the left side, passing out between the masseter and maxilla; and on 
 this side, too, the zygoma appeared more jDrominent, and the temporal 
 fossa more full. 
 
 This operation seems well suited to growths in the pterygo-maxil- 
 lary fossa. Its drawbacks seem to be that, (1) if the upper jaw has to 
 be sawn from behind forwards, this cannot be done easily unless the 
 fossffi at the back of the jaw and the spheno-palatine foramen are 
 much dilated ; (2) if the growth is mainly limited to the naso-})harynx, 
 this region will not be well exposed unless the pterygoid process is 
 removed as well ; (3) very disfiguring scars are left. 
 
 Other osteoplastic operations have lieen described bearing the names 
 of von Bruns* of Tubingen, in which the whole nose is turned over 
 to one side, and that of Roux f of Toulon, in which the whole upper 
 jaw and malar bone, together with the soft parts which cover them, 
 are turned outwards and upwards on to the temple. The former is 
 said to have been performed three times successfully,! but I have been 
 
 * Bed. Klin. Woch., Nos. 12 and 13, 1872; Syd. Soc. Bien. Retr., 1871-1872, p. 235. 
 
 t Oaz. des Hop., 1861. p. 354; Syd. Soc. Bien. Retr., 1862, p. 296. 
 
 J In-tlie Berl. Klin. Woch., April 27, 1874 (Syd. Soc. Bien. Ret,:, 1873-1874), is the 
 report of a case operated on by von Brnns's method, in which, after raising half of the 
 nose, there was so ranch bleeding that it was needful to ping the part and to defer the 
 operation for two days. The operation was then completed, and liq. ferri perch, 
 applied to the stump of the pedicle. There was no recurrence six months later. 
 
 19 
 
290 OPEKATIONS ON THE HEAD AND NECK. 
 
 unable to learn how far the success was really permanent. M. Roux's 
 operation has not, I believe, been performed on the living subject, the 
 patient for whom it was planned refusing to undergo an operation. 
 M. Huguier, * having raised the soft parts off the facial aspect of the 
 upper jaw, divided this bone horizontally from the maxillary tuber- 
 osity to the anterior nares ; an incisor tooth was then drawn, and the 
 hard palate notched with the saw on the left side of the septum. The 
 base of the pterygoid process being cut through, the lower part of the 
 jaw (detached from the other bones except towards the middle line, 
 where it is still held by the soft parts covering the two surfaces of the 
 hard palate and by part of the alveolar process) is dislocated down- 
 wards and to the opposite side, within the mouth, by means of a chisel 
 used as a lever and by means of a ligature passed through the nose 
 and out of the mouth by a Belloc's sound. The polypus was well 
 seen adhering extensively to the basilar process, back of the pharynx, 
 and base of the left pterygoid process. Up to this stage there had 
 been little bleeding, but frightful htemorrhage took place on removing 
 the polypus with gouge and scissors. The patient made a good 
 recovery, being able to masticate, swallow, and speak without the 
 least difficulty. 
 
 Dr. Chevers,t of Boston, performed the following osteoplastic opera- 
 tion on both the upper jaws at the same time : Having dissected up 
 flaps on either side by incisions such as Fergusson's, so as to expose 
 the bones as far as the malar prominences, the facial surfaces of the 
 bones were divided by horizontal incisions resembling those of Mai- 
 sonneuve from the middle meatus outwards to a point below the 
 zygomata. The seiJtum and the vomer being divided with strong 
 scissors, the lower parts of the jaws were depressed, moving on their 
 attachments to the pterygoid processes as upon a hinge. The growth, 
 resembling a large lemon attached to the ethmoid and body of the 
 sphenoid, was then removed partly with the finger and partly with 
 the scissors and gouge. The depressed bones were wired in position. 
 The patient, who seems never to have really rallied, died on the fifth 
 day. 
 
 The Choice of an Operation for Removal of Naso-pha- 
 ryngeal Polypus. — The relative values of several of the above 
 operations have already been brieliy given. The surgeon will have 
 to weigh duly the following : On the one hand, the desire to get the 
 growth away with as little mutilation and danger to his patient as 
 possible, and, on the other, the fact that these growths are most cer- 
 tainly malignant in nature, and that any partial operation, while 
 
 * Gaz. des H6p., 1861, p. 337. 
 
 f 3Ied. and Surg. Repa. of the Boston City Hospital, 1870. 
 
NASO-PHARYXGEAL POLYPUS. 291 
 
 probably as difficult and as bloody as one on a larger scale, will, if 
 incomplete, be certain to lead to increased growth in the tumor by the 
 irritation which it causes, while for naso-pharyngeal polypi which 
 come early under treatment, in which the growth is of moderate size 
 {i.e., not larger than a hen's egg), with a pedicle situated well forward 
 in the roof of the pharynx or within easy reach from the posterior 
 nares, especially polypi which can be made out to occupy chiefly the 
 region of the nose, such operations as those of Lawrence, Nekton, or 
 the first one of Langenbeck's may be made use (if 
 
 In cases of greater difficulty, from the longer duration, more 
 extensive attachments, larger size, and, with this last, the certainty of 
 a more extensive pedicle and numerous large sinus-like vessels, the 
 question of deformity and disfigurement must be entirely set aside * 
 In order to secure adequate space for making certain of all the attach- 
 ments of the tumor, for eradicating these, and, at the same time, 
 satisfactorily meeting the haemorrhage which is usually inevitable, a 
 freer removal of bone will be required. No doubt, for this purpose, 
 removal of the upper jaw would be the best preliminary step. Every 
 surgeon who has performed this operation knows how free is the 
 access which it gives to the back of the nose and to the pharynx. A 
 further advantage, pointed out by Dr. Sands, is the following, that, 
 owing to the wide gap left by this operation, recurrence of the disease 
 can be more readily recognized and treated than after an osteoplastic 
 operation. 
 
 But while willingly admitting the great advantages which removal 
 of the upper jaw gives for free exposure of the growth, I cannot quite 
 agree with Dr. Sands,t who recommends this step on the ground that 
 " excisions of the upper jaw are, as a class, remarkably successful 
 operations." On the contrary, I should look upon this as a distinctly 
 serious and grave operation, J especially in patients who, though 
 young, often come before the surgeon with strength reduced by ha?m- 
 orrhages, dysphagia, and dysjjncea, especially when this is accom- 
 panied by attacks of choking interfering with sleep, etc. On this 
 account I should prefer to try and get at the growth by some partial 
 resection of this bone, as by the method of Maisonneuve, aided, if 
 need be, by cutting away the pterygoid process and septum § if need- 
 
 * I may again remind tlie reader that these naso-pharyngeal polypi usually occur 
 in males, often in lads or young adults. The growth of hair wliich can usually be 
 secured in these cases lessens to a considerable degree the amount of disfigurement 
 which operations on a larger scale entail. 
 
 t Xoc. aapra cit., p. 516. 
 
 X See the remarks on the mortality of removal of the upper jaw, p. 277. 
 
 ^ So as to expose completely any outlying attachments in the pterygoid and zygo- 
 matic fossse, and to get full access to the pharynx and nose. 
 
292 OPERATIONS ON THE HEAD AND NECK. 
 
 ful, only resorting to more complete removal when the partial 
 operation does not give sufficient room. 
 
 Dangers and Drawbacks of Osteoplastic and other 
 Operations for Naso-pbaryngeal Polypus.— Many of these 
 have been already given under the head of removal of the upper jaw, 
 p. 276; other ones, more particularly to be expected here, are: 
 
 1. Hajmorrhage, not from large arteries, as the internal maxillary, 
 but from the sinus-Hke veins in the growth itself. To meet this 
 inevitable risk a preiiminary laryngotomy should be performed, and 
 the fauces plugged with sponge. 
 
 2. Meningitis, from damage to the base of the skull (p. 280), or 
 from inilammation spreading to the membrane of the brain. 
 
 3. Necrosis and exfoliation. 
 
 4. Non-union of the temporarily resected fragment. 
 
 TAPPING THE ANTRUM. 
 
 This operation is from time to time required for suppuration in the 
 antrum, nearly always in adults, and most frequently after alveolar 
 abscess. 
 
 It may be performed in either of the following ways : (i.) Through 
 the alveolar process, (ii.) Through the facial aspect of the upper 
 jaw, above the alveolar process. 
 
 (i.) Throvgh the Alveolar Process. — This method has the following 
 advantages : (a) It drains the cavit}' at the most dependent part. 
 (/J) By withdrawal of the tooth at the same time it removes the cause 
 of the trouble, (y) It does not involve any cutting. 
 
 The disadvantage connected with this method is, that, unless special 
 precautions are taken, food tends to enter the antral cavity by the 
 opening made by this method. 
 
 A tooth has usually to be first drawn, and, as long ago pointed out 
 by Mr. Salter,* "the tooth whose fangs are most intimately connected 
 with the antrum is the first permanent molar ; f and its removal in a 
 case of antral abscess, is especially indicated from this circumstance, 
 and from the frail and perishable nature of the tooth itself, which 
 gives it less often than other teeth a long tenure of usefulness." This 
 being done, the orifice made should be enlarged by pushing a trocar 
 up through the alveolus. In doing this the trocar, closed, should be 
 of sufficient size to ensure a free orifice, and, in driving it up through 
 the lione, care should be taken that when it enters the antrum, it 
 should not plunge against and perforate the orbital plate. 
 
 * Sysl. of Surg., vol. ii. p. 467. 
 
 t Any other tootli, ;is Mr. Salter advises, molar, bicuspid, or canine, whose disease 
 is possibly (he cause of the abscess, will, of course, be exU'acted, as absorption round 
 any carious tooth facilitates perforation of the alveolus. 
 
REMOVAL OF THE LOWER JAW. 293 
 
 (ii.) Above the Alvcolur Process. — If the offending tooth has already- 
 been extracted, perhaps a long time before, if the alveolar process is 
 largely absorbed, or its remains condensed, it will be preferable to 
 make the opening above. This may be effected by everting the cheek, 
 incising the mucous membrane, and thus exposing the bone above 
 the position of the second molar tooth, and then perforating here 
 with a gimlet, drill, stout trocar, or, as Sir B. Brodie suggested, with 
 a strong pair of scissors, held closed in the hand and bored into the 
 bone with a twisting movement. 
 
 Where the bone is much condensed, the instrument used in per- 
 forating will be held so tightly that the surgeon will need to withdraw 
 it once or twice and use a probe before he can make certain of having 
 opened the antrum. 
 
 The antrum having been opened by one of the above methods, the 
 chief objects to be held in view are, getting and keeping sweet the 
 cavity of the antrum and preventing any food making its way in here, 
 while at the same time the artificial opening is kept patent. 
 
 To ensure these ends frequent syringing tlirough a gum elastic 
 catheter or an Eustachian catheter must be made use of, the lotion 
 used being mercury perchloride, carbolic acid, iodine tincture, potas- 
 sium permanganate — the lotion itself not being of so much importance 
 as the assiduous frequency with which it is used. After a while, 
 when the discharge is no longer offensive, and no inspissated putty- 
 like stuff comes away, some such astringent as silver nitrate (gr. 1 or 
 2-lj) may be used.* 
 
 To prevent the entrance of food, and at the same time to keep the 
 opening patent, a short tube should be worn, let into a plate fitted 
 over the perforation. Through this tube the patient can readily 
 syringe out the cavity and by the insertion of a small plug of cork at 
 meal-times the entrance of food can easily be prevented. When 
 there is no longer any need to keep the artificial opening patent, re- 
 moval of the short tube and soldering up the hole which held it, will 
 facilitate the closure of the antral opening by excluding air, saliva, 
 etc. If the complete closure is still tardy, it may be hastened by the 
 careful application of the cautery. 
 
 REMOVAL OF THE LOWER JAW, PARTIAL OR 
 COMPLETE. 
 
 Indications.— These are much the same as those already fully 
 given for removal of the upper jaw, p. 267. Mr. Butlinf has recently 
 
 * Tlie patient should be warned at the commencement how very tedious tliese cases 
 are, and told of the need of persevering and patiently prolonged treatment, 
 t Oper. Treat, of Mali g. Dis., p. 137. 
 
294 OPERATIONS ON THE HEAD AND NECK, 
 
 treated of these growths, and has pointed out that here great differ- 
 ences are observable between the central and sub-periosteal sarco- 
 mata. Thus the central (most often myeloid) sarcomata grow slowly, 
 the sub-periosteal quickly ; the former are cncapsuled, and even when 
 they make their way into the surrounding structures they do not 
 show that tendency to infiltration which is so marked in the sub- 
 periosteal sarcomata. The central ones are rarely associated with 
 affection of the lymphatic glands, or with secondary growths. 
 The following operations will be considered : 
 
 A. Partial removal of the lower jaw. 
 
 B. Complete removal of one-half of the lower jaw (Fig. 62). 
 
 C. Complete removal of the jaws, upper or lower. 
 
 A. Partial Removal of the Lower Jaw.— This is frequently 
 
 required in cases of epulis. The steps are the same as those given 
 already at p. 268. The alveolar border should always be removed ; 
 in the case of a growth very far back around the lower molars it is 
 quite justifiable to slit the cheek, especially if the growth is becoming 
 doubtful in character, and thus requires thorough extirpation. 
 
 The above remarks still more hold good in the case of a growth 
 about the gums, situated far back in an older patient, and becoming 
 epitheliom atous . 
 
 Cases are occasionally met with where, owing to an epithelioma of 
 the lip not having been treated, or to its recurrence, the symphysis of 
 the jaw is infiltrated and requires removal. The soft parts being re- 
 flected by incisions on either side of the diseased parts converging 
 towards the hyoid bone, and the vessel secured, the bone is sawn 
 through in two places* well beyond the level, where its softened, 
 spongy state, and the loosened teeth, show that it is invaded. The 
 tongue, prevented from falling back by a loop of silk passed through 
 its tip, is now detached liy snipping through the mucous membrane, 
 and the muscles attached to the genial tubercles. Any further haem- 
 orrhage being looked to, the sub-lingual sub-maxillary glands are 
 examined, and, together with any enlarged lymphatic glands, re- 
 moved if needful ; flaps are dissected up from the neck to make a 
 new lip (p. 316, Figs. 72, 73), and drainage provided, the tubes being 
 brought out below at the lowest level of the region from which the 
 flaps have been dissected up. The adjustment of these to form the 
 new lip will be the more easy in proportion to the amount of bone 
 which has been removed. 
 
 * Mr. Heath {Dirt, of Surg., vol. i. p. 839) gives the following practical hint with 
 reference to diviiling the jaw in two place.s: "In making these sections it is better not 
 to complete one before the other is begun, because of the loss of resistance consequent 
 upon breaking the [•(intiuuitv of the bone, but each cut being carried nearly through 
 the bone with the saw may be conveniently finished with the bone-forceps." 
 
REMOVAL OF THE LOWER JA\V^. 295 
 
 So, too, occasionally in epithelioma of the angle of the jaw, primary 
 or secondary to that of the tongue, the surgeon may be led, in order 
 to relieve his patient's condition, if he cannot cure him, to operate 
 extensively here. Thus, after turning up a horseshoe-shaped flap, 
 with the concavity upwards, and clearing the masseter off the jaw, 
 this bone is divided above the angle, then through the horizontal 
 ramus, and removed, together with the sub-maxillary, sub-lingual, 
 and lymphatic glands, which will probably be enlarged, and also ad- 
 herent. The hemorrhage will certainly be free from the facial and 
 lingual vesssls, and veins communicating with the external jugular. 
 Free drainage must be provided. 
 
 Removal of part of the horizontal ramus or of the angle is some- 
 times called for in cases of new growths which are limited to these 
 parts, and the surgeon may, especially in the cases of women, ask how 
 far it is worth while to try and remove these from the mouth, detaching 
 the soft parts with a raspatory, and sawing the bone in front and be- 
 hind the growth, as in the case of an epulis, but the section here pass- 
 ing through the whole thickness of the jaw. Mr. Maunder on two 
 occasions removed large portions of the bone in this way. The follow- 
 ing remarks of Mr. Heath* should be carefully considered before the 
 surgeon, for the sake of saving a scar which will be very httle noticed, 
 undertakes a much more difficult operation, and one which, owing to 
 the limited space it gives, may tend to his working dangerously near 
 the growth : " The principal difficulty in these operations was not so, 
 much the separation of the tumor, as its 'delivery ' through the mouth, 
 which was slightly split in one instance. Fortunately the hajmor- 
 rhage in both cases was slight, and the patients did well ; but another 
 surgeon was less fortunate, and lost his patient by secondary hajmor- 
 rhage, but, considering the close proximity of the facial artery, and 
 the necessary division of the inferior dental artery, this is not to be 
 wondered at. It may be doubted if the extra trouble and risk of the 
 proceeding are balanced by the absence of a scar, whicli, in the ma- 
 jority of cases, need not involve the lip, and, if properly placed, will 
 be nearly invisible afterwards." 
 
 Qiiextion of Removing a Portion or the Whole of One Lower 
 Jaw. — This matter will have to be decided when the surgeon, having 
 a case of growth before him which involves the horizontal ramus as 
 far back as the angle, is in doubt as to whether to saw through the 
 horizontal ramus or to disarticulate. In the great majority of cases, 
 especially where the patient is no longer young, where the growth is 
 not a central one, where it has been attacked before, the operator had 
 much best place his patient and himself on the safe side and disar- 
 ticulate. The lower jaw being " a floating bone," this radical step 
 
 * Diet, of Surg., vol. i. p. 837. 
 
296 
 
 OPBRATIOXS ON THE HEAD AND NECK. 
 
 often gives a better prognosis for operation here than in the case of 
 the upper jaw. On the other hand, the lower jaw is so imbedded in 
 soft parts, and so near to important parts — e.g., pharynx and ptery- 
 goid fossa;— that delay may render the extirpation of the growth im- 
 possible. I would refer my readers to two cases in which, after par- 
 tial operations, even in Mr. Heath's hands (Hunt. Lects., Brit. Med. 
 Journ., June 18 and July 2, 1887) fatal extension and recurrence of 
 the growth took place. 
 
 B. Removal of Half of the Lower Jaw (Fig. 62).— The 
 
 patient's shoulders being supported and a preliminary laryngotomy 
 performed if the growth is so vascular as to make plugging of the 
 fauces a wise precaution, the surgeon, standing usually on the same 
 side, makes an incision from just lielow the lip* down through the 
 tissues on the side of the chin, then along ai.d below the border of the 
 lower jaw to the angle, and then upwards as high as the lobule of the 
 ear. The finger of an assistant is placed on the facial artery as soon 
 as it is cut in this incision, and when it is completed the ends should 
 be tied or twisted at once. The flap thus marked out is raised up- 
 wards, the masseter going with it if sound, and the cavity- of the mouth 
 opened by dividing the buccal mucous membrane at its junction with 
 
 the alveolar border. An incisor 
 being extracted if needful, the jaw 
 is divided to one side of the syra- 
 I)hysis well in front of the growth, 
 b^' means of deeply notching it with 
 the sawf before using the bone-for- 
 ceps. If it lie needful to remove 
 tlie bone so freely that the sjanphy- 
 sis and the genial tubercles are re- 
 moved also, the tongue must be 
 carefully previented from falling back 
 upon the hnynx by means of a loop 
 * of stout silk passed through the tip. 
 
 The bone being divided and pulled outwards the knife is passed along 
 the inner side of the jaw so as to detach the mylo-liyoid, with perhaps 
 the digastric and the mucous membrane, and at the angle, the inter- 
 
 FiG. 62. 
 
 * If tliere are reasnns for especial speerl, siicli as the condition of the patient, or if 
 the growth is very large, the red border shonld be divided, as this facilitates matters 
 ninch, and the additional deformity is very slight. 
 
 t When the condition of things admits of it, the jaw should always be divided as 
 far from the symjihysis as possible, in order to preserve (he anterior belly of ihc di- 
 gastric and its insertion, which will thns counteract the tendency of the innscleson the 
 opposite side to draw the chin somewhat over. It is convenient to be provided with 
 a saw with a movable back. 
 
EEMOVAL OF THE LOWER JAW. 297 
 
 nal pterygoiil. In doing this tlie knife should be kept very close to 
 the line so as to fcave behind the sub-maxillary gland. 
 
 The anterior half of the jaw lieing thus freed, the surgeon, taking it 
 in his left hand, everts it so as to divide the internal pterygoid more 
 freely, and also the inferior dental nerve and vessels. The jaw is next 
 strongly depressed so as to bring down the coronoid process, and the 
 insertion of the temporal muscle. This strong tendon requires com- 
 plete division, as depression of the bone brings fasciculus after fasci- 
 culus into view. If the coronoid jjrocess is very long it may hitch 
 against the malar bone or be jammed against it l)y the bulk of the 
 tumor: in such case it had l)etter be cutoff with bone-forceps, and, 
 after the removal of the growth, dragged down with sequestrum-for- 
 ceps and removed. After the temporal tendon is thoroughly detached* 
 strong depression of the jaw is continued so as to bring the condyle 
 within reach, no eversion or rotation outwards of the bone being per- 
 missible at this stage of the operation, or the internal maxillary artery 
 which passes between the neck of the jaw and the internal lateral lig- 
 ament will be brought into the wound, and very likely cut, causing 
 profuse and troublesome hemorrhage. The inferior dental nerve and 
 vessels being divided, and the external pterygoid fibres partly torn 
 through with the finger or the director, the capsular ligament is 
 opened in front with the careful use of the point of the knife, which 
 next, kept close to the bone, divides the lateral ligaments, when the 
 jaw comes away, the final operation being usually effected by the re- 
 maining fibres of the external pterygoid being torii through, together 
 with the stylo-maxillary ligament and the periosteum to which it is 
 attached. The knife, if it is required here, should be kept very closely 
 in contact with the posterior border of the ascending ramus. 
 
 If the internal maxillary artery has been divided, which is some- 
 times excusable in cases of large growths extending far up, it can be 
 readily secured in the large wound. 
 
 If the operator finds the vertical part of his incision insufficient, 
 and yet does not like to prolong it for fear of damaging the chief part 
 of the seventh nerve, the soft parts should be forcibly dragged up- 
 wards with a retractor, after being pushed upwards with the handle of 
 the scalpel. 
 
 In cases where the jaw has been extensively thinned or eroded by 
 growth, it is very likely to fracture under the depression which is re- 
 quired to bring down the condyle. If this accident occur, removal of 
 the condyle and coronoid process is rendered difficult, as the latter is 
 drawn upwards under the zygoma by the temporal muscle. Their 
 removal will be facilitated by dragging them down with lion-forceps 
 and detaching the temporal tendon with blunt-pointed scissors. 
 
 * When this is effected the jaw comes down more easily. 
 
298 OPEEATIONS OX THE HEAD AND NECK. 
 
 All hajmorrhage being arrested by ligature or spgnge-pressure, the 
 flap is brought down and adjusted with one or two points of silver 
 suture and sutures of horsehair, gut, or carbolized silk, drainage being 
 first provided for by bringing a drainage-tube from the neighborhood 
 of the condyle through the wound below. 
 
 Especial care must be iaken in exactly uniting the red line of the lip 
 if this has been divided. 
 
 The wound is then dressed, as at p. 275, and the patient here also 
 should be propped up to facilitate escape of the discharges. 
 
 Difficulties and Possible Mistakes during the Operation. 
 
 1. Slipping back of the tongue, if the symphysis has been re- 
 moved. 
 
 2. Wound of the pharynx by not keeping the knife close to the bone 
 in separating the soft parts from the angle of the jaw. This interferes 
 with the patient's being able to swallow from the very first. 
 
 3. Fracture of the jaw. 
 
 4. Jamming of the coronoid process. 
 
 5. Rigidity and permanent contraction of the temporal, masseter, 
 etc. 
 
 6. Wound of the internal maxillary vessels. 
 
 C. Operations for Complete Removal of Both Jaws. 
 
 Before leaving the subject of removal of the jaws, a few words may 
 be said of those rare cases which occasionally call for removal of both 
 the upper, or the whole of the lower jaw. My space does not admit 
 of my doing more than giving brief references to a few cases. The 
 chief conditions calling far such extensive operations are phosphorus 
 necrosis in the case of the upper or lower jaws. The diminishing fre- 
 quency of this disease is well known ; where the whole of the upper or 
 lower jaw requires removal, half should be taken first, and the opera- 
 tion should be conducted, as far as possible, sub-periosteally and with- 
 out skin incisions. 
 
 The growths which call for removal of both upper jaws, simultane- 
 ously, fall mainly under the two heads — (a) Epithelioma of the palate 
 and alveoli involving one or both of the antra.* (/J) Growths, usually 
 sarcomatous, springing often from the base of the skull or some part 
 of the naso-pharynx, and projecting forwards the jaws with hideous 
 deformity .f These cases are much less favorable than the epithe- 
 liomata. 
 
 In either case the parts are exposed by slitting the centre of the 
 upper lip and then carrying the incision round the nose on either side, 
 Fergusson's incision being made use of as far as needful. After the 
 
 * Godlee, Clin. Soc. Trans., vol. x.\. p 260. 
 
 f Lane, Lancet, January 25, 1862; Dobson, Brit. Med. Journ., October 11, 187.3. 
 
REMOVAL OF THE LOWER JAW. 299 
 
 full account already given of renaoval of the upper jaw no description 
 need be given of these operations for removal of both halves simul- 
 taneously. The greater risk of shock, the liability to more profuse 
 hfemorrhage, the probability of finding the growth extending far back 
 into the different fossa?, and along the base of the skull, are obvious. 
 Later on, if the patient make a good recovery, the help of a dentist 
 will be much needed in fitting some form of obturator, as articulation 
 is now much more imperfect. 
 
 Question of Gouging, etc., in preference to Partial Re- 
 moval of the Jaw. 
 
 The treatment of dentigerous cysts, if simply cystic and uncompli- 
 cated by growth, by measures short of removal of part of the jaw, has 
 already been given (p. 270). The same treatment will suggest itself 
 in other cases, especially those cases of cystic disease, more common 
 in the lower than in the upper jaw, the multilocular variety of which 
 will perhaps be known for the future, in Mr. Eve's words,* as cystic 
 epithelial tumors. 
 
 The treatment of cystic tumors of the jaw, whether single or multi- 
 locular, has usually been extraction of any teeth which are in the way, 
 freely opening up the cyst by cutting away part of its walls, turning 
 out its contents, and then obliterating it thoroughly by vigorously 
 gouging wide of the disease. 
 
 Any surgeon proposing to make use of this method, in preference 
 to more radical means, should weigh thoroughly the sentences with 
 which Mr. Heath closed his Hunterian lecture on this subject. " I 
 have now treated a considerable numlier of simple and multilocular 
 cysts by Mr. Butcher's method,t and, as has been noted, with recur- 
 rence in at least two of the latter. Air. Butcher does not appear to 
 have met with further trouble in his cases, and this may depend upon 
 his carrying out the gouging fearlessly and far wide of the disease." 
 I should, in future, be guided by the age of the patient, and the 
 amount of the solid material found in the cysts. In young persons 
 with cj'sts having fluid contents and little growth in the bone, I 
 should be still inclined to adopt palliative measures, and to gouge 
 very freely, carefully watching the case with a view to a more radical 
 proceeding, should further development take place. In cases of much 
 solid deposit in connection with multilocular cysts, and still more in 
 
 * Mr. Eve (Brit. Med. Journ., January 6, 1883) believes that many of these cysts 
 are produced by an ingrowth of the epithelium of the gum. 
 
 t I.e., by cutting away the expanded bone freely and tlien using the gouge. In Mr. 
 Butcher's words: "the proceeding according to this plan is troublesome and difficult, 
 but its value to the patient in having no deformity left is priceless." A caution is 
 given respecting the facial artery, which might without care be divided from within 
 the mouth in a position where it would be very difficult to secure it (p. 295). 
 
300 OPERATIONS ON THE HEAD AND NECK. 
 
 solid tumors with one or more large cysts, there should, I think, be no 
 doubt as to the removal of one-half or more of the lower jaw, or of any 
 portion of the upjDer jaw * involved. 
 
 OPERATIONS TO RELIEVE FIXITY OP THE LOWER 
 
 JAW. 
 
 The above condition may be due either to changes in the temporo- 
 maxillary articulation resulting in ankylosis, or to cicatricial bands 
 between the jaws, or to both. 
 
 Operations. — The two usually performed are : 
 
 (i.) Excision of the condyle, an operation indicated when the mis- 
 chief is limited to the joint itself. 
 
 (ii.) Esmarch's operation of removing a wedge of bone from the 
 horizontal ramus in front of the cicatrices and masseter, this operation 
 being preferable to the first when scars are present wliich interfere 
 with excision of the condyle. 
 
 Conditions justifying One of the Above Operations.— 
 Inaliility to open the mouth, resisting the use of wedges, etc. Foetor 
 of sahva and breath. Difficulty of speech. Inability to eat solid 
 food. The above are brought about by the following causes, which 
 will be enumerated together here, though some call for one of the 
 above operations and some for the other — viz. : 
 
 1. Inflammation of the joint set up by a punctured wound,t gonor- 
 rhoeal arthritis, severe contusion X or sprain, osteo-arthritis, or suppu- 
 
 * Mr. Lawson brought befure the Cliiiiciil Society (Tra-ns., vol. vi. p. 20) the case of 
 a man, aged sixty-five, in which he succeeded, by excision and application of zinc- 
 chloride paste, in extirpating an epitheliomatoiis growth of the upper jaw fnngating 
 through the skin of the face. The growth recurred Hvice during convalescence, and 
 on each occasion an anfesthetic was given, and the actual cautery and the zinc-chloride 
 paste applied. Mr. Lawson points out — (1) that patients advanced in life stand large 
 cutting operations, such as tlie complete removal of the upper jaw, very badly, whilst 
 they will bear with but little shock (he destruction of large growths by escharotics; 
 (2) that the treatment was accompanied with very little pain; (3) that the deformity 
 produced by such an operation is nuich less than that after an equally efficient opera- 
 tion by the knife which would have involved cutting widely of the growth. It is to be 
 regretted that no details are given of how the growth was e.tclsed, nor of how much 
 of the bone was removed. Fm-thermore, the report is only carried on four months 
 after the patient's leaving the hospital. 
 
 f Cf. Mr. Hilton's case (Res^l and Pain. p. 114), in which bony ankylosis of this 
 joint, and of the upper cervical vertebra', seemed to date to a pnnctured wound in the 
 neck. 
 
 X Mr. Heath [R.O.S. La-is., 1SS7, vol. ii. p. 114). mentions a case in which ankv- 
 losis of the temporo-maxillary joint followed on a kick from a horse on the side of the 
 face. 
 
FIXITY OF THE LOWER JAW. 301 
 
 rative arthritis, from abscesses burrowing into the joint, e.g., abscesses 
 connected with otitis media. 
 
 2. An unreduced dislocation in whicli much stiffness remains after 
 attempts at reductions have failed in a patient healthy and not 
 advanced in life. 
 
 3. Cicatrices after sloughing set up by scarlet fever, measles, typhus, 
 cancrum oris, or mercurial stomatitis. 
 
 4. Cicatrices after suppuration due to necrosis or alveolar a1)seess. 
 Excision of the Condyle.— This operation is indicated when 
 
 the mischief is limited to the joint itself, as in the first two conditions 
 given above. 
 
 It may be performed as follows : 
 
 An incision about 1} inch long is made on a level with the tragus 
 along the lower border of the zygoma. The parotid and branches of 
 the facial nerve being drawn down, the masseter fibres are cleared 
 away from their insertion with a narrow elevator, and the joint ex- 
 posed. The neck of the condyle is now sawn through with a fine saw, 
 or divided with an osteotome, and the condyle turned out with an 
 elevator. The bone, which must not be splintered, may require fur- 
 ther paring down, and the operation need repeating on the opposite 
 side before sufficiently free movement is regained. After the operation 
 the mouth should be opened with a gag to a full inch, more if pos- 
 sible, and this should be frequentlj' repeated, and the case watched 
 most carefully owing to the frequency with which relapses take place.* 
 
 Prof. Humphry f made use of the following method in a woman, 
 aged twenty-one, many years ago. The case was one of osteo-arthritic 
 
 * 1 may here quote some remarks made in my article ''On Injuries of tlie Face ' 
 {Syst. of Surg., vol. i. p. 728) when discussing the causes of the early and marked 
 fixity of the jaw after an unreduced dislocation. " It is more probable that the dis- 
 placed coronoid process and the neighboring parts of the ramus become quickly 
 imbedded in inflammatory products, wliich, in this region especially, are so rapidly 
 effused, and whicli here so soon undergo at least partial organization, leading perhaps 
 not only to fixity of the displaced condyle and coronoid process, but also to filling up 
 of the glenoid cavity. This consolidation of efTused inflammatory products will be 
 hastened by the patient, owing to the pain, keeping his jaw as quiet and fixed as 
 possible." 
 
 t A Report of Some Cases of Operation. Pamph. 1856. Some interesting cases of the 
 same kind (one occurring in a woman aged thirty), with figures, are given by Mr. 
 Heath (loc. supra cit., July 9, 1887). Two other modes of treatment are here given— 
 viz., subcutaneous division of the adhesions between the condyle and glenoid cavity, 
 as practiced by Mr. Spanton with good results in two cases ; and divisio'u of the ascend- 
 ing ramus beneath the masseter by a saw introduced from the mouth by means of a 
 small incision immediately above the last molar tooth, a director being first passed to 
 clear the way. Mr. Heath had found this operation give satisfactory results in one 
 case. 
 
302 OPERATIONS ON THE HEAD AND NECK. 
 
 alteration of the right condyle, pushing the jaw to the left, and caus- 
 ing most annoying deformity with crepitus in mastication : 
 
 A curved incision was made from the side of the orbit across the 
 zygoma to the ear, a little below the temporo-maxillary joint, and a 
 second from the end of the first directly upwards in front of the ear, 
 over the zygoma again, cutting carefully to avoid the temporal artery. 
 The flap being reflected, the condyle was brought into view, and the 
 bone divided with a narrow saw, cutting from before backwards. 
 This was prolonged, as the bone was hard and the space to work in 
 confined. When the condyle had been turned out with bone-forceps, 
 it was found that the section had passed through the condyle, and 
 thus, owing to insufficient removal of bone, the jaws could not be 
 brought into apposition. The bone was accordingly sawn a second 
 time, through the neck, and all the condyle and the external ptery- 
 goid removed. The jaws could now be brought into much better 
 position. The facial nerve and the temporal artery were not cut. The 
 deformity was almost entirely removed, and the patient was enabled 
 to masticate without inconvenience. 
 
 Esmarch's Operation. — Where the fixity of the jaws is brought 
 about by cicatrices within the mouth rather than by mischief limited 
 to the joint, removal of a wedge-like piece of bone is to be preferred. 
 
 An incision 2 or 21 inches long is made along the lower border of 
 the jaw in front of the masseter and cicatrices, and a wedge removed 
 with a narrow saw and bone-forceps. The sections should be made 
 as cleanly as possible to avoid risk of necrosis, and the periosteum 
 should be removed with the bone. The wedge should measure at 
 least IJ inch below and f inch above,"^ and it must be taken from a 
 part entirely in front of any cicatricial tissue. 
 
 Owing to the tendency to relapse,t j^assive and active movements 
 should be made use of early, and, at first, if needful, with the aid of 
 an ana?sthetic. 
 
 Dr. MaasJ relates the following case: A man, aged twenty-seven, 
 suffered from immobility of the jaw, dating to scarlatina at the age 
 of seven. Secondary dentition had been attended with great diffi- 
 culty in the removal of the first teeth, the permanent ones being 
 irregularly developed, and mostly displaced laterally. There was not 
 
 * In two of Mr. Heath's cases the wedge removed inchided the mental foramen. 
 
 f This relapse is more likely if the wedge is not removed well in front of all cica- 
 trices. Thus Mr. Henth {Dis. and Iiij. of the Jaws, p 332) found, two years after 
 Esmarch's operation fur complete closure of the jaws, that the interval between the left 
 molars had diminished from ^ to | inch, and that between the lateral incisors from 
 I to I inch. Mr. Heath thought that in this case he had not been sufficiently careful . 
 to make the bone section entirely in front of the cicatrices. 
 
 J Arch. f. Klin. Ohir., Bd xiii. Heft 3. 
 
HARE-LIP. 
 
 303 
 
 the least movement under anaesthesia. Esmarch's operation performed 
 on both sides produced movement with voluntary painless opening 
 of the mouth amounting to U inch. 
 
 The above shows the importance of operating early in cases where 
 severe ulceration is certain to lead to increasing fixity of the jaw 
 ultimately needing operative interference. ' 
 
 Mr. Heath* thus states his opinion of Esmarch's operation : It is 
 " a comparatively easy proceeding ; and in cases where only one side 
 of the jaw is affected, restores the patient a very useful, though one- 
 sided, amount of masticatory power in two or three weeks, and with 
 very little suffering or annoyance. One side of the jaw is', however, 
 rendered permanently useless (its previous condition), and there is a 
 necessarily resulting deformity, which is not, however, of a very dis- 
 tressing character. The paralysis, from the division of the nerve, is 
 so slight as not to be worthy of mention." 
 
 CHAPTER VIII. 
 OPERATIONS ON THE LIPS. 
 
 HARE-LIP AND OTHER PLASTIC OPERATIONS ON 
 
 THE LIPS. 
 
 HARE-LIP (Figs. 63-71). 
 
 Best Time for Operation.— Any time after the second or third 
 month. For most cases the third to the sixth month is the best. All 
 should be over by the seventh month, when dentition begins. 
 
 With regard to operations at an earlier or later date than the above,, 
 it is interesting to note what Sir W. Fergusson, whose experience was 
 unrivalled, advocated with a riper experience. Thus, in his Practical 
 Surgery (fourth edition, p. 573, 1857), he writes : " I have myself oper- 
 ated very frequently within the first three weeks ; " and a little later, 
 " Prom all my reflections and experience on the question, I am more 
 than ever disposed to recommend a very early operation." In his 
 Royal College of Surgeons Lectures on the Progress of Anatomy and Sur- 
 gery (1867), with an experience of between 300 and 400 cases, he 
 writes : " I decidedly prefer about the end of the first month." Writing 
 later on (Brit. Med. Journ., 1874, vol. i. p. 403), Sir William stated that 
 his favorite time was from " three weeks to three months." 
 
 While the rule of British surgery is to get the operation over before 
 
 * Loc. supra cit., p. 338. 
 
304 OPERATIONS ON THE HEAD AND NECK. 
 
 dentition, many German surgeons defer taking any steps till the child 
 has entered on the second year. Thus Prof. Billroth* announces his 
 practice as follows: " Unless the parents urgently demand an opera- 
 tion as early as possible, I generally prefer to operate on children 
 when they are more than one year old. I always advise this in strong 
 children with complicated hare-lips, especially when the inter-maxil- 
 lary bones are displaced and the hare-lip is doable. I have been particu- 
 larly satisfied with the results of operation, as far as appearance is 
 concerned, on children at rather later periods of life and in adults." 
 Some further remarks of Prof. Billroth are quoted at p. 313. 
 
 My reasons for deferring the operation, as a rule, till after the third 
 month, are — 
 
 1. That the difficulties of getting children with hare-lip to take 
 sufficient food are exaggerated. Very often, unless the palate is cleft 
 in addition, children with hare-lip can suck well and are in good con- 
 dition. When the palate is also cleft, a serious difficulty may arise 
 from the food passing into the nose, but this may be usually met by 
 careful feeding with a small spoon put well back, if a sucking-bottle 
 with a large teat fails (p. 318). 
 
 Where the child really cannot get sufficient nourishment, and is 
 marasmic from this cause and this only, the surgeon will of course 
 operate at an earlier date than three, or even two, months. But a child 
 that is daily wasting is, daily, less and less able to meet the strain 
 entailed by the operation, and consequent repair. This should be 
 clearly understood by the friends, and also the following fact : 
 
 2. It is not uncommon for children with hare-lij:) to die soon after 
 birth from causes with which this deformity has nothing to do — viz., 
 diarrhoea, lung-trouble, exhaustion. If an operation be performed 
 early in such cases death will be put down to it, and not to the 
 above causes, which would have destroyed the child in any case. 
 
 3. As stated by Mr. T. Smith,t "the operation can be done much 
 more perfectlj^ and artistically on a j'oung child than on a new-born 
 infant, the parts being larger, more fleshy, and more easily handled." 
 Sutures also cut out less readily. 
 
 4. For the first few weeks of life the child has scarcely got over the 
 change from intra-uterine to extra-uterine life, the function of digestion 
 is not yet, so to speak, in full swing, and a very slight shock may be 
 too much for the low vitality of this period. 
 
 Ciiii/lition of the ILi.ir-lip. — Before operating, the following points must 
 be inquired into. As in other plastic operations, one or two careful 
 examinations should be made of the parts before any attempt at 
 
 * Clin. Sure)., Si/'l Soc. Trans., p. 78. 
 t Lancet, 1867, vol. ii. p. 761. 
 
e 
 
 e 
 or 
 
 HARE-I.IP. 305 
 
 uniting them. Is the cleft single or double? If single, is it simple, 
 I.e., without involving the nose, and without fissure of the palate ? Are 
 the sides equal and acute-angled, or divergent and unequal? Other 
 sources of difficulty are, much flattening of the nose from the septum 
 being adherent and dragged over to the superior maxilla on one side, 
 and the ala of the opposite side being sprea.l out and stretched over th.' 
 upper part of the fissure. Or the edges of the lip are widely apart, and 
 by no means to be approximated, the alfe being so widely separated 
 that lines let fall vertically through them only come just within the 
 angles of the mouth. 
 
 Other more general points will of course be remembered as influ- 
 encing the result of the operation. Amongst these are, the digestive 
 and sleeping power of the infant; its family history; the existence of 
 any weakening condition, such as otorrhcea ; and, by no means least, 
 the good sense and patience of the nurse. 
 
 The Single Hare-lip operation and the one appHcable to th 
 largest number of cases will be first described fully, and then one 
 two modifications. 
 
 (i.) The Usual Operation (Fig. 63).— The child being wrapped 
 in a long towel, mummy-wise, to ensure the hands being secured if it 
 " come to " prematurely, ether or chloroform is given, and the head is 
 held suitably presented to the operator by an assistant whose hands, 
 at the same time, make pressure upon the facial arteries as they cross 
 the jaw. The lips, and, if needful, the alte also, are now freely sepa- 
 rated from the subjacent bones to allow of their coming together with- 
 out tension ; during this step the knife should be kept very close to the 
 bone, otherwise the haemorrhage will be free. If one maxillary bone 
 project inconveniently beyond its fellow, it must now be forcibly bent 
 back with non-serrated forceps covered with thin drainage-tube or 
 wash-leather. The bone should be felt to crack when this is done, 
 otherwise, if merely bent back, it springs forward again and causes 
 tension on the flajjs. The edges of the cleft are now 
 pared. This, the most important part of the whole 
 operation, must be done carefully and thoroughly as 
 well. The surgeon seizes the lower angle of each flap, 
 alternately, either with his left forefinger and thumb, 
 or, if the parts are very small and slippery, with 
 tenaculum-forceps which should not hold the soft 
 parts too near the edge, or it will tear out too soon. 
 The edges being thus made tense, the surgeon with a 
 narrow bladed small knife pares them as widely as possible by two 
 
 * Simple hare-lip with equilateral sides. To ensure as broad a surface as possible 
 the incision should be made rather farther from the sides of the fissure. 
 
 20 
 
306 OPERATIONS ON THE HEAD AND NECK. 
 
 incisions beginning above at the upper angle of the cleft, curving out- 
 wards somewhat as they descend, and then, in the lower part, curving 
 inwards again through the red prolabium ^;Fig. 63). The pared sur- 
 faces shouid be made as wide as possible, especially below, in order 
 that the sutures may hold better and the lip be deeper. If one mar- 
 gin of the flap is longer than the other, this should be pared first, and 
 after this its fellow, that both may correspond. During this paring, 
 hasmorrhage must be prevented either by the assistant who compresses 
 the facial while he supports the head, or by an assistant compressing 
 the coronary artery, between his finger and thumb, at the corner of 
 the mouth, or by hare-lii3 clamps placed at the corners of the mouth. 
 
 The assistant who steadies the head and keeps pressure on the facial 
 arteries, now, with two fingers, presses the cheeks together, so as to bring 
 the flaps into apposition while the surgeon introduces his sutures. I 
 much prefer for these, first, one of medium silver wire to command the 
 coronar}^ arteries and passed close to the mucous membrane. If one 
 flap is still shorter than the other, this stitch may be passed through 
 the opposite side from below upwards, then entered on the shorter side 
 at a point a little higher than that at which it left its fellow and passed 
 from above downwards so as tilt down the margin which is highest 
 and bring it level with the other. This first stitch being passed, and 
 the chief fear of bleeding removed, three or four others of fishing-gut, , 
 horsehair, or fine carbolized silk are inserted, one being placed in the 
 free margin of the lip to keep the wound carefully closed here against 
 the entrance of milk, saliva, etc. In adjusting the top stitch care must 
 be taken that it does not too much depress the tip of the nose, if the 
 cleft has been one running up into the nostril. All the chief stitches 
 should be inserted i inch from either side of the cleft. They are in- 
 serted with very fine needles. 
 
 It will be gathered from the above that I do not advise the use of 
 hare-lip pins. They are useful no doubt in promoting close and 
 accurate union where the parts conie together easily, but at the expense 
 of the risk of sloughing and scars even here ; where tension is con- 
 siderable this risk is very much increased. The surgeon will, I think, 
 do more wisely who adopts the sutures already described, preventing 
 tension by freely separating the soft parts from the bone. If pins are 
 used they should be far slenderer than those usually sold, the first 
 should be inserted low down so as to command the coronary arteries, 
 and if one side of the cleft is shorter than its fellow the pin should be 
 passed, so as to draw it down, in the manner already described. 
 
 The sutures being inserted and tied, the nostrils are cleared of any 
 clots, some iodoform is dusted over the wound, a tiny bit of lint 
 smeared with eucalyptus ointment is placed over the wound, some 
 
HARE-LIP. 307 
 
 collodion is painted on evenly, and, if any tension remains, one or 
 two pieces of strapping, cut narrow in the centre, are applied. 
 
 We still want some instrument easily applied for hare-lip, and 
 adaptable in hospital practice to different-sized heads. Hainsby's 
 truss, ingenious as it is, has serious drawbacks. As it is not adjust- 
 able to other heads than that for which it was made, the surgeon needs 
 several sizes. It should always be worn for several days before the 
 operation, not so much to approximate parts as to prevent pressure- 
 sores, which form extremely easily and leave disfiguring scars. 
 
 To support the flaps and keep them in place, M. Louis's bandage 
 may be made use of. It is thus described by Mr. Mason ;* A double- 
 headed roller, about an' inch wide and a yard and a half long, is placed 
 with its centre over the middle of the forehead, and the two ends are 
 then carried behind the head over the ears to the occiput, where they 
 are made to cross, and brought forward again. Two slits are now 
 made in one end, and the other end slit into two. The two ends are 
 then passed through the two slits, and then by making traction on the 
 ends the edges of the lip are brought together. The ends are carried 
 back again to the nape and tlxere fastened. 
 
 In the after-treatment, the wound may be looked at on the second 
 or third day, the silver wire removed on the fourth day, and the others 
 left in much longer. A camel's-hair brush is the best way of cleansing 
 the wound. On each occasion the cheeks must be most careiully sup- 
 ported. 
 
 There is one point of great importance which is not alluded to in 
 surgical works, and that is, that in some cases of hare-lip death from 
 dyspnoea may take place very soon after the operation. Thus, where 
 the cleft has been a large one, and the upper lip when restored is tight, 
 when it overhangs the lower, if the nostrils are flattened and partially 
 closed by the operation, owing to the tension of the parts, so little 
 breathing space may be left that temporary interference with respira- 
 tion may occur, with grave and even fatal results before the breathing 
 can be accommodated to the altered circumstances, and before the 
 parts dilate and stretch. 
 
 The first case that drew my attention to this accident occurred in 
 the early part of 1887 at Guy's Hospital. I had operated on an 
 infant, aged three months, with a large cleft with unequal sides, and 
 going through the alveolar margin, the two halves of these being on 
 different levels. The projecting alveolus was broken back into posi- 
 tion, pared, and stitched with chromic catgut to its fellow. The edges 
 of the cleft were then pared and united. They came together excel- 
 lently, the wide cleft being replaced by a deep upper lip. One nostril 
 was rather chink-like. About half an hour after, whilst I was engaged 
 
 * St. Thomas's Hasp. Eeps., vol. vi. p. 160. 
 
S08 OPERATIONS ON THE HEAD AND NECK. 
 
 in another operation, a message came that the child was livid and 
 dying. I had the child at once brought to me in the theatre, the 
 strapping was removed, the tongue carefully drawn forward, and arti- 
 ficial respiration performed. The child quickly came to and began 
 to cry, though not very vigorously. Three-quarters of an hour later 
 its breathing again failed, and though Mr. Wacher, at that time senior 
 house-surgeon, at once repeated the artificial respiration, we were un- 
 able to resuscitate the child. At the post-mortem examination no 
 clot was found in the fauces, nor anything else wrong.* 
 
 Hunting about to see if others had met with this untoward result, 
 I found that my old friend, G. A. Wright,! of Manchester, had 
 recorded two cases of a like nature. The children here were aged 
 three and five weeks respectively, the hare-lips double ; in one it was 
 noticed that after the operation the lower lip was drawn in so much 
 as to leave but a small opening, but there was not apparently any 
 dyspnoea. In one case dyspnoea came on suddenly, and, as no relief 
 followed on pulling the tongue out, tracheotomy and artificial respi- 
 ration were performed. The child came round, but a few hours later 
 the breathing failed again, and the child died. In the second case, the 
 child was found dead in the night. " The cause of death was prob- 
 ably valve-action of the lower lip." 
 
 In cases of hare-lip where the divergence is great, and where the 
 sides of the cleft are very unequal, the following operations may be 
 made use of, but it will be found that, on the whole, the first-mentioned 
 is not only the quickest performed, but also gives the best results 
 wherever, by free separation from the jaws and broad paring of the 
 edges, the flaps can be adjusted together. 
 
 (ii.) Operation of Clemot| or Malgaigne (Pigs. 64, 65). — The 
 edges are pared down to, but not beyond, the red lines, the flaps thus 
 detached above are turned downwards and kept in this position out of 
 the cleft with a probe. The upper part of the cleft is then sewn together 
 with the sutures already advised, while the projecting tongue is 
 shortened as required with a pair of sharp scissors and united with one 
 
 * I think that I ought to mention that Louis's bandage was applied in this case. 
 The month was quite free, but the effect of the bandage mnst have been to increase the 
 diminution of the aperture, and to maintain the altered condition of parts, which was 
 very considerable. 
 
 t Abstracts of Cases Treated at the Pendlebury Hospital, 1885, p. 146. In his Abstracts 
 for 1883 Mr. Wright records a case in which, after operation for hare-lip, there was so 
 much dyspncea, from the tongue clinging to the roof of the mouth at each inspiration, 
 "that it had to be pulled out and fastened by a ligature." 
 
 J M. N^laton {Pathol. Chirurg., t. iv. p. 496) states that M. Malgaigne here imitated 
 M. Cl^mot, of Rochfort. 
 
HARE-LIP. 309 
 
 or two points of horsehair. The chief objection to this method is, that, 
 unless great care is taken, a little skin, imperceptible at first, but 
 
 Fm- 64. Fig. 65. 
 
 (Nelaton.) (Nfelatoii.) 
 
 showing white after a time, may remain below the red line or as a 
 break in it. 
 
 Where the divergence is more marked and the sides of the cleft 
 very unequal, the Tollowing may be made use of: 
 
 (iii.) Method of Mirault (Figs. 66, 67).— On the side which is 
 
 the most vertical of the two an incision is to be made downwards and 
 
 outwards from the apex of the cleft to the junction of skin and mucous 
 
 membrane, so as to leave a flap on this side free above, but attached 
 
 below. The other more sloping side is then freely pared throughout 
 
 • 
 
 Fig. 66.* Fig. 67. 
 
 (Nflaton.) (Nilaton.) 
 
 its extent from the apex downwards and outwards. Any adhesions 
 of the lips to the gums being then thoroughly separated, the flap is 
 brought across and attached to the pared opposite side with the sutures 
 already mentioned. 
 
 If this method be made use of the flap must not be a mere paring, 
 but cut as thick and succulent as possible, and the opposite side must 
 be thoroughly and widely refreshed. 
 
 (iv.) Method of Nelaton (Figs. 68, 69).— This gives another 
 means of substituting a protuberance for the cleft. An incision 
 
 * The sides, especially the one which is refreshed throughout its whole extent, 
 should be pared as in Fig. 67 — that is, somewhat angularly — so as to promote the 
 adjustment of the flaps, as it were by interlocking. 
 
310 OPERATION Oy THE HEAD AND yECK. 
 
 resembling a v reversed i- made around the up>per angle of the cleft. 
 Bv thi- means tl.e red eiue of the cleft i^ separated from the two 
 halves of the lip, except at each comer below. This red edge is next 
 
 Fig. fji. Fi'i. "iS. 
 
 turned downwards, or reversed so that the A -shaped wound becomes 
 diamond-shafjed. The bleeding surface; are then brought together 
 by the i-terr.- already rh-en. 
 
 ilr. HolniTS* con-iier- that X4hi ton's operation is j>ecnliarly 
 adapted to clefts which do not extend thr-urh the whole dertr^ of the 
 lip, but terminate at some distance from the nostril. Ti.ese in.-tvinces 
 are rare, but Mr. Holme; further point- out that in cases where an 
 unsightly notch is left her.ind. if there be not much cicatrization 
 around the incision, the deformity may be almost .-rvinly remedied 
 by tiiis operation. 
 
 DOUBLE HARE-LIP (Figs. Tic 71 
 
 This i; often ea-ier of cure than sir.-ie hare-lip ■nith very diveri'ent 
 sides and the alveolar maT^in cleft and its tvr;. part; on unequal l:-v-l;. 
 For in double hare-lip the mi-'.hief is symmetrical, and the -ii-; le-s 
 divergent. 
 
 Mr. T. >mit-^ '-■'.'. ivp-a cit.. p. 7'-:''-^ ;;ive; the ti;ree rollt'^in^ vari- 
 eties of hare-lip which are met with here and which are cf practical 
 importance : 
 
 (aj ^\'hien the pre-maxillary bone i- in iit-j. and tliC t^j i-ft; are 
 
 simrde and tairly bilateral. 
 (': ^^'hen tlie ] re-maxiUary bone is -eparated from the rest of 
 the jaw and projects f-rwar ;-. in -ome oases slishtly. in 
 otb>or- b>ring atvi'/hed t ■ the vomer and i. ut.iria- from the 
 tip. of the n -se. 
 0) When th- ore-n.axiii .r\- bone i; -Hiall and Hi-developed, and 
 when the cl- ft- are widelv iapini'. 
 («' If the pre-niuxiUary bone i- in proper po-iti-r.. the skin over it 
 is fre-'l from it- att i< a!..::.*; behind and pared to a point. The -iie; 
 
 * .N., 
 
 •g. Dis. ■:■/ Children, p. li.4. 
 
HAEE-LIP. 311 
 
 of the cleft are next pared from above downwards (as in Fig. 63), and 
 the parts brought together by transfixing the sides and the central 
 flap with a silver wire suture, every care being taken to keep the cen- 
 tral piece well down. Horsehair and gut sutures are also used as 
 well. As the central piece is always shorter than the lip itself, the 
 resulting wound is Y-shaped, and it is the side flaps wliich meet each 
 other in the middle line below. Care must be taken to free the central 
 flap right up to the nose, and not to depress it too much with the 
 sutures, otherwise the nose will be flattened. 
 
 (/?) Cases in which the pre-maxillary bone is separated from the 
 maxillae, projecting forwards, sometimes being even attached to the 
 very tip of the nose. 
 
 The question of removing or leaving the pre-maxillary bone arises 
 here, and the very best authorities have differed widely. On the one 
 hand, Sir W. Fergusson, writing as late as 1874,* advised its removal. 
 
 Fig. 71,t 
 
 Fig. 70. 
 
 (N^laton.) 
 
 (Holmes.) 
 
 if it projected much, as pressing it back was difiicult and unsatis- 
 factory, as the teeth in it could not be relied upon to come through 
 usefully, as, if a cleft palate was present, the gap narrows better after 
 the removal of the bone, and a dentist can fit a plate that will answer 
 the purpose quite as well. On the other side, Mr. Holmes X argues 
 thus : " It is of the highest importance to preserve, if possible, this 
 portion of bone, for three reasons : (1) If the bone be removed, there 
 must be a permanent gap through the hard palate. (2) There 
 
 * Brit. Med. Journ., vol. i. 1874, p. 403. 
 
 t From Mr. Holmes's book, quoted above, Fig. 21. 
 
 % Surg. Bis. of Children, p. 108. 
 
312 OPEEATIONS ON THE HEAD AXD NECK. 
 
 must also be a flattening and malposition of the upper lip, in con- 
 sequence of its having lost its bony support ; and from this flattening 
 of the upper jaw it will result that the lip will be very short and 
 tense, and the patient extremely 'underhung,' a very unpleasing 
 deformity " (Fig. 71). While no doubt the hands of Sir W. Fer- 
 gusson, with his great operative experience, were able to secure 
 good results after removal of this bone, most surgeons will prefer 
 to follow Mr. Holmes's advice. Mr. Holmes, a little later,* goes on 
 to say that in a few cases it may be necessary to sacrifice the bone, 
 e.g., where it is very far forward, very much out of proportion to 
 the neighboring parts, and the child very weak. 
 
 I am of opinion that, if the following points be attended to, the 
 pre-maxillary bone, however advanced and firmly based, can be 
 replaced and preserved ; weakness on the part of the child, which 
 is undoubtedly a matter of grave consideration in cases like this, 
 where the loss of blood is considerable, is best met by doing the 
 operation by two stages— in other words, being content to first get 
 this bone replaced, and leaving the uniting of the soft parts till 
 another time. 
 
 Where the stalk of attachment of the pre-maxillary bone is slender, 
 and where there is plenty of room between the two maxillae, it 
 may be often broken back into place by the operator supporting with 
 his left hand the back of the child's head and then with his right 
 thumb sharply fracturing back the bone. This should be done 
 thoroughly, and, if needful, by the aid of non-serrated forceps cov- 
 ered with drainage-tube, or bone-forcejjs may be applied to the stalk 
 in front and also behind till it is almost completely cut through. If 
 now it can be replaced, but tends to come forward again, it should be 
 sutured, on one side at least, to the maxillte with chromic catgut or 
 oarbolized silk, or wire. 
 
 If the maxillary bones on one side or both are in the way, and 
 prevent the replacing of the pre-maxillary bone after it has been de- 
 tached sufficiently, or if this is too voluminous, its sides must be cut 
 away and the maxillfe also pared till the central piece can be pushed 
 back between them and retained with the suture, as above advised. 
 
 A severer method, one, therefore, which should only be tried when 
 all other means of replacing the pre-maxillary bone have failed, is to 
 cut a wedge-shaped gap out of the septum nasi and to press or fract- 
 ure the partially detached bone into the gap. Some have passed a 
 suture t through the septum before the wedge is cut out and then 
 united the ends over the pre-maxillary bone to keep it in place. 
 
 * Loc. supra eil., p. 109. 
 
 t If he do tliis the surgeon must be provided with needles of different curves. 
 Small curved ones in a holder offer more variety than those in handles. 
 
HARE- LIP. 313 
 
 The ht-eraorrhage may be very free in these cases where very vascu- 
 lar bones are cut through. I have generally found that it is at once 
 arrested by suturing the bones, but in some cases it may be needful 
 to apply a fine point of actual cautery or of the thermo-cautere ; if 
 this has been necessary, or if the child is very weakly, the uniting of 
 the soft parts had better be left to another time. 
 
 It is absolutely necessary, by some means or other, to get the pre- 
 raaxillary bone quite back and to make it stay there, as otherwise 
 the soft parts over the projecting bone, or the line of union which 
 often comes just opposite to it, will be pressed upon and give way. 
 
 So where the surgeon is unable to get the bone back by any method 
 he may follow the advice of Sir W. Fergusson, * and incising the 
 mucous membrane over the bone, separate this sufficiently to intro- 
 duce a small gouge about i inch broad, scoop out the temporary 
 incisors, and cut away the wall of bone, which for the first eight weeks 
 consists of merely a few plates. By this the projection is removed, 
 and the tissues which remain offer no obstruction to the union of the 
 lip in front. Only the mucous membrane and some periosteum are 
 left to form a soft cushion behind the united lip.f Furthermore, by 
 this means any spirt of blood is avoided. 
 
 Mortality after Operations for Hare-lip. — Facts appear, as 
 yet, to be wanting to decide whether it is the malformation itself or 
 the operation which influences the mortality. German surgeons have, 
 with their usual painstakingness, collected statistics bearing on this 
 subject. 
 
 Dr. HofFa,J of Wiirzburg, considers that the malformation, Dr. 
 Gotthelf,§ of Heidelberg, that it is the operation, which has the inju- 
 rious effect. However this may be, it seems to be clear that the 
 mortality is much higher with them than with us. Thus, of 134 
 cases, the total mortalitj' amounted, for the first three months, to 23.4 
 per cent. Again, of 121 cases operated on by Billroth, Rose, and 
 Czerny, 41 or 34.1 per cent, died within a year. Of course the cause 
 of death in these cases cannot be entirely attributed to the operation. 
 The fact that primary union followed in about half of Czerny's cases 
 of hare-lip seems to support strongly the view that it is the weakness 
 of the infant which influences the mortality. 
 
 Repetition of Operation. — I cannot leave this subject without 
 reminding my younger readers that in many cases a perfect result can- 
 not be secured by one operation. Where parents are likely to be 
 unreasoning and unreasonable, the surgeon should warn them of this. 
 
 * Brit. Med. Journ., loc. supra cit. 
 
 t This cushion can be stitched to the maxillse, if needful. 
 
 J Annals of Surgery, January, 1887. 
 
 § Ibid., January, 1886. 
 
31 J: OPERATIONS ON THE HEAD AND NECK. 
 
 In cases unfavorable^ owins to the malformation, or the general 
 condition, and already alluded to (p. 304), hare-lips, which have been 
 operated on, often cause disappointment, however much they resemble 
 pictures in books up to the third day. Incomplete closure, below or 
 above, a little inequality in the level of the halves of the new lip, some 
 flattening and closure of the nostrils, any of these may mar the first 
 operation. The more operations a surgeon does the more difficult 
 and trying cases will he meet with. He can scarcely do better than 
 remember the words of the great surgeon of Vienna : * " Operations 
 on little children do not always succeed as well as could be wished, 
 on account of the diminutive size and softness of the parts. The flaps 
 of the lips cannot always be ada]ited as exactly as desired, and even 
 if this be satisfactorily accomplished, the result does not in every case 
 quite come up to expectation, so tliat, some few years after, further 
 slight proceedings become desirable, in order to improve the appear- 
 ance." And, again, a little later, the same surgeon, spealiing of 
 operations on " quite little children," says: "I decline to give any 
 absolute guarantee with regard to the result in such cases." 
 
 OTHER PLASTIO OPERATIONS ON THE LIPS 
 
 (Figs. 72-75). 
 
 These are ver_v numerous, especially for the restoration of the lower 
 lip after ulcerations, epitheliomatous, etc., injuries and burns. A few 
 of the chief will be described here. 
 
 The chief objects which the surgeon must keep before him are : (1) 
 to get sufficient flaps of healthy tissue, consisting of skin outside and 
 mucous membrane within, and to secure as free a margin as possible 
 of this last ; (2) to keep the flaps together with as little tension as pos- 
 sible ; (3) to cover in the teeth sufiiciently, preserving the mouth 
 opening of appropriate size. 
 
 Lower Lip. 
 
 (i.) Method of Serre (Fig. 72). — Where a growth implicates the 
 whole of the lower lip, but does not extend far down upon the chin, 
 this operation gives excellent results. If the angles of the mouth are 
 also involved, the operation consists practically in removing three 
 triangular portions of soft parts, as shown in the dotted lines in Fig. 
 72. Two of these have their apices on the checks, and their bases at 
 the angles of the mouth, while the central triangle has its apex down- 
 wards towards the chin, and its base turned upwards to the mouth. 
 
 If the angles are not involved, straight incisions, and not triangular 
 ones, may be made out on to the cheeks, while, if needful, the apex 
 
 * Billroth, Clin. Surg., p. 19. 
 
BESTORATION OF LIPS. 
 
 315 
 
 of the central can be carried down on to the chin or even on to the 
 i^eck, some further incisions being usually required in such a case — 
 viz., curving outwards laterally from the apex along the jaw or in the 
 submaxillary region, as in Fir;. 72. The flaps are united with silver 
 wire, salmon-gut, and horsehair ; a few fine hare-lip pins beinw used, 
 if needful, to overcome te^nsion. The sutures should be put in suffi- 
 ciently close to distribute any tension evenly, and the chief ones 
 should be one-third of an inch from the edges of the wound, and 
 should be passed close to the mucous membrane. As far as firacti- 
 cable, bleeding points should be commanded by sutures, and torsion or 
 ligatures dispensed with as far as pos-ible. Any pins used should be 
 removed on the second or third day and the sutures one or two at a 
 time. Iodoform and collodion is as c^ood an application as any. 
 
 (ii.) Method of Syme* (Fvi. 7-!j. — The principle of this opera- 
 tion is to leave the central and prominent part of the chin undis- 
 turbed, two lateral flaps supjplying the defect. 
 
 Supposing the whole lower lip affected, the growth is removed by 
 two incisions passing from the angles of the mouth to the prominence 
 
 Fig. 72. 
 
 Fig. 7.3.t 
 
 The dotted lines show the operation of 
 Serre, the continuous ones that of Syme. The 
 central part of each runs too near to the 
 growth. 
 
 The quadrangular inoi-ions on the 
 chin will indicate the method of Chop- 
 art. The triangular incLsions show how 
 a growth at the comer of the mouth 
 may be dealt with. (After Serre.) 
 
 of the chin. Bleeding-points being compressed by assistants, the sur- 
 geon makes two incisions from the apex of his first, passing at first 
 straight downwards and outwards, and then curving outwards and 
 upwards, so as to free two large lateral flaps, which are dissected up 
 
 * Ohserv. in Clin. Surg., p. 60. 
 
 t This and the next two figures are taken from M. Serre's atlas accompanying his 
 Traile mr I'art de reetaurer les DIfformites de la Fcu-e, selon la melhade par deplacement. 
 Montpellier: 1842. 
 
316 OPERATIONS ON THE HEAD AND NECK. 
 
 as thick as possible and united in the manner already described. The 
 first part of the two lateral incisions— viz., those passing downward^ 
 and outwards, meet in the middle line to form the new lip. This is 
 supported by the prominence of the chin, which retains its natural 
 connections. The lower and more curved parts of the incision must 
 be carried outwards as far as necessary to the angles of the jaw in 
 order to allow the flaps to come into position readily, and without 
 tension, and without leaving gaps to granulate. 
 
 (iii.) Method of Buchanan. — This is planned on the same lines 
 as that of Prof. Syme. The growth is removed, here, by an elliptical 
 incision. From the centre of this two incisions are made, first down- 
 wards and a little outwards, and then from the ends of these two 
 curving outwards and upwards, much as in Prof. Syme's operation. 
 When flaps thus marked out are detached and raised, the elliptical 
 incision becomes horizontal and forms the new lower lip. 
 
 Both in this and Prof. Syme's operation, when the gap is very large 
 or the soft j^arts scantj', two small triangular gaps may be left below. 
 The heahng of these will take place by granulation, and should be 
 promoted by skin-grafting. 
 
 (iv.) Method of Ohopart. — Here the growth is removed by a 
 quadrangular incision, the upper margin being formed by the lip, the 
 lower by an incision parallel with it across the chin, and at the 
 sides by two vertical lines dropping down over and below the jaw. A 
 square-shaped flap is then dissected up from below, and brought up 
 to form the lower lip. The objection to this is that, in spite of keep- 
 ing the head flexed, the flap tends to sink down. This tendency 
 might be, in part, prevented by freeing the flap more completely by 
 carrying out into the sub-maxillary regions lateral incisions curving 
 outwards and upwards from the ends of the vertical ones. 
 
 Upper Lip. 
 
 (i.) Operation of Sedillot by Vertical Flaps (Fig. 74).— Flaps 
 quadrangular in shape are raised by the following incisions : (1) the 
 internal one, starting from a point midway between the angle of the 
 mouth and the lower eyelid, and ending usually at a point on a level 
 with the prominence of the chin ; (2) a horizontal one passing out- 
 wards from the lower end of the first for J to 2 inches ; and (3) a sec- 
 ond vertical incision passing upwards from the outer end of the hori- 
 zontal one to a point on a level with the ala of the nose. 
 
 These flaps, comprising the whole thickness of the cheeks, are 
 moved inwards so that their lower extremities meet vertically in the 
 middle line. 
 
 (ii.) Operation of Dieflfenbach and Chauvel by Vertical 
 Flaps. — Here the flaps are cut in the reverse direction to that of Sedillot. 
 This method is to be preferred in one respect, as, owing to the base 
 
CLEFT PALATE. 
 
 317 
 
 being below, there is less tendency for the new lip to be raised by the 
 contraction of the scar, and thus to expose the upper teeth. 
 
 (iii.) Operation by Lateral Flaps.— Here the flaps are taken 
 laterally from the cheeks. They should be cut off the full depth of 
 Fig. 74. Fio 75. 
 
 The 'dotted lines show the operation of 
 S4dillot, the continuous ones that of Dieffen- 
 bach.for nialiins:a new upper lip. (After 
 Serre.) 
 
 (After Serre.) 
 
 the new lip, and at their outer extremities should curve downwards so 
 as to diminish the tension.* Their inner extremities are united in the 
 middle line below the nose. 
 
 (iv.) Operation for Restoring the Angle of the Mouth.— 
 Fig. 75 shows the steps which would be adapted for restoring the right 
 angle of the mouth which has been distorted by cicatricial contrac- 
 tion : the same proceeding being available for a growth situated here. 
 
 CHAPTER IX. 
 
 OPERATIONS ON THE PALATE. 
 
 OPERATIONS FOR CLEFT PALATE— REMOVAL OF 
 GROWTHS OF THE PALATE. 
 
 OPERATIONS FOR CLEFT PALATE (Figs. 76, 77). 
 
 Age for Operation. — If the general health be good,t the temper 
 fairly sweet, and the cleft not a very wide one, the first attempt to 
 
 * Dr. Port, of New York, who figures this operation and numerous other methods 
 from Szyinanowski (Hnndb. d. Chir. Med. Braunschweig: 1870), lays stress upon this 
 precaution (Inter. Encyc. Surg., vol. v. p. 489). 
 
 f The difficulty of feeding these cases is often put forward by the friends as a reason 
 for an early operation. Cases are extremely rare in which sufficient food cannot be 
 
318 OPERATIONS ON THE HEAD AND NECK. 
 
 close the gap may be made any time after three-and-a-half or four 
 years. If any further operation is required it should be performed in 
 the fifth or sixth year, and any case, however difficult, should be 
 completed, if possible, by the ninth or tenth year. As a rule, the 
 healthier the child and the smaller the cleft, the earlier may the oper- 
 ation be tried. 
 
 Operations have no doubt been performed during the first year of 
 life, but the risk of failure is great owing to the effects of haemorrhage, 
 the readiness with which convulsions are excited, the delicacy and 
 proneness to tear of the soft parts, while, as has been pointed out by 
 Mr. T. Smith, during the first three or four years, clefts of the bony 
 l>alate generally diminish much in width. 
 
 Severity of the Case and Kind of Patient.— It is not so much the ex- 
 tent of the fissure — whether the soft palate is alone affected, partially 
 or completely, whether that common form, in which the cleft involves 
 the soft and a portion of the hard is present, or whether the whole 
 palate is split — that is of importance, as the width of the cleft and 
 the thickness of the tissues which bound it. Sir W. Fergusson was, I 
 believe, the first who pointed out the influence which the height of 
 the vault of the hard palate has upon an operation for closing a cleft 
 of it. He showed that the higher the vault the more easy was it to 
 dissect down flaps of muco-periosteum, while, on the other hand, the 
 less arched the vault, the greater was the difficulty in getting suffi- 
 cient flaj^. Other points of importance are the size of the mouth, a 
 very narrow or small one interfering with the use of the needful in- 
 struments ; and finally, a point always to be noted, the length of the 
 palate, for the shorter this is, the more impossible will it be for this to 
 touch the pharynx later on, however perfectly it has been united, and 
 the more marked, consequentl}^ will be the nasal tone of the voice. 
 
 Other points of importance, but not connected especially with the 
 cleft, are, some which bear upon the general health of the patient — 
 viz., fretfulness or a sunny temper, greediness, as likely to cause bolt- 
 ing of surreptitious food, coexisting ear disease, or congenital syph- 
 ilis; whether the child has had the usual illnesses and exanthemata; 
 an attack of whooping cough, scarlet fever, mumps, or measles inter- 
 fering much with the result of an operation. 
 
 Amount to be Closed at One Sitfiiuj, and Order of Operation. — Where 
 
 given by one of tlie following methods (especially after any coexisting harelip has 
 been closed), if only sufficient pains are persevered with — viz., a small spoon passed 
 well back into the mouth ; a feeding-bottle with a teat big enough to fill the gap, the 
 teat being perforated underneath for the escape of the milk ; an ordinary feeding- 
 bottle, with a leaf-like piece of india-rubber attached above the teat, so as to fill up 
 the gap (as advised by Mr. Coles) ; finally sometimes deglutition will be facilitated if 
 the nurse closes the nostrils with her finger and thumb every time the child swallows. 
 
CLEFT PALATE. 319 
 
 the cleft involves both palates, that through the soft is usually taken 
 first, the severer operation being left till later. As to the amount 
 which should be attempted at the first sitting, each case must be de- 
 cided by itself, according to the experience of the operator, the severity 
 of the case, and the safety with which the anaesthetic is taken. Mr. 
 T. Smith, the highest authority we have on this subject, recommends* 
 that the whole cleft should be closed at one sitting, " unless there are 
 circumstances of peculiar difficulty in the case. When the bringing 
 together of the whole cleft in one operation would necessitate so free 
 a division of the soft parts as to endanger the vitality of the flaps, it 
 is advisable to close first that part of the cleft that can be most easily 
 approximated, whether it be the hard or the soft palate." 
 
 Had it not been for this opinion of Mr. Smith's, I should have un- 
 hesitatingly' advised the surgeon in his earlier operations only to 
 attempt to close those parts which come readily together. Any more 
 that can be closed will only be so at the expense of a good deal of 
 tension, and after much difficulty and a varying degree of bruising, etc. 
 
 Operation on the Soft Palate. — The instruments which would 
 be required for closing a complete cleft of the palate may be enumer- 
 ated here once for all. One sharp and one blunt-pointed knife (like 
 a large tenotomy knife on a long handle), one pair of dissecting-for- 
 ceps, and one with fine tenaculum or mouse-tooth ends, at least four 
 rectangular needles with eyes at the point, or, better, a supply of small 
 needles of difi'erent curves, to be used with a holder, a stout aneurism 
 needle, four raspatories of varying curve and strength, a pair of curved 
 scissors (with a i-inch curve) for detaching the soft palate from the 
 hard, one of Mr. Smith's gags, which has previously been found to fit 
 the patient, and sponge holders. In addition to the above, a tubular 
 needle with a reel for passing wire, a wire-twister, and a rectangular 
 knife, if it be found needful to take a flap from the septum, will be 
 found useful. 
 
 The patient's stomach being just empty, so that he shall not vomit 
 during the operation, nor want food immediately after, is placed on a 
 narrow table of suitable height, and in a good light. As soon as he is 
 under the anesthetic, his hands are tied to the bandage which secures 
 him to the table, or wrapped in a jack-towel, one being always left 
 within reach of the chloroformist. The head and shoulders being 
 suitably propped up with firm pillows, Mr. Smith's gag is then in- 
 troduced, the tongue tucked under the central plate and the jaws 
 widely opened. The gag, which is never to be tied, is then held by 
 an assistant who, at the same time, supports the head, and moves it to 
 suit the operator. Another assistant hands instruments and gives 
 
 * Did. of Surg, Art " Cleft Palate." 
 
320 OPERATIONS ON THE HEAD AND NECK. 
 
 Other help, while sponges are wrung out and supplied on holders by 
 a nurse. 
 
 The edges of the cleft are first pared in one of two waj^s— viz., by 
 holding in the tenaculum-forceps the tip of one-half of the uvula, 
 and thus making the soft palate tense, and then paring from behind 
 forwards ; the opposite half is then seized, and that side pared from 
 before backwards ; or, if it is preferred, the surgeon may, after making 
 tense the soft palate, transfix the centre of each cleft alternately with a 
 double-edge tenotome, and cut first up and then down. In either case 
 the whole of each side should be made raw, and with as wide a sur- 
 face as possible ; it is the anterior angle and the tip of the uvula which 
 are liable to remain unrefreshed. As far as possible this should be 
 the only occasion on which the flaps are touched with the forceps. 
 
 The sutures may be made of wire (without kinks), carbolized silk, 
 salmon-gut, and horsehair. Of these ]Mr. Smith prefers wire for the 
 hard palate and for any part of the soft in front of the uvula, prefer- 
 ring horsehair for the uvula itself. 
 
 If the flaps are thick and abundant, if they fall easily together, the 
 material is, I think, of less importance. Each surgeon will, in difficult 
 cases, find advantage from being used to certain sutures. If the sur- 
 geon has tubular needles, and if both sides of the cleft can be spanned 
 at once, he will find it very easy to work with silver wire. Salmon- 
 gut and horsehair seem to me to be the least irritating next to wire, 
 and very easy to work with after being softened for ten minutes in a hot 
 solution of carbolic acid. But if the cleft is a wide one, and if Aveling's 
 method is preferred, it is difficult to obtain the last two forms of suture 
 in sufficient length, and carbolized silk should be fallen back upon. 
 
 The following methods will be found useful according to the width 
 of the cleft, and the needles used : (1) If a tubular needle is at hand, 
 silver wire can be passed with great facility, if the cleft be a narrow 
 one, save in the case of the uvula, for which horsehair should be used. 
 (2) If the cleft be a wide one, the sutures may be passed in one of the 
 two following ways : (a) Aveling's : A double loop of suture — this is 
 much more easily done with silk — is passed on one side and the loop 
 drawn out of the mouth and held bj^ an assistant; a single suture is 
 then passed through the opposite side at a point opposite to this, and 
 the end also drawn out of the mouth ; this single suture is then looped 
 into the double one, and liy pulling this latter back the single one is 
 drawn across the cleft. (6) Here they are passed much as in uniting 
 an ovariotomy wound. A needle is threaded at each end of a suture, 
 and one is first passed from right to left and the other from left to 
 right. If this method is used an assistant holds one needle while the 
 surgeon is using the other, and in this, as in Aveling's method, the 
 
CLEFT PALATE. 321 
 
 sutures must be sufficiently long. I prefer this way, using small 
 needles of different curves. 
 
 After the first suture is passed through the halves of the uvula, it 
 should be used to make the edges tense, thus doing away with any 
 need of the forceps. Attention should be paid to inserting the sutures 
 at a sufficient distance from the edge and a due distance from each 
 other so as to duly distribute amongst themselves any tension that 
 may be present. In passing any suture, the needle point should be 
 quickly stabbed through at the intended spot. When sufficient 
 sutures have been passed, two or three should be tied (the wire being 
 twisted with the fingers, with a twister, or torsion-forceps), the gut and 
 horsehair requiring a third knot. Then if there is too much tension 
 on the rest longitudinal incisions may be made on each side of, and 
 parallel to, the cleft. The length of these relieving incisions must 
 vary ; they usually begin on a level with the highest stitch in the soft 
 palate and run backwards about midway between the teeth and the 
 cleft, care being taken not to prolong them so far back as the posterior 
 edge of the palate, or dangerously near the posterior pterygo-palatine 
 canal (p. 324). 
 
 The amount of relief which the above incisions give, even if freely 
 prolonged, is often disappointing, and they should always be dispensed 
 with if possible. If there is much tension the surgeon will, I think, 
 usually do best by not attempting too much. 
 
 Throughout the operation haemorrhage must be arrested by sponge- 
 pressure, and as little wiping as possible should be done, otherwise the 
 secretion of viscid mucus is much increased. The surgeon will from 
 time to time have to suspend his operation, to allow of additional chlo- 
 roform being given, or for vomiting, when the head must be quickly 
 turned on one side. 
 
 The after-treatment and the causes of failure are given a little later, 
 at pp. 323-4. 
 
 Operation on the Hard Palate— The edges of this being 
 
 pared, an incision is made down to the bone with a small stout scalpel 
 about midway between the cleft and the teeth, or rather nearer the 
 latter, and reaching from the anterior edge of the cleft to the posterior 
 edge of the hard palate. Through this incision raspatories of suitable 
 length and curve are introduced next to the bone and pushed inwards 
 till their points appear in the cleft. By to-and-fro movements the 
 mucous membrane and periosteum are separated from the bone, every 
 possible care being taken to raise these of even thickness and without 
 laceration or button-holing. The chief difficulty will be met with at 
 the two ends of the bony clefts. If the anterior extremity of the gap 
 reaches as far as a point just behind the incisors, much difficulty will 
 be met with in separating the muco-periosteum here, and the surgeon 
 
 21 
 
322 
 
 OPERATIONS ON THE HEAD AND NECK. 
 
 will do well to be provided with two or three small raspatories of dif- 
 ferent curves* Again, at the junction of the hard and soft palates, the 
 soft parts are firmly bound down to the former by fibrous tissue. To free 
 them a pair of angular scissors should be used, one blade being placed 
 under the micro periosteum, between it and the bone, and the other 
 passed through the cleft-, above the soft palate, the fibrous tissue being 
 thus divided close to the bony palate. 
 
 While the soft parts are thus separated the hemorrhage will be free, 
 but always yields to pressure, either with sponge or with a finger. 
 
 When all bleeding has stopped, the sutures are inserted as before, 
 wire or salmon-gut being used here. 
 
 Tension may in part be removed by prolonging the lateral incisions 
 backwards. 
 
 Mr. T. Smith points out that in bringing together the halves of the 
 palate care must be taken to evert the edges of the cleft with a small 
 double hook in passing and twisting uji the sutures. 
 
 Sir W. Fergusson's Method t (Figs. 76, 77).— This surgeon, 
 finding that even in his hands attempts to completely close the hard 
 
 Fig. 76. 
 
 Fig. 77. 
 
 A, Preliminary punctures witli brad-awl to give line for chisel. 
 
 B, Incisions through bone completed by chisel. 
 Ki, Holes in hard and soft palato for s-utures. 
 
 D, Junction of hard and soft palate. 
 
 E, Lateral openings subsequently tilled up by granulations. (Bryant.) 
 
 palate often failed owing to the contraction of granulations, b}' which 
 the lateral fiaps were drawn back to their original position, introduced 
 the following modification, which he especially recommended for 
 
 * Mr. T. Smith {he. supra cil.) reconinieiids the use of a small rectangular knife 
 here. 
 
 t Brit. Med. Journ., April 4th, 1874. Sir W. MiicCorniae in the same journal 
 (Maj' 20th) points out that Dieflenbach and AVutzer had first used a very similar 
 operation. 
 
CLEFT PALATE 323 
 
 apertures in the hard psdate, hut whicli he had used with great succi'ss 
 in a complete cleft of both. 
 
 Sir W. Fergusson, having pared the edges, divides tlie palate, both 
 soft tissues and bone, first with a scalpel and then with a cliiscl,* about 
 i incli from the margin of the gap on each side. With the chisel 
 pushed up into the nose througli each incision, by slight movements 
 from side to side, each lateral portion is i)rised towards each other 
 until they meet in tiie middle line, when sutures are inserted between 
 the pared edges of the soft i)arts. In some cases sutures were inserted 
 not merely into tliese edges, but were passed through the lateral aper- 
 tures right across the gap.f Ha'morrhage is arrested by plugging the 
 lateral incisions, if needful. Nowadays some aseptic gauze is best used 
 for this purpose. 
 
 Nasal-Flap Method.— iM. LannelongueJ: has closed several clefts, 
 involving only the hard palate, by means of a rectangular flap brought 
 doAvn from the side of the septum of the nose. The fla}) is marked out 
 by a horizontal and two vertical incisions— the former parallel to the 
 edge of the cleft and at a suital)le distance above it, tlie latter extending 
 downwards from each end of the horizontal one to the angles of the 
 cleft. The flap, composed entirely of the mucous membrane of tlie 
 septum, is dissected from above downward with a curved blunt ele- 
 vator, and left adherent at its inferior border. The opposite edge of 
 the cleft is then freshened by the removal of a superficial strip 1 inch 
 broad, and the upper border of the flap attached to it by sutures. 
 
 After-treatment. — A small injection of morphia (gr. i) may be 
 given, but no food should be allowed for three hours, only a little ice 
 being given to suck. For the first forty-eight hours milk only should 
 be allowed, with a little port wine and water. After this, yolks of eggs, 
 arrowroot, brotlis, and soups, light puddings, jellies, may be allowed 
 increasingly during the first two or three weeks. After the first week 
 the patient may get up, under supervision. There should be no hurry 
 to remove the sutures, which may remain for two or three weeks. 
 
 * Preceded in some cases by drilling a line with a chisel, as in Figs. Tti, 77, drawn 
 by Mr. Rose for Mr. Bryant's Surgery, vol. i. Figs. 184, IS-D. 
 
 t Sir W. MacCormac (loc. supra cit.) shows that Diefienbach made nse of similar 
 sntnres, sometimes securing furtlier approximation by ajiain twisting tiiem np later on. 
 Sir W. Fergusson stated his belief that the objections which at first arise to his method 
 are not valid — (1) There is no caries or necrosis; (2) there is no dangerous hfemorrhage ; 
 1 3) there is less risk of sloughing than by the old method; (4) the lateral incisions 
 heal well. He admits that if, as sometimes occurs, the vomer is found attached by its 
 lower margin to the palate, it would be difficult to introduce stitches. But approxi- 
 mation alone of the edges would probably convert the gap into a mere chink, avoiding 
 ordinary observation. 
 
 J Ball, de la Soc. de Chir., 1877, p. 472. For the above account of the operation I 
 am indebted to Stimson's Operative Surgery, p. 315. 
 
324 OPERATIONS ON THE HEAD AND NECK. 
 
 Causes of Failure.— 1. Vomiting;* 2. Premature cutting of 
 sutures from tension; 3. Haemorrhage. Serious hffimorrhage in 
 children, either at the time or later, is very rarely met with, but it is 
 otherwise in adults. 
 
 Mr. H. Marsh,t in the case of a patient aged twenty-one, was com- 
 pelled to plug the posterior palatine canal owing to severe haemorrhage 
 on the sixth day. The haemorrhage recurred twice, the last being as 
 late as the fourteenth day, and was arrested on each occasion by the 
 following means: "Searching with a sharp-pointed probe, passed 
 through the lateral cut, about i inch in front of the hamular process, 
 which can be easily felt through the soft palate, and about the same 
 distance directly inwards from the wisdom tooth, I felt, after two or 
 three attempts, that I had fixed the probe in the orifice of the canal, 
 and at the same time the patient screamed with pain, when the large 
 posterior palatine nerve was touched. A wooden plug, made by 
 sharpening a piece of firewood, was then passed firmly into the canal, 
 by holding 'it in a pair of strong forceps with its point looking upwards, 
 and a little backwards in relation to the roof of the mouth. Directly 
 the plug was introduced the bleeding ceased." The recurrence was 
 due to the plug slipping out. 
 
 4. Whooping cough. 5. Exanthemata. 6. Child putting his finger 
 into the wound. 7. By swallowing of solid food. 8. Feeble condition 
 of the child, with congenital syphilis, etc. 
 
 REMOVAL OF GROWTHS OF THE PALATE. 
 
 Growths here, though rare, have a special interest, from their posi- 
 tion, and may thus be briefly noticed. For the best account of them 
 I would refer my readers to a very helpful paper by Mr. Stephen 
 Paget,! ii^ which the following points are brought out: (1) The chief 
 groups are the polypoid and warty, the adenomatous, the sarcoma- 
 tous, and the carcinomatous ; this last including the encephaloid, 
 which are very rare, and the epitheliomatous, commencing in irrita- 
 tion here as elsewhere. (2) That it is hardly possible to tell before- 
 hand to which group the growth belongs. (3) Many of them, especially 
 the adenomata, can be shelled out with surprising ease. (4) That the 
 growth itself should not be cut into. 
 
 * Mr. Mason {Brit. Med. Journ., 1872, vol. i. p. 14) gives the case of a child, aged 
 nine, in which the vomiting of two lumbrici led to failure. 
 
 t Oiin. Soc. Trans., vol. xi. p. 71. On the occasion of the third hseniorrhage tlie 
 patient was in a state of profound syncope. The suggestion of plugging the canal was 
 originally made by Mr. T. Smith, in a similar case also successfully treated by Mr. 
 Willett. 
 
 X St. Barlh. Hasp. Reps., vol. xxii. 
 
REMOVAL OF THE TONGUE. 325 
 
 In the case of large and vascular growths, the aids of splitting the 
 cheek or performing a preliminary laryngotomy and plugging the 
 fauces (p. 347) may well he resorted to. 
 
 From what I have seen of two cases of epithelioma of the palate, 
 starting from the alveolar process, and in one case certainly originating 
 in an old syphilitic sore, no time should be wasted with such means 
 as the application of acids, or the cautery, and I think that removal 
 of the bone itself by some such operation as that of Maisonneuve (p. 
 287) is preferable to attacking the growth with gouge or chisel. 
 
 CHAPTER X. 
 REMOVAL OP THE TONGUE (Figs. 78, 79). 
 
 Before describing the diiferent operations it will be well to say 
 something with reference to two or three very practical points which 
 rise up with every case of tongue cancer, a form of cancer which, it 
 must be remembered, is very frequent and increasing in frequency ;* 
 which attacks all ranks of life ; which, after its early stage, is especially 
 malignant ;t in which, finally, an operation is as much dreaded and 
 deferred by men as one for carcinoma mammae is by women. 
 
 A Pre-Oancerous Stage. — However tongue cancer begins, it 
 passes through the above stage, i.e., a stage (the duration of which is 
 unknown and varies extremely) in which inflammatory changes only 
 are present, ulceration and other changes iii the epithelium, not 
 amounting as yet to epithelioma, but onAvhich epithelioma inevitably 
 supervenes. The boundary line between this pre-cancerous stage and 
 cancer is extremely narrow ; the duration of this stage may be, and 
 -often is, extremely brief. 
 
 Aids in recognizing this stage : (1) The duration of the ulcer, (2) 
 Its obstinacy to treatment. (3) The age of the patient. (4) Absence 
 of any induration or fixity. (5) Careful scraping of the surface of the 
 sore, and microscopic examination. J In doubtful cases, after cleaning 
 
 * Amongst common cancers — e.g., of breast, rectum, uterus, etc. — cancer of the 
 tongue stands about third, although so rare in women. Mr. Barker, in his carefully- 
 worked out article on " Diseases of the Tongue " (Syst. of Surg., vol. ii. p. 578), gives a 
 series of tables showing that in the last about thirty years there has been ii steady in- 
 crease from 2.6 to 11.5 per cent. 
 
 t This is shown in the following facts: (a) The rapidity here is quite different 
 from other epitheliomata. Epithelioma, usually thought si slow cancer, here, in a 
 moist, warm cavity, much irritated, and never dry and warty, is terribly rapid, (p) 
 Gland invasion is here not only certain, but inevitably early as well." 
 
 t Butlin {Sarcoma and Carcinoma, p. 154, pi. iv. Figs. 1, 2, 3). The use of cocaine 
 will nowadays facilitate the above examination. 
 
326 OPERATIONS ON THE HEAD AND NE("K. 
 
 tlio surlaco, sera]io lightly wit.li a spatula, or blunt knife, and examine 
 the result mieroseopieally. In a sore not yet epitheliomatous the epi- 
 thelium is still regular, squaiuoiis, flatlened, and the nuclei small and 
 single. In an ulcer bccomini;- epitheliomatons, the cells are no longer 
 regular, but variable in shajie and size, oval and caudate, instead of 
 sipiare, with nuclei large and multiple. Not infrequently cell-nests, 
 or fragments of ci-ll-nests, may be found. 
 
 Questions Arising before Operation. 
 
 The operating surgeon will often be called upon to give an answer 
 to the two following qui'slions: ^\'iIl the disease b(> permanently 
 cured? If a permanent cure is inqiossililc, will life \>v bettered and 
 prolonged ? 
 
 A. jrm the <7i.sc(is(' he periiiattentty cured? 
 
 Really permanent cures are, as yet, too few, 10 per cent, of eases 
 oiiera.ted on (liarkcr);* V^ per cent. (Rutlin ).f The explanation of 
 this is not altogetlier to tlu' credit of oui' ju'ofession. I'atients and we 
 alike are too often both to blame. The gravity of the disease is over- 
 lot)ked, the time of the " ]>re-caucerous stage " is lost. IVecause tongue- 
 cani^cr is so often preceded by syphilis, or local irritation, the prac- 
 titioner diagnoses tlie above, and suggests them as the essential part 
 of the mischief: "give drugs another chance "' — <',(/., potassium iodide, 
 potassium chlorate, mercury, caustics. To these there are, in nearly 
 every case, the strongest objections in the pre-cant-crous stage. Time 
 is lost, strength is lost, and the patient is lulled and befooled, while 
 all the time the vascularity and irritation all around the ulcer are 
 increased. Furthermore, the patient is in part responsilile for the 
 delay, as he very naturally dreads the operation, exaggerating its 
 danger, painfulness, and the supjioscd inevitable loss of speech. The 
 above delays lead to '" cultivation of cancer " and to miserable deaths. 
 We shall never be able to suct'cssfuUy combat the above till (1) the 
 impoi-tance and value 1)1' the pre-i'ancerous stage are recognized; ('2) 
 getting cases of ti>ngue-cancer early, :|: we are enabled ti> assure the 
 patient that removal of one-half of the tongue will be sullicit>nt, and 
 that half can be safely and usefully spared to him. It has been denied 
 by some that leaving half the tongui' is attended by any good result. 
 Prom an experience of twenty-three eases of removal of the tongue, I 
 am able to say jiositively that a patient in whom the tongue has been 
 
 "^ Lnc. !<ii.pi'a fit , y). (104. 
 
 t l)i«.of Ihr 7'.h;/»c, p. 'J!I5. Mr. ISiitlin'.s iH-rconta,i;e iw calculated from seventy 
 caseH. lie iti inclined to doubt wlietlier a largo iiuiid)or of oases would aftbrd so good 
 a |iorooolaf;o of rocoverios. 
 
 t If uli'oralioii liaa liooii per.siatent for longer tlian three months, perinaiiont roeoverv 
 is very doubtful. If it has persisted for over six months, if more than one-third of the 
 toof^ne is invaded, if the lloor of the uioulh is involved, i>erinaneiit reeoverv is well- 
 nigh eei'l.'iinly hopeUvss, 
 
REMOVAL OF THE TONGUE. 327 
 
 split longitudinally and half removed has in that which is left a 
 member which most usefully represent^ the tongue, and over which 
 the patient has, in spite of wh-at is said to the contrary, most service- 
 able control.* 
 
 B. If « permanent cure is impossibli', will life be bettered and 
 prolonged ? 
 
 Cases which are not operated on die within eighteen months, many 
 in twelve months. A.n operation wisely planned and well carried out 
 often gives a gain of six or eight months. Tliis is a gain not only of 
 time, but also of comfort. Death by glandular recurrence in the neck 
 is less painful and noisome than death by mouth-cancer. Nu one 
 who has seen much of tongue-cancer will have any difficulty in 
 answering the question which of the two is most painful to the patient 
 and distressing to those around liim, tongue-cancer with its horrible 
 foetor, profuse and foul salivation, its agonizing pain, its racking ear- 
 ache, or recurrence in the cervical glands, an alternative in which the 
 patient is often able to work up to near the last, and, till towards the 
 close, is free from the agonizing tenderness, the stinking fcetor, the 
 dribbling of foul saliva, and the slow starvation, day by day, of tongue- 
 cancer. Where an operation is certainly attended witli risk, the patient 
 in facing it may be relieved by tlie assurance that a life prolonged in 
 hideous misery and constant agony is worse than death following 
 close on an operation. " When a man has only, suppose, two or three 
 years to live, it is no small advantage if at least half the time can be 
 spent in comfort rather than in misery, and in profitable work rather 
 than in painful idleness " (Paget). If a patient cannot make up his 
 mind to an operation, and is losing precious time, he should be 
 warned, without being unduly frightened, of the state of things, alluded 
 to a few lines above, whicli will inevitably follow. Usually, as soon 
 as this sets in, i.e., when the condition of the tongue renders liim a 
 nuisance to himself and others with the disgusting fcetor, the constant 
 dribbling of foul saliva which cannot be swallowed, the weary aching 
 day and night, lit up into agonizing flashes when the parts are tou,ched 
 or moved, the patient becomes willing to run any risk. But, too often, 
 by this time, not only are the glands already enlarged, but the mis- 
 chief has reached the floor of the mouth or the alveolar mucous mem- 
 brane by extension, though not yet, perliaps, with ulceration. 
 
 Operations.— The following four will be carefully described, viz..: 
 (1.) Whitehead's (Fig. 78). 
 
 (ii.) Syme's (Fig. 79). 
 
 (iii.) Kocher's (Fig. 79). 
 
 (iv.) The Ecraseur. 
 
 * In a patient from whom I removed half the tongue, two and a half years ago, the- 
 hypertrophy of the remaining half is very marked, and the speech excellent. 
 
328 OPERATIONS ON THE HEAD AND NECK. 
 
 With these, certain aids—e.g., slitting the cheek, preliminary laryn- 
 gotomy, and ligature of the Unguals — will also be considered. One or 
 two other methods will then be briefly alluded to. 
 
 While the above operations — and I allude especially to the first 
 three — give a choice which will enable the surgeon to meet any case 
 of tongue-cancer, whichever is chosen must be completely carried out 
 " niggling " operations lead inevitably to return and accelerated growth 
 in the tongue itself. 
 
 (i.) Whitehead's. — The advantages of this are very great. They 
 are : (a) The transverse section of the body of the tongue can be placed 
 deliberately well behind the growth. However far behind the growth 
 the loop of the ecraseur is placed before the operation, and however 
 securely it seems to be retained in situ by large curved needles, as the 
 loop is tightened up, owing to the enormous strain which is gradually 
 applied, the needles and the loop are forced forwards nearer and 
 nearer to the growth. Now the neighborhood of this is all ready to 
 become the seat of malignancy. All around the growth the epithelial 
 columns are ready to dip down into the vascular connective tissue 
 beneath, on which in health they never encroach. Again, the parts 
 around are loaded with inflammatory cells, soft and vascular. If, as 
 is very likely, owing to the tremendous tension to which it is sub- 
 mitted, especially when the parts are very soft, the loop comes crushing 
 into this neighborhood and makes the section here, the indipping pro- 
 cesses which extend for some distance around the actual epithelioma 
 may, owing to the vascularity and inflammation consequent on the 
 operation, break out into speedy recurrence. Again, the insertion of 
 the needles which are intended to keep the loop well behind the 
 growth is not always an easy matter, especially if the growth is far 
 back, and if the front teeth are well developed whilst the molars and 
 pre-molars are too deficient to allow of wide opening of the mouth 
 with a gag. (b) The resulting wound is very clean, there being very 
 little laceration and no charring. The slight decomposition which 
 would take place from an extensive operation, even with scissors, is 
 readily checked by the use of iodoform and ether. The advantage of 
 this in saving a patient, whose vitality is already lowered, from the 
 depressing effects of being liable for days to breathe and swallow with 
 a fetid sore in his mouth, in securing rapid granulation and healing, 
 and thus enabling the patient to be early propped up, and soon to 
 leave his bed, must be obvious to every surgeon who knows how great 
 .the risk is of fatal septic bronchitis in these cases. For the same 
 reason secondary hemorrhage is unknown, {c) The instruments 
 required are extremely simple and few, as will be seen from the 
 .account of the operation. 
 
REMOVAL OF THE TONGUE. 329 
 
 The Operation. 
 
 It is most essential that the annesthetic should be in the hands of a 
 man who can be thoroughly trusted. It is often taken badly in these 
 cases, with much dyspncea and restlessness at first; and during the 
 operation, owing to the open mouth admitting much air, and the fear 
 of interfering with the operator, the patients often " come to " fre- 
 quently. The only thing is to get them well under at first; later on 
 it will be well not to keep them too much under the influence of the 
 anffisthetic, in order that, the sensibihty of the larynx not being lost, 
 the blood may not enter the air-passages. The administrator must 
 watch the tint of the lips, the veins in the cheeks, and know when a 
 little blood is only safely, though noisily, bubbhng at the l)ack of the 
 fauces, and when it is getting into the trachea. I look upon the 
 administrator of anajsthetics in these cases as quite as important as 
 the operator. Two reliable assistants are needed who understand the 
 steps of the operation, one to take the gag in charge, and to sponge 
 when needed, and the other to hook back the corner of the mouth 
 with two fingers while he is ready to sponge, and thus, with the posi- 
 tion of the head over to this side, enable the blood to escape freely 
 from the wound into the cheek and out of the mouth with the aid of 
 deft sponging. Two nurses should be ready to supply sponges ; these 
 being absolutely clean, soft, thoroughly wrung out of iced Condy's 
 fluid, and firmly secured on holders. The following instruments 
 should be close to the operator's right hand, viz., scissors, a pair of 
 torsion-forceps, and Spencer Wells's forceps, a needle in handle, 
 threaded with stout silk, and one or two medium-sized ligatures of 
 carbolized silk.* 
 
 A good light is absolutely essential. Daylight close to a window is 
 far the best. If it is needful to operate when the above cannot be 
 obtained, as in a succession of foggj^ November afternoons, a good 
 lamp light, concentrated by a laryngeal mirror, will be useful. In 
 making arrangements for a good light, the surgeon will remember that, 
 while the removal itself takes but a short time, getting the patient 
 under the anaesthetic, and keeping him under its influence, often ren- 
 der the operation much prolonged. 'It may not be superfluous to add 
 here that this is an operation which calls for coolness and decision on 
 the part of the operator, and for promptness with their help on the 
 part of all those who assist. No crowding on the operator, no obstruc- 
 tion to the light by bystanders, should be permitted for a moment. 
 
 Preliminary Laryngotomy. — The question of the advisability of 
 this operation now arises. It forms no part of a " Whitehead " proper. 
 
 * Mr. Whitehead, hearing that I had twice operated by his method in 1881, kindly 
 sent me a pair of his scissors. They are rather longer than usual, perfectly flat, very 
 sharp up to the tips, which are square and blunted. 
 
330 OPERATIONS ON THE HEAD AND NECK. 
 
 The operator who introduced the scissors method, and whose success 
 with it is so well known, never, I believe, uses a preliminary laryn- 
 gotomy. In my first six cases I followed him closely. In the later 
 seventeen I have performed laryngotomy on several occasions, though 
 I fear Mr. Whitehead will consider this admission on my part as a 
 sign of " falling away." With a wider experience, I am led to think 
 very highly of this preliminary step, and of the plugging of the back 
 of the mouth, which it renders safe, and I do so for this reason. With 
 the fauces plugged, and the patient breathing through a laryngotomy 
 cannula, the surgeon can neglect the hemorrhage more, can operate 
 more deliberately, and thus (and this is the value of this preliminary 
 step in my mind), at every step of the oiaeration, can have the parts 
 more thoroughly sponged dry, and thus be enabled throughout to 
 keep more surely wide of the disease. In other words, I do not dread 
 the haemorrhage which accompanies a scissors-operation for itself, but 
 because it is liable, in spite of careful and prompt sponging, to obscure 
 the field, and thus lead to cutting dangerously near the growth— a 
 danger especially likely to happen if the haemorrhage is at all free, if 
 the parts cut are very much softened, and if the patient is not taking 
 the anaesthetic well. For these reasons, I am inclined to recommend 
 a preliminary laryngotomy, with plugging of the fauces, in these cases : 
 (1) When a surgeon who values Whitehead's operation is doubtful as 
 to his means of meeting hsemorrhage. (2) When the growth extends 
 beyond the middle of the tongue, into the posterior third. (3) When 
 the floor of the mouth is at all involved. In growths limited to the 
 anterior half of the tongue, unless there is much fixity, laryngotomy 
 is not needed, for, as will be seen below, sufficient of the tongue in 
 such cases, after very little use of the scissors, comes right out of the 
 mouth. 
 
 If it is decided to perform laryngotomj^, this operation is done as at 
 p. 347, and a soft clean sponge, dusted with iodoform, is tied with silk 
 into appropriate size and fixed at the back of the fauces, the silk being 
 brought out of the mouth and held by a finger of the assistant who 
 has charge of the gag. Tliis sponge must be pressed well back, and 
 care taken that it does not draw back and down the base of the 
 tongue, or it may cause some difficulty in securing the Unguals when 
 the transverse section of the tongue is made far back. The anaesthetic 
 is now given through the tube, an additional advantage, brought 
 about by the laryngotomy, as the administration of the anaesthetic 
 does not interfere with the field of operation. So very little sloughing 
 and swelling of parts follows on Mr. Whitehead's operation that the 
 laryngotomy tube may be removed as soon as the patient is back in 
 bed and has " come to " comfortably. 
 
 Whether laryngotomy is performed or not, the patient, being 
 
REMOVAL OF THE TONGUE. 
 
 331 
 
 propped up, is brought quite to that side of the table on which the 
 surgeon stands. A gag* is placed on the side of the mouth opposite 
 to the growth, and the mouth widely opened. The tongue is then 
 transfixed on the diseased side well back in its anterior third, with a 
 needle in a handle loaded with stout silk, this is looped and knotted, 
 and the tongue thus well drawn out of the mouth. The surgeon then, 
 with a sharp-pointed bistoury, splits the tongue longitudinally along 
 the raphe, to a point thoroughly well behind the growth. This is 
 another departure from a stricth^ performed " Whitehead," but it has 
 the following advantages, while it causes no troublesome haemorrhage 
 if the blade be kept in the middle line : (1) If the whole tongue is to 
 
 Fig. 78. 
 
 ^♦^/>^ 
 
 The lower of these figures shows " grooving " of the tongue, preparatory to securing the lingual, 
 
 p. 332. 
 
 be removed it places the ha:;morrhage much more under the control 
 of the surgeon, as he can deal with each half separately, and with one 
 lingual, securely, at a time; (2) It enables the surgeon to leave half 
 
 * Of these I prefer Krohne and Seseman's modification of Mason's gag as tlie best 
 all-round instrument. It waa first brought to my notice by Dr. Hewitt, who has found 
 it the readiest and most efficient in case of need in the administration of anfesthetics. 
 Mr. Gowan's gag is also a good one, but I have found it liable to slip in spite of its 
 ingenuity. A gag is still needed for edentulous jaws. 
 
332 OPERATIONS ON THE HEAD AND NECK. 
 
 the tongue if he find it safe to do so. It has been said that leaving 
 half the tongue is useless, the part left being but little under the 
 patient's control. I am of an opinion entire!}' different. In cases 
 where I have been able after splitting the tongue to leave half of it 
 the part was most useful both in speaking and swallowing, etc.,* and 
 I am further most strongly of opinion that if patients could be assured 
 that half only of the tongue would be removed they would submit 
 much more readily to an operation they dread so peculiarly, and to 
 the grievous putting off of which is due the very small percentage of 
 permanent cures. 
 
 The tongue having been split and the diseased half drawn well out 
 of the mouth, the surgeon next divides with scissors the mucous 
 membrane between the tongue and the alveolar process, keeping close 
 to the bone so as to be wide of the disease. The anterior pillar of the 
 fauces is next divided. While the above steps are taken the two 
 assistants sedulously sponge away any hsemorrhage .into the hollow 
 of the cheek and out of the mouth, the cheek being retracted as above 
 directed. Careful sponging, and sponge-pressure on bleeding points, 
 are most essential if the surgeon is to cut wide of the disease. 
 
 If the disease has implicated the frsenum and its vicinity two or 
 three of the lower incisors should be drawn so that the scissors may 
 be introduced on a level with the disease. If this is not done the 
 scissors have to be dipped in over the teeth in an awkward way, and 
 one which, as soon as bleeding occurs, makes it impossible to make 
 sure of getting below the disease. The scissors can be introduced 
 with much greater facility, and used to much better purpose, if a gap 
 is made in the teeth. These can be kept and fitted to a plate later on 
 by a dentist. 
 
 When half of the tongue has been freed all round, the muscles 
 between it and the floor of the mouth are cut through with a series 
 of short snips until the diseased half is separated on the level of the 
 lower part of the jaw, as far back as is needful. During this stage 
 oozing will take place, and one or two small arteries jet with varying 
 freedom in different cases, but these will yield to pulling steadily on 
 the tongue and to firmly applied sponge-pressure. 
 
 The tongue having been freed horizontally up to a point well behind 
 the disease, the transverse section is now made, and here I have found 
 the following precaution useful : Instead of cutting straight across 
 the half and trusting to being able to secure the lingual on the face 
 of the stump, a step by no nieans always easy of accomplishment, 
 owing to the artery being often at once obscured by a small pool of 
 blood, and to the not unfrequent softness of the tissues in these cases, 
 
 * See foot-note, p. 327. 
 
EEMOVAL OF THE TONGUE. 333 
 
 I cut a deep groove through the tough mucous membrane of the side 
 and dorsum (Fig. 78), and tear through the softer muscular tissue with 
 the closed scissors or a steel director till the lingual nerve and artery 
 are seen, then, having applied a long-bladed pair of torsion-forceps 
 to the remaining tissues, cut away the half of the tongue in front of 
 the forceps, and then twist or tie the lingual artery which has thus 
 been secured.* 
 
 If it be needful, the surgeon then proceeds to deal with the other 
 half of the tongue, a step which is much facilitated by the room given 
 for manipulation by the removal of the first half. 
 
 Slitting the Cheek (Fig. 79). — This step is an excellent one. It 
 may be made use of in cases where the disease is situated very far 
 back, extending close to or on to the anterior pillar of the fauces, 
 where the hasmorrhage is expected to be especially free, where the 
 light is unavoidably very bad, or where there is unusual difficulty in 
 getting the jaws well apart. The cheek is slit as far back as the ante- 
 rior border of the masseter, the facial artery and other small branches 
 being secured at once. The parts require most careful adjusting after- 
 wards, especially at the corner of the mouth, where, from the dribbling 
 of saliva, primary and exact union is not always secured. 
 
 Preliminarg Ligature of the Linguals. — This step has been 
 very largely practiced by Prof. Billroth.f Unfortunately he expresses 
 no opinion as to its value. He states that he ligatured the artery 
 twenty-seven times (apparently in all as a preliminary step), but only 
 adds that no secondary haemorrhage ever followed, and that the wound 
 always healed satisfactorily. 
 
 Dr. Shepherd, of Montreal, has recorded J three cases in which he 
 tied both linguals previous to excision of the tongue, which operation 
 was bloodless. 
 
 I have never taken this precaution myself, and I do not recommend 
 it, for the following reasons : (1) In three cases in which I know of 
 this precaution having been taken, the hfemorrhage was as free as in 
 the usual operation with scissors, performed without any such pre- 
 
 * If any difficulty occur in dealing with a divided lingual, especially if the tongue 
 has been divided far back, a suggestion of Mr. Heath's will be found mo.<it useful — 
 ■piz., to hook one or two fingers into the pharynx over the stump of the tongue, and to 
 draw this forwards, thus at once arresting the haemorrhage by pressure, and bringing 
 into view the bleeding point. 
 
 f Clin. Surg., Syd. Soc. (translation by Mr Dent), p. 113. 
 
 t Ann. of Surg., November, 1885. Mr. Treves {Lancet, April 21, 1883) publishes 
 four cases of the removal of the tongue, in which ligature of the linguals was resorted 
 to. The haemorrhage which followed on the operation on the tongue is stated to have 
 been "very insignificant, and usually immediately arrested by firm pressure with a 
 sponge. It is only far back, in the region of the tonsil, that any bleeding may occur 
 that does not cease almost spontaneously." 
 
3-4 
 
 Ot-FKAnONS ON TllK lUWl^ A N O NKCK. 
 
 lin>in:\rv> ^-J" 1 think tl>ai ;in o\poii<'iu\- dovivod iVoiu opor;(ii>>ns in 
 i\vomv-!\\o I 'iM-s justiru's mo in s:iyini; tliat it' llio opor:\tion with scis- 
 sors bo porionnod with nttomii>n lo tlio <lot,\ils uivon alvno, tho l);oiu- 
 ovvluico >s not so liillionlt to ilo:il with as to roquiro this prooaniion.f 
 (,o1 Tho lii;:iiviio ol" both liimuals is l>\ no moans ;n> oponitioi\ that 
 oan bo liono quiokly,* anii voiiniros a ^ooii Iii;ht. It ni:!\ ilms t:!ko 
 up a 1:0. vl iloal ot"tho tinio roqniroil lor ih-ahnu with tho ilisoaso ot"tl>o 
 tonguo iisolf. If it bo answoiwl that ilisoasod ulands oan bo doah 
 with at tho san\o timo ai\d h\' tho sanio inoisions. 1 must stato, in no 
 ooiniailik'totv spirit, that 1 am ol' a (iistinolly oontraiy opinion. IJo- 
 moval ol' opithohomatons ulanils io,|uiri\s ol' it.solf nutoh timo and 
 painsiakins:, 1\ inc. as thov dk>, in lonu ohains. and in rolation with 
 most impovtant struotnios. It'lhoy aio to ho romovotl witli that 
 thoroni:bnoss whioh alono jnsiiiios an\ attaok on thon\. tliis slmnhi bo 
 (iono with tho t'ull allowanoo o( timo and tho ninli\ idoil atlontiou 
 whioh aro uivon hv a sopavato operation, oilhor bol'oro or al'lor tliat on 
 tho toniiuo. 
 
 vii.) Syme's Oporation >i (.I'^iu. 7:'\- Thi^ v'onsists in dividiuiitho 
 syniphysis monti and thon romo\ iiic tin- w holo Ioul^uo and ihuir o\' 
 tho montli witii knil'o or soissors. or p.arlly wiilt ono ol'iluso and partly 
 with tl>o oorasour. 
 
 It is a t"ar ntoro sorions oporation than tho 0110 ab'oady uivon, and 
 ofton involvos proKniiiod at'tor-troalinoni, i>\\ini;- to tho lardy m\ion i>r 
 tho jaw. It slunihi bo rosorvod t'or thoso o.iscs in whioli tho nU'or in- 
 volvi's llio tUior ot" tho month, or in wliioh, in addiiimi to ;ii\ nh'ov on 
 tho sido. a hard mass o\' inliUration oan bo I'oh in tlio suhstaiioo ol'tlio 
 origan. \\'hori> this oporation is ooiitontplatod in an auod or broUon- 
 down pationt, o\ory attomjit shouhl bo inado to inipro\ tlu\;;onoral 
 lioalth proxionsly. .\n nna'slhoiio boiiiu L;i\on,and a prolin\in,ai'y 
 larynuoiomy port'ormod, tho paliout's lioad and shonhhas aro raisod, 
 and tho siiruoon di\ idos tho soil parts of tho ohin. as l'ai-dowi\ as tho 
 liyoid bono, if tho soft p.aiMs in iho lUior of tho mouth aro iniioh impH- 
 oatod. Tho \os,no1s hi-iiiL; soourod. Iho j.aw is drdK-d bolow iho loolli a 
 qnartor of an inoh on oillior sid(> of (ho middlo lino, and thon sawn 
 lhrouji'h.|| .\ sponuo is now plaood at Iho haok of tht' fauoos, and tiu> 
 
 * Tlu' oiioiMlioiis \\rii- luMi- iH'iloiiwi'il b\ Iw.i 111' iiiv <'iilli-.\i;\u-s, :\\\A llu'vo I'lHiM W 
 iumIomIiI lliiil llio v<"^-<i'ls wi-ii- sorun-il. 
 
 t 111 wriliiig lliis 1 am liikini;' it lor ;;r,'uili'il lli:il llu' ■<\ii!;o.iii will lu' :n,lril liv lu-lpi'iN 
 
 M.-i U|ll :liul li'Mllv !I,S I llMVO lu'i'U loll IIUMli- iM1011s;ll 111 lillil. 
 
 X 'I'lu' oiu-i:ilion will lio |'m11\ ilcsriilu'il, iiiul ils ilillioiillii's onli'ml ii\li., liilor on. 
 
 S l.,i,i,:i. 1S,".,S, vol, i. 11, li;.;nia vol. ii, (.. n;S. S.-o mUo llio m.'.oiuiI l.y l>r. l''iil.l<'s 
 ol' his I'M,-;!-, t-iliih M,,l. .loiini., vol. iv. p. lO'.l?. Vs :\ luool'or I ho M'voiil v of lliis opor- 
 iilioii liolli ol' I'rol'. Sviiio's liisl Iwo pMlii'iiU ilioil. 
 
 II Ity soiiio il is :ulvisoil lo sMw (Ills soiiu-\vli;il Miif;iil;iil v iiisloiul ol' vorlioMlly lo pro 
 inolc iiil.-rlookiiit; niul iiiiiou ol' llio rrnniui-iils. As, liowi-vor, iii'oiosis iiiiiy I'oUow (liis 
 
REMOVAL OF THE TOXGUE. 335 
 
 hnlves of the jaw beinp; forcibly retracteil, the tonone is well drawn 
 out by a loop of silk, the imieous nienibrane snipped through between 
 the tongue and the alveolar pvoeess, and the anterior pillars next 
 divided. The geuio-hvoglossi * and genio-hyoids are next divided, 
 and the tiss\ies in the tloor of the mouth separated as deeply as neces- 
 sary with the scissors or blunt-pointed bistoury aided by the linger, 
 partly by cutting and partly by tearing, any vessels that require it 
 being tied or twisted. The tongue being thus freed laterally and 
 below as far back as is needful, the transverse section is made, one-half 
 at a time, with tlie precautions recommended at p. ;i.'>2. 
 
 The floor is now carefully inspected, and any suspicious patches or 
 enlarged glands most carefully removed. In raising the former, before 
 using the scissors, a tenaculum is often very useful. If it be preferred, 
 though I in no way recommend it, as soon as tlte attachments of the 
 tongue to the floor and sides of the mouth are sutliciently divided, the 
 transverse section can be made with an ecraseur, the loop of which is 
 slipped over the tongue and kept in position by two curved needles as 
 at p. oo7. 
 
 The two halves of the jaw can then be wired, but to promote speedy 
 union a cap of vulcanite or silver had best be fitted on to prevent dis- 
 placement of the fragments. A drainage-tube sliould be brought 
 through from the mouth to a point jitst above the hyoid bone, before 
 the sott parts are united with sutures. 
 
 (iii.) Kocher'st Method, by Lateral Infra-Maxillary Inci- 
 sion t^Fig. 791. — This operation, like the last, is a severe one; it also 
 opens up freely the connective tissue of the neck. It has the great 
 advantage of enabling the surgeon to deal with mischief far back in 
 the tongue and at the same time of removing enlargeil sub-maxillary 
 glands. Fin'tiiermore, it caii be performed antiseptically. The mouth 
 being disinfected with a 1 in UXXl pcrchloride of mercury solution, 
 and a preliminary laryngotomy performed, an incision is made from 
 just below the symphysis down to the hyoid bone, and following the 
 digastric muscle back to the anterior edge of the sterno-mastoid, and 
 then np to near the lobule of the ear. The flap thus marked out of 
 platysma and fascia^ is then turned up, and the facial artery tied. 
 The sub-maxillary region is then thoroughly cleaned out and the Un- 
 as well as the other form of bone-seetion, the longer time that it entails is soaioelv 
 worth giving. 
 
 * If only one-half of the tongne neeil removal — a rare contingency in the cases 
 which c.ill for this operation — the complete separation of these mnscies and the conse- 
 quent danger of the falling back of the tongne will alike be avoided. 
 
 t T>fiif. Zdlsch./. Chii:. Ed. xiii. ISSO. Mr. Barker was tlie first, I believe, to draw 
 the attcmion of English surgeons to this operation f l">iseases of the Tongne," 5;/s(. o 
 Sniff,, vol. ii.). 
 
336 OPERATIONS OX THE HEAD AXD XECK. 
 
 gual artery secured on the hyoglossus. By cutting tlirough the molo- 
 hyoid muscle the cavity of the mouth is now freely opened into, and 
 the tongue brought out through the wound and di\ided as far back as 
 
 Fig. 79. 
 
 The incisions on tlie nose are those of Oilier for the removal of nnso-pharyngeal polypi, p. '2S6. 
 Below are seen three for the removal of the tongue — viz., that fir ^littin;; the cheek, and that of 
 Syme's operation. The third, that of Kocher, should have been brought further forward, curv- 
 ing up towards the chin. 
 
 is needful, one-half being removed after splitting the organ, or the 
 whole tongue removed, the opiK>site lingual being tied if needed. 
 
 The large wound is then carefully packed with strips of antiseptic 
 gauze, a drainage-tube being first inserted. The patient continues to 
 breathe through the laryngotomy tube until the wound and mouth 
 are quite sweet, and thus there is no danger of septic broncho-pneu- 
 monia. 
 
 If it be desired to conduct the operation as strictly antiseptically 
 as possible, before it is begun, plugs of salicylic wool must be placed in 
 the nose, the cavity of the mouth well washed out with 1-2000 mercury 
 perchloride solution, and the spray used at the operation and at each 
 dressing. As, however, it is impossible to render aseptic the closely 
 contiguous cavities of the posterior nares and pharynx, and as the 
 patient will require feeding at regular intervals with a nasal tube, I 
 would prefer to trust to sufficiently frequent changes of the gauze with 
 which tlie woiuid is plugy;ed, dusting on iodoform and powdered 
 boracic acid, painting on with a camel's-hair brush iodoform and ether, 
 and securing free drainage by a drainage-tube which has one end 
 
REMOVAL OF THE TONGUE. 337 
 
 brought out of the mouth and the other cat the lower and posterior 
 angle of the wound, both lodged in aseptic dressings. 
 
 (iv.) The Ecraseur. — This may be used in different ways ; the 
 two following are the chief ones : 
 
 1. Through the mouth, in combination with scissors, a method 
 used by ]\[r. Baker.* 
 
 2. By means of a puncture in the suli-maxillary region, or through 
 a wound which has to be made here in the removal of enlarged 
 glands. 
 
 The first of these only will be described here, as, if the Ecraseur has 
 to be made use of, it is by far the simplest and speediest method of 
 using it. 
 
 In addition to the instruments already given in the description of 
 the operation with scissors, the surgeon must be provided with a stout, 
 short 6craseur, curved on the flat, working smoothly and carrying a 
 strong loop of whipcord. f 
 
 The first part of the operation resembles that given at p. 330. The 
 tongue being well drawn out with a silk loop, the anterior pillar and 
 the mucous membrane between the alveolar margin and the tongue 
 being cut through, the tongue is then split with a bistoury along the 
 raphe as far back as is needful, and its attachments to the floor of the 
 mouth partly snipped through with scissors, partly torn through with 
 the finger. The tongue being now freed sufficiently to make the 
 transverse divisions, two slightly curved needles, in handles, are made 
 to perforate the tonge a full inch behind the posteiior limit of the dis- 
 ease, and the loop is then slipped on and adjusted behind the needles. 
 Before doing this, I would strongly recommend that a groove be cut 
 with the scissors through the mucous membrane of the dorsum and 
 sides of the tongue (p. 332) ; this simple step will serve to steady the 
 bite of the 6craseur and lessen the risk of its gradually coming, as it 
 is tightened up, dangerously near the growth, and it will also shorten 
 the time that the loop takes to effect its work. When first adjusted, 
 the ecraseur may be worked more quickly, but as soon as real resistance 
 is felt the screw must be turned more slowly, a half or three-quarter 
 turn being made every minute, or at longer intervals if the loop seems 
 to be cutting too quickly. It should aln-ays be remembered that, if 
 oozing takes place from hurried use of the ecraseur, it will be far more 
 difficult to arrest on a surface bruised by this instrument than on one 
 clean cut by scissors. J: 
 
 * Lancet, April 10, 1880; Diet, of Surg., vol. ii. 
 
 t Not of wire. See the next foot-note. 
 
 t Mr. Butlin (Dm. of the Tongue, p. 334) gives the following case: The only instance 
 of death from haemorrhage "in m_v table occurred in the case of a man whose tongue 
 was removed with a strong wire Ecraseur, which cut through the tissue of the tongue; 
 
 22 
 
338 OPERATIONS OM THE HEAD AND NECK. 
 
 If the whole tongue is removed, the (5craseur should always be ap- 
 plied to each half separately. Making the transverse section across 
 the whole tongue at once is most tedious, and the great strain is likely 
 to be too much for the loop or instrument itself. It also causes the 
 constricted tongue to swell into a large livid mass, which much ob- 
 structs the breathing ; and if, as is likely, both the Unguals, which are 
 left to the last, are divided simultaneously, the furious spirting of these 
 vessels in two crossing streams is most embarrassing. 
 
 I do not recommend the use of the 6craseur, for these reasons: 
 
 1. However well behind the disease the loop is placed at first (a step 
 by no means easy to secure where the disease is situated far back), as 
 it is slowly tightened up it tends to come forward (even when a groove 
 has been cut in the mucous membrane), gradually grinding the nee- 
 dles placed to keep it in position and the loop closer and closer upon 
 the diseased area, or, if not actually into this, into one from its close 
 contiguity ready to take on disease (p. 328). 
 
 2. I have seen, again and again, however carefully the tightening 
 of the loop has been managed, that this is, finally, not fine enough to 
 divide the lingual artery which is dragged out in the eye of the loop, 
 and has, after all, to be secured l>y ligature or torsion, often not with- 
 out previous furious bleeding. 
 
 The galvanic ^craseur has not lieen described. I mention it here 
 only to condemn it. During the operation the loop may break, or it 
 may cut its way too rapidly through the softened tissues, especially if 
 the heat used is too great. Later on, the patient has still to run the 
 gauntlet of the risks of septic lung trouble and secondary haemorrhage 
 which the use of this treacherous instrument entails. 
 
 After-treatment. — The chief objects here are: (1) To keep the 
 wound sweet; (2) to give sufficient food. 
 
 Several English surgeons have lately drawn attention to Kocher's 
 method, already alluded to, of packing the wound with antiseptic 
 gauze and bringing a drainage-tube out into the submaxillary region. 
 Mr. Butlin gives, with especial care, the details with which this method 
 has been employed by Kocher himself, wlio lost only one patient from 
 the operation in fourteen cases, and by Billroth, whose results, pub- 
 lished by Wollffler, show the last seventeen cases thus treated to have 
 been all successful. 
 
 I have not myself made use of this method, for these reasons: I 
 consider (1) that other means give as good results, and in a way more 
 
 like a knife, miicli more quickly and cleanly than had been intended. There was 
 Bome Bmart hfemorrhage at tho time, and it was not easy to get the man ont of the 
 operating tlieatre alive. The artery was not thoroughly secured, the bleeding re- 
 curred, and the patient sank and died a few hours later." 
 
REMOVAL OF THE TONGUE. 339 
 
 agreeable to the patient, and T may add here tliat, out of twenty-three 
 cases (>( Wliitelicad's method, I have only lost one from the (jjicration * 
 (2) That this nn'thod of packing with gauze docs not, and cannot, give 
 absolutely reliable asejitic results. It would, I think, be easy to prove 
 this from the constant soaking of saliva and other matters, in which 
 this wound differs I'roiu others, but no better pi'oof can be given than 
 the fact that a patient on whom Mr. Butlin himself made trial of this 
 method died, on the eighth day, of septic, pneumonia. 
 
 The treatment I bavi^ made use of is as follows: For some days 
 before the o])eration, I make tlie patient ]irac.ticet fi-eijuently washing 
 out his nioutb with ('ondy's fluid, sitting up, and with the head alter- 
 nately de]iendent to cither sidi'. He also gets used to feeding himself 
 with a drainage-tube attached to a roe<I(.'r-sp<)Ut and passed by himself 
 to the liaek of his throat.J 
 
 After th(! o|)eration, the cut surface is brushed over with a solution 
 of zinc-chlorid{!, gr. x.-ij,§ or iodoform in (.'tlier; of the two, I prefer 
 the latter at this time. Murphia is given as freely as is safe, with ice 
 to suck, and if the patient's condition is low, milk and brandy are ad- 
 ministered either by a soft (esopliageal tube or by enemata. But I have 
 generally ibund that, after the first six liours, a patient previously prac- 
 ticed in the matter will give himself sufficient food. || 
 
 After the patient has had his first sleep, the surface is washed over, 
 every two or threct hours at first, with iodoform and ether, and the 
 patient is soon encouraged to sit up and wasli out his moutli constantly 
 with Condy's fluid. He should be kept warm and free from draughts, 
 and either pi'ojipcd up or turned on to either side. I try that my pa- 
 tients sit up a little on the second day, if possible, and get them, when 
 this is feasible, into an armchair by the fifth or sixth day. Yolks of 
 eggs, arrowroot, soups, pid)ied vegetables in broths, and such like are 
 soon addctl to the milk and brandy. 
 
 Causes of Failure. 
 
 (1) Broncho-pneumonia. Pneumonia. A1)sces8 and gangrene of 
 the lungs. These must bo placed first on account of their frequency. 
 Septic in their nature, and due to the patient breathing foul gases, and 
 
 * The patient here was a Jew, prematurely aged, with epithelioma supervening on 
 syphilis, who died on the eighth day of bronclio-pneiimonia. I fear that thin was 
 septic, though my colleague. Dr. Mahomed, who saw the patient during life, and who 
 made the post-mortem examination, being influenced chiefly by the sweet condition of 
 the mouth, was of a diflferent opinion. 
 
 t This gives him something to occupy his mind, and cleanses the mouth. 
 
 X If the patient is at all intelligent he will do this for himself far more painlessly 
 than an assistant can. 
 
 ? No stronger solution shotild be used for fear of causing cellulitis in the sub-max- 
 illary regions. 
 
 II If this is not the case, a soft tube must be passed. 
 
340 OPERATIONS ON THE HEAD AND NECK. 
 
 drawing down putrid fluids into his lungs, the treatment must be pre- 
 ventive, every endeavor being made to keep the mouth sweet, and to 
 relieve the patient's breathing by attention to the details already given. 
 
 (2) Hjemorrhage. This is rarely met with at the time of the oper- 
 ation or soon after, if every spirting artery has been properly secured. 
 It will also be rarely met with as a secondary complication if the 
 wound has been kept sweet. In cases of bleeding, if the application 
 of a silk ligature to the bleeding point taken up by a Spencer Wells's 
 forceps or a tenaculum is impossible, firm pressure with a sponge on 
 a holder should be made use of after all clots have been removed. If 
 the wound is foul, it must be cleansed by brushing it over with iodo- 
 form and ether, or with turpentine— a most powerfully cleansing 
 styptic,* and one always to be used in preference to perchloride of iron. 
 If all the above fail, either applying and leaving in situ a pair of 
 Spencer Wells's forceps, packed around with soft gauze, or ligature of 
 the lingual, must be resorted to. 
 
 (3) Cellulitis. Erysipelas. 
 
 (4) Pysemia. 
 
 (.5) Exhaustion — more rarely, shock. 
 
 (6) CEdema of the glottis. 
 
 (7) Suffocation from falling back of the tongue. 
 
 (8) Recurrence. 
 
 CHAPTER XL 
 
 OPERATIONS ON THE TONSIL, 
 
 REMOVAL OF NEW GROWTHS OF THE TONSIL. 
 
 The new growths here are most commonly round-celled sarcomata 
 and epitheliomata. 
 
 In sarcomata there is steady enlargement of one tonsil in an adult, 
 without pain at first or inflammation, a globular swelling, the size of 
 a walnut, making its appearance, firmly elastic, and tending to infil- 
 trate adjacent structures. f 
 
 In the epitheliomata, the patients are older: the mischief often 
 begins " as a sore throat." The mass occupying the site of the tonsil 
 is now much harder and soon ulcerates, forming an excavated ulcer 
 with the characters of epithelioma. The base of the tongue may be 
 
 * If the bleeding is of the nature of oozing, one or twa injections of ergotin should 
 certainly be tried. 
 
 t E-pecially the lymphatic glamK (ride infra). 
 
NEW GROWTHS OF THE TONSIL. 341 
 
 involved secondarily. Dysphagia, emaciation, etc., are more rapid 
 here. 
 
 Before describing any operations for removal of tonsillar growths, it 
 is right to allude to their great malignancy, owing to the rapidity with 
 which the glands are affected. In this, rather than in the importance 
 of its relations, lies the failure of operations on the tonsil, and no one 
 who has watched the rapidity with which enlargement of the glands 
 at the angle of the jaw takes place in subacute tonsillitis, will wonder 
 at this. 
 
 Mr. Butlin* writes on this point : " So early in the course of the 
 disease are the glands affected that they may appear as large swell- 
 ings in the neck, within a few weeks of the period at which the first 
 signs of the disease were noticed by the patient. On the other hand, 
 there may be no visible or tangible glandular enlargement until six or 
 more months have elapsed from the first occurrence of enlargement of 
 the tonsil. The disease proves fatal, in very many instances, within 
 a year, or even six months of its first appearance ; indeed, few per- 
 sons survive for more than three-quarters of a year." 
 
 Operations. 
 
 A. Through the Mouth. 
 
 B. By Incision in the Neck. 
 
 A. Through the Mouth.— This method can only be made use of 
 (a) in the very early stage of tonsillar new growths, when there is no 
 evidence of glandular enlargement ; or (b) when epithelioma of the 
 tonsil coexists with a similar condition of the tongue. 
 
 In such cases, the patient's head being suitably raised and supported, 
 in a good light, the cheek on the affected side is divided from the 
 angle of the mouth to the masseter, and the two ends of the facial 
 artery tied or twisted. The mouth is now kept widely open by a gag 
 inserted on the opposite side, the tongue drawn out of the mouth, and 
 the masseter pulled backwards by a retractor. As much room and 
 light as possible being thus obtained, the surgeon divides the soft pal- 
 ate first in the middle line, and then from within outwards with a 
 Paquelin's cautery ; he next, either witli the same instrument or with 
 a blunt dissector and his nail, dissects around and enucleates the ton- 
 sil with the anterior pillar. 
 
 Where the growth is at all caulifiower-like in its prominence, the 
 chief part may be first removed with a heated wire or with the Paque- 
 lin's cautery, so as to get more room in dealing with the base. In any 
 case the cautery must be used at a dull red heat only for fear of 
 haemorrhage. The surgeon must be prepared for its leaving indurated 
 tissues which may simulate deposits of growth, and for the tendency 
 
 * Oper. Surg, of Malig. Dis., p. 174. 
 
342 OPERATIONS ON TJIE HEAD AND NECK. 
 
 oflho instrument, ;iM it in quickly cooled down by its conL;i.ct with 
 succulent tiHHUcH, to ntiek to th(^ni. A little iulditioniil licat IVcch it at 
 once, far more HatiH^ietoriiy than pulling it away. 
 
 Mr. r.utlin points out that Konje of the new f^rowths met with here 
 are ho i^'isily Bcjiarable, bo eircniiiHeribod, if not eneapsuled, that th(tre 
 is not the least didiculty in shelling them out.* 
 
 I'.efore or durin;,' the aJiove operation tliC; surf,'e(jn must h(! guided 
 by the charae.ter of the growth and other facts as to the advisability 
 of performing a, preliminary laryngotorjiy. 
 
 ]',. By Incision through the Neck. 
 
 (1) (;he.i'rn:-i\^ Mdhud.. 
 
 The following clear account of the aJtove method, sliglitly niodifi(;d, 
 is taken from a case of Mr. 'eilding Bird's. f "An oblique incision 
 was made from the lobub^ of tlie left ear, downwards and forwards, to 
 the hyoid bone. The supei-ficial sfiuctures and deep fiscia were 
 divided, a branch of the external jugular vein alone requiring liga- 
 ture. 
 
 "An cidarged lymidiatic gland was shelled out and the digastric 
 exjiosed. This and the stylo-hyoid w(-re then divideil, ainl a. second 
 hard gland being found, it was also i-emoved; it lay against the inter- 
 nal jugular vein. On retracting the posterior border of the wound 
 and pulling forwards tije angle ottlie ja.w, th(; stylo-glossus and stylo- 
 pharyngeus were seen and divided, fibre by fibre, on a direetor. 
 Neither the hypoglossal nerve nor the glosso-pliaryngeal was ohserved. 
 Tfie fascia investing the posterior jjart of the subjoaxillary gland was 
 now slit up, and the facial artery ligaluicd and divided. The inter- 
 nal jugular vein was now fully exjiosed Wir njore than 1 iindi. The 
 internal cartjtid was not seen, but, covered with fascia, was felt pul- 
 sating. These two vessels being drawn oufwards Vjy a retraetor, the 
 wall of the pharynx was, by tearing through sorjir^ yellow fat, fully 
 ex|jf)Hed, bulging to and fro with i\\i; respiration. No vessel save the 
 two already named ref|uired securing; and at the upper ])artoftlic 
 wound was wha.t appCiired to be the pes ansei-ina. A si^rond ijicision 
 was now made through the eheek frfun the angle of the mouth J: to- 
 
 * fjiK. sij/im fil , p. 17^). Mr. liiitlin iillows tii.'it, unfcirliiri.-iti-ly, rpciirrence i» not 
 less j)roliahl(; .-ifterHtielling out. I prtlVr the iiiciIhii! ;ilri:i(lv given. 
 
 f <;llii.iSfiK. 'I'mia.^ vol. xvi. |i. 0. Tlie i"n<: w;is in\i- of i-|iitljelioma, in a patient 
 aged forty-fivf;. 
 
 X In (;ii(:(.-v(;r-','M rm;llii«l the Hcconil inriHinn is in;i'li- .ilDng the horizontal ratiiiiM of 
 the lower jaw. If this is madi; use of, it is made at the ln^ginnirig of tln' n|per:ilion, 
 and tlie flap thus marked ont tiirown down. This would give inure room for the hiiIi- 
 seqiient diKseclion (es|>c(ially in aMtoiit patient), .-uid would he more likely to expose 
 enlarged gliindn. Tin- iriiMsion through the cheek might lie mai\c an well, later on, as 
 in .\Ir. Oolding Bird's ease. 
 
NEW GROWTHS OP THE TONSIL. 343 
 
 wards that of the jaw. There was no haniiorrhage, as the facial artery 
 had ah'eady been secured. With the left forefinger in the mouth and 
 the right in the wound, the enlarged tonsil could easily be moved be- 
 tween them, and it was removed, together with the adjacent piece of 
 the pharyngeal wall, by the electric cautery, employing this partly as 
 a knife and partly as an ecraseur."* 
 
 The patient made a very good recovery, air ceasing to pass through 
 the wound in the neck on the 16th day. 
 
 In spite, however, of the thoroui;hness of the operation the disease 
 recurred in the glands within six weeks, and within two months it 
 returned in the throat as well. 
 
 The following remarks of Mr. Golding Bird deserve most careful 
 consideration. After speaking of the entire feasibility of the opera- 
 tion, he says: "The question of expediency, however, demands the 
 fullest attention ; and I am inclined to think that the plan adopted in 
 my second case referred to— namely, feeding by a soft (esophagus 
 tube, with the alternative eventually of performing gastrotomy, more 
 likely to meet all the real requirements of these cases, unless seen so 
 early that there can be no suspicion of the growth having extended 
 beyond the tonsil, nor of having invaded the lymphatic system except 
 to a very limited and remediable extent." 
 
 The account of the next two operations is taken from Mr. But- 
 lin.t 
 
 (2) Czcrm/s Method. 
 
 A fireliminary tracheotomy having been }ierformed, and the larynx 
 or fauces plugged, an incision is made downwards and outwards from 
 the angle of the mouth to the anterior border of the masseter, and 
 beyond it to the level of the hyoid bone. Through this incision the 
 lower jaw is exposed and sawn through, between the second and third 
 molars, from above downwards and outwards, and the two fragments 
 are held asunder. The grt)wth is liy this means laid bare, and to re- 
 move it it may be necessary to divide the digastric, stylo-hyoid, and 
 stylo-glossus muscles, and the hypo-glossal, glosso-pharyngeal and 
 gustatory nerves, as well as the lingual and other vessels. The growth 
 is then cut or torn out, and the bleeding points are touched with the 
 cautery. The wound is thoroughly washed out with carbolic lotion, 
 or dusted with iodoform, the fragments of the lower jaw wired, a sec- 
 ond wire twisted round the adjacent molars, and the external wound 
 closed with sutures, except at points for the exit of drainage tubes. 
 
 * Mr. Golding Bird, in his remarks on this case, stated that in another case he 
 should open the pharynx with scissors, owing to the difBculty which the use of the 
 cautery creates in knowing wliether the required deptli has been reached in tlie extir- 
 pation of the growth. 
 
 t Loc. supra cit., pp. 176, 177. 
 
3-14 OPERATIONS OX THE HEAD AND NECK. 
 
 (3) MickuUtzs Method. 
 
 This is intended to be even more radical than that of Czerny. An 
 incision being made from the mastoid process downwards and for- 
 wards as far as the great cornu of the hyoid, the soft parts are raised 
 fi-om the jaw, the facial nerve being preserved if possible, and the peri- 
 osteum is separated from the onter and inner aspects of the jaw just 
 above the angle. The jaw is then sawn through beneath the perios- 
 teum, the tendon of the temporal divided, and the ascending ramus 
 resected. After drawing aside, with strong liooks, the body of the 
 jaw, the masseter, internal pterygoid, digastric, and stylo-hyoid,3Iick- 
 ulitz found that the surface of his wound corresjionded as nearly as 
 possible with the region of the tonsil, and by dividing the lateral wall 
 of the pharj'ns, he obtained access to the palate, the base of the 
 tongue, and the posterior wall of the pharynx as far up as the naso- 
 pharynx; and bj' dividing the digastric muscle and the hyjioglossal 
 nerA'e, he could reach the entrance of the larynx. ]\[ickulitz prefers 
 to do a preliminary tracheotomv, and claims for his operation not 
 only ease in reaching and removing the disease, and in dealing with 
 lymphatic glands, but further, that the whole wound communicates 
 freety with the outside, and can be dressed antisepticallj-. So far from 
 the resection of the ascending process being a disadvantage, it otFei-s 
 the positive advantage of giving more mobility of the jaw than is 
 otherwise present after the contraction of the scar which takes place 
 after any of these operations. 
 
 Mickulitz's patient was a woman, aged sixty-five, and the disease 
 had existed about four months. She recovered and remained well for 
 two years, when recurrence appeared in the glands. 
 
 CHAPTER XII. 
 
 OPERATIONS ON THE AIR PASSAGES IN THE 
 
 NECK. 
 
 THYROTOMY-LARYNGOTOMY— TRACHEOTOMY-RE- 
 MOVAL OP FOREIGN BODIES IN THE BRONCHI- 
 EXCISION OP THE LARYNX. 
 
 THYROTOMY. 
 Indications. 
 
 (i) Growtlis M'hicli cannot lie removed through the mouth, but 
 which do not require severer operations on the larynx itself The fol- 
 lowing are the chief conditions which must decide the removal of 
 laryngeal growths lay an operation from the mouth or by thyrotomy : 
 
THYEOTOMY. 345 
 
 (a) The amount of special laryngeal skill possessed by the oper- 
 ator. 
 
 (6) The nature of the growth, whether multiple or no, if jieduncu- 
 lated, if recurrent after attempts at removal from the mouth. 
 
 (c) The extent of the growth. 
 
 (d) The irritability of the larynx. The amount of self-control of 
 
 the patient. Any tendency to asphyxia. 
 
 (ii) Large rough foreign bodies * e.g., bits of bone, etc. In a case 
 brought before the Clinical Society t by Dr. Taylor and Mr. Golding 
 Bird, a bit of mutton-bone was impacted between the vocal cords, 
 where it could be seen with the laryngoscope. It was removed by 
 Mr. Golding Bird by a vertical incision with its centre over the cricoid 
 cartilage, the crico-thyroid membrane being incised horizontally. A 
 tracheal dilator being introduced, the bone was seen at once and ex- 
 tracted with Toynbee's ear forceps. The large size of the fragment, 
 its apparently firm position, the fact that the broad surface and not 
 the edge presented, together with its position just at the crico-thyroid 
 membrane, led to the external operation being made use of. 
 
 Operation. — A preliminary laryngotomy (p. 347) or a high trache- 
 otomy, according to the amount of room required, having been per- 
 formed, the incision is prolonged upwards and the skin and fascise 
 over the centre of the thyroid cartilage are carefully divided; all 
 hseniorrhage is then arrested and the cartilage opened along its centre 
 with scrupulous exactness, the thyro-hyoid and crico-thyroid mem- 
 branes being also divided, if needful. The halves being now held 
 widely open, the foreign body is picked out or the papillomata re- 
 moved. 
 
 During the above operation it may be well to remember the fol- 
 lowing points: If much haemorrhage is expected, as in the case of 
 some papillomata (if large or recurrent), it would be well to plug the 
 air passage below, by the side of, and around the tube which has been 
 inserted, either by a sponge attached to silk, or by putting the tube 
 into a collar of drainage-tube of sufficient thickness. The division of 
 the thyroid cartilage should be effected from without inwards, a stout 
 knife, bone forceps, or even a saw being sometimes needed in adults. 
 As soon as the upper part is divided the surgeon should examine if 
 he has sufficient room without further division, and if it is really 
 needful to cut down lower, the meeting of the cords must be treated 
 
 * Mr. Holmes (Med Ohir. Trans., 1882) has drawn attention to the fact that large 
 substances may be impacted in the ventricle or between the alse of the thyroid carti- 
 lage without causing any symptoms of immediate urgency. As they are liable to give 
 rise to spreading inflammation of the mucous membrane, they should be removed as 
 soon as possible. 
 
 f Trans, vol. xvii. p. 214. 
 
346 OPERATIONS ON THE HEAD AND NECK. 
 
 with the utmost delicacy, and if the parts have to be opened out, as 
 little tension and stretching as possible should be thrown upon this 
 spot.* 
 
 The removal of papillomata is often attended with much difficulty 
 owing to their friability. f They are best snipped away with scissors 
 curved on the flat, and their bases touched with some powerful astrin- 
 gent, Mr. Parker recommending chromic acid. 
 
 The object of the operation being accomplished, and all haemorrhage 
 arrested, the alse of the thyroid are united by one or two points of 
 silver suture not passed through the entire thickness of the cartilage. 
 A little iodoform is dusted on, and lint out of boracic acid (warm or 
 cold, according to the feelings of the patient) is kept constantly ap- 
 plied. 
 
 The tracheotomy tube must not be removed till all risk of intra- 
 laryngeal oedema, etc., has passed by, though it may be early replaced 
 by one of india-rubber. The after treatment and complications are 
 much as after tracheotomy (p. 356). Coughing will be especially 
 harmful now. 
 
 Impairment of the voice is not unlikely to occur after thyrotomy, 
 quite apart from any injury inflicted on the cords during the opera- 
 tion, owing to the cicatrix subsequently involving the anterior com- 
 missure of the cords. Other possible causes, in spite of aseptic 
 precautions and gentle handling, are chronic laryngitis, the formation 
 of granulations, impaired movement of the thyroid, or displacement 
 of the cords. Where the masses of papillomata are large, though the 
 removal has been complete, the patient may never be able to dispense 
 with his tube. 
 
 LARYNGOTOMY. 
 
 In this operation the tube is inserted through an opening in the 
 crico-thyroid membrane. It is called for, in preference to tracheotomj'', 
 on account of the greater facility with which it is performed, in cases 
 of emergency, and in those where a tube can quickly be dispensed 
 with. J Finally, it is inapplicable before adolescence. 
 
 * Mr. Parker {Diet, of Surg., vol. ii. p. 623), advising that, if it is needful to out the 
 anterior commissure of the cords, the two alaj of the tliyroid should not be quite 
 severed, points out that, in children, the parts being elastic, retraction will accomplish 
 much, but that in old people, or where the growth is large or extensive, not only all 
 the cartilage and the thyro-hyoid membrane must be divided, but that, to secure still 
 more room, horizontal incisions may be needed through the crico-thyroid and the 
 thyro-hyoid membranes, close to the bordere of the cartilages. 
 
 t Mr. Parker {loc. supra cit.) found in one case much difficulty in seizing the 
 growths, owing to the reflex excitability set up, notwithstanding deep narcosis. He 
 thinks that the use of cocaine will here be a material aid. 
 
 X Owing to the proximity of the tube to the cords this operation is not suited to 
 cases in which an instrument has to be worn for any time. 
 
LAEYNGOTOMY. 347 
 
 Indications. 
 
 1. Sudden impaction of large foreign bodies threatening suffoca- 
 tion, as when a bolus of food carelessly swallowed lodges in the upper 
 aperture of the larynx* 
 
 2. Before operations likely to be attended with much bleeding, e.g., 
 those on the tongue, jaws, tonsils, etc., in order that the fauces may 
 be plugged with a sponge. 
 
 3. "When spasm of the larynx is threatening very suddenly, as in 
 tetanus, or aortic aneuriRm,t as a rule tracheotomy, when there is time 
 to perform it, is preferred in these spasmodic affections, and it will be 
 considered later (p. 364). 
 
 Operation. — An anassthetic will be given in those cases in which 
 laryngotomy precedes another operation ; in other cases the patient's 
 head must be kept steady. In either instance the head will be thrown 
 back as far as possible, while the neck rests on a firm support. The 
 precise position of the thyroid and cricoid cartilages is then distinctly 
 made out, the notch in the upper part of the former and the ring of 
 the latter being almost always recognizable. The larynx being then 
 steadied (not squeezed) with the left fingers and thumb, and the 
 skin at the same time made moderately tense, an incision about an 
 inch and a half long is made, exactly in the middle line, over the 
 lower part of the thyroid, the crico-thyroid interval, and the 
 cricoid. 
 
 If reUef is urgently called for, the knife should pass down to the 
 crico-thyroid membrane at once, and the left index having identified 
 this, the membrane is opened by cutting horizontally just above the 
 cricoid cartilage. 
 
 If the surgeon have more leisure, he may reach the crico-thyroid 
 membrane more gradually, feeling his way, using retractors, and per- 
 haps identifying the interval between the sterno-hyoids and the crico- 
 thyroids. The only advantage of this is that all haemorrhage can be 
 arrested before opening the air tube. 
 
 In inserting the tube, care must be taken that both the crico-thyroid 
 membrane and the adjacent mucous membrane are punctured, and 
 that the tube is really within the cavity of the larynx, not pushed 
 down into the cellular tissue outside it. The cannula, which should 
 be shorter than those used for tracheotomy, of uniform bore through- 
 out, and oval in section, is then secured with tapes. 
 
 * In these very urgent cases the operation may be performed with, /ante de mieux, a 
 sharp penknife and a toothpick quill. 
 
 + Mr. Erichsen, in his Surgery, gives many other conditions for wliich a high tra- 
 cheotomy is usually reserved. 
 
348 OPERATIONS ON THE HEAD AND NECK. 
 
 TRACHEOTOMY. 
 
 This operation will be carefully considered under the first of the 
 following indications, and more briefly in its relation to the other 
 ones. 
 
 Indications : 
 
 1. Croup and diphtheria. 
 
 2. Syphilitic and tubercular ulceration, in order to give rest to the 
 
 crippled part. 
 
 3. Malignant disease of the larynx. 
 
 4. Acute laryngitis. 
 
 5. Certain spasmodic affections— e.gr., tetanus, or aneurism of the 
 
 thoracic aorta. 
 
 6. Foreign bodies in the air passages : the removal of those which 
 
 may lodge in the bronchi being treated separately (p. 367). 
 
 TRACHEOTOMY FOR MEMBRANOUS LARYNGITIS.* 
 
 General points all bearing upon a successful result :t (A) The age 
 of the patient. (B) Right time of operating and wise selection of 
 cases. (C) Skilful operation. (D) Painstaking and appropriate 
 after-treatment. 
 
 A. Age. — Recovery before the age of two is very rare. Some of the 
 youngest cases recorded are Mr. Bell's at seven months, and Mr. 
 Cooper Forster's at eleven months. J On the other hand, M. Trousseau 
 considers the frequency with which tracheotomy is unsuccessful in 
 adults with membranous laryngitis is due to the fact that the large 
 size of the larynx retards asphyxia till the bronchi are invaded. 
 Again, the older children are, the more strength have they and the 
 better the hope of recovery ; whereas younger children fail more 
 quickly with their poorer vitality and the greater facility with which 
 their narrow air passages are choked up with membrane, etc. 
 
 Average of Recoveries after Tracheotomy for Membranous Lari/ngitis.^ — 
 
 * Under this head are inchided the two disea-ses whose identity is disputed — croup 
 and diphtheria. 
 
 f If a little amplified, the conditions chiefly affecting success would run somewhat 
 thus : 1. How far has the operator picked his cases ? 2. What proportion was diph- 
 theritic ? 3. How many were very young ? 4. Was the operation an early or late 
 one ? 5. Was the operator experienced ? 6. Was the after-treatment skilled ? 
 
 i M. Bazeau {Oaz. des H6p., 1867, p. 397) mentions successful cases of tracheotomy 
 in infants of ten and fifteen months. The very youngest cases with which I am 
 acquainted are one in which Mr. Croft operated successfully in an infant, aged six 
 months, with erysipelatous ojdema of the neck and chest. One still younger is quoted 
 in the Med. Times and Oaz., 1880, vol. ii. p. 593. 
 
 ? Turning to the results of foreign surgeons, Dr. Lindner {Deut. Zeitsch.f. Chir., Bd. 
 xvii. Heft 6) states that after the second year there was a marked improvement. In 
 
TRACHEOTOMY. 349 
 
 One case in three or four is a good average. Prof. Buchanan* cured 
 nineteen out of fifty, or one in every 21 cases. 
 
 B. Right Time for Operating,! and Wise Selection of 
 
 Cases. — The nature of the dyspnoea is very various, and on this 
 account the above two points are most important. 
 
 The four following conditions of dyspncca are met with : (i.) Dys- 
 pncea rapid, urgent, and localized to the larynx ; much anxiety and 
 restlessness ; orthopnoea ; stridor, the loudness of which is probably 
 proportionate to the degree of obstruction in the larynx and the pat- 
 ency of the small tubes. In Prof Buchanan's words, it points to a 
 cavity ready to receive air if it could but get it, and to a passage nar- 
 rowed either by false membrane or spasm, or both. On inspection of 
 chest, the extraordinary muscles of respiration are seen to be in action, 
 there is much sucking-in of infra-costal and epigastric, and, later on, 
 of supra-sternal, and supra-clavicular regions. While this sucking-in 
 is vigorous and well-marked, the lungs are probably free. Ausculta- 
 tion and percussion are difficult. If the bases are resonant, and show 
 vesicular murmur, it is of good omen. So, too, if the eyes, though 
 staring, are bright, the face suffused, not livid, the lips of fairly nat- 
 ural color, the cervical veins not much distended, the extremities not 
 cold and the seat of stasis. In such cases the membrane, if present, 
 is limited to the larynx, and the tendency to death is by laryngeal 
 apnoea. Tracheotomy here is not only justifiable, but imperatively 
 called for, if previous treatment has failed ; the prognosis is favorable 
 if the operation is not too long deferred. Hopeful conditions : Sud- 
 den onset, previous good health, sub-maxillary glands not enlarged, 
 absence of albuminuria. 
 
 this yeai- the recoveries amounted to 12 per cent., in the third year they rose to 55 
 per cent. Dr. Passavant, of Frankfort-on-Main {Annals of Surgery, vol. i. p. 582), gives 
 67 cases of cure out of 229, or about 1 in 4. 
 
 * Trans. Intern. Med. Congr., 1881, vol. iv. p. 208. 
 
 f Those surgeons who recommend an early operation, and I am of that number, rely 
 especially on the establishment of much sucking in and of undoubted dyspncea. With 
 regard to the first, Dr. Passavant (loc. supra cit., p. 153) holds that tracheotomy, if de- 
 ferred, allows prolonged dyspnoea to bring about, simultaneously with retraction of the 
 epigastrium, etc., an action on the lung-surface analogous to that of a cupping-glass 
 upon the skin — viz., hypersemia, stasis, hyper-secretion of mucus, splenization, and 
 atelectasis. With regard to dyspno?a, Dr. Eanke, of Munich, lays great stress upon 
 an early operation : " If a child with pharyngeal diphtheria has become hoarse, and 
 shows laryngeal stridor and diflSculty in breathing, which has already led to ever so 
 short an attack of real dyspnoea, that child ought to be operated upon at once." 
 Another practical point bearing upon the right time for operation is the fact that at 
 night-time children often get worse. If, then, a case is advancing, and parents cannot 
 towards the day's close make up their minds to sanction an operation, they may be 
 warned that the patient's condition may call for an operation which will be of neces- 
 sity hurried and performed under much less favorable circumstances as to light, etc. 
 
350 OPERATIONS ON THE HEAD AND NECK. 
 
 (ii.) When the dyspnoea increases more slowly though continu- 
 ously. The restlessness is less violent, and the respiratory effects less 
 exaggerated. The sucking-in is much less marked, especially above. 
 The chest seems to be impeded in its movements, puffing or heaving 
 out en masse, and with difficulty ; on auscultation and percussion, 
 instead of vesicular murmurs, or conducted hoarse laryngeal rhonchus, 
 and normal bases, will be found sibilant rales, small crepitation, and 
 deficient resonance. These point to the exudation being no longer 
 localized to the larynx, but more probably invading the finer bron- 
 chial tubes and air-vesicles, the former being swollen and infiltrated 
 with membrane, the latter clogged with viscid mucus. The tint of the 
 face is now pale or leaden. The operation is here much less likely to 
 be successful, from the extension of the membrane, the condition of 
 the lung and of the right heart. Other unfavorable conditions : 
 Onset with much asthenia, albuminuria and enlarged sub-maxillary 
 glands. 
 
 (iii. and iv.) Dyspnoea intermittent or paroxysmal. In the former 
 case it is due probably to collections of viscid mucus or membrane in 
 the larynx and trachea. Good power of expectoration is here very 
 important. Paroxysmal dyspnoea means spasm. This, very common 
 in all laryngeal dyspnoea, is especially so in children. The danger of 
 this is obvious, and the question of tracheotomy will have to be 
 decided according to whether the spasms are increasing, and by the 
 distance of the medical man from his patient. 
 
 Three chief dangers of deferring the operation too long. 
 
 (1.) CEdema of the lungs.* Owing to the deficient entrance of air, 
 reflex contraction of the pulmonary arterioles takes place, leading to 
 distention of the main trunk, the right heart, and systemic veins. 
 The bronchial veins being also engorged, serous exudation takes place 
 into the finer tubes and vesicles at the bases, and respiration is thus 
 further impeded. 
 
 (2.) Thrombosis of pulmonary artery. Owing to the stagnation in 
 front, the blood current moves more and more slowly, and this 
 obstruction by thrombi is not remediable by operation. The signs of 
 this condition are, increasing dyspnoea, very feeble pulse, and com- 
 bined pallor and lividity. 
 
 (3.) Exhaustion of heart. Children if they repair quickly are 
 exhausted quickly also.f 
 
 Recommendation of the operation to the friends. — (a) In reply to ques- 
 
 * See also the note, p. 349. 
 
 t Prof. Buchanan {loc supra cit, p. 208) makes an important distinction between 
 sthenic and asthenic cases. In the latter, where the vital powers are rapidly failing, 
 tracheotomy will not save the patient, and scarcely, if at all, mitigates the suffering. 
 
TRACHEOTOMY, 351 
 
 tions as to the chance of cure, the surgeon will answer, with caution, 
 that the operation conduces to cure by removing the most urgent 
 danger, by giving relief to the lungs, and thus also improving the 
 strength by sleep and quiet. (/?) He will be able to say that if death 
 occur after tracheotomy it will be by exhaustion, not by apncea most 
 distressing to witnesses as well as to the patient. 
 
 Operation. 
 
 Question of Ansesthetic— A little * chloroform is, as a rule, safe 
 and advantageous. It aljays spasm and thus improves the breathing. 
 It prevents struggles and promotes sleep afterwards. Any vomiting 
 afterwards will probably be beneficial. It is especially useful in 
 recent and vigorous cases, where the surgeon is very short of assist- 
 ance, and where, if I may say so, his practical experience of the 
 operation is not large. Under the opposite conditions it is not needed ; 
 and it will, of course, not be given where there is any tendency to 
 cyanosis and unconsciousness. 
 
 Site of Operation.— High or low, i.e., above or below the isthmus. 
 It will be worth while just to consider here the parts met within the 
 middle line, (A) above, and (B) below, the thyroid isthmus. (A) Skin, 
 superficial fascia, branches of transverse cervical and infra-maxillary 
 (7th) nerves, lymphatics, cutaneous arteries, anterior jugular veins — 
 which, with their transverse branches, are smaller here — deep fascia, 
 cellular tissue, superior thyroid vessels, the isthmus, usually over the 
 second and third rings,t and tracheal layer of deep fascia. The im- 
 portance of this last is twofold, if the trachea be insufficiently opened 
 the tube may be passed between the trachea and the fascia overlying 
 it, embarrassing the breathing and the operator alike. If the wound 
 become unhealthy, this layer, continuous below with the pericardium, 
 may conduct pus into the mediastina. (B) The surface-structures are 
 much the same, but the anterior jugular vein and its transverse 
 branches are much larger. The sterno-thyroids are here J quite close 
 together. The inferior thyroid veins are larger. A thyroidea ima 
 may be present, and the innominate artery cross as high as the seventh 
 ring. The trachea is also deeper, smaller, and more mobile, having 
 no steadying muscles here as higher up. The thymus, too, in young 
 children, might present a difficultJ^ In addition to the above anatom- 
 ical objections to the low operation, there are three surgical ones, viz.: 
 
 * Just enough to prevent struggling during the operation. After the skin is incised, 
 less is needed. 
 
 t Mr. Parker {Trcicheotomy, p. 37) says that in children the isthmus is almost always 
 higher up, generally on the crico-tracheal membrane and the first tracheal ring. 
 
 t Above, the sterno-hyoids are almost in contact in the middle line, with only an 
 interval of about i inch, a, strong argument in favor of keeping in the middle line 
 exactly (Parker). 
 
352 OPERATIONS ON THE HEAD AND NECK. 
 
 (1) Pus is now more easily conducted into the mediastina. (2) In 
 the same way broncho-pneumonia is more probable from a wound in 
 the trachea lower down. (3) From the proximity of the chest, and 
 its suction-action, the tube is much more pulled into the wound, and 
 if it has to be worn for a long time, the tube and shield may part 
 company.* 
 
 Operation. — The instruments required are — a small scalpel, with 
 a triangular-pointed handle to act as a blunt dissector, two pairs of 
 Spencer Wells's forceps, dissecting forceps, steel director, silk or chromic 
 gut ligatures, one or two wire sutures, pilot and tube.t The question 
 of the anaesthetic has already been alluded to (p. 351). The child's 
 neck and head, at first raised and relaxed, J are stretched over a sand- 
 bag or a large bottle wrapped up in a towel, while the hands are 
 secured in the jack-towel which firmly encircles the body. Two 
 assistants are desirable, one to supj^ort the head and give the ansesthetic, 
 the other to sponge. It is almost superfluous to add that the light 
 should be the best possible, a laryngeal mirror may be of much use 
 in illuminating the bottom of the wound. The surgeon § with his 
 left thumb and forefinger steadies the trachea, and makes it a little 
 prominent as well, without any compression ; he then incises the soft 
 
 * Mr. J. Wood, Lancet, 1872, vol. i. p 317. 
 
 f The best tracheotomy tubes are those of Mr. Durham, Mr. Bryant, and Mr. 
 Parker. If the first are chosen they must be of reliable manufacture. The ball-and- 
 socket of Mr. Bryant'.'! tubes allows of free play. Mr. Parker (loc. supra cil., p. 42) 
 argues strongly in favor of angular tubes. He shovrs that the usual J-inch tubes im- 
 pinge with their lower extremity on the anterior wall of the trachea, thus tending to 
 produce ulceration and grave risks fp. .361). Mr. Parker, I think, entirely proves his 
 point. I have used his tubes, but find the absence of a pilot troublesome in dealing 
 with little children. 
 
 Whatever tube is chosen, it should be as large and as short as possible ; it should be 
 of the same size throughout, without tapering; the inner tube should project a little 
 beyond the outer one; while the whole tube should fit snugly, standing out as little as 
 possible in the neck. 
 
 As to the size of the tubes needful, Mr. Parker recommends a series running from 
 No. 18 to No. 30, French gauge, the most useful sizes for children being Nos. 18, 20, 
 22, 24, 26, and 28 for the outside tube. On this matter of the size of the tube and its 
 relation to the aperture of the glottis and size of the air-tube, the reader should con- 
 sult Mr. Holmes {Dis. of Children, p. 324), jMr. Howse (Guy's Hosp. Reports, 1875, p. 
 495), and Mr., Marsh {St. Barlhol. Hosp. Reports, vol. iii.). 
 
 X Whenever an aniesthetic is being given in cases of dyspnoea, the patients, whatever 
 the age, should be allowed to choose their own position at first, and any movements or 
 alterations in the position of the head and neck, preparatory to the commencement of 
 the operation, should be carefully made. 
 
 J He first, as soon as the head and neck are in position, marks the chief spots in the 
 middle line — viz., centre of the chin and manubrium, and (when they can be felt) the 
 hyoid bone and the thyroid and cricoid cartilages, especially the last. 
 
TRACHEOTOMY. 353 
 
 parts in the middle line from about the centre of the cricoid * down- 
 wards for about two inches, cutting well through the fat, often abun- 
 dant here, and exposing the interval between the sterno-hyoids, he 
 then incises this interval, and, if he has reason to fear ha3morrhage, 
 with the point of a steel director t placed in the upper part of the 
 wound he slits down the remaining soft parts in the middle line till 
 he can distinctly feel or, with the aid of retractors, see the tracheal 
 rings4 The point of the knife is often required here to incise surely 
 the tracheal fascia. Until the tube is distinctly exposed the left fore- 
 finger and thumb must not be removed from their steadying position 
 on either side. With the blade of the knife held upwards the middle 
 line of the front of the trachea is then punctured, stabwise, and two 
 or three rings divided. Sufficiency of the opening is known by a free 
 and noisy rush of air, accompanied often by the expulsion of mem- 
 brane, which should be sponged away at once. On the other hand an 
 inadequate opening will be indicated by the hissing only of qir through 
 the slit-like opening, without any free rush and with no escape of the 
 membrane or relief of the dyspnoea. In this latter case the first opening 
 must be found by the finger-nail and carefully enlarged. § The can- 
 nula is then inserted on a pilot and secured with tapes in situ. Some 
 prefer to use a pair of dressing-forceps to dilate the opening, but this 
 is not necessary in the high operation, when the tracheal opening has 
 been rightly made both as to size and site, and when a pilot is used to 
 introduce the cannula. If it be desired to try and remove any mem- 
 brane,! | the cannula should not be inserted at once, but the opening 
 
 * This cartilage is often incised, a point to be, however, avoided. Tlie parts are so 
 small in a child that a tube put in by incising the cricoid is likely to irritate the larynx. 
 Of this the cricoid is the narrowest and a very rigid part. Only tlie smallest cannulae 
 can be used here. 
 
 t Mr. AVhitehead {Lancet, April 30, 1887), having found that tlie sharp point of a 
 director will tear open the thin-walled veins here, uses a raspatory after the skin inci- 
 sion. With this he separates the sterno-hyoids, splits the fascia running from the hyoid 
 to the thyroid isthmus, and then, pushing this split fascia on either side with the raspa- 
 tory, pulls down the isthmus and exposes the trachea, the whole operation being thus 
 rendered easy and bloodless. 
 
 J Dr. Buchanan considers the following a golden rule : " Never plunge the knife into, 
 the trachea till the white rings are clearly seen in the bottom of the wound." In eases 
 of real urgency the surgeon must be satisfied with touch and not with sight. 
 
 § If the opening be to one side, as well as too small, a fresh and adequate oneshould 
 be made in the middle line. 
 
 II Mr. Parker, one of the chief authorities on this subject, strongly advises that all 
 membrane as well as mucus be got rid of, on account of its impediment to respiration, 
 its infectiousness, and the patient's inability to get rid of it himself by coughing after 
 tracheotomy. On this account Mr. Parker recommends gently twirling about a feather, 
 soaked in solution of sodium carbonate, and passed several times, not only down into 
 the trachea, but up into the glottis. Mr. Parker condemns attempts to suck out mem- 
 
 23 
 
354 OPERATIONS ON THE HEAD AND NECK. 
 
 dilated with dressing-forceps, or with Mr. Golding Bird's or Mr. 
 Parker's dilator. When inserted, the cannula must lie in the middle 
 line, otherwise there will be troublesome irritation of the trachea and 
 plugging of the cannula. 
 
 Chief Difficulties.— (1) Insufficient skin incision giving no room for 
 the deeper work.* (2) Not keeping the middle line, the abundant fat, 
 and the indistinctness of landmarks— e.g'., a flat thyroid in a little child 
 aiding this mistake. (3) Not steadying the trachea. This omission 
 leads to missing the tube altogether. Cutting to one side of it, or 
 cutting into it laterally instead of centrally, and insufficiently. (4) 
 Haemorrhage, the chief bugbear of the operation, varies extremely. 
 Generally it is not great. Any artery which springs should of course 
 be tied at once or caught in Spencer Wells's forceps, and a vein of any 
 size which lies in the way should be caught between two of these for- 
 ceps before it is divided. Venous hfemorrhage, as a rule, stops as soon 
 as the trachea is opened and respiration established. A sufficient 
 median skin incision aids the meeting of hsemorrhage. With regard 
 to the isthmus of the thyroid, this may usually be neglected by the 
 surgeon ; if felt with the finger to be large it may be depressed.f If 
 encountered in older subjects, or if large in children, it may be com- 
 pressed by two pairs of Spencer Wells's forceps before division, or liga- 
 tured on either side by passing an aneurism-needle beneath it. If, as 
 very rarely happens, the venous bleeding is very free, and the patient's 
 condition from dyspnoea critical, the trachea must be felt for and 
 opened before the hfemorrhage is arrested. The urgency of the case 
 must here come before the amount of the bleeding. In these cases the 
 moment the tube is opened the patient must be turned well over on to 
 his side. Entrance of blood, to any amount, into the lungs, must be 
 avoided, as not altogether harmless ; it will add to the dyspnoea now, 
 and later on, may set up broncho-pneumonia. (5) Insertion of can- 
 nula. If the trachea has not been steadied, and the rings not clearly 
 made out by sight or touch, the opening will very likely be made in- 
 adequate, or to one side. Another difficulty may arise here from the 
 tracheal fascia not having been sufficiently cut, or from the tube being 
 pushed down between this fascia and the trachea, this, of course, only 
 further embarrassing the breathing. Lastly, though the tracheal rings 
 are cut, the swollen and inflamed mucous membrane may not have 
 
 brane by putting the lips directly to (he wound, as of no service to tlie patient, and as 
 possibly very disastrous to the operator. 
 
 * As in a colotomy, or any other deep incision, the wound should not be funnel- 
 shaped. 
 
 t In children this may certainly be ignored. If the knife is used to open cleanly 
 and sufficiently the deep fascia, and then a fine-pointed steel director to clear the way 
 down to the trachea, the operation will be almost bloodless. 
 
TRACHEOTOMY. 355 
 
 been sufficiently divided, or a false membrane may have, in the same 
 way, been carried before the knife. (6) Little or no relief after inser- 
 tion of the cannula. Though this may have been well and truly done 
 it is not followed by the relief which has been expected. This may 
 be due (a) to the tube being passed between the tr.achea and some 
 membrane which plugs it; (6) to the trachea and bronchi being 
 blocked with membrane, etc. ; (c) to the child, owing to the operation 
 being performed late, being practically asphyxiated before the com- 
 pletion of the operation. The indications now are to remove the tube 
 and to clear out the trachea, while artificial respiration is vigorously 
 performed and kept up, the opening into the trachea being kept patent 
 by dressing-forceps or by one of the retractors above mentioned (p. 354). 
 If feathers or brushes fail to reach and remove the membrane, trial 
 may be made of aspiration by the mouth. The best means of effecting 
 this is by Mr. Parker's tracheal aspirator,* which consists of a small 
 glass cylinder, 3 or 4 inches long, to one end of which the end of a silk 
 catheter is attached, and to the other an india-rubber tube ending in 
 a mouthpiece. It can be taken to pieces to facilitate cleaning. Before 
 use a little cotton wool is packed into the cylinder to prevent any dan- 
 gerous membrane reaching the operator's mouth. Direct suction should 
 never be performed in membranous laryngitis ; where blood alone is 
 the cause of the dyspnoea, it may of course be thus removed. 
 
 Before leaving the subject of operation, one or two other methods 
 may be briefly alluded to. 
 
 Method of Bose.f — This is largely made use of in Germany, as it is 
 thought to do away with those dangers which a large thyroid isthmus 
 may present in the high operation. An incision is made vertically in 
 the middle line for about I2 to 2 inches from the centre of the thyroid 
 cartilage. The cricoid being exposed, a transverse incision is made 
 along its upper border so as to divide the layer of deep cervical fascia 
 by which the isthmus is tied down. A director or blunt dissector is 
 then introduced through this incision, and the fascia and the isthmus 
 with its veins displaced from the trachea and depressed. The upper 
 rings are thus exposed bloodlessly. I have no experience of this opera- 
 tion, but it would appear not unlikely that even if this layer of fascia 
 were quickly hit off and detached, this additional transverse incision 
 and separation of soft parts might lead to cellulitis. 
 
 Tracheotomy by the Cautery. — This method, used of late in Germany 
 and France,! has found very little favor in England. It is best per- 
 formed by Paquelin's therm o-cautery, used with a series of light 
 touches. Owing to its toughness the skin should be divided with a 
 
 * Loc. supi-a cit., Fig. 10, p. 53. 
 
 t ArcLf. Klin. Chir., Ed. xiv. s. 137, 144; Brii. Med. Journ., 1878, vol. i. p. 572. 
 
 t Poinset, Track, par le Thermo- Cautire. Paris: 1878. 
 
356 OPERATIONS ON THE HEAD AND NECK. 
 
 knife, and when the trachea is exposed this should be opened in the 
 usual way. This method has no bond fide advantages. Fatal hasmor- 
 rhage has followed its use. The relations of parts are much altered. 
 The heated condition of the soft parts is most unpleasant to the finger 
 as it feels its way before each application of the blade. 
 
 After-treatment. 
 
 This subject, neglected in most books, is often too little looked to in 
 practice. The question of the most suitable atmosphere for the pa- 
 tient will first arise. By most a tent (readily improvised by convert- 
 ing a cot into a four-poster, by fastening on four vertical pieces of 
 wood at the corners, joiniiig these by four horizontal pieces, and 
 throwing a sheet over all) is recommended, and, one side of the cot 
 being left uncovered, steam is conducted thither by one of the dif- 
 ferent forms of croup-kettles. While fully aware of the need of 
 moisture when the atmosphere is dry, when the membrane tends to 
 crust and become fixed, I am of the opinion that the above unvary- 
 ing rule of cot-tenting and use of steam is disadvantageous. The 
 weakly condition of children with membranous laryngitis, and all 
 that they have gone through, must be remembered. Believing that 
 such seclusion and so little admission of air tend to increase the 
 asthenia, and any tendency to sepsis, I much prefer to Vje content 
 to keep off draughts by a screen, which allows of the escape of vitiated 
 air above, using steam, if needful, according to the size of the room, 
 fireplace, etc., and according to the kind of expectoration, whether 
 easily brought up by cough or feathers, or viscid, quickly drying, and 
 causing whistling breathing. If the temperature can be otherwise 
 kept up to 60° or 65°, I much prefer to use a thin fiat sponge, often 
 wrung out of a warm solution of boracic acid. The inner tube must 
 be frequently removed and cleansed, every hour or two at first. If 
 the secretions dry on and cling to it, they are best removed by the 
 soda solution mentioned below. At varying intervals between the 
 removal of the tube any membrane, etc., which is blocking it, appear- 
 ing for a moment at its mouth and then sucked back, must be got rid 
 of by inserting narrow pheasant feathers and twisting them round 
 before removing them. If the exudation is slight, moist, and easily 
 brought up by cough or feather, sponging and brushing out the trachea 
 are not called for, but they should be made use of when there is much 
 flapping, clicking, or whistling of the breathing, and if this is harsh, 
 dry or noisy, instead of moist and noiseless, two of the best solutions 
 are soda3 bicarb., gr. v-xx to aq. §j, or a saturated one of borax with 
 soda. These may be applied l)y a hand or steam spray over the can- 
 nula for five or tt'u minutes at a time, at intervals varying according 
 to the relief which is given, or applied with a laryngeal brush, feather, 
 
TEACHEOTOMY. 367 
 
 or a bit of sponge twisted securely into a loop of wire. When any of 
 these are used, the risk of excoriation and bleeding, and the fact that 
 only the trachea and large bronchi can be cleaned, must be borne in 
 mind, and with regard to manipulations for cleansing the trachea, and 
 removing the inner tube, it is most important to remember that the 
 caretaking may be overdone, and a weakly child still further exhausted 
 by meddlesome interference. This point requires especial attention 
 from the surgeon in the case of some of the nurses of the present day, 
 who seem to wish to transfer the entire charge of the case into their 
 own hands. 
 
 There is often much difficulty in getting sufficient food taken. The 
 pain in swallowing, the impairment of the act, owing to the presence 
 of the tube, etc., and thus the facility with which liquids may reach 
 the lungs, the need of waking up the child frequently to give it food, 
 are all facts to be duly remembered. It will usually be better to pass 
 a Jaques' catheter (No. 4 or 6) by the nose, and then to feed the pa- 
 tient, at regular intervals, with definite amounts. Care must be taken 
 to see, by the absence of irritation, that the tube is not in the pharynx, 
 and, if the above soft tubes are used, that they do not coil up at the 
 back of the tongue. 
 
 The removal of the tube next requires consideration. It 
 should be dispensed with at the earliest possible opportunity, either 
 altogether, or replaced by an india-rubber tube between the fourth 
 and ninth days. Quite apart from the danger, which is inseparable 
 from a metallic tube, of irritation and ulceration of the trachea, there 
 is this object in getting rid of the tube as soon as possible, that the 
 longer the child is allowed to breathe through the tube the more is 
 the act of breathing through the natural passages allowed to be, as it 
 were, forgotten, with the result that, on the tube being removed, as- 
 phyxia is threatened. 
 
 Conditions which Impede the Removal of the Tuhe.—(1) Prolonged for- 
 mation of membrane. The longest possible period for this is proba- 
 bly about ten days. Patience and support are the main indications 
 in the treatment here. (2) The larynx is crippled like any other in- 
 flamed part. (3) The air-tube is closed by granulations, usually above 
 the cannula. Here the tube must be removed, and astringents and 
 caustics carefully applied from below, with the aid of an anesthetic 
 if necessary. (4) Closure of larynx by deep ulceration cicatrizing 
 after detachment of membrane. In such a case, with the aid of anaes- 
 thetics, the larynx must be opened up by probes of increasing size 
 and laminaria tents introduced from below, and later on by the use of 
 Macewen's tubes (p. 359). (5) Paralysis of the dilating crico-aryte- 
 noidei postici, or spasmodic action of the closing ones, arytenoidei or 
 
358 OPERATIONS ON THE HEAD AND NECK. 
 
 crico-arytenoidei laterales, from fear, excitement, or during effort* 
 The commonest cause of inability to dispense with the tube is proba- 
 bly due to the rapidity with which the larynx falls into abeyance 
 when a child is allowed to breathe through a tracheal cannula, the 
 patient at this age being not intelligent enough to understand the im- 
 portance of dispensing with the tube, being perhaps too young to care 
 to talk, and, if older, not realisiing the need of again using its voice 
 while all its wants are supplied. With the above condition often goes 
 a nervous dread of having the tube removed, and paroxysms of 
 temper and struggling which rapidly produce embarrassed breathing. 
 Any organic mischief, such as adhesions in the larynx, are, I think, 
 extremely rare, and granulations above or below the tube are more 
 often talked of and given as a reason for inability to dispense with 
 the tube than really seen. 
 
 But while real organic mischief is rare and the usual cause is due 
 to conditions which would seem to be only temporary, it is well 
 known that, in some cases, getting a little child to dispense with the 
 tube is a most baffling and prolonged affair. The following points are 
 worthy of attention: Early attempts to remove the cannula, whether 
 metal or india-rubber. A reliable nurse, ability on the part of the 
 surgeon so to arrange his time as to be himself frequently present at 
 first, and in the intervals to be represented by an assistant who will 
 not replace the tube before it is absolutely necessary to do so, and 
 who can dilate the opening with a pair of dressing-forceps, and per- 
 form artificial respiration if these steps are required. Shortening the 
 india-rubber tube, till eventuall}' little more than the shield is worn, 
 the child being comforted by the apparent presence of the tube. En- 
 couraging the child to make use of his larynx by breathing through 
 the tube and expiring through the larynx while the tube is closed. 
 Patiently persevering efforts to get a child to talk, or in the case of a 
 younger one to use his larynx by blowing out a spirit-lamp or using 
 a penny trumpet.f 
 
 All this time every attempt should be made to improve the general 
 health. Wise feeding— too frequent or too large meals provoke 
 dyspnoea — attention to the bowels, such tonics as Easton's syrup, 
 proper clothing, cold or tepid sponging followed by friction, change of 
 scene and air in every possible way, especially to the seaside. 
 
 * In a case in which I had performed tracJieotoray, and was watching the child for 
 the first few hours after the tube liad been dispensed with, most urgent symptoms came 
 on during the slight straining which accompanied an action of the bowels, the child 
 falling ofl' from the niglit-stool on to the floor apparently lifeless. Artificial respira- 
 tion restored the child, and the case did well. 
 
 f I may advise my readers to consult a most practical paper by Dr. Steavenson (St. 
 Barthol. Hasp. Reports, 1881). 
 
TRACHEOTOMY. 359 . 
 
 In a large majority of cases the above, treatment, aided by patience, 
 tact, and time, which allows of development of the air-passages, will 
 suffice. In a few, the attempts at removing the tube will still fail. 
 Where this is so, and in fact in any case where the use of the tube 
 seems likely to be protracted, the larynx should be dilated— a step 
 which is brought about by simple means, as the larynx is merely func- 
 tionless from disuse, not blocked up, or the glottis closed— by a tube 
 through which the child is made to breathe. 
 
 In a recent case the simplest way of effecting this is, after chloroform 
 has been given, to remove the tracheotomy tube, dilate the wound if 
 needful, and pass upwards from it a drainage-tube or catheter with a 
 double-silk web ; the upper end of this is drawn out of the mouth 
 (with the aid of a gag if needful), and tied to the lower end which 
 projects through the wound. The tracheotomy tube is then replaced 
 for a day or two, and on the withdrawal of the tube from the larynx 
 it can usually be dispensed with altogether. 
 
 In cases of longer standing the above simple treatment may not be 
 sufficient, and here the use of Macewen's tubes passed through the 
 larynx* and into the trachea below the wound should be made use of. 
 Chloroform being given, one of the above tubes— they resemble stout 
 gum-elastic catheters with terminal carefully bevelled openings — is 
 passed from the tracheal opening f up through the larynx into the 
 mouth. Having hooked this end out of the mouth, J the surgeon now 
 passes the other end down the trachea beyond the wound, a step some- 
 times accompanied with much difficulty, and one which is aided by 
 the pioneering use of probes and small bougies or catheters. The 
 object of the surgeon should be to place this lower end of the tube 
 only just below the tracheal opening, so that air is drawn in from the 
 end projecting through the mouth into the trachea, without leaving 
 any needless length of the tube here or in one bronchus for fear of 
 setting up irritation and secretion. To prevent the child pulling out 
 the tube the hands should be secured for the first few hours, and to 
 prevent the tube being bitten, it is well to pass a piece of drainage- 
 tube! O'^^J" the first few inches. This end is then secured with tapes 
 around the head. The tube may be left in from twelve to eighteen 
 hours, according to the amount of secretion and the facility with which 
 the tube is blocked. While this treatment is being carried out it is- 
 well to isolate the child in a separate ward, as the breathing through 
 
 * See a paper by Mr. Bilton Pollard (Lancet, 1887) oa this subject. 
 
 t It is more easy to pass the tube this way owing to the facility with which the tube, 
 when passed from above, finds its way into the oesophagus. 
 
 % The tube will be found to pass readily behind the soft palate. 
 
 § This simple means is much better borne by the child than the gag. I owe its 
 suggestion to an old friend, Arthur E. Poolman. 
 
360 OPERATIONS ON THE HEAD AND NECK. 
 
 the tube is very noisy, being often accompanied by very loud bub- 
 bling sounds, and the aspect of the child while this necessary dilating 
 of the larynx is going on is one of apparently great distress. When 
 it is evident the tube is clogged it must be withdrawn and cleansed, 
 and, a little anesthetic being given, again inserted. At any time, if 
 needed, the cannula must be re-inserted and artificial respiration per- 
 formed. It will readily be understood that during this time the pres- 
 ence of the surgeon, and reliable assistants who will not lose their 
 heads, and nurses with much tact and temper, are pre-eminently 
 required. Even when laryngeal breathing is restored and the tube 
 has been dispensed with, the child must be carefully watched, espe- 
 cially at night. If natural breathing fails, it is better, whenever there 
 is time, to replace the Macewen's tube through the larynx rather than 
 to re-insert the tracheotomy-tube into the old wound, a mode of relief 
 which is too likely to be resorted to on account of its facility, but one 
 which tends to keep up the sinus-like nature of the wound in the 
 trachea, and brings back that most pernicious tendency of the child to 
 prefer and confide in this mode of breathing. 
 
 Oomplications of the After-treatment. 
 
 (a) Hemorrhage. — This is not common ; if immediate, it is due to 
 some vessels having been left unsecured. Later on, it may be brought 
 about by ulceration of the trachea by the cannula,* separation of the 
 false membrane by sloughing ; a velvety and swollen condition of the 
 mucous membrane ; or by prominent granulations. The treatment is 
 clearly preventive, to dispense with a tube, especially a metal one, as 
 soon as possible, and from the first to use one of appropriate length 
 and curve (p. 352). 
 
 (6) A Sloughy Condition of the Wound. — If this is threatening, atten- 
 tion must be paid to the tightness of the tapes, so that the cannula is 
 not needlessly buried in the wound, and to the wearing of a collar of 
 lint behind the shield. The tube must be removed at intervals, or re- 
 placed by an india-rubber one, air tending to enter without a tube as 
 soon as the edges of the wound are set and rigid. If the wound is not 
 only sloughy, but gangrenous and diphtheritic, in addition to frequent 
 cleaning with a camel's-hair brush, the use of antiseptic powder and 
 lotion, stronger measures, such as the application of pure nitric or 
 carbolic acid, will be called for. The general treatment will not, of 
 course, be neglected in these cases. 
 
 (c) Emphysema.f — This is usually the result of a faulty operation. 
 
 * Some undoubted cases of ulceration into the innominate after low tracheotomies 
 in children are on record — e.g., Path. Soc. Trans., vol. xi. p. 20. 
 
 f On this subject the reader should consult the laborious, accurate, and researchful 
 papers of my old friend Dr. Champneys, in vols. Ixv. Ixvii. and Ixviii. of the ^[ed., 
 Chir. Trans., and his work on Artificial Bespiration. The following are amongst the 
 
TRACHEOTOMY. 361 
 
 The incision into the trachea is either wrongly placed, i.e., it is not in 
 the same line with that in the soft parts, or it is too small — perhaps 
 two small ones have been made ; very rarely is the emphysema due 
 to too large an incision in the trachea. Or, the incision may have 
 been correctly made, but some fault connected with the tube may pro- 
 duce the emphysema ; thus it may have been originally too short, or 
 have been pushed out of the wound by swelling of the soft parts, or 
 by coughing. As a rule, this complication is not dangerous unless it 
 be extreme in very young children, or unless it travel deeply ; under 
 these circumstances scarification must be made use of, if possible. 
 
 (d) Ulceration of the Trachea. — This is usually due to the pressure of 
 a cannula faulty in length or curve, much more rarely to separation 
 of membrane or sloughs. There are no definitely characteristic signs 
 of this complication; the following point to it : Streaks of blood ex- 
 pectorated a day or two after the operation, and perhaps discoloration 
 of the lower end of the tube. This accident is especially likely to 
 occur in cases of diphtheria, as the vitality of the tissues is here much 
 lowered. The tube should be left out if possible, or an india-rubber 
 one substituted, and worn as short as possible, and cut obliquely so 
 that the end does not impinge upon the anterior wall of the trachea. 
 If it is necessary to dispense with all tubes, attempts may be made to 
 keep the edges of the tracheal wound stitched to that in the soft i^arts 
 for a few hours, or Mr. Golding Bird's dilator may be worn. 
 
 (e) Suppuration in MediaMina. — This is a rare complication. When 
 it does occur it is liable to be very rapid. It results from a descend- 
 ing cellulitis from the wound. The only treatment is prevention by a 
 well-performed operation and by attention to the wound. 
 
 Other complications which are not surgical may of course be pres- 
 ent — viz.. Extension of exudation downwards. General infection. 
 Paralysis. Albuminuria. Broncho-pneumonia, a very frequent one, 
 known by a rise of temperature with frequent respiration and dyspnoea, 
 dulness on percussion, bronchial breathing, with large bubbling and 
 crepitant r^les. 
 
 practical conclusions with which his pages abound: (1) Emphysema of the anterior 
 mediastinum, often associated with pneumothorax, occurs in a certain number of trache- 
 otomies. (2) The conditions favoring this are, division of the deep cervical fascia, 
 ob.struetion to the air-passages, and inspiratory efforts. (3) The incision in the deep 
 cervical fascia downwards should not be longer than needful ; it should on no account 
 be raised from the trachea, especially during inspiratory efforts. (4) The frequency of 
 emphysema probably depends much on the skill of the operator, especially in inserting 
 the tube. (5) The dangerous period during tracheotomy is the interval between the 
 division of the deep cervical fascia and the efficient introduction of the tube. (6) If 
 artificial respiration is necessary, the tissues should be kept in apposition with the 
 trachea, and any manipulations performed without jerks. 
 
362 OPERATIONS ON THE HEAD AND NECK. 
 
 TUBAGE OF THE LARYNX AS A SUBSTITUTE FOR 
 TRACHEOTOMY IN MEMBRANOUS LARYNGITIS. 
 
 This is one of those new modes of treating an old disease about 
 which it is difficult to give a decided opinion, as the matter is still 
 sub jud'ice. 
 
 Attention was called to this subject by Dr. Macewen* in 1880. It 
 has been, recently, more prominently brought forward in America.f 
 
 The advantages claimed, if verified, will no doubt be very great. 
 Of these the chief are — (1) That objection on the part of friends is less 
 likely than in the case of tracheotomy ; (2) That the tubes are easily 
 and quickly introduced ; (3) That there is no severe and difficult 
 operation; (4) That the inspired air is warm and moist; (5) That the 
 tubes are self-cleansing ; (6) That there is no prolonged after-treat- 
 ment. 
 
 The tubes used have been mainly of two kinds — (a) Macewen's 
 long cylindrical tubes of the pattern of gum-elastic catheters, intro- 
 duced from the mouth into the trachea through the larynx, and 
 removed at intervals of about twelve hours for cleansing ; (6) O'D wyer's 
 short tubes (under 3 inches) of metal with the antero-posterior diam- 
 eter larger than the lateral. These are self-retaining, partly by an 
 enlarged head which rests upon the ventricular bands, and partly by 
 a fusiform enlargement a little lower down. They are introduced and 
 removed from the mouth by special instruments. A gag must be 
 used. 
 
 I am unable to recommend intubation. Within a few months of 
 the appearance of Dr. Macewen's paper I made use of his method in 
 three patients with membranous laryngitis at the wish of my friend 
 Dr. Goodhart. Every one of these came to tracheotomy, most of the 
 drawbacks enumerated below being most strongly present. I ought 
 to say that of Dr. O'Dwyer's tubes I have no personal experience, but 
 I am most strongly of opinion that, in children at least, they cannot 
 meet with a» large amount of general success. Their necessarily 
 narrow chink-like calibre appears to me to be certain to obstruct the 
 free expectoration of mucus, membrane, etc., which is so essential in 
 
 * Brit. Med. Journ., July 24 and 31, 1880. Dr. Macewen's cases were all four in 
 adults, the two acute ones being cases of oedema of the glottis. 
 
 t Dr. O'Dwyer's first paper is in the New York Med. Journ., August, 1885. Mr. 
 Symonds, in his summary alluded to at p. 363, gives the following references of papers 
 by followers of Dr. O'Dwyer— viz., Dr. Waxhara {Chicago Med. Journ., March, 1886; 
 Journ. Amer. Med. Assoc, October 24, 1885, and July 23, 1887) and Dr. Ingals {New 
 York Med. Journ., July 2 and 9, 1887). Dr. Waxham's results have no doubt im- 
 proved, but in the Chicago Med. Journ. and Exam., November, 1885, Ann. of Surg., 
 January, 1886, four cases are given which were treated by him, after O'Dwyer's plan, 
 of which only one recovered. 
 
TRACHEOTOMY. 363 
 
 these cases. Even when this is liquid and abundant, I fear thcat the 
 tubes will be plugged ; when the expectoration is dry, thick, and 
 tenacious, its escape must surely be impossible. 
 
 Drawbacks : (1) The tubes are likely to become plugged ; (2) There 
 is very great difficulty in getting children to take sufficient food, as 
 swallowing is, in them certainly, much embarrassed. The importance 
 of getting sufficient food down in these cases has already been alluded 
 to, p. 367 ; (3) Part of what liquids are taken now easily finds its way 
 into the trachea and lungs; (4) The tube may be coughed out ; (5) 
 The facilities for extracting membrane, spraying the trachea, etc., are 
 much fewer than after tracheotomy. 
 
 Mr. Symonds, in a summary* of the results of O'Dwyer's method, 
 states that in passing the tubes membranes may be pushed down, thus 
 increasing the dyspnoea, and, with this difficulty before us, he points 
 out that it will be wise, when making use of intubation, to be prepared 
 for immediate tracheotomy ; while I feel, I trust sufficiently, that the 
 results of tracheotomy for croup admit of very great improvement, I 
 doubt if intubation will be more successful. I venture to think that 
 this is one of those diseases in which sufficient attention has not been 
 paid to some of the anatomical surroundings. I shall, perhaps, be 
 condemned as holding a j)essimist's views when I say that, consid- 
 ering the narrowness of the glottis, its proneness to spasm, the ready 
 downward extension of the disease, the age and rapid exhaustion of 
 the patients, I doubt much if it is not expecting too much when a 
 larger proportion of cures are looked for here, either by tracheotomy 
 or, still less, I think, by tubage. And while I allow that I have not 
 myself had personal experience of the recent modification of tubage, 
 I would add that I have very lately seen two cases in which the im- 
 proved method was made use of with much temporary edat, followed 
 by tracheotomy, deferred, but ultimately called for, and by fatal results. 
 
 OTHER INDICATIONS FOR TRACHEOTOMY. 
 
 (i.) Syphilitic and Tubercular Ulceration.— Tracheotomy is 
 more frequently called for in the first of these, in which also it is 
 decidedly more useful. The conditions which demand it temporarily, 
 are cedema of the glottis setting in on old mischief, fibroid thickenings, 
 which may, later, yield to treatment, and more permanently, prob- 
 ably, deep ulceration, necrosis, and cicatricial contraction. 
 
 In tubercular mischief tracheotomy rarely gives much relief, dysp- 
 noea being now a rarer misery than cough and difficulty of swallowing, 
 both of which are conditions which may be intensified by the pres- 
 ence of a tube. 
 
 * Brit. Med. Journ., November 19, 1887. 
 
364 OPERATIONS ON THE HEAD AND NECK. 
 
 (ii.) Malignant Disease of the Larynx. -Here tracheotomy 
 is often called for. Till statistics of extirpation of the larynx are more 
 complete, the question which of these modes of operative interference 
 has the soundest basis must remain uncertain. One difficulty alone 
 which besets this matter is scarcely to be surmounted, and that is that 
 an increasing number of cases shows that, to be really successful, 
 extirpation of the larynx must be performed early, but how many 
 patients will submit to it at this stage ? (p. 370). 
 
 In deciding between advising a palliative tracheotomy and extirpa- 
 tion of the larynx the surgeon will be guided by the condition of the 
 disease and that of the patient. The latter operation can alone be 
 justified when the disease is strictly localized. Enlargement of the 
 lymphatic glands, extension of the disease, especially in cases of car- 
 cinoma, to the pharynx, back of the tongue or tonsil, should put this 
 operation aside. Again, the condition of the patient, how far he is 
 exhausted, how far his strength is sufficient for such an operation as 
 extirpation, how far he gains ground after a prehminary tracheotomy, 
 have all to be considered. 
 
 (iii.) Acute Laryngitis.— The rapidity with which this may run" 
 a fatal course, especially after exposure to cold in reduced consti- 
 tutions, is well known. If treatment, including application of strong 
 solution of silver nitrate and scarification of the aryteno-epiglottidean 
 folds and adjacent parts fails to relieve the dyspnoea, tracheotomy 
 should be performed at once to meet the increasing exhaustion. 
 
 (iv.) Certain Spasmodic Affections,— e..^.. Aortic Aneurism 
 and Tetanus.— Owing to these diseases destroying life, usually in 
 other ways, tracheotomy is rarely called for here. Occasionally, how- 
 ever, the laryngeal dyspnoea which they bring about calls for this 
 operation. 
 
 Probably there is no form of dyspnoea more agonizing to the patient 
 or more distressing to the friends, than that which may accompany 
 thoracic aneurism. The surgeon, however, when called upon to per- 
 form tracheotomy in one of these terrible cases, must remember that 
 the dyspncea may be tracheal as well as laryngeal in its origin, and 
 that it is in the latter only that operation will give relief. 
 
 I would refer my readers on this point to one of Dr. Bristowe's in- 
 teresting Lumleian Lectures,* and especially to this passage : " De- 
 struction of the functional activity of one recurrent laryngeal nerve is 
 attended with, of course, paralysis of the corresponding vocal cord 
 (which can be recognized by means of the laryngoscope), with impair- 
 
 * Lancet, May 10, 1879. Dr. Bristowe goes on to show that the exacerbations of 
 dyspnop.a in narrowing of the trachea may be due partly to spasm of the muscular 
 fibres, but mainly to accumulation of mucus below the narrowing, and to the difficulty 
 of dislodging it by coughing. 
 
TRACHEOTOMY. 365 
 
 ment of the musical quality of the voice, and apparently with some 
 difficulty of swallowing, owing to the tendency of food to slip into the 
 trachea, but is certainly not necessarily attended with stridor or 
 dyspnoea; in the second place, compression of the trachea involves 
 stridor and dyspnoea, which is often paroxysmal and is liable to end 
 in sudden death, but does not itself interfere with intonation or pho- 
 nation, excepting in so far as it may render the voice weak by 
 diminishing the supply of wind to the vocal organ." As the paryox- 
 ysmal nature of the dyspnoea may then be met with in cases of press- 
 ure on the air-tube below the larynx as well as in laryngeal dyspnoea, 
 the chief points to rely on will be the result of a laryngoscopic exami- 
 nation, and the freedom of the lungs and air-tube from pressure. Dr. 
 Hall* thinks that "the absence of respiratory excursions of the 
 larynx points to the chief impediment being below the glottis." 
 
 With regard to tracheotomy in tetanus, the same warning has to be 
 given. In the rarer cases in which tetanus threatens life by asphyxia 
 and not by exhaustion, the surgeon, before performing tracheotomy, 
 must decide where lies the seat of the asphyxia. In the few cases 
 which I have seen in which asphyxia closed life in this disease, the 
 asphyxia was due to spasm of the muscles of respiration, including 
 the muscles of inspiration and those of expiration — e.g., the ab- 
 dominal muscles also. The fatal spasm thus, usually, not lying 
 in the larynx, tracheotomy seems contraindicated, unless it were 
 done with the object of relieving, with the aid of artificial respiration, 
 that congested, gorged condition of the lungs which is due to the con- 
 tinued spasm of the muscles of respiration. And it is to be feared that 
 if these steps were taken, the gentle violence of artificial respiration 
 would, as has happened with tracheotomy itself in this disease, only 
 bring on a final and fatal spasm. 
 
 (v.) Scalds of the Upper Aperture of the Larynx.— Tra- 
 cheotomy is here usually deferred till late, and its want of success is 
 well known. This is not, however, an instance of cause and effect, the 
 mortality in these cases being rather due to the shock, pain, and ina- 
 bility to take sufficient food. Unless the case is seen late, tracheotomy 
 
 * Clin. Soc. Trans., vol. xix. p. 82. Quoting from Gerhardt (Lehrh. d. Ausc, Tubin- 
 gen, 1871), Dr. Hall points ont that in a case of aortic aneurism the following causes 
 for dyspnoea (Dr. Powell, Reynolds's Syst. of Med., vol. v. p. 32) may all be present 
 together: (1) Undoubted paresis of the abductors of the cords. (2) Though the post- 
 mortem may "not show any very distinct bulging inwards of the trachea, the aorta 
 and sac being emptied of blood, yet I can readily believe that during life, when these 
 parts were distended with blood, considerable pressure was exerted on the trachea, and 
 that this narrowing led to accumulation of the tough mucus which so bothered the 
 patient." (3) Gairdner (Clin. Med., p. 486) states thai paroxysms of dyspncea, closely 
 resembling those of asthma, may be occasioned by compression of one of the pulmonary 
 plexuses. 
 
366 OPERATIONS ON THE HEAD AND NECK. 
 
 should not be performed in these cases till a trial has been made of 
 scarification, or rather of acupuncture, by means of a guarded bistoury 
 point, of the mucous membrane of the epiglottis and the glosso-epi- 
 glottidean and aryteno-epiglottidean folds, the left fore-finger guiding 
 the point of the instrument. In doing this, the surgeon must remem- 
 ber the amount of dyspnoea which is already present, and the cer- 
 tainty that this will be increased by the struggles of the child, by the 
 finger coming in contact with these inflamed parts, and at any moment 
 the child must be turned on its side, artificial respiration performed, 
 or even tracheotomy resorted to. 
 
 (vi.) Foreign Bodies in the Air-passages.— We will suppose 
 a child brought to the surgeon with a history of having swallowed one 
 of the usual foreign bodies. Two questions now call for an answer. 
 
 (1) Is there a foreign body at all in any part of the air-passages ? and 
 
 (2) if so, where is it? In regard to the first tjuestion, it is well to 
 remember that the history is often far from clear, especially in children, 
 and the symptoms by no means as obvious as they are often described 
 to be. Thus, the chief aids in distinguishing the entrance of a foreign 
 body from such a disease as membranous laryngitis are the sudden 
 onset and, not unfrequently, the well-marked intermissions. The 
 symptoms characteristic of the entrance of a foreign body into the 
 larynx — viz., the urgent dyspnoea, the cyanosis, the struggling against 
 impending death — may not be got at on account of the youth of the 
 patient, or because no one saw the onset; while if the body has passed 
 from the larynx into the trachea, or into one bronchus, the dyspnoea, 
 brassy cough, and alteration in the voice, may all have disappeared 
 before the surgeon sees the child, and yet he will be expected to give 
 a definite opinion. Again, the body may have been coughed up, and 
 perhaps swallowed. Again, in adults, usually hysterical and egotis- 
 tical women, who come with a history of cancer, dysphagia, owing to 
 a pin which they aver to be in their throats, the diagnosis will be far 
 from easy.* 
 
 Having settled that a foreign body is really present, the surgeon, 
 unless tracheotomy is urgently called for, tries to decide where the 
 body is lodged. A careful examination should be made with a good 
 light and with the finger in the fauces, and with the laryngoscope when 
 feasible, any information about the size and nature of the body having 
 been previously obtained. 
 
 (a) A large or irregular body, such as bolted — i.e., unmasticated — 
 food, or artificial teeth, usually lodge above the upper aperture of the 
 larynx, and cause urgent and often fatal dyspnoea. If, however, the 
 
 * I would refer my readers to some instructive remarks by Mr, Lund on tlie delusive 
 impressions which may arise from the imagined swallowing of false teeth, etc. (Hunt, 
 Lect, 1885, p. 34.) 
 
FOREIGN BODIES IN THE BRONCHI. 367 
 
 first attack be survived, bodies of considerable size— e.g., a plate with 
 one or two false teeth, or halfpennies — have been known to lodge near 
 the base of the epiglottis and aryteno-epiglottideon folds for a very 
 considerable time. 
 
 Such cases should be treated by laryngotomy to meet the urgent 
 dyspnoja, and extraction of the bodies either by the finger, or appro- 
 priate forceps, or probangs. 
 
 (/?) A small and light body — e.g., a bead, a pea, or more likely an 
 irregular one, as a bit of nutshell — may stick in the rima or ventricle 
 of the larynx. If the first urgent symptoms pass off without opera- 
 tion,* the position of the body will be pointed to by the shortness of 
 the intermissions between the attacks of spasm, and by the pain and 
 the marked alteration of the voice. 
 
 The treatment, here, would be first to perform a high tracheotomy, 
 and to dislodge the body from below with a female catheter or bougie 
 of appropriate size, the cricoid cartilage being divided if needful.f If 
 the body cannot be dislodged in this way, a partial or complete thy- 
 rotomy (p. 345) must be performed. 
 
 (j) If the body pass through the larynx it will depend mainly on its 
 outline and weight whether it remain in the trachea or pass into one 
 of the bronchi. Thus, if it is light and smooth — e.g., a cherry-stone — 
 it may frequently shift its position, and then, from time to time rising 
 into the larynx, cause spasm, and thus attacks of urgent dyspnoea, 
 with paroxysmal cough and temporary aphonia. 
 
 In such cases tracheotomy should be performed with a free opening 
 into the air-tube, this being kept open by wire ligatures passed through 
 the edges of the wound and tied behind the neck, or a dilator such as 
 Mr. Golding Bird's may be inserted. 
 
 (5) If the body is smooth and heavier it will probably fall into one 
 of the bronchi. This subject is next dealt with separately. 
 
 FOREIGN BODIES IN THE BRONCHI. 
 
 Amongst these may be tracheotomy tubes,! especially ill-made ones, 
 tubes worn too long, particularly if a low operation has been done 
 
 * Occasionally, when the body is in the ventricle, the consequences may be very 
 slight for a long time, especially if it is smooth and soon coated with mucus and partly 
 encapsuled. Mr. Durham {Syst. Surg., vol. i. p. 760) mentions a case of Dfesault's, in 
 ■which a patient, with a cherry-stone in one of the ventricles, refused operation and lived 
 for two years, death then taking place from laryngeal disease. 
 
 t In adults, attempts at removal with the laryngoscope and laryngeal forceps, aided 
 by a 20 per cent, solution of cocaine may be successful. 
 
 % Dr. Cohen {Inter. Emycl. Surgery, vol. v. p. 665) thus speaks of the frequency with 
 •which th«se bodies have slipped in when ill- made or corroded : "This source of the 
 accident, so readily avoided by proper circumspection and admonition, is so inex- 
 cusable that I desire to emphasize the point with quite an array of references : Porter, 
 
368 OPERATIONS ON THE HEAD AND NECK. 
 
 (p. 351) ; pebbles ; fruit stones ; part of toy-whistles ; pieces of nut- 
 shells; etc., etc. 
 
 Site of Lodgment— li has been shown by Mr. Goodall that, owing to 
 the septum being a little to the left and the right bronchus the larger, 
 the foreign body usually lodges in this. According to M. Bourdillat's 
 statistics,* out of 156 cases of impaction 80 were in the trachea, 35 in 
 the larynx, 26 in the right bronchus, and 15 in the left. Out of 21 cases 
 analyzed by Prof. Gross,t in which death took place without operation, 
 and without expulsion of the foreign body, in 4 the foreign substance 
 was situated in the larynx; in 1 partly in the trachea, partly 
 in the larynx; in 3 in the trachea; in 1 in the right bronchial 
 tube; in 1 in the lung; in 9 in the right pleural cavity. Out of 
 42 cases subjected to operation and general treatment, the extraneous 
 substance was situated twice positively, and 11 times probably, in the 
 right bronchial tube, 4 times certainly, and 4 times probably, in the 
 left bronchus tube ; 7 times in the trachea and 14 times in the larynx. 
 From these statistics it would appear that the trachea, larynx, and 
 right bronchus are the most likely places in which a foreign body will 
 be arrested. 
 
 Evidence of a foreign Body having lodged in a Bronchus. — Perhaps 
 there may be a history of a foreign body in the mouth ; pain dull, and 
 heavy behind sternum, at about its junction with the second right 
 costal cartilage ; % shortness of breath, cough, expectoration ; more or 
 less diminution of breath sounds over a portion of the chest-wall ; § 
 rales ; increased breath sounds on the opposite side ; and, later on, evi- 
 dence of inflammation and destruction of lung-tissue. 
 
 On the Larynx and Trachea, p. 144 ; Gross, Foreign Bodies in the Air Passages, p. 325; 
 Albert, Arch. f. Clin. Chir., Bd. viii. s. 177 ; Waters, Brit. Med. Journ., vol. i. 1868, p. 
 141 ; Boston Med. and Surg. Journ., February 23, 1871; Buck, Trans. New York Acad. 
 Med., 1870; Pick, Trans. Path. Soc, 1870, p. 416; Ogle, Med. Times and Oaz., 1870, 
 vol. ii. p. 531 ; Holthouse, Lancet, 1872, vol. i. p. 113 ; Ogle and Lee, Lancet, 1872, 
 vol. i. p. 81 ; Hulke, Lancet, 1876, vol. ii. p. 785 ; Davy, Brit. Med. Journ., 1876, vol.ii. 
 p. 45; Burow, Berl. Klin. Woch., No. 36, 1876; Thornton, Tracheotomy, p. 36; Howse, 
 Lancet, April 17, 1877." 
 
 * Cohen, loc. supra cit., p. 668. 
 
 f Durham, Syst. of Sury., vol. i. p. 758. 
 
 X The division of the trachea is opposite the spine of the third, in some cases the 
 fourth, dorsal vertebra. In front, this division is on the level of the junction of the 
 first with the second bone of the sternum. The root of the spine of the scapula is on a 
 level with the third intercostal space. A stethoscope placed here would cover the 
 bronchus, more especially the right (Holden). 
 
 5 " Obstruction of the left bronchus usually produces absence of respiration over the 
 entire lung of that side, but occlusion of the right bronchus usually produces absence 
 of respiration over the lower lobe of that side only, the division of the bronchus taking 
 place much nearer the bifurcation, and the foreign body rarely lodging above the point 
 of division" (Dr. Cohen, loc. supra cit., p. 671). 
 
FOEBIGN BODIES IN THE BRONCHI. 369 
 
 Treatment. — A low tracheotomy (p. 351) should be performed at 
 once, and with as free an opening as possible. The edges of the 
 incised trachea being held open with sutures of wire (not too tine), 
 inversion and succussion should be tried, and the mucous membrane 
 excited with a feather or probe in order to excite cough. 
 
 If provided with suitable instruments (see below), the surgeon may 
 at once proceed to attempts at extraction, but it is well to remember 
 the fact pointed out by Mr. Durham,* that in a large proportion of 
 the cases which have done well, expulsion has not been effected until 
 some time after the operation.f Whenever a fit of coughing brings 
 the body into view, the next inspiration will draw it back again, so 
 that careful watching and prompt use of forceps, etc., will be required. 
 
 If from its shape, or from the interval which has elapsed, the body 
 is too firmly impacted to be expelled by exciting coughing, the fol- 
 lowing instruments should be resorted to,viz. : Gross's flexible German- 
 silver tracheal forceps, long and slender and easily bent into any 
 curve ; or Durham's forceps, equally flexible and giving a better grip. 
 
 Failing the above, stout silver or copper wire should be bent into 
 the form of a blunt hook, or a long probe fashioned into the same 
 shape. J The above instruments are first used as sounds and searchers, 
 aided by the forefinger, which can be passed as far as the bifurcation 
 of the trachea, and the orifice of each primary bronchus, as pointed 
 out by Dr. Sands. § 
 
 The operation should not be too prolonged, especially if the parts 
 are inflamed : when this condition has subsided spontaneous expul- 
 sion will often take place. Annandale|| recommended that this be 
 promoted by the patient's taking a deep inspiration ; the surgeon then 
 closes the tracheotomy wound till expiration, thus rendered more 
 violent, follows and often drives out the body. 
 
 * Loc. supra cit., pp. 769-770. 
 
 t Thus, in a case of Dr. Smith's at Halifax. (Lancet, 1876, vol. ii. p. 148) a boy, aged 
 eight, swallowed a whistlfe (as thick as a penholder, and about J inch long) on January 
 8 ; it was not expelled till May 7, the child having, for the previous six weeks, had 
 increasing cough and expectoration with increasing emaciation. The child recovered, 
 and Dr. Smith draws attention to the fact that, owing to the very slight discomfort, it 
 is doubtful if the cause would have been recognized if the impacted body had not pro- 
 duced a whistling sound, and thus demonstrated its presence. 
 
 X Mr. Hulke (Lancet, 1876, vol. ii. p. 785) used a long piece of German-silver wire, 
 one end of which was bent into a blunt hook about J inch long, and the wire again 
 bent about IJ inch above this, at an angle roughly estimated as that which the right 
 bronchus and trachea include. The other end was bent into a large loop, the plane of 
 which coincided with that of the tracheal end of the wire beyond the angle, and thus 
 allowed it to be guided into the right bronchus. 
 
 I Amer. Clin. Led., vol. ii. p. 199, Putnam, New York, 1876. Quoted by Mr. Dur- 
 ham, he. supra cit., p. 771. 
 
 II Med. Times and Gaz., February 27, 1875. 
 
 24 
 
370 OPERATIONS ON THE HEAD AND NECK. 
 
 EXCISION OF THE LARYNX, PARTIAL AND COMPLETE 
 
 (Figs. 81-83). 
 
 The value of these operations is still mh judice; much, therefore, of 
 the following will require confirmation : 
 
 Indications. 
 
 (1) Sarcoma and carcinoma of the larynx, if intra-laryngeal. Some 
 recommend its performance in the above affections if they are extra- 
 laryngeal as long as they are circumscribed and not widely infiltrating 
 adjacent structures and glands.* Owing to the persistency with which 
 recurrence will talic place in these cases it is probable that extirpation 
 of the larynx will give no better results as to the amount of real relief 
 which it affords than a palliative tracheotomy, which, according to 
 some observers (e.g., Lennox Browne, vide infra), gives a prolongation 
 of life amounting to two and a half years. It must never be forgotten 
 that this operation, apart from the question of relapse, has certain 
 special risks of its own — e.g., shock, septic cellulitis, etc., broncho- 
 pneumonia — and that thus an early extiriDation may, if fatal, shorten 
 a life materially. Furthermore, the surgeon, if once he begin an extir- 
 pation in these cases of extra-laryngeal growth, may not know when 
 to stop, owing to the extent of the disease. j 
 
 Dr. Newman, in two very interesting lectures on Tumors of the 
 Larynx,J speaks thus of the indications for the operation in malignant 
 disease : " Laryngeal carcinomata are, as a rule, intrinsic for a con- 
 siderable period, and therefore the time during which the operation 
 may be performed is considerable, but, notwithstanding, it is of the 
 utmost importance that, if the operation is to be performed at all, it 
 should be undertaken as soon as the disease is recognized. § When 
 
 * In some cases this can only be told during the operation, as in a case of Mr. 
 Holmes's [Brit. Med. Journ., 1884, vol. ii. p. 809), in which at the time of the operation 
 part of the epithelioma was fonnd to lie outside the larynx, extending upwards. 
 
 t Thus Czerny (quoted by Dr. Newman, loc. infra eit.) in p. case of lympho-sarcoma, 
 which had perforated the thyroid cartilage and involved the neighboring glands, 
 operated repeatedly. The internal and external carotids, the internal jugular, and the 
 vagus were divided, and the patient died fifteen months after the primary operation. 
 
 X Brit. Med. Journ., 1886, vol i. p. 868. 
 
 § On this subject the difficulty of always recognizing carcinoma — a matter to which 
 a well known case has lately drawn much attention — Dr. Semon made some weighty 
 remarks at the International Medical Congress in 1 >S1 ( Trails., vol. iii. p. 264). " Who, 
 in a large proportion of these cases, will take upon himself to diagnosticate early and 
 positively carcinoma ? and who, again, if carcinoma is diagnosticated, will sav posi- 
 tively whether it is in an early or more advanced stage?" The speaker went on to 
 point out that not only is the laryngoscopic differential diagnosis often exceedingly 
 difficult for a long time, but that in a large proportion of cases the administration of 
 potassium iodide produces an improvement, and, in some, apparently even a temporary 
 arrest of tlie disea'ie. With regard to the second question—" Is it always possible to 
 
EXCISION OF THE LARYNX. 371 
 
 the disease is associated witli infiltration of lymphatic glands, or if the 
 primary tumor be extrinsic * or if there be persistent bronchitis or 
 pulmonary catarrh, an operation is contraindicated ; for if it be per- 
 formed in such cases, not only may the patient be deprived of the 
 small remnant of life left to him, but the chances of eradicating the 
 disease are very remote. Cases are on record in which, besides the 
 larynx, portions of the thyroid gland, trachea, cesophagus, and phar- 
 ynx have been extirpated, but the results are far from encouraging, 
 not only on account of the immediate dangers of the operation, but 
 also from the fact that recurrence takes place in a limited time." 
 
 In deciding as to whether the disease is extra-laryngeal the surgeon 
 will be aided by observing whether the larynx moves in deglutition,f 
 and from side to side, whether the glands are enlarged, and by infor- 
 mation gained by the finger passed from the mouth, and of course by 
 the rate of the changes observed with the laryngoscope. 
 
 That malignant disease of the larynx can be occasionally removed 
 with great benefit to the patient, even when the glands outside are 
 clearly involved, is shown b}^ Dr. Gerster's case, quoted at p. 381. 
 
 Mr. H. Morris| showed, from a case which he brought before the 
 Clinical Society, that removal of the larynx might be called for in 
 cases where a palliative tracheotomy had been done ; but owing to 
 the downward extension of the growth, the tracheotomy-tube becom- 
 ing a source of continual irritation and distress, though absolutely 
 necessary for respiration, the suppurative cough and dyspnoea could 
 not be relieved by other means. The patient, a man of fifty-nine, 
 sank on the eighth day from exhaustion. The whole of the growths 
 had been removed, and there were no secondary deposits. 
 
 A valuable contribution has been lately made to the statistics of 
 
 decide whether the carcinoma is in an early or advanced stage — i.e., has or has not am 
 infection of the neighboring parts already taken place?" Dr. Senion quoted an 
 instrnctive case of a patient, aged sixty, who, having had syphilis twenty years before, 
 began to .suffer from his throat in October, 1880. The diagnosis remained long doubt- 
 ful between specific perichondritis and carcinoma, potassium iodide not yielding, 
 decisive results. It was not till early in March, 1881, that the diagnosis of carcinoma, 
 could be actually established, and at this time the cervical lymphatics became slightly 
 hardened, but not perceptibly enlarged. On March 9 tracheotomy was required, and. 
 exactly one week after the operation a swelling of the size of a hazel-nut, quickly increas- 
 ing, appeared behind tlie right sterno-mastoid. Dr. Semon points out that if extirpation 
 had been performed instead of tracheotomy there would have been a recurrence within 
 one week of the operation. 
 
 * E.g., commencing in the pharynx and involving the larynx secondarily by invad- 
 ing the epiglottis or aryteno-epjglottidean folds. 
 
 t It is noteworthy that the larynx may be movable and yet the pharynx be impli- 
 cated, as in a case reported by Surgeon-Major McLeod (Lancet, April 26( 1884). 
 
 t Brit. Med. Journ., 1886, vol. ii. p. 975. 
 
372 OPERATIONS ON THE HEAP AND NECK. 
 
 this subject by Mr. Butlin * from whose book the following quotations 
 
 are taken : 
 
 "Mortality Due to the Ojirrntion.—ln respect to this question, the 
 most valuable information may be obtained from the very complete 
 tabli's of Hahn. In these there are seventy-four cases of excision of 
 the entire larynx for new growths, but three of the seventy-four must 
 be excluded from consideration, liccause the disease for wliich the 
 larynx was removed was neither sarcomatous nor carcinomatous 
 (tuberculosis, papillomata, and po]yi)i). Of the seventy-one patients, 
 twenty-five died within the first fortnight, and five within six or seven 
 weeks of the operation. Death was due, in the very large majority, 
 to pneumonia or purulent bronchitis, and was not in any case due to 
 recurrence of the disease. There appears, therefore, to l>c a mortality 
 of about 40 per cent., directly due to tlie operation itself. But this is 
 only a, partial statement of the actual facts. To olitain a more accu- 
 rate knowledge, it is necessary to consider separately the eases of 
 sarcoma and of carcinoma, for not one of the patients whose larynx 
 was removed on account of sarcoma died. This may be, of course, a 
 mere accident, and a much larger number of casus may give a very 
 different result 
 
 " There remain, then, sixty-five cases in which the larynx was en- 
 tirely removed on account of carcinoma, and, of these, thirty were 
 fatal from the immediate, or almost immediate, results of the operation 
 — a very enormous mortality, which can only be justified by a bril- 
 liant success on the side of complete cure 
 
 " A study of the nine cases in Hahn's tables, in which only a par- 
 tial excision was performed, may perhai>s throw some light on the 
 enormous mortality due to the major operation. In every one of 
 them, one-half of the larynx was removed — in seven for carcinoma, in 
 two for sarcoma — and only one patient died from the direct effects of 
 the operation, a i^erson who had made admirable progress until the 
 twelfth day, when sudden and unexpected death took place, appar- 
 ently from some unknown cause. Here, again, the number of cases 
 is too small to admit of a comparison between them and the cases of 
 removal of the entire larynx for carcinoma, but the difference is so 
 striking that one cannot but draw from it the conclusion that the 
 severity of the operation must have much to do with the greater mor- 
 tality. To this, however, must be added the better position of the 
 parts after i)artial excision, and the greater ease Avith which the 
 patients can be fed, and, no doubt, tlie less extensive nature of the 
 disease before operation. 
 
 " Ciiirs Dim to Operation. — It will be convenient, first, to consider 
 the sarcomas, on account of their small number and the ease with 
 
 * Oper. Surg, of Maliy. Dis-, p. 192. 
 
EXCISION OF THE LARYNX. 373 
 
 whirli an ana]ysis may be made of them. "We have records of six 
 complete and two partial excisions for sarcomatous tmiiors. The 
 further history of five of the six is known. Two died with recur- 
 rence of the disease — one at the end of seven, and the other at the 
 end of fifteen, months. Of the remaining three, one was quite well 
 and free from disease six years after the operation, the second, two 
 years after the excision, and the third died of phthisis a year and a 
 half after the removal of the larynx, without any sign of recurrence of 
 the disease. In these cases the operations had been very extensive, and 
 had included the removal of parts outside the larynx as well as of the 
 larynx itself. In the two instances in which the excision was partial, 
 and concerned half the larynx, the result of i >ne was that the patient died 
 ten months after the ojjeration of inflammation of the lungs or pleura, 
 without any appearance of recurrence, although the operation in- 
 cluded the removal of the side of the pharjaix and base of the tongue. 
 In the other case there was no recurrence some time after the opera- 
 tion, but the length of time is not stated. 
 
 " Far otherwise are the results when we come to consider the exci- 
 sion of the larynx for carcinoma. It has been already shown that 
 thirty of the sixty-five patients for whom complete excision was per- 
 formed died of the operation. Of the remaining thirty-five, twenty 
 are known to liave suffered from recurrence and to have died within 
 a few months of the opieration. The duration of life varied from three 
 to nine months, thirteen of the twenty dying within the first six 
 months. There remain, therefore, fifteen patients to account for. In 
 one case the further result was unknown ; two patients died of pneu- 
 monia at the end of three and four months respectively, apparently 
 in both instances without recurrence. In five of the remaining twelve 
 cases, less than a year had elapsed between the operation and the last 
 report. There are, then, seven patients alive without recurrence at 
 periods respectively of fourteen, sixteen, sixteen, seventeen, eighteen, 
 nineteen months, and four years. Even the most ardent admirer of 
 active interference in cases of malignant disease can scarcely regard 
 these results as satisfactorj', for only one patient can be claimed as 
 cured by the operation. The table of seven partial excisions, although 
 it contains only one death which could in any way be attributed di- 
 rectly to operation, is not very attractive. Three of the six patients 
 died of recurrence of the disease — one at the end of three, one at six, 
 and one at seventeen months. There was no recurrence in the re- 
 maining three cases, but only fourteen months had elapsed in one, 
 eleven months in the second, and an unknown time in the third. 
 
 " It is only fair, in the consideration of these results of excision of 
 the larynx for carcinoma, to say that there does not appear to have 
 been any great care in the selection of fit cases for operation. The 
 
374 OPERATIONS ON THE HEAD AND NECK. 
 
 establishment of the diagnosis of laryngeal cancer seems, in a large 
 number of instances, to have sufficed, and the patient was forthwith 
 submitted to operation. Further, some, if not many, of the patients 
 were greatly weakened by the effects of the disease, and were not fit 
 to undergo even a gentle surgical operation, much less an operation 
 requiring really a strong constitution. Better results may in future 
 certainly be obtained by performing the operation with the help of 
 Hahn's tube, performing a preliminary tracheotomy some days before 
 the excision in those cases in which the patient is exhausted by long- 
 continued dyspncea, and feeding through a tube and funnel during 
 the first days (or longer if need be) after the operation. 
 
 " And better results may, I am sure, be obtained, so far as the cure 
 of the patient is concerned, by selecting cases of intrinsic carcinoma, 
 and rejecting all cases, whether of intrinsic or extrinsic carcinoma, in 
 which there is associated affection of the lymphatic glands." 
 
 (2) A few cases may arise in which there is no malignant disease, 
 but the laryngeal cavity is destroyed, and a constant source of discom- 
 fort and danger. Thus, in Dr. Henry Watson's case,* a gentleman 
 aged thirty-six, palliative tracheotomy liad been performed to relieve 
 the ulceration of tertiary syphilis. The larynx healed, but the puck- 
 ering gave rise to a condition of matters liy which some portion of all 
 fluid nutriment and saliva made its way into the trachea and occa- 
 sioned fits of spasmodic cough. Feeding by the tube did not prevent 
 the saliva from passing down, and, in almost every instance, on its 
 withdrawal some fluid regurgitated and some part of it passed into the 
 trachea, etc. The patient rallied from the operation for removal of 
 the larynx, but died some weeks afterwards from pneumonia. 
 
 Both in this case and one in whicli Rubio, of ]Madrid,t removed the 
 larynx for necrosis of the cartilages in a man aged forty-one, with a 
 fatal result on the fifth day, there was great debility before the opera- 
 tion. With regard to this group of cases, Dr. Foulis remarked, " May 
 we excise the larynx as we would a knee-joint when it is hopelessly 
 thickened and ulcerated? When the breathing and voice are im- 
 peded, and the parts are no longer capable of distension by dilatation, 
 it appears to me that the diseased larynx may be properly removed 
 and replaced by an artificial one." 
 
 As to the propriety of removing part of the larynx in these cases of 
 stenosis and ulceration, Dr. Foulis did not favor it, as two cases in 
 which he had performed a modified operation of this kind did not do 
 well, one dying of diabetes, and the other developing perichondritis 
 and dying in three months. The operation does not, however, seem 
 
 * Quoted by Dr. Foulis, Trans. Internat. Med. Congr., 1881, vol. iii. p. 251. 
 f Foulis, loc. mpra cit., p. 252. 
 
EXCISION OF THE LARYNX. 375 
 
 to have been, in either case, what is now considered partial removal 
 of the larynx. 
 
 (3) It is possible that excision of the larynx may, in the future, be 
 performed as part of an operation for removal of a thyroid gland the 
 site of malignant disease. It is well-known how fatal removal of the 
 thyroid gland often is in these cases from interference with the recur- 
 rent laryngeal, injury to which is often unavoidable. It has been 
 suggested* that, in these cases, if it will facilitate extirpation of the 
 malignant disease, or if there is reason to think that the above nerve 
 has been injured, the larynx be removed, thus not only giving more 
 room for dealing with the original disease, but also for removing a 
 fertile source of dysj)noea and spasm. 
 
 Operation. 
 
 Preliminary Tracheotomy. — This should be done a week at least before 
 the operation for excision. The advantages are that : (1) The patient 
 gets used to breathing through an artificial apparatus. (2) The easier 
 breathing will improve his t!cn(;ral health. (3) The lungs, being less 
 engorged after thus receiving air free]}', will be less likely to become 
 the seat of broncho-pneumonia. (4) When the operation is performed 
 less time will be taken up, and no blood will enter from this source. 
 (5) The trachea will have become adherent to the skin, and thus tends 
 less to fall away when the larynx is severed from it, so preventing 
 diffusion of pus. 
 
 With regard to the site of the tracheotomy, it should be low rather 
 than high, for if done high up (1) it may be too near the seat of the 
 disease, and (2) a more important point, if a high operation is per- 
 formed, the lower end of the excision-wound will come into parts 
 infiltrated and altered, and thus difficult to distinguish at a very criti- 
 cal stage of the operation. f 
 
 * Dr. Fonlis (loc. supra cit, p. 2-58) quotes briefly a case of Dr. Bircher's, in which 
 a scirrhous thyroid had been excised ; six months later recurrence took place, and the 
 larynx was excised with part of the gullet. Death took place in ten days from pneu- 
 monia and gangrene of the lung. Prof. Caselli (Inter. Med. Oongr., 1881, vol. iii. p. 
 262) stated that he had performed partial excision of the larynx in the case of an enor- 
 mous myxo-fibro-chondroma of the hyoid and larynx, the patient, who was much 
 exhausted, dying in three days. 
 
 t On this account Gussenbauer prefers a high tracheotomy with horizontal severance 
 of the trachea as the initial step in laryngectomy, owing to the fact that after a pre- 
 liminary tracheotomy the tissues become so infiltrated and matted that they are less 
 readily recognized, and also complicate the detachment of the soft parts and make 
 hjemorrhage more serious. On this point Mr. Butlin's argument, that in patients 
 exhausted by long-continued dyspnoea there can be no question that it is essential to 
 success that tracheotomy should be performed some time previous to the operation, 
 will carry great weight with most surgeons. 
 
376 OPERATIONS ON THE HEAD AND NECK. 
 
 While the above is believed to be the wiser course, some have had 
 good results with a high operation, performed before or at the same 
 time as the removal of the larynx. Thus Mr. Lennox Browne (foe. 
 infra cit.), having performed a high tracheotomy (between the second 
 and third rings), introduced Hahn's tampon-cannula, consisting of a 
 tube surrounded with compressed sponge.* Other ojDerators have 
 dispensed with tracheotomy altogether. 
 
 The patient being brought under the influence of an ansesthetic 
 given at first in the ordinary way, and, later on, if desired, through 
 the tampon, the surgeon must decide whether he will perform the 
 operation with the patient in the usual position, cutting from above 
 downwards, or with the head supported in the position dependent, 
 pillows being placed under the dorsal spine, the incision being now 
 made from below upwards. f 
 
 The former course, if the tampjon to be used is a reliable one, is 
 probably the best, the tampon-cannula of Trend elenberg, Dr. Semon's 
 modification of this (Fig. 80), or Dr. Hahn's tampon being introduced 
 instead of the ordinary tracheotomy cannula. If no tracheotomy is 
 performed either some time previously or immediately before the 
 operation, the median incision being made, the trachea is usually first 
 isolated and divided, and then a large tube or tampon-cannula in- 
 serted. 
 
 * Caunulie with air or water tampons are liable to the serious drawback of sudden 
 rupture. On this account it seems best to use ordinary cannulse surrounded with 
 aseptic sponge. Mr. Butiin prefers the tube recommended by Hahn for these reasons : 
 (1) It consists of an inner and an outer tube, the inner of which is the longer, pro- 
 jecting about IJ inches in front of the shield so as to render the entrance of blood very 
 unlikely. In order to prevent this projection inconveniencing the operator, it is made 
 to bend down parallel with the trachea before it stands out at a right angle with the 
 neck. (2) The outer tube is partly covered with a layer of compressed sponge, pre- 
 viously soaked in iodoform and ether (1 in 7). The sponge is fastened on by sutures 
 and by silk tied round its upper and lower end. (3) About ten minutes after the 
 introduction of the tube the sponge swells up from the absorption of moisture, and the 
 entrance of liquids into the trachea is thus prevented. This arrangement of sponge 
 seems to hold the tube more steadily in position than the India rubber bag of Trende- 
 lenberg's tampon, which is liable to become slippery, and which, moreover, may burst 
 during the operation. 
 
 t Dr. Cohen {loc. infra cit.) thus states the chief merits of the two methods: "Re- 
 moval from above downwards is the more tedious. To some operators it appears to be 
 the safer plan, inasmuch as it effectively avoids all risk of escape of blood and other 
 matters into the tracheal extremity of a severed windpipe during the important stages 
 of the dissection, for the severance of the larynx from the trachea is the last step of 
 the procedure instead of the first, and may be delayed until all hiemorrhage is under 
 control. The opposite plan is said to possess the advantage that, the trachea being 
 taken care of in the first instance, the operator clin proceed more rapidly, and be re- 
 lieved from all anxiety as to the entrance of blood into the air-passages." 
 
EXCISION OF THE LARYNX. 377 
 
 If the operation is begun from above, an incision is first made from 
 the lower border of the hyoid bone exactly in the middle line, verti- 
 cally down to the level of the first or second ring of the trachea, and 
 a second at right angles to the 
 
 first, either at the level of the hy- ^^"^- ^'^■ 
 
 oid bone or across the thyroid 
 cartilage, in either case passing 
 outwards to the sterno-mastoids. 
 The vertical incision sliould go 
 down to the thyroid and cricoid 
 cartilages and trachea. The soft 
 parts over the thyroid and cri- 
 coid are then raised en masse by 
 inserting a blunt dissector or rasi3- 
 
 atory so close to the cartilages ^'- S™°"'^ mcdifloation of Trendelenberg's 
 
 r^ . tarapon-canuula.* (Mackenzie.) 
 
 that the perichondrium itself is 
 
 lifted up with its relation to the soft parts over it undisturbed. This 
 separation is carried back as far as the middle of the junction of 
 larynx and pharynx, tire thyroid and cricoid cartilages carefully 
 severed in the middle line with stout scissors or cutting forceps, the 
 two halves separated with retractors, and the interior examined to see 
 if partial removal of the larynx will be sufficient. 
 
 The above method of working very close to the cartilages with a 
 blunt instrument only was first used by Mr. Browne at the suggestion 
 of Mr. Henry Morris ; it has the conspicuous advantages of disturb- 
 ing but little the soft parts and of causing but trifling haemorrhage. f 
 
 * This instrument is thus described by Sir M. Macl^enzie [Dis. of the Throat and 
 Nose, vol. i. p. 516, Fig. 107, from which the above illustration is taken) : " It consists 
 of an ordinary tracheotomy-tube, with a broad groove running round its lower extremity 
 externally. This groove receives a hollow india-rubber air-belt, which, when unin- 
 flated, is flush with the surface of the cannula. A tine capillary silver t\ibe, soldered 
 inside the cannula, communicates at one end witli the air-belt, and, at the other, opens 
 near the anterior orifice of the cannula. To this extremity is attached a piece of elastic 
 tubing about 6 inches in length, with a stopcock at its free end. The cannula having 
 been introduced into the trachea, the belt is inflated by means of the tube, and the 
 stopcock turned off'. The expansion of the belt blocks up the space between the can- 
 nula and the walls of the trachea, and thus renders it impossible for any blood to pass 
 from the larynx into the air-passages. It is very iiuportant not to fill the air-belt too 
 full, as much pressure suddenly applied to the trachea is apt to produce an asthmatic 
 paroxysm." Another risk, that of bursting the bell, is alluded to elsewhere. In Tren- 
 delenberg's original instrument the capillary tube was placed outside the cannula, and 
 rendered the latter very difficult of introduction. 
 
 t In thus raising the soft parts, by keeping close to the cartilages of the larynx, care 
 should be taken not to separate needlessly the soft parts from the trachea. Some of these 
 — e.g., the lateral masses of the thyroid gland, which are now also detached with a 
 blunt dissector— are useful in preventing descent of the trachea. 
 
378 OPEEATIONS ON THE HEAD AND NECK. 
 
 The transverse incision was not found necessary in this, a unilateral 
 removal of the larynx. 
 
 Where the parts do not admit of the above step, or where the parts 
 outside— e.^., glands, are found involved, flaps of skin and fascia are 
 reflected, and the larynx exposed as freely as possible, any enlarged 
 glands now seen should be removed and the crico-thyroid arteries 
 secured. The sterno-hyoids and sterno-thyroids are next peeled off from 
 the thyroid cartilage with a blunt dissector, or ligatured with chromic 
 gut and cut through, and the lateral lobes of the thyroid gland carefully 
 separated in the same way, ligatures being tied at their junction with 
 the isthmus, if needful. The soft parts at the sides which contain the 
 large vessels, etc., are now carefully retracted, and the larynx being 
 drawn first to one side and then to the other, the constrictors are 
 divided very close to their attachments to the cricoid and thyroid car- 
 tilages. The superior laryngeal vessels are next secured and divided 
 as they enter the thyro-hyoid membrane.* 
 
 Up to this point very little blood, if any, has entered the air pas- 
 sage, and if the growth have not caused obstruction the inflation of 
 the tampon may be left to this stage. If the surgeon be unprovided 
 with one of these, or if the one in use do not work satisfactorily, the 
 larynx had best next be detached from the trachea, the cricoid, or a 
 small circle of this, being left, if possible, to give support later on for 
 the artificial larynx.f If, however, there is any doubt as to the extent 
 of the growth downwards, the division had better be made between 
 the rings of the trachea itself. The lower end of the trachea is next to 
 be carefully stitched to the skin, and a large tube of vulcanite, lead) 
 etc., is put in to prevent blood, etc., descending. 
 
 The removal of the larynx is next carried on from below upwards, 
 especial care being taken, in the separation of the oesophagus from its 
 connections to the trachea and larynx, not to button-hole it (Foulis), 
 especially at its attachment to the cricoid. During this stage the 
 larynx is kept dragged forwards with vulsellum-forceps or a sharp 
 hook. 
 
 If, as the dissection is carried upwards, the laryngo-pharyngeal 
 junction is found to be infiltrated, the anterior and lateral walls ofthe 
 pharynx must be removed as well. If the surgeon decide now to re- 
 move the epiglottis, J the knife must.be carried upwards through the 
 
 * Mr. Bntlin, quoting from Halin, advises that, in detaching the soft parts of the 
 back ofthe hirynx, blunt-pointed scissors should be used with a series of short snips. 
 
 f Halin, however, removes the cricoid cartilage in complete extirpation of the larynx, 
 as he thinks that, if left, it interferes with deglutition. 
 
 X " The weight of testimony seems to indicate the propriety of sacrificing the epi- 
 glottis in all cases of carcinoma, and in all others in which an artificial larynx is to be 
 used " (Cohen). 
 
EXCISION OP THE LARYNX. 
 
 379 
 
 thyro-hyoid ligament, so as to pass between the tongue and epiglottis, 
 its course being controlled by the left forefinger passed into the mouth. 
 If the epiglottis is left, the knife is carried through the thyro-hyoid 
 membrane and the thyro-epiglottic ligaments as well. 
 
 As soon as the larynx is removed, attention should be paid to any 
 bleeding points, and the cut trachea and edges of the pharynx (if this 
 has been partly removed) stitched most carefully with carjoolized silk 
 sutures to the edges of the skin wound, if this has not been already 
 done in the case of the trachea ; secure union being of the utmost im- 
 portance to prevent burrowing in the cellular tis&ue of the neck. 
 
 PARTIAL REMOVAL OP THE LARYNX (Figs. 81, 82, 83). 
 
 The unilateral extirpation of the larynx may be made use of when, 
 after exposing it, partially freeing it from surrounding soft parts, and 
 slitting it open, it is found that the disease is limited to one side. 
 
 Br.Newmdn {luc. supra cit.) gives, the following as indications: (1) 
 Malignant disease of limited extent; (2) Stenosis or obliteration of 
 
 Fig. 81.* 
 
 Fig. 82. 
 
 tiuRCmuu 
 
 MOT RKMOV?; 
 
 t-CART.OFWBISBERO, 
 
 FaAOMt L-ARV-EpiCiLOTTia 
 
 Fold. 
 
 Epithelioma of the left cord. From 
 u patient in whom Mr. Lennox 
 Browne successfully removed half the 
 larynx. 
 
 LVENTRICIE 
 
 ANTERIOR PORT" 
 OP CKlcoia 
 
 Inner aspect of the portion removed. 
 
 larj^nx which cannot be cured by other means ; (3) Recurrent papillo- 
 mata not removable by less heroic interference. 
 
 Mr. Butlin (Oper. Surg. Mai. Dis., p. 191) is in favor of still further 
 limiting the operation. " When the disease is of very small extent, 
 
 * I am indebted to Mr. Lennox Browne for permission to make use of this and the 
 next two illnstrations. They will be found in his paper (Brit. Med. Journ., February 
 5, 1887), and in tlie second edition of his book on the Throat and its Diseases, p. 457. 
 
380 OPERATIONS ON THE HEAD AND NECK. 
 
 limited to the true and false cords of one side, not extending into the 
 structures above and below, not even adherent to the cartilage, I 
 believe the better course to pursue will be to remove the diseased 
 structures and a wide area of the surrounding soft tissues, just in the 
 same manner as one treats an epithelioma of the lip, without insisting 
 on the removal of even one-half of the thyroid cartilage. Cartilage, 
 whether calcified or not, is peculiarly resistant to the progress of can- 
 cer, and when the disease appears to be adherent to it, it is the peri- 
 chondrium which is affected, and only in the rarest instances the 
 cartilage itself Cancer of the larj'nx far more often causes the death 
 of the cartilage jjiece by piece, than infiltrates it." While the above 
 remarks, coming as they do from one who is distinguished for his 
 knowledge of malignant disease, and for being one of the few English 
 surgeons who have successfully extirpated half the larynx, are entitled 
 to every respect, it has yet to l)c seen how far this very limited pro- 
 ceeding is justifiable in malignant disease, and how far Mr. Butlin's 
 comparison above given is a just one. 
 
 The advantages of partial removal at present seem undoubted. (1) 
 The mortality 33 per cent, after total extirpation is only 20 per cent, 
 after unilateral;* (2) The dangers of recurrence are not greater if 
 cases are properly selected ;t (3j The voice may be almost perfectly 
 retained without use of the tracheal cannula ; (4) Deglutition is com- 
 pletely preserved. 
 
 Mr. Lennox Browne (loc. supra cit), in his case of removal of half 
 of the larynx (Figs. 81, 82, 83), having exposed it by sub-perichon- 
 drial raising of the soft parts, divided the thyroid cartilage with cut- 
 ting forceps, removed the half by ; («) Thorough separation of the 
 attachments to the pharynx with the raspatory aided by the knife- 
 handle and finger-nail ; (b) Division of the thyro-hyoid membrane as 
 close as possible to its thyroid attachment ; (c) Division of the left 
 superior horn of the thyroid cartilage at its root by cutting pliers ; (d) 
 
 * Mr. Lennox Browne (loc. infra cit.) states that some thirteen or fourteen cases have 
 now been recorded, and that in only one instance has there been an immediately fatal 
 result. See also the quotation from ]\[r. Butlin, p. 407. 
 
 t Drs. Hahn and Schede (Germ Sury. Congr., April, 1SS4; Land. Med. Record, 1884, 
 p. 358) showed that (1) this operation was much less severe ; (2) relapse was not more 
 frequent; (3) impairment of function was mucli less. In one of Schede's cases the 
 patient was a dentist ; he could, after a while, dispense with any cannula and follow 
 his calling, his speech not attracting notice. As a result of cicatricial contraction a 
 prominent fold of mucous membrane had formed, immovable, but capable of perform- 
 ing many of the functions of the right cord, the left moving u|) to it, and thus forming 
 a rima glottiJis. In the case of a well-known barrister, operated on by Dr. Hahn, and 
 brought by Dr. Semon before the Clinical Society (Brit. Med. Journ., 1886, vol. ii. p. 
 975), the patient recovered so well that he was able to fill the position of police magis- 
 trate. 
 
EXCISION OF THE LARYNX. 381 
 
 Division in the middle line of the cricoid cartilage, in front and be- 
 hind ; (e) The divided half of the larynx was then separated from the 
 first ring of the trachea, and a few nicks only were necessary to re- 
 move it entire. The very slight oozing* which ensued after the 
 removal of the diseased part was checked by a slight application of 
 the galvano-cautery which would also destroy any possible fragments 
 of diseased tissues not removed. The left aryteno-eijiglottic fold was 
 divided close to the cartilage of Wrisberg, and the thyro-hyoid mem- 
 brane close to its thyroid attachment, with the view of impairing as 
 little as possible the action of the epiglottis. The success of this plan 
 was completely shown by the ease with which deglutition was effected 
 three days later. 
 
 Dr. Gerster, of New York (Ann. of Surg., Jan., 1886), reports a suc- 
 cessful case of unilateral extirpation of the larynx, for alveolar sar- 
 coma, in a patient aged fifty-seven. The laryngoscope showed a smooth 
 pale tumor of the size and shape of an almond, commencing in the 
 left glosso-epiglottidean fold, extending through the substance of the 
 left vocal cord into the ary-epiglottidean fold, and ending in the aryte- 
 noid cartilage with a knob-like protuberance. 
 
 A preliminary low tracheotomy was performed, and at the same time 
 a deep-seated, hard, glandular swelling of the size of a hen's-egg was 
 removed from the left sub-maxillary region, together with part of the 
 internal jugular and the sterno-mastoid. 
 
 About six weeks later the left half of the larynx was thus removed. 
 A tampon-cannula was inserted and distended in the tracheotomy 
 wound, after this an incision — commencing at the ujjper notch of the 
 thyroid, and extending to the lower margin of the cricoid cartilage — 
 laid bare the larynx in the middle line. To this was added another 
 cut, commencing in the upper angle of the first, and extending hori- 
 zontally to the anterior margin of the left sterno-mastoid. The crico- 
 thyroid ligament was split to admit a strong pair of bone-pliers for the 
 division of the thyroid cartilage, but it was found impossible to per- 
 form this act, as the Btrongly inclined ijosition of the cartilage did not 
 permit an effective handling of the instrument. Therefore access was 
 gained by an incision through the thyro-hyoid ligament, and an exact 
 division of the calcified cartilage thus effected. After this the epiglottis 
 was cut through lengthwise, the left half of the crico-thyroid ligament 
 divided, and the superior thyroid artery included in a double ligature 
 and cut through. The most difficult part of the operation consisted 
 in the dissection of the lateral portions of larynx and pharynx, closely 
 adherent to the carotid artery by cicatricial tissue, caused by the pre- 
 
 * Only two small vessels required torsion, a happy result, due to the use of the ras- 
 patory, and to keeping so close to the cartilage. 
 
382 
 
 OPERATIONS ON THE HEAD AND NECK. 
 
 vious extirpation of tlie glands. Shallow incisions, running parallel 
 with the course of the artery, were cautiously made, and the difficult 
 task seemed almost completed, when suddenly a powerful jet of arte- 
 rial blood welled up from the bottom of the wound. The bleeding 
 point was easily secured, and then it was ascertained that the trunk 
 of the superior thyroid (doubly ligatured further below prior to this) 
 had been cut away level with its origin from the carotid. Two catgut 
 ligatures were applied around the main trunk above and below the 
 forceps, and when the instrument was removed a round hole in the 
 
 Fig. 84. 
 
 Fig. 83. 
 
 Laryngoscopic view from the same 
 patient four months after operation. 
 
 Dr. Foulis's raodiflcation of Gussen- 
 bauer's artificial larynx. The upper 
 tube Is shown aboye. b, The lower 
 tube, c, The reed. (Mackenzie.) 
 
 side of the carotid became visible. The remaining adhesions, corre- 
 sponding to the left lateral portion of the pharynx could now be easily 
 dissected out. The patient made a good recovery, but a plastic oper- 
 ation was required to close the wound, and about seven weeks after 
 the operation a small suspicious glandular swelling was removed from 
 the supra clavicular region. Five months later the general condition 
 was remarkably improved. Swallowing of solids and semi solids was 
 excellent, drinking had to be slowly and carefully done. The patient 
 could speak with a hoarse whisper, readily understood at a distance 
 
EXCISION OP THE LARYNX. 383 
 
 of 10 or 15 feet. The cicatrices were soft and normal. The laryngo- 
 scope showed a smooth, rather extensive, scar occupying the left side 
 of the pharynx and larynx. The right cord was normal. 
 
 After- Treatment — AW htemorrhage being arrested, the wound is 
 brushed over with a 10 per cent, zinc-chloride solution, or iodoform 
 and ether, and dueted with iodoform ; one or two sutures may be placed 
 at the ends of the transverse incision, but the vertical incision should 
 be left widely open for drainage, the wound being lightly packed with 
 strips of iodoform or sal alembroth gauze. These should not be 
 changed too frequently, and, at each renewal of the dressings, the 
 wound should be irrigated with some antiseptic solution and carefully 
 cleansed with camel's-hair brushes. Thiersch, to prevent lung infec- 
 tion, keeps the head low for the first few days. ]Mr. Butlin advises 
 that an ordinary tracheotomy tube covered with iodoform gauze be 
 substituted for the compressed sponge-tube at the end of twenty-four 
 hours. The gauze should be sufficiently thick to stop any discharges 
 getting into the trachea, and should be changed once a day. It is very 
 important to keep the wound sweet and clean to prevent the jDueu- 
 monia which has so frequently proved fatal after excision. Nourish- 
 ment must be suppHed, for the first week, by a soft tube passed either 
 by the nose or mouth, and if it is desirable to retain this, it would be 
 well to make trial of this method before the operation. Feeding by 
 enemata alone is not reliable, considering the debilitated condition of 
 these patients, and the profound shock which often accompanies this 
 most serious operation. 
 
 The temperature of the room must be from 65° to 70°. A moist 
 carbolized sponge or layer of gauze should be kept in front of the tra- 
 cheotomy tube. When the wound has become firm, the patient should 
 be encouraged to take some solid food by the mouth, liquid food thus 
 taken having, always, a greater tendency to get into the trachea. 
 
 After partial removal, the patient will be able to dispense with the 
 cannula, and to take food by the mouth within a few days of the opera- 
 tion. In about a month, an artificial larynx may be fitted. Of these 
 the chief forms are Gussenbauer's, and Irvine's modification of this. 
 
 The following account is taken from a very complete, clear and prac- 
 tical article by Dr. Cohen,* of Philadelphia, to which I am already 
 much indebted for information. The appliance consists of three parts f 
 — (1) a tracheal cannula ; (2) a pharyngeal cannula, the two having 
 
 * Inlernat. Encylc. Surg., vol. v. p. 777. 
 
 t Originally a substitute for the epiglottis was provided, maintained erect by a 
 watch-spring weak enough to yield readily to the descent of the base of the tongue in 
 deglutition. This has been found unnecessary and rather in the way. Dr. Cohen (loe. 
 supra cit.) figures an instance of the very complicated apparatus which will be required 
 when the anterior wall of the oesophagus has been removed. 
 
384 OPERATIONS ON THE HEAD AND NECK. 
 
 apertures by which they can be passed through each other and admit 
 a free current of air from below upwards; (3) An adjustable plate 
 carrying a vibratory reed. This is detachable for purpose of cleans- 
 ing from mucus, being pushed in and out like a table- drawer. The 
 apparatus being in position, the expiratory current, on its way to the ■ 
 mouth, sets the reed in vibration, and the tone thus -produced, broken 
 with articulate speech, is monotonous, modulation being imprac- 
 ticable. 
 
 Great difference is presented in the toleration of these appliances. 
 In some instances they give little trouble, and are used with great 
 comfort. Some subjects bear the naked apparatus well, but cannot 
 tolerate the phenol reed, which may impede respiration, may become 
 obstructed with desiccated mucus, and may yield a tone to every 
 breath of expiration. Some abandon them altogether, and stick to the 
 simple tracheal cannula. In some instances saliva, mucus, and food 
 will get into the tubes and descend into the trachea. Some patients 
 prevent the escape of food by plugging the upper orifice when they eat. 
 
 Dangers and Causes of Death. 
 
 1. Shock. 
 
 2. Exhaustion. Both these are rarely met with, save when the 
 hsemorrhage has been severe. 
 
 3. Lung trouble— viz., broncho-pneumonia, purulent bronchitis, etc. 
 This is the most frequent cause of death, from the passage of food, 
 blood, etc., down the trachea in spite of careful plugging.* Dr. Cohen f 
 thinks that the period of danger from lung complications does not last 
 over two weeks, and that if the patient survive this date, he is tolerably 
 secure up to the fourth month, when death from recurrence begins to 
 be imminent. 
 
 4. Septic cellulitis, mediastinitis, etc. 
 
 After-Oondition of the Patient. — This is a most important 
 matter, and one which should be fully explained to the patient. The 
 amount of comfort will maiialy depend upon two things : (1) whether 
 half or the whole of the larynx has been removed ; (2) whether much 
 of the skin and soft parts have had to be taken away, or have 
 sloughed. 
 
 With regard to the first point, if only half of the larynx have been 
 removed, the patient usually swallows early and easily, and speaks 
 quietly and hoarsely, but with very fair distinctness, and without any 
 
 * If the patient have, previous to the operation, any bronchitis, these fatal King 
 complications are especially likely, the bronchitis running on into broncho-pneumonia. 
 For this reason Billroth (Clin. Surg., p. 134) urges in such patients that every attempt 
 should be made to improve the bronchitis, a preliminary tracheotomy being performed 
 if needful. 
 
 f Loc. supra cit., p. 770. 
 
OPERATIONS ON THE THYKOID GLAND. 385 
 
 need of mechanical aid. Where the whole larynx has been taken 
 away, some such appliance as that of Gussenbauer's will be required 
 to enable the patient to make himself understood. Even after com- 
 plete removal, if the pharynx has been left untouched, the power of 
 swallowing will be but little impaired. If, however, the surrounding 
 soft parts have had to be widely extirpated, so large a gap will be left 
 that swallowing will be impossible, and it will be necessary to feed the 
 patient with a tube. 
 
 While, for the present, it must remain uncertain how far the after- 
 condition of the patient will be better than that foretold after the earlier 
 laryngectomies,* there is no doubt that, when the soft parts in front 
 of the pharynx have had to be extensively removed, the after-condi- 
 tion is one of great discomfort.f 
 
 CHAPTER XIII. 
 
 OPERATIONS ON THE THYROID GLAND. 
 
 REMOVAL OF THE THYROID GLAND, t PARTIAL 
 AND COMPLETE. 
 Indications. 
 
 1. Failure of previous treatment and increase of bronchocele lead- 
 ing to 
 
 2. Dyspnoea sufficiently constant to jDrevent the patient from fol- 
 lowing any active employment, or one of a sedentary kind whicli in- 
 volves stooping of the neck and head. 
 
 3. The existence of tracheal stridor, especially if accompanied by 
 much enlargement of the isthmus (see p. 400) or extension of the 
 bronchocele downwards. 
 
 4. Attacks of sudden, suffocating dyspnoea. 
 
 It is not yet sufficiently recognized by the j^rofession that a bron- 
 chocele, whether moderate in size or large, may from some sudden en- 
 
 * Thus, Sir M. Mackenzie at tlie International Medical Congressi, 1881 (Trans., p. 
 263), stated that "the condition of a patient after extirpation of the larynx is usually 
 one of great misery." Dr. Cohen, of Piiiladelphia, holding the same view, drew 
 attention to the importance of distinguishing between ''recovery" and mere "sur- 
 vival after the operation." 
 
 t A good illustration of this condition and an idea of its results is given by Dr. 
 Cohen from Lange, Fig. 1095 (Inter. Encycl. of Surg., vol. v. p. 776). He also points 
 out that too early attempts to use an artificial larynx only cause haemorrhage, while an 
 apparatus which is adjustable at first, is often rendered useless by further cicatrization. 
 
 t A distinction must always be made in these operations between removal of parts 
 of the thyroid itself and that of encapsulated adenomata in it, however large. 
 
 25 
 
386 OPERATIONS ON THE HEAD AND NECK. 
 
 gorgement or rupture cause urgent and fatal dyspnoea. A first attack 
 may here only herald in the end* 
 
 The following may be quoted to prove that the above danger is well 
 founded : 
 
 Dr. Hurry {Lancet, March 19, 1887) gives the case of a girl, aged 
 thirteen, the subject of a moderate goitre. Dyspnoea was first com- 
 plained of November 3 ; on November 7 dyspncea was urgent, and 
 tracheotomy was called for. The operation gave very little relief, and 
 death followed !■• hour later. The post mortem examination showed 
 a moderately large goitre, the two lobes of which entirely encircled 
 the trachea and reduced the lumen to a narrow slit, to which the 
 tracheotomy wound did not quite reach. Dr. Hurry gives the follow- 
 ing ingenious explanation of the insidiousness and urgency of the 
 dyspnoea in these cases : Owing to the slowly progressive enlargement 
 of the thyroid the dyspnoea at first is slight, one day some extra 
 exertion calls into play the additional muscles of respiration — e.g., 
 sterno-mastoid, sterno-thyroid, sterno-hyoid, these, pressing on the 
 trachea, still further close its lumen, already narrowed by the slowly 
 progressive growth, this brings about additional dyspnoea, and so in- 
 duces still further contraction of the inspiratory muscles, and, so, to 
 further closure of the trachea and increasing dyspnoea and death. 
 
 Dr. Dewes (iJ/vV. jl/eri. Jo«™., 1879, Januar)- 18, p. 84) records the 
 case of a patient who was found by the Coventry police apparently 
 dying of suffocation. On his admission into the hospital a large 
 bronchocele was found, and a free median incision was made by Mr. 
 Read down to the tumor. The breathing at once improved, and soon 
 became natural, the tumor decreased in size, and all went well till the 
 evening of the seventh day, when the dysj^noea suddenlj^ returned, 
 the tumor again enlarging, the patient dying in two or three minutes. 
 It was found, post-mortem, that in the last agony the posterior part of 
 the tumor had broken down, giving rise to a large extravasation of 
 venous blood, pressing on the respiratory nerves. " The only part of 
 the trachea at all approachable was under the manubrium sterni, 
 where it was covered by the innominate artery." 
 
 I wish to draw attention to this fact, that extravasation may take 
 place suddenly into a bronchocele, thus producing urgent dyspnoea. 
 In 1885 a woman, aged forty-four, came under my care with enlarge- 
 
 * Thus, in one case, a woman with a bronchocele which, as far as was known, had not 
 given previous trouble, waiting out of sleep suddenly, was terrified by seeing her little 
 child playing about the room with a piece of wood taken alight from the fire. Most 
 urgent dyspnoea set in, and before surgical relief could be given, death took place from 
 suffocation. In another case, that of a woman, tlie subject of bronchocele, and strain- 
 ing violently in the throes of parturition, the same dyspnoea set in as rapidly, and 
 with the same result. 
 
OPERATIONS OX THE THYROID GLAND. 387 
 
 ment of the thyroid, the right half having been increasing in size for 
 some years, but her chief trouble was due to a swelling, in the posi- 
 tion of the isthmus, of the size of a small orange. This had existed 
 about a year, but had suddenly increased in size, while the patient 
 was singing, six months before. The patient's voice, originally an 
 alto, was now hoarse and gruff, and of very small compass. On re- 
 moval this proved to be an encapsuled adenoma of the thyroid (per- 
 haps, originally, in the main cystic), containing in the centre firm 
 coagulum, and occupying the isthmus. Two years later, when the 
 patient was last seen, the right lobe had subsided to the size of its 
 fellow, but the voice was still deep and somewhat hoarse. 
 
 5. Difficulty of deglutition, if associated with the others not given. 
 
 6. Steady or rapid enlargement, with or without dyspnoea, if the 
 enlargement be in a downward direction so as to become sub-sternal. 
 The lower down the growth has been allowed to extend the greater 
 the risk of mediastinal cellulitis, if an operation is performed for the 
 removal of the bronchocele, and the smaller the hope of giving relief 
 by tracheotomy, if the dyspnoea comes on in these cases too urgently 
 to admit of any attempt at extirpation. 
 
 The following case, given liy Mr. Bryant,* is a good instance of the 
 truth of the above : A young man, aged nineteen, three months before 
 his death, " became the subject of paroxysmal attacks of asthnif tic 
 dyspnoea, associated at times with a wheezing or whistling respiration 
 and some general enlargement of the base of the neck. Three days 
 before his death this difficulty became extreme, the paroxysms be- 
 came more frequent and more severe, and on the day of his death a 
 severe paroxysm took place, which passed on to a forced and heaving 
 respiration, beyond anything I had ever before witnessed, and speedy 
 death resulted. I performed tracheotomj' with the slender hoi^e that 
 some light might be thrown upon the nature of the case to guide us 
 in its treament, if not to give relief, but in doing so what was proba- 
 ble before became evident — viz., that the obstruction was below. I 
 had no perforating instrument with me long enough to force down, so 
 a female catheter was used, but it struck against some solid body that 
 prevented its progress. After death the thyroid body was found to 
 be much enlarged, but mainly below the sternum and along the sides^ 
 of the trachea. The trachea below my opening was flattened later- 
 ally to within i inch of the bifurcation ; it was also twisted to the left,, 
 and was surrounded by the greatly enlarged and firm lateral lobes of 
 the thyroid." 
 
 7. Improvement of personal appearance. An operation should 
 never be here entertained by the surgeon, unless he is dealing with a 
 
 * Surgery, second edition, vol. i. p. 192. 
 
3S8 OPERATIONS ON THE HEAD AND NECK. 
 
 Bmali growth and has sufficient reason to have confidence in himself 
 and his patient to be able to keep the wound aseptic from first to last* 
 0(.«'x in which an operation is contraiiulicated, or in which it must be 
 performed with odditional caution. 
 
 1. Huge bronchoceles, especially if broadly fixed. 
 
 2. Calcified bronchoceles. 
 
 S. Those with ill-defined limits. 
 
 4. Those which are already sub-sternal, owing to the risk of medi- 
 astinal cellulitis. 
 
 5. Kge^e.g., in patients over fifty. 
 
 6. Patients with very feeble pulse, Schwartz thinks that feeble 
 action of the heart will be often met with in goitre, and attributes this 
 partly to interference with respiration due to pressure on the veins 
 and the trachea, and partly to the intervention of a more or less volu- 
 minous vascular network in the circulation, thus producing a strain 
 •on the heart. 
 
 Dangers of the Operation. Immediate and Later. 
 
 1. Hosmorrhage. This can usually be met by paying careful atten- 
 tion to the details given below in the account of the operation. The 
 arteries are usually easily commanded ; it is the veins which give 
 trouble, being numerous and thin-walled, and, in the severer cases, 
 met with at every step of the operation. In these cases also, when 
 the growth is soft as well as vascular, any opening of the capsule is 
 liable to give rise to flooding of the wound with blood and great diffi- 
 culty in finding the bleeding point, thus causing risks of including in 
 the ligature or otherwise injuring important parts, such as the recur- 
 rent laryngeal. 
 
 2. Injury to the recurrent laryngeal nerve, asj^hyxia, ajihonia. 
 This most grave accident has happened with sufficient frequency to 
 put any surgeon on his guard. The injury may be due to including 
 the nerve in a ligature, cutting the nerve, or seriously bruising it. 
 Ilichelot,t writing in 1885, found nine cases in which it was certain 
 that the recurrent laryngeal had been cut during the operation. He 
 gives the following causes of aphonia after the operation : (1) Wound 
 of inferior laryngeal nerve; (2) dragging of this nerve; i^3) perhaps 
 section of the crico-thyroid branch of the superior laryngeal; (4) 
 months after operation it may come on from exclusion of the inferior 
 
 * The following is the advice of Billroth on this matter: "Large prominent bron- 
 choceles in people above forty years of age, with slight or no dyspnwa, should not be 
 operated on just for the sake of appearance. I think that small bronchoceles con- 
 nected to the lower part of the thyroid in children and young people should be more 
 often removed, especially when their situation is such that the tumor might, with the 
 increased growth, possibly entail some danger." 
 
 t L' Union Med., Nos. 17 and 18, 1885 ; Med. Chron., June, 1885. 
 
OPKEATIONS ON THE THYROID GLAND. 389 
 
 laryngeal nerve in the cicatrix ; (5) when the laryngeal symptoms are 
 progressive from ascending neuritis (Schwartz). This may be present 
 before the operation, and so, too, may be (6) compression of the infe- 
 rior laryngeal by the goitre. 
 
 M. Richelot, after discussing the results of section and irritation of 
 the recurrent laryngeal, thinks that the sudden dyspncea and aphonia 
 must be attributed to division of the recurrent with irritation of the 
 upper end. 
 
 Whatever the exact cause is, it is certain that the dyspnoea and 
 aphonia are not always permanent. As bearing on these points, the 
 two following cases of M. Richelot are of much interest : * 
 
 In a woman of twenty-five, suffering from suffocating dyspnoea, the 
 operation was followed by aphonia, which lasted for three months, 
 and by complete paralysis of the cords. The operation was performed 
 with great care, and there is no reason to think that either of the 
 recurrents was cut, but it is possible that they were bruised or stretched ; 
 however, in four months the cords regained movement and the voice 
 was fully restored. 
 
 In the second case, aged twenty, a hard mobile tumor, the size of a 
 walnut, wa,s attached to the isthmus by a narrow pedicle, and the 
 gland itself, though apparently somewhat hypertrophied, was not 
 prominent. But, when exposed, it was found that the tumor had a 
 broad attachment to the isthmus, and that the two lobes of the thyroid 
 were greatly hypertrophied, closely embracing and compressing the 
 trachea ; it was therefore thought desirable not only to snip off the 
 tumor, but to dissect out and to remove the whole gland. When 
 recovering from the effects of chloroform, the patient was suddenly 
 seized with cyanosis and threatening asphyxia, and though she par- 
 tially recovered, on the next day there was aphonia, dysphagia, and 
 uninterrupted dyspnoea, and she died asphyxiated in the evening. 
 Both recurrent laryngeals had been cut, and the upper end of the left 
 one was included in a ligature. 
 
 Injury to the nerve is especially likely to occur under the following 
 conditions : (a) when the growth is huge ; (b) when it is verj^ fixed by 
 adhesions (which are uncommon), or by a broad base; (c) when it is 
 ill-defined ; (d) when it encircles the trachea and CESophagus closely; 
 (e) when it is malignant. 
 
 3. Septic cellulitis leading to purulent and diffused mediastinitis. 
 These are very likely if the wound becomes septic. In such cases the 
 latter complication is almost certain, even in small goitres, if they dip 
 down behind the sternum, owing to the difficulty of providing ade- 
 quate drainage. The accompanying symptoms are : Pain in the 
 
 * With them the case I have given at p. 404 may be referred to. 
 
390 OPERATIONS ON THE HEAD AND NECK. 
 
 region, coming on soon after the operation and increasing, followed 
 by feebleness of the pulse, distress, and dyspncsa, and speedy death. 
 
 4. Myxoedema, both acute and more deferred. This strange con- 
 dition, which has so unexpectedly overclouded otherwise successful 
 operations for complete removal of an enlarged thyroid gland, was 
 first noticed and published by two Swiss surgeons, Kocher and Eev- 
 erdin.* The correct explanation will probably be found to be the 
 one which Prof Horsley brought before the profession in his lucid 
 and convincing Brown lectures of ISSS.f The issues here treated are 
 so wide, the experimental researches are so complete and far-reaching, 
 that any abstract must, unintentionally, seem to do them an injustice. 
 The following are the points of chief importance to the operating 
 surgeon : 
 
 Effects of Excision. Phenomma follouiag Complete Thyroidectomy in 
 Monkeys. — "At a variable period after the operation, but averaging five 
 days, the animal is found to have lost its appetite for a day or two, 
 and, on closer examination, to exhibit slight constant fibrillar tremors 
 in the muscles, of the face and hands and feet more especially. These 
 tremors disappear at once on voluntary effort. At the same time the 
 animal is noticed to be growing pale and thin, in spite of the appetite, 
 etc., returning quickly with great increase ; rapidly the tremors in- 
 crease, affect all the muscles of the body without exception, the 
 animal becomes languid, paretic in its movements, and imbecile. 
 Then puffiness of the eyelids and swelling of the abdomen follow, 
 with increasing hebetude. During thtse last stages the temperature, 
 gradually falling, becomes subnormal, and then the tremors disappear 
 as they came. Meanwhile the pallor of the skin often becomes 
 intense, and, leucocytosis having been well marked, oligsemia follows, 
 and the animal dies perfectly comatose in a variable period, but 
 usually about five or seven weeks after the operation." 
 
 Post-mortem Appearances met irith after Complete Thyroidectomy.— Frof. 
 Horsley thus sums these up : ''Ablation of the thyroid causes atrophic 
 changes in the central nervous system, and in the fat generally. It 
 causes an increase in the general connective tissue, and a mucoid con- 
 version of the ground substance. This increase of mucin in the 
 connective tissue is accompanied by an extraordinary secretion of the 
 same stuff by means of the salivary glands, and also those of the ali- 
 mentary canal." 
 
 * Arch.f. Klin. Ghir., Bd. xxix. p. 254, 1883. 
 
 t Brit. Med. Journ., Januai-y 17 and 31, 1885 : " The Thyroid Gland : its Relation 
 to the Pathology of Myxoedema and Cretinism ; to the Question of the Surgical Treat- 
 ment of Goitre; and to the General Nutrilion of the Body." 
 
OPERATIOKS ON THE THYROID GLAND. 391 
 
 While these changes are going on, the hajmapoietic tissues, especially 
 the spleen, are found to have undergone obvious compensatory 
 hypertrophy. 
 
 Theories ex-plaining Myxcedema, Cachexia Strumiprivei, anel Cretirmm. 
 'Prof. Horsley discussed the three following, maintaining, himself, 
 the third to be the correct one : 
 
 i. Kocher's view, that the symptoms of myxoedema which follow 
 complete thyroidectomy are brought about by chronic asphyxia, due 
 to narrowing of the trachea, consequent on softening and atrophy, 
 produced by ligature of the thyroid vessels which supply the trachea 
 and oesophagus as well. Prof. Horsley finally disposes of this view 
 by remarking that there are numerous cases of marked stenosis of the 
 larynx and trachea on record, but not a symptom of myxcedema has 
 here been noticed. Furthermore, in his experimental thyroidectomies, 
 the larynx and trachea were found absolutely normal and patent. 
 
 ii. Dr. Hadden's views that the my xoedematous state of malnutrition 
 is brought about by a general spasm of the arterioles and caj)illaries, 
 the spasm being maintained Ijy central disturbance in the sympathetic 
 ganglia. This view regards the atrophy of the thyroids as due to 
 constriction of the bloodvessels, and therefore of secondary impor- 
 tance. It has been accepted by Kocher on the assumjotion that in the 
 operation the sympathetic nerves are injured and irritated by being 
 included in the ligatures placed on the vessels. It is set aside by 
 Prof Horsley because (a) it has been found experimentally that if the 
 gland be exjiosed, and the nerves going to it are divided, the symp- 
 toms of myxcedema do not appear; (,?) in Prof Horsley 's experi- 
 mental thyroidectomies which were followed by myxoedema, the 
 irritation of the nerves was only, he considers, momentary, (y) The 
 sympathetic trunk and ganglia appear to be, microscopically, abso- 
 lutely normal. 
 
 iii. The theory* that the four varieties of a general state of mal- 
 nutrition, given below, are due to the loss of function of the thyroid 
 
 * Prof. Horsley also deals with some objections which have been raised to his theory 
 — (1) Even if in the above-named conditions — viz., cretinism, myxosdema, cachexia 
 strumipriva, and cachexia after thyroidectomy, a thyroid body be discovered post- 
 mortem, it does not follow that this was in full normal function. (2) If one lobe be 
 excised, the other hypertrophies; if this enlarged half be now removed, the animal 
 presents many of the symptoms described. In answer to the statement of SchiflC that, 
 provided an interval of about three weeks elapses between the operations, the symp- 
 toms do not appear, or, at any rate, are not fatal. Prof Horsley replies, that even if the 
 above observation is to be trusted the mitigation of symptoms can readily be under- 
 stood, as the spleen will have had time to provide for the hsemapoietic functions of the 
 gland. 
 
392 OPERATIONS ON THE HEAD AND NECK. 
 
 gland, perhaps through disturbance of the nervous centres, leading to 
 vaso-motor or trophic changes in the tissues* 
 
 The following cases, with the results of operation, support Prof. 
 Horsley's views. They might be multiplied by other published cases, 
 and it is proliable that many other temporarily successful thyroidec- 
 tomies have been followed by myxosdema, but that this ending of the 
 cases has not been made known. 
 
 Volkovitch, of Kiev,t removed the whole gland in a woman aged 
 thirty-eight, for dyspnoea and dysphagia indicating operative inter- 
 ference. Death took place four months after the operation, with 
 marked evidence of cachexia strumipriva — i.e., anaemia and weakness, 
 tetany of hands and legs setting in five days after the operation, and 
 becoming, later on, more general, numbness of hands, myxoedema- 
 tous contrition of the integument, striking apathy, difficulty in articu- 
 lation and respiration. 
 
 Sir W. Stokes J has published a case in which a somewhat similar 
 fatal result followed complete thyroidectomy. A healthy woman, 
 aged eighteen, was admitted with extensive enlargement of both thy- 
 roid lobes, causing urgent dyspnoea, especially at night. It was found 
 impossible to remove more than the left lobe, owing to the profuse 
 hsemorrhage, which proved almost fatal. A good recovery took place, 
 followed, for a while, by relief of dysi^ncea and diminution in the size 
 of the right lobe. In about six weeks, however, the right lobe was as 
 large as before, and the thrill and dyspnoea were again present in an 
 intensified form. The right lobe was removed with even greater 
 
 * Prof. Horsley thii.s tabulates the most striking of tlie anatomical and physiological 
 facts bearing upon experimental niyxcedema: 
 
 " 1. The thyroid gland appears to consist of two distinct portions — (a) glandular, 
 consisting of highly vascular acini, which excrete into their interior a mucoid sub- 
 stance, this substance, or something closely similar, being found in the lymph-vessels 
 of the gland — mncin-excreting function? (6) highly vascular, lymphoid nodules — 
 hsematogenous function. 
 
 " 2. Excision of the gland is followed, according to my experiments, by an increase 
 in the amount of mucin in the tissues which normally possess it, by a retrograde his- 
 tological change, by an increase in the activity of the glands wliich normally excrete 
 it, and, what is still more striking, by the assimiption of the muciparous function by a 
 gland which normally produces none, or very little, mucin — the parotid gland. 
 
 "3. Excision of the gland is followed by [irofound changes in the blood — namely, a 
 diminution of the number of corpuscles, preceded, as regards the number of the white 
 elements, by a temporary increase in their number, by an alteration in the coagula- 
 bility and albumins, and by an abnormal presence of mucin. 
 
 "4. Excision of the gland is followed by nerve-symptoms indicating changes in the 
 lowest motor centres, these changes causing tremors, with rigidity and paresis; it is 
 also followed by changes in the higher psycho-cortical centres, such producing imbe- 
 cility, and, ultimately, death in the comatose state." 
 
 t Land. Med. Record, April 15, 1885, p. 148. 
 
 t Brit. Med. Joum., October 16, 1888. 
 
OPERATIOKS ON THE THYROID GLAND. 393 
 
 danger from syncope. Within a fortnight convulsive seizures set in, 
 and fatty swellings were noticed about the eyelids, backs of the wrists, 
 and over the metatarsi. Mental torpor also appeared, and the aspect 
 of the face became gradually one of imbecility. The convulsive 
 seizures recurred, with lividity of the face, stertor, dyspnoea, protrusion 
 of eyes, dilatation of the pupils, and throbbing of the carotids, fol- 
 lowed by copious perspiration. The patient became weaker and died, 
 with symptoms of pulmonary infiltration, ten days after the second 
 operation. The very brief account of the post-mortem only mentions 
 the brain, heart, and lungs; of these, the two former "contained 
 nothing abnormal ; the lungs were highly oedematous." 
 
 Mikulicz, of Cracow,* states that the published cases of cachexia 
 strumipriva after thyroidectomy already number thirty-five, and he 
 adds another. As to other evils which may result from total thyroid- 
 ectomy, he says that Weiss, in 1883, found thirteen cases of tetany, 
 and Mikulicz himself has had four cases in seven operations. He also 
 cites three cases, two of his own, in which epileptic convulsions fol- 
 lowed total extirpation. 
 
 It is right to state that other observers have failed to trace the above 
 sequence. Foremost amongst these is the experience of Billroth, who, 
 in 1883, had performed extirpation sixty-eight times, with a mortality 
 of only 7.3 per cent., and without once observing cachexia strumi- 
 priva. Crede, of Dresden {Congress of German Surgeons, 1884), reported 
 fourteen cases of complete extirpation without one case of myx- 
 oedema following. 
 
 Sir W. MacCormac (Brit. Med. Jour., 1884, vol. ii. p. 231) mentions, 
 in explanation of Kocher's results, the opinion of Bardleben, " that 
 the cretinoid condition observed by Kocher may very well have fol- 
 lowed in his cases, irresi^ective of the extirpation of the gland, and 
 that the enlarged thyroid was but a link in the chain of symptoms, 
 dependent rather on the locality from which the patient came, than 
 on the circumstance that extirpation of the goitre had been prac- 
 ticed." 
 
 However this matter may finally be cleared up, the fact remains 
 beyond dispute that in many parts of Europe symptoms akin to those 
 of myxoedema have followed complete thyroidectomy, especially in 
 young subjects.f Why this sequence has not been invariable, and what 
 the explanation of it is when it does appear, is as yet uncertain. But, 
 till this matter is cleared up, I am distinctly of opinion that complete 
 extirpation of the thyroid is as yet unjustifiable. It is certainly an 
 
 * £rit. Med. Journ., October 16, 1886 
 
 t Of Koolier's sixteen cases, in which cachexia strumipriva was developed, nine 
 were under twenty years of age, live between twenty and thirty, and only two above 
 thirty. Eleven were yonng women ; five were males. 
 
394 OPERATIONS ON THE HEAD AND NECK, 
 
 operation of many undoubted risks, such as haemorrhage, injury to 
 the recurrent laryngeal and the trachea, and septic trouble. In addi- 
 tion, the great risk of myxoedema remains, an uncertainty perhaps, 
 but still to be reckoned with. On the other hand, we have operations 
 which are infinitely safer, such as ligature and removal of the isthmus 
 and removal of one-half, to be followed, if needful, by ligature of the 
 arteries to the opposite half later on. 
 
 Operation for Removal of One-Half, and the Isthmus 
 
 as well, if required. — The parts having been cleansed, and the 
 patient's head and shoulders conveniently supported, the surgeon 
 makes a free incision over the most prominent part of the tumor 
 which he is going to remo\'e, avoiding any large veins. An ample 
 longitudinal incision * will nearly always give all the room that is 
 required, and such a scar will be little conspicuous, falling, as it does 
 eventually, into the sulcus just internal to the sterno-mastoid, a point 
 of much importance in women. 
 
 The skin and platysma being cut through, any superficial veins 
 carefully tied, the deep fascia is slit up and the gland itself exposed, 
 bluish-red and with large veins on its surface. Spread also over this 
 are often one or more of the depressors of the hyoid bone; these are 
 separated with a blunt dissector, or, if needful, divided between silk 
 ligatures. One or more large retractors are now inserted so as to 
 draw outwards the sterno-mastoid and large vessels, while the surgeon 
 with his left index finger, or a blunt dissector, frees the enlarged jDart 
 of the thj'roid from its bed, shelling it forwards, and probably finds 
 it only fixed above, below, and internally, by the thyroid vessels and 
 the isthmus. In eff'ecting this separation, the greatest care must be 
 taken to work gently and to keep close to the tumor,t the veins being 
 often much enlarged and thin-walled. J The upper extremity of the 
 
 * The incision can either be made as above, laterally, or it ma_v be angular with a 
 straight limb in the median line from hyoid to sternum, and one passing obliquely 
 outwards and upwards fiom the upper end of the first. If the surgeon still persist in 
 removing the whole gland, the inci-iiim may be Y-shaped. In ca,ses, as in that of Sir 
 W. MacCormac {loc. supra cit.), where the skin is adherent after the use of setons, etc., 
 the incisions must be made so as to enclose and remove the adherent skin and cica- 
 trices. 
 
 t The capsule of the tumor must nowhere be opened. Such a step not only leads to 
 flooding of the wound with blood, but thus also obscures and may lead to damage of 
 important parts — e.g., the recurrent laryngneal and trachea. 
 
 t While it is quite impossible to give any adequate idea of the number of vessels 
 which may be met with in a large and difficult case, it will be well to recall the prin- 
 cipal vein-trunks. The superior thyroid vessels enter at the upper angle; a little 
 below these emerges laterally a superior accessory vein (Kocher). The same surgeon 
 describes as constant a superior and inferior communicating vein as lyino- above and 
 below the isthmus, the former joining the two superior thyroids, and the latter entering 
 
OPEEATIONS ON THE THYROID GLAND. 395 
 
 tumor being first isolated, the superior thyroid vessels are found and 
 tied with double ligatures of chromic catgut or carbolized silk passed 
 with an aneurism needle. This effected, the tumor is next isolated in 
 a downward direction, and any outlying masses turned out from 
 beneath the sterno-mastoid. The next step usually taken is similar 
 isolation, ligature, and division of the inferior thyroids, but the writer 
 prefers to take the isthmus next, being of opinion that the more the 
 growth is freed and isolated, and the less fixed it is, the more easily 
 are the inferior thyroid vessels dealt with, and the less danger is there 
 of damaging the recurrent laryngeal. 
 
 The separation of the isthmus is best effected with a steel director, 
 care being taken to keep the isthmus as much off the trachea as possi- 
 ble, and the point of the director close to the isthmus. When this 
 body has been sufficiently separated, it may be ligatured after trans- 
 fixion with an aneurism needle carrying carbolized silk or strong 
 chromic gut, or it may be carefully torn through with the point of a 
 director, and each bleeding-point secured.* The amount of hfemor- 
 rhage met with in detaching and dividing the isthmus varies very 
 much. If the separating is effected piecemeal, the bleeding is often 
 very slight. This is probably accounted for by the fact that the 
 intimacy of connection and continuity of structure between the halves 
 of the thyroid and the isthmus varies much also; in many cases the 
 connection is mainly by connective and a little glandular tissue, with 
 very few vessels. 
 
 The tumor, now almost completely isolated, is drawn to one side, 
 and especial care is taken before ligaturing the inferior thyroid vessels. 
 These should be most carefully isolated and inspected, so as to avoid 
 injury to, or including, the recurrent laryngeal. Owing to the fact 
 that the trunk of the inferior thyroid artery does not come into rela- 
 tion with the recurrent laryngeal till both are close to the trachea, the 
 vessel should be ligatured and cut at some distance from it. 
 
 If the vessel is tied at all en masse, the nerve may very likely be in- 
 
 into the thvroidea ima vein. The inferior thyroid vessels pass behind the outer border 
 of the thyroid, and for some distance behind it, before penetrating it with its several 
 branches. A little above the inferior thyroid vessels emerges the inferior accessory 
 thyroid vein. The anterior jugular will have to be dealt with, and the positions of 
 the internal jugular, and, below, of the innominate veins, jvill have to be remembered 
 in the case of huge tumors. The above veins are figured by Sir W. MacCorraac {loc. 
 supra cit.) in an illustration taken from Kocher. 
 
 * If the pedicle seem too thick and vascular to treat in this way, which may be the 
 case in colossal bronchoceles, it should be subdivided and tied in several pieces, like a 
 stout ovarian pedicle. If this cannot be managed, and if the patient's condition admits 
 of it, the pedicle may be divided by an ^craseur, or seared through with the cautery. 
 In such case the stump should be brushed over with a strong solution of zinc chloride, 
 dusted with iodoform, and, if possible, brought outside the wound. 
 
396 OPERATIONS ON THE HEAD AND NECK. 
 
 eluded, and the same risk is run if at this stage the wound is not kept 
 dry and bloodless. 
 
 Baumgartner of Baden, and Crede of Dresden (quoted by Sir W. 
 MacCormac, foe. siqyra cit.), lay stress upon the importance of tying 
 the branches of the inferior thyroid close to the gland itself, thus 
 avoiding any risk of tying the recurrent laryngeal nerve and of injur- 
 ing the small vessels to the trachea, oesophagus, and larynx. Sir W. 
 MacCormac also approves of this plan. 
 
 After the removal of the tumor, the wound should be examined for 
 any bleeding-points, adequate drainage then provided, and the wound 
 carefully closed, save below, to allow of free escape of discharges here, 
 and thus to avoid any risk of burrowing, and mediastinal cellulitis. 
 
 If during the operation there is any evidence of syncope, the head 
 should be lowered and injections of ether or brandy given. Both the 
 surgeon and the assistant who is giving the ansesthetic must be on the 
 look-out for evidence of dyspnoea or asphyxia. If any evidence of it 
 occur, it is an indication for the surgeon most carefully to examine 
 the tissues which he is handhng, and the amount to which he may be 
 dragging upon the air-passages in the manipulation of the tumor. 
 Tracheotomy seems nearly always to be a fatal complication,* partly 
 by rendering such a deep and important wound septic, partly by 
 causing septic broncho-pneumonia, and partly by adding to the shock 
 in a patient already collapsed by so severe an operation. 
 
 If tracheotomy appear urgently needed, the surgeon should try 
 first slitting up more freely the deep cervical fascia or dividing or 
 retracting any stretched muscles, in order to relieve the trachea and 
 breathing. 
 
 In the event of the operation having to be performed, great difficul- 
 ties must be expected, and the surgeon should be provided with long 
 soft tubes, in case there is any mediastinal prolongation pressing upon 
 the lower part of the trachea. Every possible attention must be paid 
 to keeping the tracheotomy wound sweet with applications of iodo- 
 form, iodoform and ether, etc. Sir W. MacCormac draws attention to 
 the need of keeping the head very steadj' at the time of the tra- 
 cheotomy, and, later on, with sand-bags ; he advises leaving the thy- 
 roidectomy wound open and treating it with frequent irrigation, if 
 tracheotomy has been found necessary. 
 
 For the first few days after thyroidectomy, care must be taken to 
 keep the dressings securely in position. This is especially difficult in 
 a mobile part like the neck, which does not admit of compression. 
 The safest plan is to pass the gauze bandages under the axillos below, 
 
 * In five of Billroth's cases in which tracheotomy was performed three died. 
 Kocher's experience has been the same. 
 
OPERATIONS ON THE THYROID GLAND. 397 
 
 and, above, to wind them over the chin and forehead, points of friction 
 being carefully packed with salicylic wool, and all made secure by 
 stitching. This alone will keep the dressings from slipping down. 
 
 Unless primary union is secured throughout, any silk ligatures 
 used are hable to come away for many months. Thus, Sir W. Mac- 
 Cormac (foe. sicpra cit.) relates a case of thyroidectomy lasting two 
 hours, in which at least a hundred ligatures were used. Six months 
 later a sinus was still discharging ligature-threads.* 
 
 Question of Operation in Cases of Malignant Disease 
 
 of the Thyroid.— The surgeon must consider here most carefully 
 whether any operation is justifiable. In the first place the risk of 
 injury to the recurrent laryngeal is much increased from the tendency 
 of a malignant growth to creep round the trachea, dip into the sulci 
 between the large vessels and the windpipe, and to infiltrate important 
 parts. Secondly, these growths, especially if rapid, tend to creep 
 down into the anterior mediastinum,t behind the sternum. Thirdly 
 in addition to these dangers, must be considered that of glandular 
 invasion,! ^''■'"^ the doubtfulness of getting all the growth away, and 
 the increased risks of hemorrhage and cellulitis. 
 
 Dr. Rotter (Arch.f. Clin. Chir., Bd. xxxi. Heft 4 ; Year-book of Treat- 
 ment, 1S85, p. 138) gives details of fifty cases of cancer of the thyroid 
 submitted to operation. Of these eight died in the first twenty-four 
 hours, five at the end of the first week, and eight at the end of the 
 second week. Only four patients remained free from a recurrence at 
 the end of six months. These figures point very strongly to the con- 
 clusion that in malignant disease of the thyroid an operation is most 
 rarely justifiable. 
 
 Mr. Butlin {Operat. Treat, of Malig. Dls., -p. 206) thinks that "at 
 present the number of instances in which a cure of the disease can be 
 claimed is so small § that the operation is scarcely justified." The 
 
 * See, on this point, the footnote, p. 404. 
 
 f A remarkable instance of malignant bronchocele is figured by Billroth (Clin. 
 Surg., pi. ii. and iii.). It was a soft carcinoma, and extended down behind the sternum, 
 compressing the right innominate vein, and causing enormous dilatation of the super- 
 ficial veins of the neck and front of the trunk. 
 
 J E.g., Cervical, mediastinal, bronchial. 
 
 § He thus analyzes the cases in the paper by Dr. Better, quoted above, and two 
 others by Dr. Rose and Dr. Braun (Langenbeck's Arch., 1879,1883). Of fifty cases 
 submitted to operation thirty were fatal. Of the twenty which survived the operation, 
 a recurrence took place in ten, which was either fatal or promised rapidly to be so. In 
 two the operation was abandoned In three the further history was not known, and 
 in one it only extended to a period of two months after the operation. In four only 
 was a result, which Mr. Butlin courteously calls favorable, obtained. One, a patient 
 of Bircher's, was well eleven months after operation. In the second, Bruns removed 
 some enlarged glands a year after the first operation, and two and a quarter years later 
 
398 OPERATIONS ON THE HEAD AND NECK. 
 
 following facts, to which Mr. Butlin draws attention, are worthy of 
 careful notice : (1) The large number of cases in which secondary 
 affection was discovered at the autopsy, even when death occurred 
 within a few days after the operation ; (2) The frequency with which 
 it was found imj^ossible to entirely remove the tumor ; (3) The diffi- 
 culty of diagnosis in the early stage of malignant disease of the thy- 
 roid. The chief points which should be looked to here are early fixity 
 and irregularity of outline, to which Mr. Butlin, quoting from Rose, 
 adds continuous growth * and marked dysphagia. 
 
 Treatment of Enlarged Thyroid by Operations on the 
 
 Isthmus. — This method consists in excising the isthmus after apply- 
 ing double ligatures, or in trusting to double ligatures alone. It was 
 first recommended in this country by Sir D. Gibb,t and has more re- 
 cently been used and advocated by Mr. Sydney Jones. 
 
 In Sir D. Gibb's cases the patients were young women whose bron. 
 choceles had resisted other treatment. In one case there was general 
 enlargement of the thyroid, esj)ecially on the right side, the isthmus 
 could be felt, distinctly rounded, and projecting somewhat over the 
 trachea. Mr. Holthouse exposed the isthmus, and, after placing a 
 ligature on either side, removed it. About six months later the patient 
 was entirely free from her old symptoms —tension, dyspnosa, etc., — 
 and the lobes appeared to have receded laterally, and to be less 
 prominent. 
 
 In the second case there was much enlargement of the veins owing 
 to extension downwards of the bronchocele. Cough, dysphagia, and, 
 at times, urgent dyspncea were present. When Mr. Holthouse 
 exposed the isthmus it suddenly cropped up like a hernial tumor. 
 After cautiously detaching it with curved scissors, two ligatures were 
 passed under it as widely apart as possible. As they seemed likely to 
 become detached if the isthmus was cut away, they were left in to 
 slough out. The patient made a good recovery with much relief to 
 her symptoms. 
 
 A very interesting case has been recorded bj^ Mr. Sj^dney Jones : J 
 
 the patient died of inflammation of the Inngs. The third, a patient of MaaS', was re- 
 ported to be quite well nearly four years after the operation ; and the fourth, under the 
 same surgeon, died in twelve months of some uncertain lung affection. 
 
 * Kose has pointed out that the surgeon is liable lo be deceived on this point by the 
 effect of remedies. Thus, potiissium iodide may cause a diminution in the size of the 
 neck, a fact wiiich may be attributed to the effect of the drug on the general enlarge- 
 ment of the gland, which is frequently as-:ociated with the occurrence of more or less 
 limited malignant disease. Attention has already been drawn at pp. 326, 370 of this 
 book to the procrastination (sometimes pernicious in its results) which this temporary 
 result of giving potassium iodide may bring about in malignant disease. 
 
 t Lancet, 1875, vol. i. p. 120. 
 
 X Lancet, November 24, 1883, p. 900. 
 
OPERATIONS ON THE THYROID GLAND. 399 
 
 The patient, aged eighteen, had noticed the swelling about eight 
 years, latterly it had increased rapidly. The dyspnoja was marked, 
 the least exertion bringing on paroxysms. The thyroid was greatly 
 enlarged, the right lobe being much the larger, while the isthmus could 
 be traced extending below its usual position, as a band about 1 inch 
 in vertical measurement. An incision alaout 3^ inches long being made 
 in the middle line, transverse branches of the anterior jugular vein 
 being tied and turned aside, the isthmus was detached by the finger 
 and director from the from of the trachea. An aneurism needle was 
 then made to perforate, which it did easily, the junction of the isthmus 
 with each lateral lobe. The double ligature on each side was tied as 
 with an ovarian pedicle, and the isthmus cut away. There was very 
 little hffimorrhage. The trachea was very much compressed, of tri- 
 angular shape, with the apex forwards, and each lateral surface some- 
 what concave. Immediately on removal of the isthmus much relief 
 seemed to be afforded to the patient. The dyspncea quickly ceased, 
 and when the patient left, in less than two months, the thyroid could 
 not be felt. 
 
 Sir W. MacCormac* alludes to three other cases thus treated by Mr. 
 Sydney Jones : The second was- one operated on for exophthalmic 
 goitre. Here great benefit followed as far as shrinking of the lateral 
 lobes went, but the patient died some time after from cerebral mischief ' 
 in connection with the general disease. In the two remaining cases, 
 the isthmus not being so well marked, the lateral lobes were so approx- 
 imated that the inner portions of both lateral lobes were removed, 
 after transfixion with a double ligature. Great relief to the breathing 
 and swallowing, and shrinking of the lateral lobes followed. Mr. S. 
 Jones considers the chief object of this operation to be to create a gap 
 between the lateral lobes, a deep gutter being made in front of the 
 trachea,- from which free drainage is secured during the process of 
 healing. 
 
 I have followed Mr. Sydney Jones in three cases, and can recom- 
 mend this operation most strongly. All three cases presented enlarge- 
 ment of the gland generally, in addition to hypertrophy of the isthmus. 
 In two of them the women were over thirty, with marked distress in 
 breathing on exertion and altered, hoarse voice. The mother of one 
 of the patients had died, aged forty-four, suddenly with dyspncea 
 accompanying enlargement of the thyroid. Two of these cases have 
 been kept under observation for three, and one and a half, years 
 respectively; in both the general enlargement has subsided steadily, 
 with entire relief of symptoms. The third case showed great hyper- 
 trophy of the whole thyroid, the isthmus consisting of a bi-lobed 
 
 * Loc. supra cit. 
 
400 OPERATIONS ON THE HEAD AND NECK. 
 
 tumor reaching from the top of the thyroid cartilage to just below the 
 manubrium. This patient was operated on more recently, but the 
 measurements of the neck showed a diminution of li inch within a 
 week of the operation ; this decrease went on advancing, so that a 
 fortnight later the enlargement of the right lateral lobe had entirely 
 disappeared, and that of the left almost equally so. The marked 
 tracheal stiidor, breathlessness on any exertion, but only weakened 
 voice, were accounted for by finding the windpipe in this case an ex- 
 cellent instance of "the scabbard trachea," this tube being bluntly 
 keel-like in front with concave surfaces from the strap-like pressure 
 of the enlarged isthmus. The sides of the thyroid cartilage showed, 
 from the same cause, very marked concavities. 
 
 I would most strongly urge a further trial of this operation in cases 
 of general enlargement of the gland, especially where the isthmus 
 itself is enlarged. This can be raised without difficulty with a steel 
 director or blunt dissector from the trachea, it is then transfixed at its 
 junction with the lateral lobes, or through these themselves, with a 
 double sulpho-chromic gut ligature (this should be tested beforehand). 
 The ligatures being tied, the gland-tissue is snipped through between 
 them, the isthmus removed, and tho stumps snipped away as close to 
 the remaining ligatures as is safe. 
 
 Treatment of Enlarged Thyroid by Ligature of the 
 
 Thyroid Arteries. — This operation was performed in thirty-one 
 known cases,* but was given up, (1) from deaths due to wound-treat- 
 ment of former days, (2) from imperfect results, as the inferior thyroid 
 was never ligatured at the same time. 
 
 Prof Wolfler,! of Vienna, considering that the various methods of 
 treating goitre are still open to olijections, has lately advocated a trial 
 of the above method. In October, ISSo, he made use of it in a patient 
 aged twenty-nine, who had much dyspnoea from a rather large colloid 
 thyroid, the right half being somewhat the larger, both the thyroid 
 arteries were tied on this side, and also the median thyroid vein. The 
 patient was discharged nine days later, the dyspnoea being consider- 
 ably relieved and gradually sulisiding completely. The neck, how- 
 ever, did not diminish in size at the same rate. A week after the 
 oiDeration the median circumference had diminished 1 cm., and seven 
 months later 6 cm., when the right side of the goitre had shrank to one- 
 half its former size ; the left side had diminished somewhat. Prof 
 Wolfler considers that facts indicate (1) that neither tving of both su- 
 perior thyroids nor of the inferior alone, can be considered sufficient, 
 
 * Wiilfler, Ion. Infni ctt. 
 
 t Wlin. Med. Woeh., ISSG, Nos. 29 and 30 ; Amu of Surg., December, 1SS6, p. 523. 
 
OPEEATIOJStS ON THE THYROID GLAND. 401 
 
 owing to the free anastomoses. (2) It is as yet questionable whether in 
 large one-sided goitres ligature of both thyroids on that side ought 
 to be accompanied by ligature of the opposite superior thyroid. (3) 
 Ligature of all four arteries could hardly lead to gangrene of the 
 thyroid. 
 
 It would perhaps be well to make further trial of this operation in 
 cases of bronchoceles requiring an operation from dyspnoea, etc., and 
 in which after removal of one-half the diminution in the opposite half 
 is either temporary or does not take place at all. I think, too, that in 
 very large thyroids this method might be combined with removal of 
 the isthmus. 
 
 The arteries may be found by the following methods. It is right, 
 however, to state that these vessels vary so much in situation and course, 
 according to the size and growth of the bronchoceles in different di- 
 rections, that any dissections for finding them must be uncertain. The 
 chief points to bear in mind are the upper and lower parts of the en- 
 larged lobe : the superior thyroid artery is often rendered superficial 
 by the upper limit of the tumor raising it up. Both vessels may be 
 enlarged and somewhat softened, and thus secondary hsemorrhage 
 may readily occur unless the wound is kept sweet. 
 
 Ligature of Superior Thyroid Artery. 
 
 Relations. — This vessel, the first branch of the external carotid, 
 arises just above the bifurcation, about a quarter of an inch below the 
 great cornu of the hyoid. At first covered only by thin fascise and 
 platysma, it ascends slightly, and then curves downwards with a tort- 
 uous course, covered by the depressors of the hyoid bone and the 
 sterno-thyroid. 
 
 Operation. — The patient's head being suitably raised, and turned 
 to the opposite side, an incision, about two inches long, is made along 
 the inner border of the sterno-mastoid, with its centre corresponding 
 to the upper border of the thyroid cartilage. The superficial parts 
 being divided, the sterno-mastoid and the large vessels are drawn out- 
 wards, and the omo-hyoid downwards and inwards, or else tied and 
 divided. The artery is then searched for with the point of a steel 
 director in the hollow between the larynx and the carotid. Some en- 
 larged veins, belonging to the superior thyroid, will probably require 
 division after the application of double chromic gut hgatures. 
 
 Ligature of Inferior Thyroid Artery.— This operation is a 
 good deal more difficult, owing to the depth of the vessel and its more 
 important relations. 
 
 Relations.— The artery, the largest branch of the thyroid axis, 
 ascends tortuously inwards behind the carotid sheath, the middle 
 cervical ganglion and its branches lying in front of it. Before entering 
 the gland it lies for a little distance in relation with its posterior sur- 
 
 26 
 
402 OPERATIONS ON THE HEAD AND NECK. 
 
 face, and in thi§ part of its course the recurrent laryngeal is in close 
 contact with it.* 
 
 Guide.— The carotid tubercle of Chassaignac, or the transverse pro- 
 cess of the sixth cervical vertebra. Sir W. MacCormac gives the body 
 of the fifth cervical vertebra, opposite to which the artery enters the 
 thyroid gland. The common carotid is also a guide. 
 
 Operation. — An incision, 3 inches long, being made along the 
 anterior border of the sterno-mastoid coming down to the clavicle, as 
 if for ligature of the carotid low down, the deep fascia is opened and 
 the sterno-mastoid and the structures in the carotid sheath drawn out- 
 wards. The head being now flexed to relax the parts, the carotid 
 tubercle is felt for, and the artery sought for below it, by carefully 
 working here with a director. The vessel should be exposed and the 
 ligature applied as close to the carotiil as possible, and thus at some 
 distance from the thyroid gland, so as to avoid injury to the recurrent 
 laryngeal, which, as above stated, crosses over the trunk or ascends 
 among the branches of the inferior thyroid. The neighborhood of other 
 important structures must be remembered. f 
 
 Treatment of Thyroid Cysts (Fig. 86). — These are sometimes 
 of much importance owing to their size, their important relations, 
 and, as shown by Mr. Glutton's case below, by their occasional vascu- 
 larity. 
 
 The best treatment is antiseptic excision whenever this is practi- 
 cable; with much larger and older ones, the safest and the one most 
 generally applicable, is antiseptic iiacision and drainage. Injection 
 with iron perchloride has given some good results, but there is always 
 the risk of suppuration and cellulitis in a very dangerous region 
 owing to the presence of the larynx above, the mediastinum below, 
 and of numerous veins, these being liable to puncture, and thus to 
 immediately fatal thrombosis, or, later on, to septic phlebitis. 
 
 * Sir W. MacCormac {Lig. of Arteries, p. 71 ) says that the nerve often passes between 
 the terminal branches of the artery. He reminds the o|ierator that the left artery is 
 in close contact with the oesophagus, and that the thoracic duct, at first posterior, arches 
 over the artery on this side to enter the left snbclavian vein. 
 
 t Wolfler {loc. supra cit.) recommends tying the artery on the onter side of the 
 carotid sheath, between the two heads of the sterno-mastoid, as less likely to damage 
 the important structures at the root of the neck. The incision reaches from the cricoid 
 cartilage to the chivicle, the lower end passing between the inner and middle tliirds 
 of that part of the clavicle which extends from the sulcus-deltoideo-pectoralis to the 
 sternum. The superficial parts being cut, and the slit between the two heads of the 
 sterno-mastoid extended upwards, if necessary, the omo-hyoid is seen and drawn up- 
 wards or cut. The outer border of the internal jugular is then recognized, and, with 
 the carotid sheath, drawn inwards, while the scalenus anticns and the phrenic nerve 
 are identified with the director and drawn outwards, when the inferior thyroid will 
 present itself. 
 
OPERATIONS ON THE THVKOID GLAND. 403 
 
 Where the cyst is moderate in size and not of very long duration, 
 it may often be excised, and the case given below shows that this may 
 sometimes be practiced where the cyst is huge in size and of long 
 duration. But in the majority of large cysts it will be a safer, though 
 more tedious, practice to incise the cyst and drain it with careful 
 aseptic precautions, a method which is appHcable to nearly all cases, 
 and which gives the surgeon the opportunity of exploring the cyst, 
 especially in those cases where it is covered over with a layer of gland- 
 tissue, or where it has complicated contents. 
 
 The above remarks apply to single cysts. Mr. Glutton * has pointed 
 out that where there are many cysts, or where a cyst is combined 
 with much disease, the whole half of the thyroid affected had better 
 be removed. 
 
 The method of incision usually involves a very simple operation. 
 The soft parts having been duly cleansed, an incision is made through 
 them down to the cyst, and any bleeding points secured. The cyst is 
 then slit open and its interior examined. These may vary consider- 
 ably both as to thickness and contents, and vascularity of lining 
 membrane. Thus the contents may be a serous, mucoid, gelatinous, 
 or grumous material, or coagulated blood-clot. The amount of vascu- 
 larity is of twofold importance : if of very long standing the cyst-wall 
 may be so fibrous and vascular that sloughing of it jnay readily take 
 place, especially if the wound becomes septic. On the other hand, it 
 may be extremely vascular, in which case such abundant hasmorrhage 
 will take place as to leave no time for suturing, and require imme- 
 diate plugging with aseptic gauze. f 
 
 Knowing how tedious these cases are in granulating from the 
 bottom and becoming completely obliterated, I prefer to suture the 
 cut edge of the cyst to the surrounding margin of the skin, and then, 
 with a sharp spoon, to scrajae over the lining membrane, thus pro- 
 moting the closing of the caA'ity from the bottom. A drainage-tube 
 is then inserted, the cavity plugged with strips of gauze, and the 
 dressings applied. Mr. Glutton, however, considers that sutures are 
 not necessary if the tissues between the cyst and the skin have not 
 been much disturbed ; if the contrary has happened, sutures may be 
 harmful, as they would tend to prevent escape of discharges from the 
 meshes of the deep cervical fascia. 
 
 I would draw attention, again, to the very important fact that in 
 these, as in all other thyroid cases (and in many others), where pri- 
 mary union is not secured, silk ligatures, if many of these have been 
 used, may continue to come away for a very prolonged period. The 
 
 * St. Thomas's Hasp. Reports, vol. xvi. p. 173. 
 
 f As happened in a case of Mr. Glutton's {loc. supra eit.). 
 
404 
 
 OPEEATIONS ON THE HEAD AND NECK. 
 
 cyst quickly falls in and puckers together, but a sinus is liable to 
 persist through which ligatures are long discharged. Thus, in one of 
 Mr. Glutton's cases a sinus persisted for two years, and then quickly 
 closed ; in another the patient was still wearing a drainage-tube, a 
 year after the operation. And in the case of mine now mentioned, it 
 was- not till nine months after the operation that the last ligature 
 came away, and the wound soundly closed.* 
 
 As bearing on the treatment of thyroid cysts by excision, and as a 
 good example of one of the complications which may follow opera- 
 
 FiQ. 85. 
 
 tions on the thyroid gland, I may now mention the following case 
 (Fig. 85) : 
 
 A gentleman, aged fifty-five, was sent to me, towards the close of 
 1885, by Mr. Cooper Forster, with a right-sided thyroid cyst, almost 
 
 * In my case plaited-twist silk (Turner's) was used. This is so closely interwoven 
 as to resist changes in the tissues and absorption most obstinately. I have been much 
 disappointed at the way in which it keeps a sinus persistent and comes away long 
 after such operations as radical cure of hernia, nephroraphy, and nephrectomy. For 
 buried sutures or ligatures ordinary silk of appropriate thickness is much to be pre- 
 ferred, being equally safe and with a much more open texture. 
 
OPERATIONS ON THE THYROID GLAND. 405 
 
 colossal in size, and reaching from the ear to below the clavicle, and 
 outwards, into the posterior triangle. The trachea was under the 
 edge of the left sterno-niastoid. The swelling was first noticed twenty- 
 six years before, being then about the size of a hazel-nut. About 
 nineteen years ago, owing to some dyspncea, the swelling was tapped 
 by Mr. Forster ; gradually refilling and increasing in size it -was 
 tapped by myself in 1885, the fluid being thick with material resem- 
 bling Partnesan cheese. As the cyst quickly refilled, I proposed free 
 incision and drainage, and sought first the opinion of my colleague, 
 Mr. Durham. As in spite of twenty six years' history the cyst had a 
 certain distinct, though limited, amount of mobility, Mr. Durham 
 advised extirpation in preference to excision. This counsel I accord- 
 ingly followed. Ether was taken very badly, especially at first. An 
 incision being made from the angle of the jaw to the right sterno- 
 clavicular articulation, the sterno-mastoid was found spread out over 
 the cyst and adherent to it, perhaps from the previous tappings. As 
 the patient was breathing very badly, no time was spent in separating 
 the muscle, but the cyst was reached by cutting away the adherent 
 part. The superior thyroids being found and tied, the cyst was turned 
 downwards out of its bed, partly with the finger, partly with a blunt 
 dissector; a vessel in the position of the middle thyroid vein was 
 found, and a small vessel below where the inferior thyroid was ex- 
 pected. The chief attachment of the cyst was in the middle line, 
 where it was connected with the isthmus (not itself enlarged) by a 
 fairly fleshy pedicle. This was separated from the trachea and tied 
 in three pieces, partly with the aid of a steel director, partly with 
 an aneurism needle. About fourteen carbolized silk ligatures were 
 used, and strict antiseptic precautions were taken throughout, includ- 
 ing the use of the spray. An enormous cavity remained when the 
 cyst was shelled out, exposing the common carotid and its bifurcation, 
 the larynx and trachea, but though a strong light was thrown into 
 the bottom with a mirror, nothing could be seen of the oesophagus or 
 recurrent laryngeal. Special care was taken to verify this, as towards 
 the close of the operation (which lasted twenty-five minutes) there 
 was some vomiting of coffee-ground stuff, streaked here and there 
 with brightish blood. 
 
 No dyspncea and no lividity had been noticed during the operation, 
 beyond the difficulty which had from the first accompanied the 
 anaesthetic. As the effects of the ether subsided, a peculiar stridor 
 was found to accompany the breathing, being much more marked in 
 inspiration. The voice was not affected, beyond being weak, and 
 there was no lividity. The stridor, but without marked dyspnrea, 
 went on increasing for about two hours, the patient being much 
 alarmed from dreaded " choking." Though he vowed that he could 
 
406 OPERATIONS ON THE HEAD AND NECK. 
 
 not swallow owing to the above alarm and from the feeling of soreness 
 " like a bone in the throat," he was persuaded to take a dose of potas- 
 sium bromide, and passed a fairly good night. The next day was a 
 comfortable one, and the breathing, which was twenty in the minute, 
 was much easier, and perfectly so while the patient slept. The next 
 two days were very anxious ones, the stridor returning, with great 
 restlessness and distress, on account of paroxysmal attacks of dyspnoea. 
 Accompanying these a condition of quiet delirium set in. The respi- 
 rations ran up to 40, the pulse to 140, while the temperature remained 
 99°. The wound was now, and throughout, perfectly sweet. As there 
 was some carboluria (without albumen), the drainage-tubes were 
 syringed out with boracic acid and iodoform gauze dressings applied 
 as before. 
 
 The pulse was of grave omen, about every ten or twelve beats drop- 
 ping, fluttering, and then, as it were, staggering on, to intermit again 
 in another ten beats. This, Dr. Goodhart thought, might be due to 
 some chloral that had been given at night. 
 
 The diagnosis at this time was doubtful — whether the case was one 
 of injury to the recurrent laryngeal or one of cedema glottidis. Mr. 
 Durham, who inclined to the latter view, advised the use of warm, 
 moist, boracic acid lint-dressings, and inhalations of steam and tere- 
 bene. 
 
 The breathing gradually became less laborious and noisy, and the 
 power of swallowing quickly returned. Recovery was retarded by a 
 succession of fogs and some localized pneumonia, which, giving 
 anxiety at first, entirely cleared up under Dr. Goodhart's hands. 
 When the patient left town, six weeks after the operation, there was 
 no difficulty in swallowing, the stridor was only noticed on deep res- 
 piration, or during quick or prolonged talking. The wound was now 
 represented by a sinus at the lower end ; all the rest was well healed. 
 Ligatures continued to come away for nine months, when the wound 
 healed at once. There is now, two years after the operation, still a 
 very little stridor on deep breathing or rapid talking, and the voice is 
 still a little husky, but the patient is able to follow his employment 
 actively and to get quickly over hilly ground.* 
 
 While the diagnosis here remains obscure, f I am of opinion that, 
 
 * A year after the operation he wrote thus : " I liave not been so strong and active 
 for many years. The other day I went in the morning to London, to the Academy, 
 Grosvenor, ' Alice in Wonderland,' Fitzroy House, then to a council-meeting of the 
 Photographic Society, and home. There was a damp fog all day, and I am not the 
 worse for it." 
 
 t Owing to a projection of the incisor teeth, and a life-long difficulty in opening the 
 mouth widely, it was found impossible — Mr. Durham and Dr. Goodheart also trying 
 — to get a view of this patient's larynx. 
 
REMOVAL OF GROWTHS IN THE NECK. 407 
 
 with the bloody vomit in the course of the operation, the great dys- 
 phagia afterwards, although the huge cyst turned out so quickly, some 
 slight injury was inflicted on the oesophagus, with stretching or im- 
 bedding in inflammatory eff'usion of the right recurrent laryngeal. 
 Whether this is right or not, I think, with all proper deference to Mr. 
 Durham's opinion, that this case shows that, in cases of thyroid cysts, 
 when large or of long standing, incision, with antiseptic precautions, 
 is preferable to excision. 
 
 CHAPTER XIV. 
 
 REMOVAL OP LARGE DEEP-SEATED GROWTHS 
 IN THE NECK. 
 
 Before deciding to undertake the removal of one of these, the sur- 
 geon should consider carefully the following points : 
 
 A. The nature and surroundings of the growth. 
 
 B. His operative skill in these cases, and his knowledge 
 
 of anatomy. 
 
 C. His experience in antiseptic surgery and in keeping a 
 
 large wound aseptic. 
 
 The chief growths which call for a decision are the following : The 
 rarely met with more innocent ones — e.g., the enchondroma of Prof. 
 Spence,* the fibrous tumor of Mr. Butcher,t glandular tumors, in- 
 cluding the more simple strumous lymphomata, when they do not 
 yield to other treatment ; sarcomata, very likely cystic, originating in 
 the neck apart from the cervical glands ; sarcomata of the glands ■ 
 carcinomata of the glands, secondary to epithelioma of the tongue, 
 lip, etc. 
 
 Of the three points above mentioned, it will only be needful to con- 
 sider separately the first ; the importance of the two others will be 
 sufficiently shown in the remarks on the operation and after-treat- 
 ment. 
 
 A. The Nature and Surroundings of the Growth.|— In ex- 
 
 * Growths of the tonsil are considered at p. 340. Bronchocele at p. 385. 
 
 t This case, in which the growth weighed over 7 lbs., is related in the Dub. Journ. 
 Jlfed!. iSa., November, ] 863. Mr. Butcher's case will be found amongst his Operative 
 Surgery Essays, p. 809. The reader should also consult Mr. Holmes's remarks on 
 these cases {Syst. of Surg, vol. viii. p. 886), a paper by Mr. Barker {Lancet, 1886, 
 vol. i. p. 194), and one by Mr. Jessett, illustrated by some admirable photographs 
 {Brit. Med. Journ., 1886, vol. ii. p. 712). 
 
 X Mr. Holmes {loc. supra cit.) quotes Langenbeck {Arch.f. Klin. Chir., Bd. 1, Hft. 
 4, s. 14) as pointing out that, in tumors which involve the sheath of the vessels, en- 
 
408 OPERATIONS ON THE HEAD AND NECK. 
 
 amining into these, careful attention should be paid to the following: 
 Duration. Rate of increase. Amount of fixity. Whether early estab- 
 lished, and how far absolute. This point is of the utmost importance. 
 The gravest cause of fixity is, of course, a growth with a wide base, or 
 numerous root-like processes extending into important parts. The 
 fixity should be tested by seeing how far the finger-tips can be insinu- 
 ated beneath the growth, how far it can be lifted up, and the amount 
 of its connection to parts such as the jaw and larynx, the head being 
 steadied by an assistant while the growth is lifted up and its deep 
 processes put on the stretch as much as possible. The outline. Is this 
 well marked or indistinct, and, if the latter, is it in dangerous regions 
 such as the parotid, the zygomatic, and other fossae, that the growth 
 is lost? Its relation to important structures, and the degree to which it 
 blends with them. Thus, any evidence of pressure on vessels and nerves, 
 trachea and pharynx, etc., should be carefully looked ior—e.g., weak- 
 ness of temporal pulse, engorgement of veins above, alteration of 
 pupil, numbness of upper limb, dyspnoea, or dysphagia. Does the 
 growth dip near or into the thorax? How far under the sterno-mas- 
 toid does it go ? Are the glands enlarged as well ? Is the skin in- 
 volved ? This last point, together with fixity, indistinctness of outline, 
 rapid growth, softness and fusion with surrounding parts, are of chief 
 importance, and, if coexisting to any extent, will usually put any 
 operation out of the question. 
 
 But even when the surgeon is doubtful, or more than doubtful, as 
 to the advisability of meddling with one of these growths, no one 
 would blame him for making an attempt under the following circum- 
 stances, even if it end in failure : 
 
 When the patient's life is rendered worthless by the present wretch- 
 edness and approaching dangers of the growth, especially if he be 
 young, as in the following vivid words of Mr. Butcher :* 
 
 " Though the boy did not suffer pain, yet his life was rendered very 
 miserable .... the weight ever tending to depress the head, occa- 
 sioning persistent fatigue and even pain in the muscles of the neck, 
 and so compelling the patient often to adopt the recumbent position, 
 the bulk thrusting up the head, embarrassing every movement, almost 
 preventing any change of position ; the pressure impeding respiration, 
 often obstructing it during sleep so as momentarily to threaten suffo- 
 cation, making the patient start from his bed in terror and alarm, 
 
 gorgement of the veins of the face is i-arely absent. In one case lie observed this venous 
 engorgement to be on the opposite side of the tumor only. This he attributed to the 
 fact that the tumor compressed the carotid artery as well as the jugular vein, as proved 
 by the weakness of the temporal pulse. 
 * Loc. supra cit., p. 871. 
 
REMOVAL OF GROWTHS IN THE KECK. 409 
 
 unrelenting or enforcing one attitude during sleep, with difficulty in 
 deglutition, except under extreme watchfulness in adopting position." 
 ^ So, too, in some cases of cancerous glands, associated with ei)ithe- 
 ]ioma,~e.g., on the tongue— the surgeon may justifiably perform an 
 extensive operation, such as Kocher's (p. 335), in the hope of removing 
 b6th the primary and secondary epithelioma, or after a successful 
 removal of the tongue operate on the infected glands widely and 
 deeply to give the patient another prolongation of life. In such cases 
 it should be the patient who urges operation after all the risks have 
 been placed before him. 
 
 Main Points in the Operation itself. 
 
 i. Free Exposure of the Growth.— The incisions should be 
 ■sufficient, the flaps turned back V, f, or X in shape. Thus, if the 
 growth be in the anterior triangle, not encroaching on the posterior, a 
 V-shaped flap ^vith the base upwards, one limb along the sterno-mas- 
 toid and the apex above the sternum, may be employed ; or one f in 
 shape, the long limb inside the above-mentioned muscle, and one at 
 right angles to it under the jaw. If the growth invade both triangles, 
 and if it will be necessary to divide the sterno-mastoid, an incision 
 obhquely across both triangles, and over the muscle, from mastoid pro- 
 cess to sternum, and then a second to make it conical, will be the best. 
 It is always to be remembered that inadequate exposure of the tumor 
 will lead to groping in the dark, bruising of the soft parts, and injury 
 to important structures. 
 
 ii. Deeper Dissection.— In this attention must be paid to — 
 
 (a) Working as miich as possible with a blunt dissector, a steel di- 
 rector, or the finger, using the scalpel and blunt-pointed scissors as 
 little as possible, and keeping them turned towards the growth. The 
 dissection should be begun, as a rule, where the growth is most free, 
 and where its relations are not important. 
 
 (/?) Tying with chromic gut or carbolized silk * every vessel before- 
 it is divided, not only to minimize the loss of blood, but also to avoid 
 the risk of air entering the veins, esi^ecially low down in the neck. 
 
 (y) Structures, hitherto thought too important, may be divided, if 
 really needful. Thus, not only the sterno-hyoid and omo-hyoid 
 should be divided, but the sterno-mastoid also. Of the structures in 
 the carotid sheath, the internal jugular is, as pointed out by Mr. 
 Holmes, the most likely to be implicated. It may be divided without 
 hesitation after it is secured with two catgut ligatures.f 
 
 In the autumn of 1877, while operating for Mr. Cooper Forster, I 
 
 * See the remarks on carbolized silk, p. 404. 
 
 t Mr. Barker [Lancet, 1886, vol. i. p. 194) records a case, probably a cystic sarcoma, 
 in which 1 J inch of this vein was involved in the growth and removed. The case did 
 well. 
 
410 OPERATIONS ON THE HEAD AND NECK. 
 
 tore through the internal jugular vein in removing some epithelioma- 
 tous glands : the haemorrhage was for a moment very profuse, but 
 yielded to sponge-pressure. Catgut ligatures were applied to the two 
 halves of the vein, and the patient recovered. In a similar operation 
 the lingual vein was separated so close to the internal jugular as td 
 leave little more than a rounded opening. In preference to tying the 
 vein above and below I left a pair of Spencer Wells's forceps on for 
 three days. Recovery took place. The common carotid and even the 
 vagus have been divided, and without a fatal result. 
 
 M. Sabat* successfully extirpated a tumor extending from the 
 mastoid process to the clavicle, and lying altogether beneath the 
 sterno-mastoid, which was divided in order to expose it. The carotid 
 and internal jugular had to be tied, and the pneumogastric nerve was 
 divided. 
 
 In a case of Dr. Gibson (Amer. Jour. Med. Sci., vol. xiii. p. 305), a 
 tumor was successfully removed after the carotid and internal jugular 
 had been tied and divided.f The descendens noni was cut, but the 
 vagus was dissected out of the mass. The patient recovered from the 
 operation, but the growth recurred, though it was enveloped in a very 
 firm and distinct capsule. 
 
 In a deep dissection the presence of some other structures must be 
 remembered.! 
 
 Mr. Godlee (Clin. Soc. Trans., vol. xix. p. 321) showed a child in whom, 
 during the removal of a deep-seated growth, the nature of which was 
 doubtful and which was pressing upon the jiharynx, the cervical sym- 
 pathetic had been wounded. The only results were, that the pupil on 
 that side was smaller but not stationary, and that the ocular slit was 
 also smaller. 
 
 Mr. Barker, in the case of cystic sarcoma to which reference has been 
 already made, removed part of the scalenus anticus to which the 
 growth was adherent. The phrenic was not interfered with. 
 
 In 1870 I saw the thoracic duct opened in an operation for the re- 
 moval of enlarged glands on the left side. Chyle escaped deep down 
 in the wound, and the case soon ended fatally. 
 
 (S) If possible, the growth capsule, which is often soft and delicate, 
 
 * This and the next case are given by Mr. Holmes {loc. supra cit, p. 887). 
 
 t Mr. Jessett {Brit. Med. Journ., 1886, vol. ii. p. 713) mentions it case in which he 
 divided the common carotid and internal jugular vein in removing epitheliomatous 
 glands from the neck. The man recovered, and lived in comparative comfort for nine 
 months, death taking place from a local recurrence. 
 
 t In the posterior triangle growths springing from the lower vertebra; or the first rib 
 may involve the cords of the brachial plexus, causing much pain and requiring very 
 tedious dissection for their removal. See a case brought before the Medico-Chirurgical 
 Society, January 12, 1886, by Dr. Bruce and Mr. Bellamy. 
 
CESOPHAGOTOMY. 411 
 
 must not be ruptured. On examining the growth after removal, the 
 capsule should not only be entire, but any process should be blunt and 
 rounded, not soft and ragged, as if torn away from parts left behind. 
 
 If the surgeon feel doubtful as to any portion being left, as in the 
 fossae, about the base of the skull, he should use a sharp spoon and 
 Paquelin's cautery, or pack in lint with a paste of equal parts of zinc 
 chloride and flour. 
 
 (e) Throughout the operations, which may necessarily be prolonged 
 and attended with loss of blood, and in which important parts may 
 be disturbed and pulled upon, the surgeon should keep himself in- 
 formed as to the effects of the anaesthetic. 
 
 iii. Closure of the Wound and Application of Dressings. 
 — After completely removing the growth and any outlying glands, drain- 
 age is provided from the extremities of the resulting cavities, and in ac- 
 cordance with the position which the patient will occupy. Tubes of 
 sufficient size being in position, the wound is brought together with 
 wire or carbolized silk, or wire and horsehair sutures ; dressings of sal 
 alembroth or iodoform gauze are then adjusted, pressure being ap- 
 plied, wherever discharge might collect, with asejDtic pads or sponges. 
 Firm, even bandaging is then made use of to distribute the discharge 
 equally throughout the dressings and to keep the parts at rest. Owing 
 to the mobility of the neck, and the impossibility of applying firm 
 pressure over the trachea, it is alwaj^s well to carry the bandages, 
 below, across the axillae, and, above, on to the face and forehead, and to 
 have them stitched in several places. Unless it is absolutely indicated, 
 the wounds should not be looked at for five or six days. 
 
 CHAPTER XV. 
 
 OPERATIONS ON THE (ESOPHAGUS. 
 
 CESOPHAGOTOMY. (ESOPHAGOSTOMY. 
 (E 3 OPHAGECTOM Y. 
 
 CESOPHAGOTOMY. 
 
 Indications.— This is required for such foreign bodies as have 
 resisted careful, justifiable attempts at extraction, bodies which are 
 certain, if left, to lead to grave results— e.g'., hemorrhage, sloughing, 
 deep cervical suppuration, etc. 
 
 Amongst such bodies are — 
 
 Tooth-plates ; bones ; pins swallowed in soft food ; coins. 
 
 It will be wise to proceed to an early operation, and thus avoid the 
 
412 OPERATIONS ON THE HEAD AND NECK. 
 
 risks of a fatal result from those conditions given at p. 416. In making 
 up his mind to submit his patient to an operation, the surgeon must 
 weigh the size and character of the body, the time it has been swal- 
 lowed, the urgency of the symptoms— e.c/., dysphagia, dyspnoea from 
 pressure on the larynx, emphysema,* oedema, etc., and whether the 
 attempts already made at extraction are all that are justifiable, and 
 whether the instruments at hand have been appropriate. 
 
 Operation.— The head being somewhat extended and turned to 
 the right t side, the neck shaved (if needful), the surgeon makes 
 an incision 3 inches long from just above the thyroid cartilage to 
 within \ inch of the sterno-clavicular joint,J a little in front of the 
 anterior border of the sterno-mastoid. Skin and fascia being divided,§ 
 the cellular tissue in front of the above-mentioned muscle is opened 
 up with a director, and the pulsation of the artery and the bodies of 
 the cervical vertebras, fifth and sixth, felt for. The omo-hyoid may be 
 drawn down, but it is best to divide this muscle between chromic-gut 
 ligatures, and, if it be needful to seek for the body low down in the 
 neck, the sterno-hyoids and sterno-thyroids also. The sterno-mastoid 
 and lar^e vessels are now drawn outwards, and the trachea || inwards, 
 with retractors, the thyroid gland probably showing plainer on the 
 inner side, and the internal jugular, if dilated, on the outer. The 
 presence of the inferior thyroid behind the carotid sheath, and that of 
 the recurrent laryngeal running up in the groove between the trachea 
 and oesophagus, must be remembered. Throughout these steps of the 
 operation the bleeding must be most carefully arrested, and the deeper 
 part of the wound, with the important structures around it, kept 
 quite dry. 
 
 * In a case where emphysema already exists with an impacted foreign body, it will 
 be wiser to open the oesophagus at once, and not make attempts at extraction. Dr. 
 Church (8t, Barthol. Hasp. Reports, vol. xix. p. 55) gives a case in which swelling of the 
 neck began three hours after the tooth-plate had been swallowed. The next day, after 
 several attempts with a horsehair probang, the plate, which lay midway between the 
 larynx and the sternum, was brought up into the reach of forceps and -extracted by Mr. 
 Savory. Death took place two days later, there being perforation of the end of the 
 pharynx, with suppuration in the neck, mediastina, and left pleura. 
 
 f The left side is preferable, as the oesophagus lies more to this side, and as opera- 
 ting on the left side allows of freer movement of the right hand, while the left is at 
 liberty to move the larynx, etc. 
 
 I If the neck is very stout, or if the parts are swollen, etc., the incision may be from 
 just below the angle of the jaw to close to the sternum. 
 
 § The anterior jugular vein may give trouble, and should be drawn aside, or divided 
 between two catgut ligatures. 
 
 II The larynx should not only be drawn to the right, but tilted over to this side also, 
 as this brings up the oesophagus. 
 
CESOPHAGOTOMY. 41 3 
 
 If the foreign body cannot be felt* projecting in the oesophagus— 
 e.g., behind the cricoid— the mouth should be opened with a gag, and 
 a bougie or probang passed as the flaccid tube-walls are naturally in 
 contact. When the oesophagus lies unusually deep, following round 
 the thyroid or cricoid cartilage with the finger will find it. 
 
 When the site of the foreign body has been made out, or when, 
 failing this, it is decided to open the oesophagus low down and to pass 
 probes, etc., the oesophagus must be opened with a clean cut, as far 
 back as possible, so as to avoid the recurrent laryngeal filaments.f 
 
 When the tube has been opened, and any bleeding from its walls 
 arrested, the opening is dilated by dressing forceps, by a probe-pointed 
 bistoury, or by curved forceps passed from the mouth and expanded 
 in the wound- Even after a free opening has been made it may be 
 impossible to dislodge the body, if this, a tooth-plate, has projecting 
 clips, or if it is tightly embraced by the contraction of the oesophageal 
 fibres. In such a case the body should be (if a tooth-plate) divided 
 with bone-forceps and removed in two portions, care being taken to 
 keep hold of each portion with forceps (Lawson, Clm. Soc. Trans., 
 xviii. 292). 
 
 If, after exposing the oesophagus, the body cannot be felt, which 
 will rarely happen, metallic probes or soft bougies should be passed 
 through the wound in the oesophagus, and the lower cervical, and the 
 upper thoracic, portions of this tube carefully explored. The ques- 
 tion may now be considered : How far down from the cesophagus can 
 a body be extracted ? The most accessible part is no doubt its junc- 
 tion with the pharynx, opposite to the cricoid cartilage, and the first 
 two inches below this point. Mr. Cock {loc. supra cit.) writes : " It 
 might even be possible to extract a foreign body from the early tho- 
 racic portion, provided it could be reached with the finger, and thus 
 brought under the influence of a pair of curved forceps. "J 
 
 * It rau.st always be remembered (hat the precise site of the foreign body is not 
 always marked by any external swelling or resistance, nor by accurately referred pain ; 
 furthermore, bougies occasionally give very slight indications of the presence of bodies 
 (even rongh ones) in the oesophagus or pharynx. 
 
 t Mr. Cock {Guy's Hasp. Reports, 1868, p. 3) draws attention to this point. Both his 
 patients were in the habit of singing; in the first (Tbid., 1858, p. 229) ca.se a fine tenor 
 voice was replaced by a bass; in the second, in which the oesophagus was opened 
 farther back, the voice did not suffer. 
 
 X The proximity of important parts to the thoracic portion of the oesophagus is well 
 known. Thus, in Path. Soc. Trans., vol xix. p. 219, is recorded the case of a man who 
 swallowed a bone which lodged in the cesophagus opposite to the arch of the aorta. 
 Death took place suddenly on the fifth day from perforation of the aorta and haemor- 
 rhage, after a slight exertion. Mr. Eve {Clin. Soc. Trans., vol. xiii. p. 174) gives a 
 case in which a fish-bone, impacted in the cesophagus, wounded the heart fatally. It 
 was thought that the position of the fish-bone was perhaps due to previous use of the 
 probang. 
 
414 OPERATIONS OS THE HEAD AND NECK. 
 
 As far as my knowledge goes, the lowest point from which a foreign 
 body has been removed occurred in the practice of Mr. Bennet May. 
 Here a child, aged seven, had swallowed a halfpenny three and a half 
 years before. The coin had ulcerated through the oesophagus and 
 opened the right bronchus, lying partly in this and partly in the 
 oesophagus. It was removed successfully by oesophagotomy. When 
 the foreign body has been removed, the question of introducing 
 sutures into the oesophagus will arise. These should only be used 
 when the wound in the gullet is clean cut, not bruised, and when the 
 body has been quickly removed ; the sutures should be of fine chromic 
 gut and only the upper part of the wound in the oesophagus should be 
 closed, the rest being left open to the bottom to allow of free drainage, 
 owing to the danger of sloughing, pent-up foul secretions, and blood- 
 poisoning (p. 416).* A drainage-tube should be inserted to the bottom 
 of the wound, iodoform dusted on, a few sutures placed in the edges 
 of the wound, dry dressings applied — viz., iodoform gauze, salicylic 
 wool, etc., if the wound has not been much probed about, and there 
 is thus good reason to expect early union. But if ulceration of the 
 soft parts has been found, if they are inflamed, emphysematous, etc, 
 the wound should be left open to the very bottom, and lint soaked in 
 saturated boracic-acid solution applied and frequently wetted. 
 
 After-treatment.^ — If the patient is in good condition, if the for- 
 eign body has been removed earlj^ or if the patient has been able to 
 swallow liquids in the interval between the accident and the operation, 
 he may be fed for the first few days by nutrient enemata and nutrient 
 suppositories,t and only a little ice given occasionally by the mouth. 
 But if the strength is not satisfactory at the time of the operation, or 
 
 * If there is any doubt sutures liad far best be dispensed with. Dr. Barton {Ann. 
 of Surg., July, 1887) has recorded the case of successful oesophagotomy in a little child 
 — the age does not appear to be given. The foreign body, a small steel roller of a 
 sewing-machine, had been swallowed three months before. This was extracted through 
 a very small opening in the oesophagus " after the manner of working a stud through 
 a button-hole which is too small for it," from the fear of causing a fistula if the opening 
 was enlarged. The wounds in the oesophagus and superjacent parts were separately 
 sutured. Epileptic fits soon followed, and frequent vomiting tore open the wound. 
 The fits having ceased with the administration of potassium bromide, the wound in 
 the oesophagus was pared and sutures re-applied as before. This limited much the 
 escape of fluids through the wound, but did not entirely stop it. The passage of a 
 tube through the mouth twice a day caused so much irritation that it was abandoned, 
 and the tube passed through the wound. The wound healed slowly though surely. 
 Dr. Barton is inclined to recommend this way of feeding when primary union is not 
 secured. 
 
 f ( )f these, the zyminized meat suppositories of Burroughs & Wellcome are amongst 
 the best. 
 
CESOPHAGOTOMY. 415 
 
 if the enemata are not retained, a soft feeding tube must be made use 
 of This should be passed by the mouth and retained, if not very 
 uncomfortable to the patient, or passed at intervals * Towards the 
 end of the first week, perhaps earlier, if the wound is healing well, 
 the patient may be allowed to swallow a little diluted wine or milk. 
 Chief Difficulties. 
 
 1. A fat, short neck. 
 
 2. Enlarged veins. 
 
 3. Wide depressors of hyoid bone. 
 
 4. Enlarged thyroid gland. 
 
 5. Unusual depth of oesophagus. 
 
 6. Detecting the site of the foreign body. 
 
 7. Firm gripping of the body by the cesophagus. 
 
 8. The fact that the foreign body may be dislodged during the oper- 
 ation. Dr. Lediard (Clin. tSoc. Trcuis., vol. xviii. p. 297) records the 
 case of a man in whom emetics and several attempts at removal had 
 failed to dislodge a tooth-plate ; emphysema of the neck was present, 
 and some blood on the forceps used. Just before oesophagotomy, a 
 bougie was thought to " scrape " as it was withdrawn. Nothing being 
 felt when the oesophagus wa^s exposed, a bougie was passed, and the 
 ossophagus incised behind the cricoid cartilage ; the finger now could 
 feel nothing, and a bougie passed on seemed to feel the plate near the 
 stomach. The plate was passed 19 days after its impaction ; it meas- 
 ured I2 inch by i inch, carried one incisor, and had '' numerous sharj) 
 points, and a formidable looking hook at one end." Though there 
 were no laryngeal symptoms, the plate must have been lying behind 
 the lower end of the larynx, as the mucous membrane of the gullet 
 showed here several ecchymoses. The dislodgment of the plate took 
 place either during the passage of the bougie or iii the administration 
 of the anaesthetic. The patient made a good recovery. 
 
 Causes of Death. — These are chiefly : 
 
 * Dr. Markoe (Ann. of Surg., September, 1886), in the case of a man, aged twenty, 
 four, in wliom he removed, by cesophagotomy, half a tooth-plate, which had been 
 broken in eating, passed a soft india-rubber tube into the stomach through the wound, 
 replacing this by one passed through the nose on the tenth day, and allowing the 
 patient to swallow on the seventeenth day after the operation. The following are the 
 reasons given for passing the tube through the wound : (1) It ensures good drainage 
 from the bottom of the wound ; (2) Anything regurgitated from the stomach passes 
 through the tube, not up into the wound ; (3) It is less unpleasant. The above reasons 
 do not seem to me to outweigh the great risks and disadvantages of irritating and 
 keeping open the wound, which it is desirable to have closed as soon as possible. As 
 a rule, the tube should certainly be passed from the mouth or nose. It is noteworthy 
 that in the above case the prolonged lodgment of the foreign body— six to seven weeks 
 elapsing between the accident and the operation — had not caused any serious abra- 
 sion, etc. 
 
416 OPERATIONS ON THE HEAD AND NECK. 
 
 1. Septicffimia* The wound having hecome emphysematous, 
 sloughy, and the discharge most foul. 
 
 2. Exhaustion. When the body has been long impacted, and the 
 patient's health has run down before the operation. 
 
 (ESOPHAGOSTOMY. 
 
 This has been proposed as a substitute for gastrostomy. Mr. Reeves, 
 who brought this subject before the Clinical Society ,t recommended 
 this operation as less dangerous than gastrostomy, and in the belief 
 also that cancer of the oesophagus is most frequently met with in the 
 upper part of the tube. J The objections, however, are so great as to 
 have prevented any adoption of this operation. They are — (1) the 
 risk of coming close to a mass of cancer, which will not only not admit 
 of dilatation, but which will be rendered more active, sloughy, etc., by 
 the necessary irritation. (2) The fact that important parts are close 
 by, and that the relations of these may very likely be much altered. 
 (3) The probability of finding the oesophagus altered near the disease, 
 and thus, perhaps, readily perforated, admitting fluids into the 
 pleura, etc. 
 
 CESOPHAGE0T.OMY. 
 
 This is another operation which has been introduced only to be 
 abandoned. Prof. Czerny's case, it is true, was temporarily successful, 
 the patient living rather more than a year after the operation. But 
 cases equally suitable from the site of the disease — only just out of 
 reach of the finger introduced from the mouth — with no glands in- 
 volved, and no adhesions to adjacent parts, though symptoms had 
 lasted five months, must be quite exceptional. Several of the risks 
 given above would be intensified here, and there would be present as 
 well the need of keeping the fistula patent.§ 
 
 * Mr. Butlin (Clin. Soc. Trans , vol. xvii. p. 129) relates a case in which a tooth-plate 
 was removed within twenty-four hours of its being swallowed, previous attempts at 
 removal, lasting thirty or forty-five minutes, having failed. No difficulty was experi- 
 enced during the operation, but the patient sunk from septicaemia four days after the 
 operation. He was allowed to swallow on the second day, about a third of what was 
 taken coming through the wound. Mr. Bntlin considered this beneficial, as conducing 
 to drainage. The wound was thoroughly washed with carbolic lotion and covered with 
 carbolic oil. Two days after, the wound being very offensive, the dressing was altered 
 to vSanitas, changed every four hours. 
 
 t Trans., vol. xv. p. 26. 
 
 X Most surgeons who have been called upon to pass bougies in these cases will agree 
 with Dr. Goodhart, who, in the discussion on the above paper, said the disease usually 
 extended from the cricoid cartilage nearly to the pylorus. 
 
 § Mr. Butlin ' Oper. Surg. Malig. Din.), to whom I am indebted for Prof. Czerny's 
 case, gives one of Prof. Billroth's, where death was caused by the passage of the 
 bougie into the tissues round the cesophagus, the opening where the lower end of the 
 oesophagus had been stitched to the skin having contracted. 
 
OPERATIONS ON THE SPINAL ACOESSOKY. 417 
 
 CHAPTER XVI. 
 
 OPERATIONS ON THE SPINAL ACCESSORY 
 NERVE. 
 
 DIVISION OR NERVE-STRETCHING. 
 
 Indications. — In cases of spasmodic torticollis in wiiich 
 
 1. All previous palliative treatment has failed — e.g., large doses of 
 conium, massage, galvanism of the affected side and faradization of 
 the opposite muscles. 
 
 2. The spasms are so severe and constant as to interfere with the 
 patients taking food or enjoying sleep, and to cause sad weariness and 
 real suffering. 
 
 3. The only muscles affected are the sterno-mastoid, or the sterno- 
 mastoid and trapezius. 
 
 Anatomy of Spinal Accessory Nerve.— The spinal or external 
 part of this nerve, having left the skull by the jugular foramen, is 
 directed backwards in front of, or behind, the internal jugular vein, 
 and appears below the digastric and the occipital artery. It then 
 descends obliquely outwards to the sterno-mastoid muscle and dis- 
 appears under this at a distance of 2 inches from the apex of the mas- 
 toid process. Having usually perforated the muscle the nerve passes 
 across the posterior triangle to end in the deep surface of the trapezius. 
 
 While passing through or under the sterno-mastoid the nerve joins 
 with branches from the second cervical. Having emerged from the 
 muscle it joins with the second and third nerve, and is often in inti- 
 mate connection with the great auricular and small occipital. When 
 under the trapezius it is joined by branches of the third and fourth 
 cervical. 
 
 Operations for Division or Stretching of the Nerve.— 
 
 These may be considered together, but it may be said, once for all, that 
 as stretching will be followed by but temporary benefit, division of the 
 nerve will be the better operation. 
 
 The nerve may be found for these purposes by two different 
 incisions. 
 
 A. By one made along the anterior border of the sterno-mastoid 
 so as to come upon this nerve before it perforates this muscle. 
 
 B. By one along the posterior border of the muscle, the surgeon 
 finding the nerve as it emerges here to cross the posterior triangle to 
 gain the trapezius, and following it up into the sterno-mastoid, so as 
 to paralyze this muscle also. 
 
 The first of these operations is in my opinion much preferable, and 
 for these reasons : 
 1. Though the nerve lies more deeply at the anterior than at the- 
 
 27 
 
418 OPERATIONS ON THE HEAD AND NECK. 
 
 posterior border of the muscle, it is here a single nerve, and not likely 
 to be confounded with other nerves— e.gr., branches of the third cervical, 
 which also emerge at the posterior border to supply the skin. Fur- 
 thermore, in this latter position, the spinal accessory is often found in 
 close connection with the small occipital and great auricular, as these 
 two nerves appear at the posterior border and curve upwards. 
 
 2. By finding the nerve at the anterior border of the muscle paral- 
 ysis of the sterno-mastoid is better ensured. When the nerve is found 
 at the posterior border and followed up into the muscle before division, 
 there is always a certain amount of uncertainty as to whether some 
 branch to the muscle may not have come off above the point at which 
 the surgeon has divided the nerve. 
 
 A. Operation above Sterno-mastoid. — The parts being shaved 
 and cleansed, and the head suitably raised and turned to the opposite 
 side, the surgeon makes an incision along the anterior border of the 
 sterno-mastoid for 3 inches, commencing at the apex of the mastoid 
 process. Skin, fasciae, and platysma being divided, the anterior border 
 of the sterno-mastoid is clearly defined and drawn strongly backwards, 
 so as to put the nerve on the stretch ; the wound being sponged out 
 dry, the nerve is found, and from 1 to i inch removed. 
 
 If there is any doubt about finding or identifying the nerve, the 
 following aids may be found useful — viz., defining the lower border 
 of the digastric and the occipital artery, remembering the direction of 
 the nerve, and looking for it at a point 2 inches below the apex of the 
 mastoid process.* 
 
 B. Operation Below or at Posterior Border of Sterno- 
 mastoid. — Mr. Campbell de Morgan, who introduced this operation 
 into British surgery with a very successful case,t made an incision 2 
 inches long, along the posterior border of the sterno-mastoid, the 
 centre of the incision corresponding to about the centre of this border 
 of the muscle. The fascia being slit up to the same extent the trape- 
 zial branch of the nerve was sought for as it emerges from the sterno- 
 mastoid to cross the posterior triangle. It will be found generally a 
 little above the centre of the wound, when found it is traced through 
 the muscle till the common trunk is discovered above its division into 
 branches for the trapezius and sterno-mastoid. Half an inch of the 
 nerve is then cut out. 
 
 If called upon to perform this operation again, I should certainly 
 prefer the first of the two methods given above, as being more certain, 
 
 * Ballance, loc. infra cit. 
 
 t Brit, and For. Med.-Chir. Rev., July, 1886. I performed the same operation on a 
 middle-aged woman about eleven years ago at Guy's Hospital in a very severe case of 
 spasmodic torticollis. The right sterno-mastoid and trapezius were paralyzed and 
 rendered quiescent, but some of the deeper muscles on the opposite side— viz., the 
 splenii — became affected, and no permanent benefit resulted. 
 
IJGATUEE OF TEMPORAL AETEKY. 419 
 
 and as not really more difficult. Though the nerve is more superficial 
 in the posterior triangle it is difficult to make certain whether it is the 
 spinal accessory or one of the superficial cervical nerves which emerge 
 close to it, from behind the muscle (p. 417). 
 
 The most interesting contribution to the literature on this subject 
 is a paper by Mr. Ballance.* His patient, a woman of forty-eight, 
 was a good instance of the distress and misery due to spasmodic tor- 
 ticollis. Division of the right spinal accessory in the anterior triangle 
 gave most decided relief At the end of four months, when the history 
 ceases, the patient is reported to have been " much better and stouter. 
 The face is happy and tranquil. There is neither headache nor pain, 
 and sleep and appetite are good. The control of the movements of 
 the head is perfect as long as she is not excited, and so long as the 
 head is not raised so that the eyes are directed much above the hori- 
 zontal plane in which they lie The right sterno-mastoid and 
 
 trapezius are atrophied." 
 
 Division of the spinal accessory deserves a further trial, even if the 
 relief given is not permanent. 
 
 The chief fear is that other muscles will become involved. Thus, 
 Mr. Ballance writes of his case : " Since the operation, it has been cer- 
 tain that some of the muscles supplied by the upper spinal nerves 
 are liable to spasm. It would be strange if it were not so, considering 
 the intimate connections between the second, third, and fourth spinal 
 nerves, and the spinal accessory in the sterno-mastoid, trapezius, and 
 posterior triangle, together with the fact that some of the fibres of the 
 spinal accessory are connected with the same cells, or with cells in 
 the immediate neighborhood of those from which arise the motor 
 rootlets of the cervical spinal nerves." 
 
 CHAPTER XVII. 
 
 LIGATURE OP THE ARTERIES OP THE HEAD AND 
 
 NECK. 
 
 LIGATURE OF THE TEMPORAL ARTERY (Fig. 89).t 
 
 Indications. — These are very few, viz. : 
 
 1. Wounds — e.g., stabs and gunshot injuries. 
 
 2. Aneurism, usually traumatic. Mr. Skey J met with a case of 
 
 * St. Thomas's Hasp. Reports, vol. xiv. p. 95. Other successful cases will be found 
 recorded by Prof. Annandale {Lancet, 1879, vol. i. p. 555), Mr. Southam (Ibid., 1881, 
 vol. ii. p. 369) ; Mr. Rivington also operated (Ibid., 1879, vol. i. p. 213), but phleg- 
 monous erysipelas carried off the patient before the wound was quite healed. 
 
 t Ligature of the thyroid arteries has already been considered, chap. siii. p. 400. 
 
 t Oper. Surg., p. 289. 
 
420 OPERATIONS ON THE HEAD AND NECK. 
 
 aneurism of doubtful origin in this artery in a young lady. Ligature 
 of the vessel below having failed, he cured his patient by the means of 
 a fine spring compress with a ball-and-socket joint which, passing over 
 the head, entirely concealed by the hair, made pressure on the tumor. 
 
 Aneurisms have been known to occur here after the operation of 
 arteriotomy. 
 
 Guide. — A line drawn upwards over the root of the zygoma, mid- 
 way between the condyle of the jaw and the tragus. 
 
 Relations. — Given off behind the jaw, this vessel passes up midway 
 between the above two points over the z^'goma, and at a point IJ or 2 
 inches higher up it divides into its anterior and posterior branches. 
 Lying at first in the parotid gland it is covered a little higher up by 
 a dense fascia passing from the parotid to the ear, by the attrahens 
 aurem, often a lymphatic gland, and one or two veins which lie super- 
 ficial but close to it. Some branches of the facial nerve cross it, while 
 the auriculo-temporal nerve accompanies it closely. Higher up the 
 artery and its branches are particularly subcutaneous. 
 
 Operation (Fig. 89). — The parts being shaved and cleansed, the 
 head fitly supported and turned to the opjjosite side, an incision 
 about 1 inch long is made in the line of the artery so as to tie it just 
 above the zygoma. The dense subcutaneous tissue and the strong 
 parotid fascia being cleanly divided the artery must be accurately 
 defined, and the vein being drawn to one side, usually backwards, the 
 ligature should be passed from behind forwards, care being taken to 
 include only the artery. 
 
 Arteriotomy. — A few words may be said here about this seldom- 
 used o23eration. The surgeon, having defined the anterior division of 
 the temporal, steadies the vessel by placing his finger just bej'ond the 
 point which he intends to open, and then with a small sharp scalpel 
 lays open the vessel till it is about half cut through. The blood 
 required having been removed, he divides the vessel completely, so as 
 to allow the ends to retract, applies a pad of aseptic gauze or of lint 
 and iodoform, and retains this in position with the twisted or knotted 
 bandage for the head. The pad should not be removed for four or 
 five days. 
 
 The reasons for preferring the anterior division to the trunk of the 
 vessel are the following : 
 
 (1) The latter lies much more deeply, under fasciae, and in the 
 parotid below ; thus so much pressure may be required to stop the 
 bleeding as to cause sloughing, secondary hoemorrhage, and dangerous 
 erysipelatous inflammation. 
 
 (2) Injury to one of the adjacent nerves may cause severe pain and 
 tedious healing. 
 
 (3) From opening a vein at the same time an anterio-venous aneu- 
 rism may result. 
 
LIGATUEB OF FACIAL AND OCCIPITAL ARTERIES. 421 
 
 LIGATURE OP THE FACIAL ARTERY (Fig. 89). 
 
 Indications. — These are much the same, but still fewer than those 
 for ligature of the temporal artery.* 
 
 The vessel's course is divided into a cervical and a facial part. 
 
 Cervical Part. — Ligature here can be scarcely ever required. 
 The vessel could be reached here by an incision similar to that for 
 the external carotid (hifra), or the lingual (p. 424). In either of 
 these cases the vessel would be found just below the posterior belly of 
 the digastric and the stylo-hyoid, these muscles being drawn upwards 
 to enable the surgeon to tie the vessel just before it enters the sub- 
 maxillary gland. 
 
 Relations in the Neck. — The facial artery is given off just above 
 or in connection with the lingual, about an inch above the bifurcation 
 of the common carotid. It ascends upwards and inwards to the lower 
 jaw, being covered by skin, fascife, and platysma, the digastric and 
 stylo-hyoid, and being embedded in the sub-maxillary gland, to which 
 structure the vein lies superficial. The tortuous outline of the vessel 
 is well known. The vein, running a straighter course, lies posterior 
 to the artery. 
 
 Facial Portion. — The artery is readily secured by an incision 
 about 1 inch long just in front of the masseter muscle, the anterior 
 border of which should be first defined, this being easily done on the 
 living subject by telling the patient to throw it into action. The inci- 
 sion should be made carefully so as to allow of any branches of the 
 facial nerve which may lie in the way. The artery will now be felt 
 when rolled upon the bone by a finger ; the ligature should be passed 
 from behind forwards so as to avoid the adjacent vein. 
 
 If there is any especial object for avoiding the small scar which this 
 operation entails, the vessel may be reached by a horizontal incision 
 just below the jaw in front of the masseter muscle ; a method which 
 also places the incision parallel to the branches of the facial nerve. 
 
 LIGATURE OF OCCIPITAL ARTERY (Fig. 89). 
 
 Indications. 
 
 1. Stabs. 
 
 2. Gunshot wounds. In the Medical and Surgical History of the War 
 of the Rebellion, part i. p. 422, two cases are given of secondary haemor- 
 rhage after wounds of the neck, in the one case from the occipital, in 
 the other from a branch of it ; in the former case 16 ounces of blood 
 
 * The reader is advised to take every opportunity afforded upon the dead body to 
 tie these and other arteries, though apparently so small and unimportant, as only by 
 such practice can dexterity be really acquired. 
 
422 OPERATIONS ON THE HEAD AND NECK. 
 
 were lost. The vessel was tied in the wound in each case, two liga- 
 tures being, of course, applied. 
 
 3. In the treatment of arterial varix, cirsoid aneurism, or aneurism 
 by anastomosis on the head (p. 448). 
 
 4. For haemorrhage from an abscess in the neck. Mr. Banks* has 
 published a most instructive case of this kind. A weakly man, aged 
 thirty-two, had had a suppurating gland incised three weeks before 
 admission. Poultices were applied, and, a week after, during a violent 
 attack of coughing, blood burst from the wound " like a tap being , 
 turned on." Three times afterwards haemorrhage ensued, pressure 
 being applied in vain. On admission he was in the last stage of 
 exhaustion. The right side of the neck from ear to clavicle was occu- 
 pied by a great fluctuating swelling. In front of the sterno-mastoid, 
 about half-way down, was the original incision, from which a little 
 sanious discharge was issuing. Behind the muscle a piece of skin 
 about an inch square was actually sloughing from the subjacent pres- 
 sure. Under ether, and in a good light, the original incision was en- 
 larged upwards and downwards, and a quantity of putrid broken- 
 down clot turned out. Then a similar incision was made behind the 
 sterno-mastoid through the sloughing skin. Everything being 
 mopped and cleaned up, blood was found to be trickling down from 
 somewhere very high up. To get at it, the sterno-mastoid and skin 
 over it were cut clean across, thus uniting the two vertical incisions 
 by a transverse one. The muscle was dissected upwards, exposing 
 the sheath of the carotid vessels, but still the blood always kept run- 
 ning from some deep-seated point high up. At last this was reached, 
 just in front of the transverse process of the atlas. From it arterial 
 blood issued, and an aneurism needle was thrust through the tissues 
 on each side of it and ligatures applied, which at once checked all 
 further bleeding. The vessel was the occipital artery not far from its 
 origin. Into it the abscess had made its way. The great wound was 
 rapidly swabbed out with turpentine and then stuffed with lint dipped 
 in the same fluid. The patient was very near to death's door, but 
 ultimately recovered. f 
 
 * Clinical Notes upon Two Years' Surgical Work at The Liverpool Royal Infirmary, p. 
 161. 
 
 t Such was the patient's condition that the surgeon was quite prepared for his dying 
 under the operation. The following characteristically vigorous words conclude the 
 account — "But I was determined, as long as he had any blood to run out of him, the 
 place whence it came should be found and tied." In connection with this case maybe 
 quoted, in his own words, some remarks of Mr. Banks on the value of turpentine as a 
 cleansing styptic. This remedy has again lately been recommended, and it is only fair 
 that Mr. Banks should have the credit of having recognized its value six years ago- 
 "In former days it was the regular thing for oozing, until superseded by the introduo- 
 
LIGATUEE OF OCCIPITAL AETEEY. 423 
 
 Relations.— A posterior branch of the external carotid, the occip- 
 ital comes off opposite to or a little above the facial, just below the 
 digastric. It at first ascends, having the ninth nerve hooking round 
 it, under cover of the digastric, stylo-hyoid and parotid, and crossing 
 the internal carotid, internal jugular, vagus, and spinal accessory. 
 Having reached the interval between the transverse process of the 
 atlas and the mastoid bone, it now, in the second part of its course, 
 turns horizontally backwards, grooving the temporal bone, covered by 
 the sterno-mastoid, splenius, digastric and trachelo-mastoid,and lying 
 on the complexus and superior oblique. In the third part of its 
 course it runs vertically upwards, piercing the trapezius, and ascend- 
 ing tortuously in the scalp. 
 
 Operation. 
 
 1. If the artery require securing low down, this may be effected 
 much as in tying the external carotid, an incision being made along 
 the anterior border of the sterno-mastoid, the deep fascia opened, and 
 the digastric and ninth nerve exposed. Care should, of course, be 
 taken to avoid the latter. 
 
 2. To tie the artery behind the mastoid process (Fig. 89), e.g., when 
 it has been wounded by a stab in the neck, the following steps should 
 be taken: The parts being shaved, and the head at first being placed 
 in much the same position as for ligature of the carotids, an incision 
 is made from the tip of the mastoid process rather obliquely upwards, 
 so as to lie over a point midway between the mastoid and external 
 occipital protuberance. The tough skin and fascise being incised, the 
 posterior half of the sterno-mastoid, with its strong aponeurosis, and 
 next the splenius capitis, must be divided, together with any fibres of 
 
 tion of perchloride of iron. This has always seemed to me most unfortunate, as iron 
 is the very worst of all styptics. Owing to its great potency and the rapidity with which it 
 acts, it soon became popular, and is at the present moment the favorite standby of the 
 chemist, who diligently swabs with it every cut that is brought into his shop, prepara- 
 tory to sending the patient off to a hospital. As a result, the wound is covered with a 
 cake of coagulated blood, and its surfaces are sometimes positively killed by the 
 strength of the application. Beneath this firmly adherent crust all sorts of purulent, 
 filthy secretions accumulate, till at the end of forty -eight hours it stinks abominably, 
 and requires to be well poulticed to get it clean. Should bleeding recur, the difficulty 
 of finding the spot is enormously increased by the mass of pus and almost cineritious 
 hard clots which cover it. I have seen so many cut hands almost ruined by it that I 
 have totally abandoned it. On the other hand, turpentine is nearly as powerful a 
 styptic, and is a most marvellous cleanser and sweetener. The plug soaked in turpen- 
 tine comes out quite easily at the end of four-and-twenty hours, leaving a wholesome 
 surface behind it. For all wounds about the perinaeum, such as lithotomy wounds, 
 fistula, cuts, or incisions for extravasation of urine, there is nothing like it, and I trust 
 it will soon be reinstated in surgical favor. Our forefathers had some excellent reme- 
 dies, and this is one of them." 
 
424 OPERATIONS ON THE HEAD AND NECK. 
 
 the trachelomastoid that are in the way. The wound being some- 
 what relaxed by turning the head over to this side, retractors deeply 
 inserted, and a laryngeal mirror used if needful, the artery will be 
 found deep down between the mastoid bone and the transverse pro- 
 cess of the atlas. 
 
 In separating it from its vein, one or more veins varying in size may 
 be met with, forming communications between the occipital and mas- 
 toid veins, and thus with the lateral sinus. The importance, therefore, 
 of keeping the wound rigidly aseptic is obvious. 
 
 LIGATURE OF THE LINGUAL ARTERY (Fig. 86). 
 
 Indications. 
 
 1. Before removal of the tongue. This subject has been considered 
 at p. 333. 
 
 2. After removal of the tongue, to arrest haemorrhage. 
 
 3. In cases of tongue cancer not admitting of operation, in the hope 
 of checking the rate of growth, diminishing the fostor, profuse saliva- 
 tion, etc. This step is uncertain as to the amount of good which it 
 effects, and any good that it may do will not be long lived.* 
 
 4. In cases of macroglossia this operation may be tried before re- 
 moving a wedge-shaped piece* of the tongue : it would require to be 
 performed on both sides, and would be attended with considerable 
 difficulty in a child. 
 
 Kelations. — The lingual artery arises about ]- inch above the supe- 
 rior thyroid, often in common with the facial, and at a point opposite 
 to the great cornu of the hyoid bone. It first ascends to a point 
 rather above the level of the hyoid bone, then descends somewhat and 
 
 * Mr. Haward {Clin. Soc. TraiiR,. vol. x. p. 129) relates a case in which he tied the 
 left lingual artery for recurrent epitlielioma. The recurrent growth was the size of 
 half a walnut when the lingual artery was tied. It at once ceased to grow, became 
 pale, and in a few days was sloughing. Gradually separation of the growth went on, 
 until the affected side of the root of the tongue became even smaller than the sound 
 side, and eventually the part healed. A fortniglit after this took place, or three 
 months after the ligature of the artery, the patient died of pyaemia, set up by erysipe- 
 las coming on after the operation. Mr. Haward points out that the greater part of the 
 tongue had been removed before the ligature of the lingual, so that therefore the 
 anastomoses between the arteries of the two sides would be greatly diminished. I 
 think, also, that the fact that Mr. Haward was obliged to tie the artery close to the 
 external carotid, may have contributed to the sloughing, by cutting off the entire 
 blood-supply, especially that through the dorsalis linguae. 
 
 On the other hand, Billroth (Clin. Surg., p. 113) states that in one case of cancer of 
 the tongue, " the lingual artery was ligatured on both sides, in the hope that the infil- 
 tration of the tongue in the cavity of the mouth might diminish. However, the liga- 
 ture led to no good results, nor did any rapid breaking-dowu of the already ulcerated 
 new formation occur." 
 
LIGATURE OF LINGUAL ARTERY. 
 
 425 
 
 runs jiist above the great cornu, and finally ascending to the under 
 surface of the tongue, it runs forward with a tortuous course to the 
 tip as the ranine. 
 
 For practical purposes the relations of the artery may be subdivided 
 into three parts, the first before it gets under the hyo-glossus, the 
 second while it lies beneath this muscle, and the third beyond this 
 muscle. 
 
 In the first it runs very deeply, though only covered by the skin, 
 platysma and fasciae, facial, lingual, and some pharyngeal veins ; it 
 lies upon the middle constrictor and the external laryngeal nerve. 
 In the second part of its course the artery again lies upon the middle 
 
 Fig. 86.* 
 
 The sub-maxillary gland is seen in the upper part of the wound. Below this is the hypo-glossal 
 on the cut hyo-glossus. A ligature is passed between the lingual artery and -vein. A hook 
 depresses the great cornu of the hyoid bone. 
 
 constrictor, and is now covered by the hyo-glossus, hypo-glossal, part 
 of the mylo-hyoid and the lower border of the sub-maxillary gland. 
 Prom this part come off the four branches of the artery, the hyoid at 
 the outer or posterior edge of the hyo-glossus, the dorsalis linguae 
 under this muscle, and the sub-lingual and ranine at its anterior 
 border, thus allowing room for placing a ligature. 
 
 The third part lies in the mouth, and runs along the under surface 
 of the tongue up to the point of the fraenum. It is only covered by 
 mucous membrane. A vein runs with it and a large branch of the 
 gustatory, nerve. 
 
 Operations. 
 
 i. Ligature under the Hyo-glossus. 
 
 ii. Ligature of the first part of the Artery. 
 
 * The lingual artery is here drawn too large, and too much of the vessel is shown 
 cleaned ; the depth of the wound is not sufficiently represented. 
 
426 OPERATIONS ON THE HEAD AND NECK. 
 
 i. The vessel is usually tied while under the hyo-glossus 
 muscle, owing to the useful guide which the great cornu of the hyoid 
 bone forms, and this is the operation which will be described here 
 (Fig. 86). Under some circumstances (p. 427) it will be needful to 
 seek it nearer its origin from the external carotid. The parts being 
 shaved, the head suitably supported and turned to the opposite side, 
 the lower jaw firmly closed, the surgeon, standing or seated on the 
 same side, steadies the tissues between his left finger and thumb and 
 makes a curved incision with its centre just above the great cornu of 
 the hyoid bone (a point previously carefully noted) and reaching, e.g., 
 on the left side, from just below and to the left of the symphysis 
 downwards, backwards, and then upwards towards the angle of the 
 jaw, ending just anteriorly to the line of the facial artery. 
 
 The incision divides skin, superficial fascia, and platysma ; the deep 
 fascia is then opened and any branches of tlie anterior jugular, facial, 
 or communicating branch with the temporo-maxillary vein are secured 
 carefully so that the wound may be kept as dry as possible. The 
 lower border of the sub-maxillary gland, which probably projects into 
 the wound, is turned ujjwards* and the hypo-glossal nerve sought for 
 which lies deeper, and is a good guide to the hyo-glossus. Lower down 
 in the neck is the glistening tendon of the digastric attached to the hyoid 
 bone. The hyo-glossus being defined, the hyoid bone is carefully 
 steadied by a finger-nail or tenaculum, a director passed under the 
 hyo-glossus, and this muscle divided cautiously. In doing this the 
 lingual vein must be carefully looked for either on the muscle or 
 beneath it, with the artery. The artery having been found under the 
 muscle just above the hyoid bone, it should be traced backwards so as 
 to apply, if possible, the ligature behind the origin of the dorsalis lin- 
 gU£e. Adequate drainage must be provided, and every care taken to 
 prevent decomposition in a wound so deep and opening up several 
 planes of deep cervical fascia. 
 
 Any enlarged glands will, of course, be removed. 
 
 Guides and Aids to finding the Artery. 
 
 1. A sufficiently free incision. 
 
 2. Carefully defining the hypo-glossal nerve, and remembering the 
 relative position of the sub-maxillary gland, the digastric tendon, and 
 the great cornu of the hyoid bone. 
 
 3. Keeping the wound bloodless. 
 Difficulties. 
 
 1. Matting of the parts from old cellulitis. 
 
 2. Presence of large veins. 
 
 * The Bub-maxillary gland should be gently handled, and not cut into. In the one 
 case troublesome swelling, in the other temporary weeping of saliva, or even a fistula, 
 will be the result. 
 
LIGATUEE OF THE COMMON CAROTID. 427 
 
 3. Depth of the wound, and oozing low down from the severed 
 hyo-glossus. 
 
 ^ 4. In one case Dr. Shepherd* found the digastric so extensively 
 tied down to the hyoid bone by the deep cervical fascia as to require 
 separation. 
 
 5. The position and condition of the lingual vein ahke is at times 
 perplexing. Usually it lies on the hyo-glossus, occasionally it lies 
 under it, with its artery. Billroth, who has tied the Ungual artery 
 twenty-seven times, tied the vein for the artery in one case, as was 
 verified post-mortem. 
 
 " Every surgeon knows the difficulty of tying the hngual artery in 
 old people ; the vessel lies so deep that it is very difficult to distinguish 
 it from thick-coated distended veins, especially when, owing to heart- 
 disease — as in this case— the veins pulsate. Never previously had I 
 met with a lingual vein of such thickness. "f 
 
 6. Abnormal position of the lingual artery itself. This is rare, but 
 the artery may lie higher than usual ; it may pierce the hyo-glossus ; 
 occasionally, one lingual is minute or absent. 
 
 7. The sub-maxillary gland may be unusually large and occupy 
 much of the space between the jaw and the hyoid bone.| 
 
 ii. If the vessel cannot be found on the hyo-glossus, or if the con- 
 dition of soft parts is such, owing to cellulitis, matting, enlargement 
 of glands, as to prevent any attempt being made here, the surgeon 
 must cut down upon the first part either by an incision similar to 
 the above but less curved and running from the centre of the hyoid 
 bone just above the great cornu to the anterior border of the sterno- 
 mastoid, or by one similar to that used for ligature of the external 
 carotid, with its centre opposite to the hyoid bone. 
 
 DiflBculties, 
 
 1. There is no certain guide to the artery here. 
 
 2. The artery itself is not constant in position here, varieties occur- 
 ring frequently in the height at which it comes off from the external 
 carotid, whether alone, or in common with the facial. 
 
 3. Large veins, e.g., the lingual and facial, will certainly be present. 
 
 LIGATURE OP THE COMMON CAROTID (Fig. 87). 
 
 Indications. 
 
 1. Wounds of the trunk itself. Owing to the rapidly fatal issue of 
 such injuries, the surgeon is not often called upon to meet them.§ 
 
 * Annals of Surgery, vol. ii. No. 11, p. 359. f Clinical Surgery, p. 113. 
 
 X Dr. Shepherd, loc. supra ait, p. 361. 
 
 § Tiiese, in reality, rare wounds of the common carotid might, at first sight, be 
 thought to be more common, owing to the inaccuracy with which wounds of the ex- 
 ternal carotid have been quoted as those of the common trunk. 
 
428 OPERATIONS ON THE HEAD AND NECK. 
 
 Cases calling for ligature for wounds of the trunk may be grouped as 
 follows : (a) For immediate hajmorrhage ; (6) For secondary haemor- 
 rhage ; (c) For gunshot injuries. 
 
 (a) For Immediate Hemorrhage. — Ligature of the common trunk is 
 here rarely called for, as above stated. In civil practice, such cases 
 may occasionally occur in cut-throat. If the surgeon arrives in time, 
 he should arrest the hasmorrhage while waiting for assistance, by 
 thrusting one or more fingers into the wound and making pressure on 
 the bleeding-point, remembering that but slight force is required if 
 the pressure is on the right spot. If the patient has to be removed 
 any distance, finger pressure must be kept up or the wound plugged 
 with carbolized sponge or aseptic gauze, and the head kept rigidly 
 still. Pressure with a finger or with a sponge on a holder should be 
 kept upon the bleeding point while the wound is enlarged, and the 
 opening in the carotid secured by ligatures placed above and below it. 
 
 Mr. Butcher, in a case of suicidal cut-throat implicating the common 
 carotid, successfully ligatured the artery above and below, the patient 
 making an excellent recovery. 
 
 While the subject of injury to the common carotid in cut-throat is 
 being alluded to, I may refer to the following case of Mr. Guthrie's,* 
 which shows that if the carotid is found to be wounded, though not 
 opened, it is best to apply ligatures above and below. 
 
 In a case of attempted suicide, the cut was deepest on the left side, 
 having laid bare the left carotid and wounded the internal jugular. 
 " The opening into the vein being distinct, I passed the point of a 
 tenaculum through the edges made by a cut into it, and, drawing them 
 together, passed a single silk thread around so as to close the opening 
 without destroying the continuity of the vessel. The ends of the liga- 
 ture were cut off close to the knot. The carotid was then clearly seen 
 by the side of the vein, having a transverse mark or cut upon it, which 
 did not appear to penetrate beyond the middle coat ; and, after due 
 consideration, it was presumed that this wound might heal without 
 requiring a ligature to be placed upon the artery. On the eighth day, 
 arterial hfemorrhage took place, and, on opening the wound, it came 
 evidently from that part of the carotid which had been cut. I placed 
 a ligature upon the common carotid immediately below this opening, 
 but the flow of blood was scarcely diminished in quantity by it, in 
 consequence of the reflux from the head. On attempting to apply 
 another ligature above the opening, I found, as I had before suspected 
 from the situation of the wound, that it was immediately below the 
 division of the common into the external and internal carotids. The 
 haemorrhage ceased on placing a ligature on the external carotid, and, 
 
 * Wounds and Injuries of Arteries, p. 78. 
 
LIGATURE OF THE COMMON CAROTID. 429 
 
 as the patient was greatly exhausted, I refrained from tying the other. 
 The bleeding did not return, but he died the next morning from 
 weakness." 
 
 At the autopsy the internal jugular was found pervious and without 
 a mark indicating where the ligature had been applied. The origin of 
 the internal carotid was filled for about 1 inch with a soft clot, the 
 wound in the common carotid was exactly below its bifurcation, and 
 Mr. Guthrie thought that the ligature on the external carotid might 
 have been sufficient* if the patient had lived. 
 
 Mr. Guthrie briefly relates (loc. supra cit., p. 79) another case in 
 which the common carotid was wounded by a penknife, and the 
 haemorrhage arrested by placing ligatures on the vessel above and 
 below the wound. 
 
 (6) For Secondary Hsemorrhage. — A remarkable instance of punctured 
 wound of the common carotid in which the vessel was tied for second- 
 ary hsemorrhage is thus recorded by Mr. Durham : f 
 
 A child aged nine was wounded with glass, owing to an explosion 
 of hydrogen gas. When admitted into Guy's Hospital, under the 
 care of Mr. Hilton, the child was cold and blanched, but the bleeding, 
 which had been profuse, had entirely ceased. There was a wound about 
 an inch long " in the left carotid region." On the eighth day after the 
 accident hasmorrhage recurred, and the common carotid was tied. 
 Nine days later, slight bleeding took j^lace, but was arrested by plug- 
 ging the wound with sponge. Repeated epistaxis occurred, which 
 weakened the child perceptibly. The sloughs became very offensive, 
 but there was no further bleeding from the wound for eighteen days, 
 when a considerable quantity was lost. The child gradually sank, and 
 died six weeks after the accident. 
 
 At the autopsy the common carotid was found to have been traversed 
 by a sharp-pointed fragment. Behind the wounded vessel was an 
 abscess implicating the sympathetic. Mr. Durham thinks that if a 
 ligature had been applied on the distal as well as on the proximal side, 
 the child's life would have been saved. 
 
 Another case of secondary hemorrhage from the common carotid 
 has recently been recorded by Mr. Rivingion {Trans. Med. Ohir. Soc, 
 vol. Ixix. p. 63). This paper, hke several others by the same writer, 
 is replete with valuable information and interesting facts. 
 
 It is an excellent instance of the way in which the carotid may at 
 any time be wounded from within, and not from outside, by a foreign 
 body penetrating the pharynx. 
 
 * This would appear very doubtfal, owing to the freeness of the collateral cerebral 
 circulation, and the readiness with which a reflux current along the internal carotid 
 is established. See the case given at pp. 441, 442. 
 
 t System of Surgery, vol. i. p. 739. 
 
430 OPERATIONS ON THE HEAD AND NECK, 
 
 A boy, aged nine, six days after swallowing a small plaice-bone, was 
 admitted into the London Hospital with stiffness and tenderness of the 
 neck, a small tender lump on the left* side opposite to the cricoid 
 cartilage, profuse salivation and inability to swallow solid food. On 
 the ninth and eleventh day haemorrhage took place, on the latter 
 occasion to half a pint. The following account of the operation by 
 which the injured vessel was found and secured will be most instruc- 
 tive to every operating surgeon, owing to the difficulties which pre- 
 sented themselves : 
 
 An incision was made along the edge of the sterno-mastoid for 
 several inches. The muscle was found glued to the subjacent parts 
 by recent adhesions. Above the anterior belly of the' omo-hyoid was 
 a dark patch about the size of a fourpenny-piece, caused by extrava- 
 sated blood looming through the fascia. The fascia over the large 
 vessels being divided, a probe was passed down into a cavity contain- 
 ing clot, hollowed out behind the vessels and on the inner side. Owing 
 to the uniform discoloration of artery, vein, nerves, fascia, and areolar 
 tissue by the extravasated blood, the structures met with, being all 
 dark and equally stained, could scarcely be recognized. The descendens 
 noni could not be seen, nor the vagus distinguished, though carefully 
 looked for. More clots being turned out from the cavity, in one of 
 these the fish-bone was found. A gush of blood which took place, 
 evidently from the distal end, was arrested partly by pressure and 
 partly by pulling forward the vessels with a blunt hook. The wounded 
 vessel being found, a ligature was passed closely, as was thought, 
 around it, both above and below the seat of injury. Owing to the 
 danger of subjecting the patient to a further loss of blood, there was 
 no time to make a prolonged dissection, and it was thought prudent 
 to divide the artery at the seat of wound to make sure that no branch 
 was given off between the ligatures. When this was done, some nerve 
 fibres were recognized on the cut section, and the question arose 
 whether these were the descendens noni or the vagus. As they were 
 in front of the vessel, closely adherent, and apparently scarcely nu- 
 merous enough for the vagus, it was concluded that they belonged to 
 the descendens noni, and no attempt was made to disengage the nerve 
 or to unite its extremities. It was proved, later on, that this nerve 
 was the vagus, which, instead of lying between and behind the artery 
 and vein, took, or had been pressed into, an unusual position in front 
 of the artery, and, owing to the inflammation induced by the injury, 
 had become firmly adherent to the vessel for some little distance above 
 and below the aperture in the artery. Externally the nerve was stained 
 
 * The left common carotid is more exposed to danger from the passing of the 
 cesophagua somewhat to this side. 
 
LIGATURE OF THE COMMON CAROTID. 431 
 
 of the same dark color as the artery, and only in the centre, after sec- 
 tion, were the white nerve-fibres to be recognized. The patient died 
 ten days after the operation, having shown no evidence of ill-effects 
 from the divided vagus, save perhaps slight cough and difficulty in 
 swallowing. Two gangrenous abscesses in the left half of the brain, 
 which were probably already in progress prior to the operation, were 
 the cause of death. 
 
 (c) Division of the common carotid by gunshot injuries is usually fatal 
 at once, as in two cases recorded in Circular No. 3 of the War Depart- 
 ment, Washington, 1871. 
 
 2. Aneurism of the carotid. Where an undoubted * aneurism of the 
 vessel exists and is increasing in spite of pressure,t or where this 
 cannot be made use of, the artery should be tied, on the cardiac side 
 of the aneurism, if possible, or failing this distally. 
 
 The Mortality after Ligature of the Common Carotid for 
 Aneurism is as yet high. Thus Mr. Johnson Smith {loc. supra cit.), 
 quoting from the tables of M. Lefort,J gives twenty-one as fatal out of 
 forty-seven cases of proximal ligature. Mr. Barwell § considers a little 
 over 25 per cent, to be the mortality in cases of aneurism proper. 
 Whichever of these estimates is correct, in the future the mortality 
 should be much reduced by the advantages of aseptic surgery and 
 modern ligatures. The chief dangers to be guarded against are 
 suppuration of the sac and hasmorrhage, brain and lung complications, 
 and haemorrhage from the site of ligature. These are alluded to more 
 fully below, p. 445. 
 
 The old operation for carotid aneurism is described at p. 442. 
 
 8. In aneurism of the innominate or aortic arch. The question of 
 
 * It is well known that this aneurism is diagnosed more frequently than it is really 
 found to exist, owing to the closeness with which some varicosity of the artery at its 
 bifurcation, glandular and other tumors lying over it, and in the root of the neck, other 
 aneurisms — e.g., of the innominate, aorta, and subclavian — simulate a carotid aneurism. 
 Few surgeons will, I think, agree with the statement of Mr. Johnson Smith {Diet, of 
 Surg., vol. i. p. 235) that carotid aneurism occurs " about as often as subclavian aneurism, 
 and with greater frequency than aneurism of the axillary artery." 
 
 f This may be applied to the artery or the sac, or both. In the former case the 
 artery should be compressed above the transverse process of the sixth cervical vertebra, 
 to avoid making pressure on the vertebral at the same time. If pain, vertigo, sickness, 
 etc., prevent a fair trial of digital pressure, an anaesthetic may be tried, but, as Mr. Bar- 
 well points out {Encyd. of Surg., vol. iii. p. 498), there may be much difficulty in de- 
 ciding how far the syncope, etc., which may be present are due to the anesthetic or to the 
 pressure. Another means of keeping up pressure on the common carotid is that sug- 
 gested by Kouge, in which the sterno-mastoid being relaxed the surgeon insinuates his 
 fingers behind one border, and his thumb behind the other border, of the muscle, and 
 thus compresses the artery between them. 
 
 t Gas. Eebd , 1864 and 1868. 
 
 J Loc supra cit., p. 502. 
 
432 OPERATIONS ON THE HEAD AND NECK. 
 
 the advisability of ligaturing the carotid either together with the sub- 
 clavian, or alone, especially in the case of the left common carotid, is 
 considered on a subsequent page. 
 
 4. In orbital aneurism, where the symptoms are becoming aggra- 
 vated, or where pressure has failed, or where it cannot be endured, even 
 intermittently, for a few minutes only at a time, and where galvano- 
 puncture and injection of coagulating fluids are set aside owing to 
 their uncertainty and riskiness* 
 
 Of the fifty-three cases (Rivington, loc. supra cit), including twenty- 
 one idiopathic and thirty-two traumatic, in which the common carotid 
 was tied, thirteen of the former were cured and seventeen of the latter. 
 The above writer, speaking of this mode of treatment, says it is "at 
 present the most successful and satisfactory means of treating orbital 
 aneurism. It should not be practiced on patients advanced in years, 
 or on those with heart disease, or evident atheromatous degeneration 
 of arteries." 
 
 5. In aneurism of the external or internal carotid. These are very 
 rare. Two cases of aneurism of the former vessel have been recently 
 published. Mr. Morris f recorded one in which, after failure of liga- 
 ture of the common carotid, the old operation of incising the sac was 
 performed, and ligatures placed on the facial and lingual arteries, and 
 upon the main trunk of the external carotid above the sac, with ulti- 
 mate recovery. 
 
 The second case was published by Mr. Heath J in order to prove 
 that ligature of the common carotid alone is sufficient to cure some 
 cases of aneurism of the external carotid. 
 
 The occurrence of aneurism here in a woman, aged twenty-three, 
 was accounted for by the state of the cardiac valves and the liability 
 for embolism to occur in consequence of detachment of a vegetation. 
 There was a smooth, round, pulsating swelling just below the right 
 mastoid process, reaching down to about the level of the upper border 
 of the thyroid cartilage. It had the size and shape of half a small 
 orange. The right tonsil was somewhat pushed inwards, the right 
 temporal pulse was markedly weaker than the left, and the tongue 
 deviated much to the right, the right half being a good deal wasted. 
 The common carotid was tied and the wound healed, pulsation in the 
 aneurism had stopped on the tenth day, and on the eighteenth the sac 
 
 * Mr. Rivington {Diet, of Surg., vol. ii. p. 131) speaka thus of injection : " It is more 
 painful than ligature, and probably involves more risk to vision, as it may set up in- 
 flammatory mischief in the loose areolar tissue around the veins, which may spread to 
 the cornea. It may also effect so much coagulation as to interfere with the requisite 
 supply of blood for the maintenance of the ocular tissues." 
 
 t Med. Chir. Trans., vol. Ixiv. p. 1. 
 
 X Ibid., vol. Ixxxiii. p. 69. 
 
LIGATURE OF THE COMMON CAROTID. 433 
 
 was smaller and quite hard. All seemed to be doing well till the 
 thirty-third day after the operation, when loss of speech occurred 
 somewhat suddenly, followed by right hemiplegia, and death on the 
 thirty-fifth day, this being brought about by cerebral embolism tak- 
 ing place through the left carotid, the aneurism being soUdified 
 throughout. 
 
 Aneurism of the internal carotid is equally rare. 
 
 The following is a brief abstract of such a case * in which the com- 
 mon and external carotids were tied, together with the superior thy- 
 roids, successfully. 
 
 The internal trunk was affected with atheroma to such an extent 
 that the ligature could not be applied to this vessel. The operation 
 was done July 24, 1883. The tumor rapidly diminished in size, the 
 patient leaving the hospital on the twenty-ninth day after the opera- 
 tion. She is now living and well. 
 
 6. In hsemorrhage caused by ulceration of the throat after scarlet 
 fever. 
 
 This is a rare but most dangerous complication of ulceration of the 
 throat, and is usually brought about either by sloughing of the soft 
 parts, or, as in the case mentioned below, by the opening of an artery 
 or vein into an abscess cavity. 
 
 My old friend Dr. Mahomed communicated a case to the Clinical 
 Society {Tnms., vol. xvi. p. 21) in which this complication occurred in 
 a patient aged 21. Secondary sore throat, after an ordinary convales- 
 cence, was noticed on the 54th day, with much swelling on the left 
 side of the neck, followed by severe bleeding (to 40 ounces) from the 
 mouth on the 58th day. The left common carotid was tied by Mr. 
 Pepper on the 59th day. Five and a half ounces of pus were brought 
 up soon after the operation, and the swelling of neck and pharynx 
 subsided, a good recovery ultimately taking place. 
 
 The common carotid was selected for ligature in preference to the 
 external, since it allowed the operation to be performed quite clear of 
 the infiltrated tissues, and thus conferred a greater immunity from 
 secondary haemorrhage. Moreover, had the original bleeding have 
 come from the ascending pharjmgeal, ligature of the external carotid 
 might have failed to arrest it, as the place of origin of the former ves- 
 sel is variable. 
 
 The next series of cases, 7 to 11, rather call for ligature of the ex- 
 ternal carotid than of the common trunk. With reference to them it 
 must be remembered, that ligature of the common carotid must be 
 resorted to, not, as has too often been the case, on account of the 
 greater facility with which this vessel can be tied, but only when the 
 
 * Dr. Wyeth, Antials of Surgery, August, 1887, p. 114. 
 28 
 
434 OPERATIONS ON THE HEAD AND NECK. 
 
 condition of the parts does not, either primarily, from an anatomical 
 point of view, or, later on, after secondary haemorrhage, admit of tying 
 the external carotid itself.* 
 
 7. Incised or punctured wound near the angle of the jaw. 
 
 In these cases, as in those below, a correct diagnosis as to the ves- 
 sel or vessels injured is by no means easy when a sharp weapon has 
 passed obliquely and deeply behind the angle of the jaw. By such a 
 wound either the external or the internal carotid or some branches of 
 the former may be laid open. A careful dissection can alone clear up 
 the source of the bleeding, and whenever it is possible this should be 
 resorted to ; where the circumstances do not admit of this, the surgeon, 
 relying upon the extreme rarity of injury to the internal carotid from 
 its protected position,! will be abundantly justified in tying the ex- 
 ternal carotid. Ligature of the common trunk is less reliable, though, 
 if resorted to, on account of its simplicity, it may be defended by 
 cases like those briefly alluded to by Mr. Le Gros Clark, J in which he 
 successfully tied the common carotid for profuse arterial haemorrhage 
 due to stabs near the angle of the jaw. " The injury was inflicted in 
 the same way, and with the same form of instrument, in both 
 instances — a pointed table-knife was plunged downwards and inwards 
 behind the angle of the jaw. The bleeding was, in each case, con- 
 trolled only by direct pressure with the fingers in the wound ; and 
 whilst this pressure was maintained I tied the artery. Not an 
 untoward symptom accompanied or followed either of these opera- 
 tions." 
 
 On the other hand, cases of penetrating woiinds near the angle of 
 the jaw, ending fatally from haemorrhage after ligature of the common 
 carotid, will be found published by Mr. Travers§ and Mr. Parft-idge.|| 
 
 8. Punctured wounds through the mouth. 
 
 Here, too, the common carotid has been tied in some cases success- 
 fully, while in others this step has been followed by repeated haemor- 
 rhages and death. 
 
 The following case may be quoted as an instance of the former re- 
 sult: A child fell while holding the sharp end of a parasol in his 
 mouth, the point being thrust forcibly to the back of the fauces and 
 
 * In some of these cases the hfemorrhage may be arrested, and the dangers of tying 
 the common carotid avoided by the temporary closure of tliis vessel by a loop of stout 
 catgut, applied as at pp. 441, 448. 
 
 f Mr. Cripps {Med. Chir. Trans., vol. Ixi. p. 235) shows that, out of eighteen cases 
 in which the bleeding vessel was identified, the internal carotid was found only to have 
 been wounded twice alone, and once in conjunction with the external. 
 
 J Lectures on Surgical Diagnosis, Shock, and Visceral Lesions, p. 222. 
 
 ? Med. Chir. Trans., 1827, p. 165. 
 
 II Lancet, 1864, vol. i. p. 659. 
 
LIGATURE OF THE COMMON CAROTID. 435 
 
 very nearly coming through the skin at the side of the neck. Con- 
 siderable hfemorrhage occurred at once, and also about a week later. 
 Ten days later a gush of arterial blood followed on coughing. The 
 common carotid artery was tied and the case ended successfully.* 
 
 On the other hand, cases ending fatally after ligature of the common 
 carotid for hasmorrhage after punctured wounds of the mouth, will 
 be found recorded by Mr. Vincent,t Mr. Arnott,! and Mr. Morrant 
 Baker.§ 
 
 9. Hffimorrhage from carcinoma of the mouth, e.g., tongue or 
 fauces. 
 
 This subject is discussed at p. 340. It would be better surgery to 
 tie the lingual in the case of tongue cancer, or, if the growth be farther 
 back, to tie the external carotid and ascending pharyngeal, and only, 
 if this be found impossible, to ligature the common trunk. 
 
 10. Haemorrhage after removal or incision of tonsils, or from abscess 
 about a tonsil. 
 
 These cases are infrequent, but when they do occur, are, in many 
 cases, most dangerous. The sources of the hemorrhage are very 
 numerous — viz., (1) One of the tonsillar arteries. (2) The tonsillar 
 venous plexus. (3) The ascending pharyngeal. (4) The internal 
 carotid. Haemorrhage from the last two is much more likely to occur 
 in suppuration in or around the tonsil, than in wounds inflicted 
 during operations on it. 
 
 The following is a good instance || of a tonsillar abscess proving 
 fatal from haemorrhage. A man, aged 39, was admitted with severe 
 tonsillar abscess, which soon burst with the escape of a little blood. 
 About 16 oz. were lost on the third day, bleeding again recurring on 
 the fourth and fifth. The left common carotid was now tied ; thirty 
 hours afterwards 22 oz. were lost, and the patient died. 
 
 There was an abscess cavity around the left tonsil which communi- 
 cated with the left carotid by an opening the size of the little finger 
 nail. 
 
 * The case was under the care of Mr. Johnson at St. George's Hospital. It is 
 quoted by Mr. Durham, Syst. of Surg., vol. i. p. 745. 
 
 t Med. Chir. Trans., vol. xxix. p. 38. In this case the bifurcation of the right com- 
 mon carotid had been punctured by a bit of broken tobacco-pipe from within the 
 mouth. Sloughy cellulitis set in, and hjemorrhage took place from the mouth a week 
 after the accident. This was arrested by ligature of the common carotid, but recurred 
 on the second, and again, fatally, on the fifth day after the operation. Mr. Vincent 
 points out that if the bit of tobacco-pipe had been discovered and removed, fatal haem- 
 orrhage must have followed instantly, as the artery was not only wounded, but plugged 
 by the foreign body. 
 
 J Lancet, 1864, vol. i. p. 135. 
 
 i St. Barthnl. Hosp. Reports, 1876, p. 163. 
 
 II Mr. Pitts, St. Thomas's Hosp. Reports, vol. xii. p. 131. 
 
436 OPERATIONS ON THE HEAD AND NEOK. 
 
 Mr. Morrant Baker has recorded the following case of suppuration 
 around the tonsil dating to an injury. Here the vessel injured was 
 the ascending pharyngeal, but too short a time elapsed between the 
 ligature of the common carotid and the death of the patient to say 
 whether the operation would have been successful. 
 
 A man, aged 23, was admitted with symptoms of acute tonsillitis, 
 the parts being tense, elastic, and prominent at one spot. A puncture 
 was only followed by the escape of blood. The patient now gave a 
 history of having fallen two days before, when drunk, and having 
 grazed his throat with a clay pipe; this had been followed by very 
 little bleeding. Some improvement seemed at first to take place, but 
 the temperature went up to 105°, and arterial haemorrhage occurred 
 on the third day after admission. A probe passed through the punct- 
 ure showed that a considerable cavity existed, this was plugged with 
 lint soaked in tr. ferri perchlor. The next day haemorrhage recurred 
 to half a pint ; when ether was given the bleeding again came on, 
 nearly suffocating the patient. On exploring the cavity with a finger- 
 tip, a bit of clay pipe was withdrawn ; the cavity was again plugged 
 and the common carotid tied. The patient died, without rallying, 
 three hours later. A wound was found in the ascending pharyngeal 
 artery. 
 
 Given a case of hsmorrhage from the tonsil (whether from a wound 
 or an abscess) which resists other treatment, including well-applied 
 pressure kept up with a padded stick inside the mouth and a finger 
 behind the angle of the jaw, the surgeon should tie the external carotid 
 as low down as possible, placing a ligature on the ascending pharyn- 
 geal as well, if this vessel can be identified. If the bleeding is from 
 one of the tonsillar vessels it would be thus arrested, but in case the 
 ascending pharyngeal is not secured, or the bleeding comes from the 
 internal carotid, a loop of stout chromic gut should be placed as well 
 under the top of the common carotid in the manner recommended by 
 Mr. Rivington and Mr. Reeves (pp. 441, 448).* 
 
 11. Hemorrhage after operations on neck or jaw. Haemorrhage 
 secondary to gunshot injuries. 
 
 In both these cases the parts may be so altered that it is quite 
 impossible to find the bleeding point, and the soft parts may be so 
 damaged, matted together, etc., that the surgeon may be driven to tie 
 the comnaon carotid, and trust to this and to plugging the wound, 
 rendered as aseptic as possible with sal alembroth or iodoform gauze,t 
 and sponge-pressure over all. 
 
 * Every care should he taken tliroughout to keep the wound in the tonsil as aseptic 
 as possible. As bearing on the use of iron perchloride as a styptic, see some remarks 
 at p. 423, foot- note. 
 
 ■j" These may first be soaked in turpentine (p. 422). 
 
LIGATURE OP THE COMMON CAROTID. 437 
 
 12. To arrest the growth of aneurism by anastomosis on the side of 
 face, head, and neck. 
 
 The treatment of this condition is discussed at p. 449. It will be 
 shown there that ligature of the external carotid cannot usually be 
 looked upon as sufficient without other measures, owing to the free 
 anastomosis between the branches of the opposite vessels. Still less 
 is ligature of the common carotid likely to be successful, and this step 
 should only be resorted to when ligature of the external carotid is 
 impossible from the disease extending too low down, when, from its 
 creeping towards the orbit or at the back of the upper jaw, it is prob- 
 able that there is a free anastomosis between the branches of the 
 external and internal carotid through the ophthalmic, or when the 
 ascending pharyngeal is sure to be involved, but this branch cannot 
 be separately ligatured. 
 
 13. To arrest the growth of malignant tumors of the jaws which 
 cannot be operated on, or which are returning after operation. 
 
 This operation, first performed by Mott, is a very proper one in 
 cases of malignant disease of the antrum, nose, etc., where the growth 
 cannot otherwise be attacked and is growing very rapidly, causing 
 frequent bleeding, intense pain, and threatening to interfere with 
 deglutition and respiration. 
 
 The surgeon must be prepared for a good deal of sloughing, foetor, 
 etc., as well as shrinking in very vascular growths which have begun 
 to f ungate. 
 
 In this case, also, it will be a question as to whether it is wiser to 
 ligature both external carotids or the common carotid. The sugges- 
 tions made at p. 451 may help here. If the common carotid is tied, 
 the opposite external carotid should be ligatured also, either at the 
 same time or very shortly after, owing to the free anastomoses, which 
 wiU bring blood over from the opposite side. 
 
 In any case it should be an operation to be performed at the 
 patient's request after the matter has been explained to him, in the 
 hope that its performance may lead to relief from the urgent local 
 symptoms of the growth, and that life may be brought to a close, after 
 an interval of relief, by increasing, but less painful, asthenia. 
 
 Line. — From the sterno-clavicular articulation to a point midway 
 between the angle of the jaw and the mastoid process. 
 
 Guide. — The above line, and the inner edge of the sterno-mastoid. 
 
 Relations. — The common carotids, as far as their relations in the 
 neck go, extend from the sterno-clavicular articulation to the upper 
 border of the thyroid cartilage along a line from the above joint to a 
 point midway between the ear and the mastoid process. 
 
438 opeeations on the head and neck. 
 
 In Front. 
 
 Skin ; fascia; ; platysma ; superficial branches of trans- 
 verse cervical and anterior jugular. 
 
 Sterno-mastoid, sterno-hyoid, sterno-thyroid, omo-hyoid, 
 sterno-mastoid artery. 
 
 Superior and middle thyroid veins. 
 
 Descendens noni. 
 
 Anterior jugular vein (below). 
 
 Outside. Inside. 
 
 Internal jugular (closer on Pharynx, 
 
 left side). Larynx. 
 
 Trachea. 
 
 Thyroid gland and vessels. 
 Recurrent laryngeal. 
 Common carotid. 
 
 Behind. 
 Rectus capitis anticus major. 
 Longus colli. 
 Sympathetic. 
 
 Inferior thyroid artery and recurrent laryngeal. 
 Vagus. 
 
 Operation. — Two sites are usually described, according as the 
 vessel is tied above or below the omo-hyoid. 
 
 A. Above the Omo-hyoid (Fig. 87). — Also known as the seat of 
 election, owing to the greater facility with which this operation is 
 usually performed. 
 
 The parts being cleansed and shaved if needful, the shoulders are 
 sufficiently raised, and the chin at first drawn a little upwards, while 
 the head is turned to the opposite side,* so as to define the anterior 
 border of the sterno-mastoid .f The surgeon, standing usually on the 
 same side, makes an incision about 3 inches long, with its centre op- 
 posite to the cricoid cartilage, in the line of the artery, through the 
 skin, platysma, and fasciae, exposing the anterior border of the sterno- 
 
 * Turning the head strongly to the opposite side should be avoided, as it brings the 
 muscle over the artery. Mr. Barwell {Eneycl. Surg., vol. iii. p. 498) gives the following 
 practical hint : " In certain aneurismal cases (aortic and innomipate) the etherized 
 patient cannot breathe while his head is thrown back; the ansesthetizer is obliged to 
 insist on bending it forward, and the operator has to get at the vessel under very try- 
 ing circumstances, since in that posture it lies much deeper, and the ramus of the jaw 
 is terribly in the way." 
 
 t Not always easy on the dead subject, or when the parts are'infiltrated, as in Mr. 
 Vincent's case (foot-note, p. 435). 
 
LIGATURE OF THE COMMON CAROTID. 
 
 439 
 
 mastoid. Any superficial veins are now drawn aside, or tied before 
 division with double catgut ligatures. The deep fascia at the anterior 
 border of the sterno-mastoid is now divided, and the cellular tissue 
 beneath opened up, usually bringing into view the upper border of 
 
 Fig. 87. 
 
 In the ligature of tlie common carotid the only structures seen are the omo-hyoid, crossing 
 the vessel below, and the superior thyroid vein above. Externally is a portion of the internal 
 jugular, and more superficially the sterno-mastoid. The deep fascia is seen in the upper and 
 lower angles of the wound. 
 
 In the ligature of the subclavian, the sterno-mastoid and the trapezius are seen in the angles 
 of the wound. Above the vessel lie the cords of the plexus, crossed by two veins, probably the 
 transverse cervical and the posterior scapular, coursing inwards to join the external jugular, 
 which is seen at the inner part of the wound. Below the subclavian artery is seen a portion (too 
 much is shown) of the supra-scapular artery. 
 
 The angular incision shows that for ligature of the innominate, the first part of the subclavian, 
 and, in cases of difilculty, the first part of the carotid. 
 
 the omo-hyoid, which, if in the way, is drawn down with a blunt 
 hook, or divided. The edge of the sterno-mastoid is now drawn out- 
 wards, and the pulsations of the artery felt for just below the omo- 
 hyoid.* In clearing the tissues which remain over the vessel, 
 troublesome haemorrhage may arise from the superior and middle 
 thyroid veins, especially if the respiration is embarrassed ; more 
 rarely the sterno-mastoid artery is cut, and requires a ligature. The 
 sheath is next exposed, and opened well to the inner side, avoiding 
 
 * This muscle should be drawn downwards, or divided if needful. 
 
440 OPERATIONS ON THE HEAD AND NECK. 
 
 the descendens noni, which usually lies to the front and outer side of 
 the sheath.* 
 
 Other difficulties which may be now met with are an enlarged thy- 
 roid lobe overhanging the artery, or overlapping of it by the internal 
 jugular when much distended. The coats of this vessel are so thin 
 that, if it be much swollen, it is easily punctured, the result being that 
 the wound is flooded with blood. It is best avoided by opening the 
 sheath well to the inner side, but, if it still give trouble, it should be 
 drawn aside with a blunt hook, or pressure should be made on it by 
 an assistant in the upper angle of the wound. If it should be opened, 
 firm pressure should be made on this spot with a sponge-holder, and 
 the artery tied at a fresh place above or below. As soon as the liga- 
 ture is tightened the haemorrhage will cease, and firmly applied press- 
 ure outside the wound for forty-eight hours will suffice to prevent 
 any recurrence. If, after wounding the vein, attempts are continued 
 to tie the artery at the same place, the wound in the vein is almost 
 certain to be made larger. Another method is to pinch up the wound 
 in the vein and tie up the opening (if small) with fine carbolized silk 
 or chromic catgut. 
 
 The sheath having been opened well to the inner side with a careful 
 nick of the knife, the artery is now cautiously and sufficiently cleaned, 
 the inner edge of the sheath being held with forceps while this side of 
 the vessel is cleaned, and then the outer in the same way, and, finally, 
 the posterior aspect, the point of the director being kept most scrupu- 
 lously in contact with the vessel here.f The needle is then passed 
 from without inwards, being kept most carefully free from the artery, 
 especially behind, so as to avoid including the vagus. 
 
 In this, as in every other artery whose relations are important, the 
 fewer of these relations that the surgeon sees the more masterly and 
 successful will his operation be. 
 
 In a deeply lying artery, in addition to relaxing the parts by flexing 
 forward the head and depressing the chin, the sterno-mastoid must be 
 drawn outwards and the larynx inwards with retractors, while the 
 omo-hyoid is drawn downwards with a blunt hook, or divided. The 
 pulsation of the artery is then felt for, or, where this is feeble or absent, 
 the rolling of the artery as a flat cord under the finger is made out. 
 
 B. Ligature below the Omo-hyoid. — Here the artery lies much 
 deeper, and has the recurrent laryngeal nerve behind it ; on the left 
 side, the internal jugular vein lies very close to the artery ; on the 
 right, there is a distinct interval between the two vessels. 
 
 The patient's head and the operator being in the same position as at 
 
 * The position of this nerve is, however, very irregular. 
 
 t Opening tlie sheath on the inner side and cleaning the vessel properly are the 
 two best safeguards against accidents. 
 
LIGATURE OF THE COMMON CAROTID. 441 
 
 p. 438, an incision 3 inches long is made in the line of the artery from 
 below the cricoid cartilage to just above the sterno-clavicular joint, 
 exposing, as before, the anterior edge of the sterno-mastoid. This is 
 drawn outwards, and, if needful, divided or detached below by making 
 a short incision outwards along the clavicle. In this case the anterior 
 jugular vein must be carefully looked for as it passes outwards in the 
 root of the neck under the stern»-mastoid. The depressors of the 
 hyoid bone next come into view ; of these the sterno-hyoid overlying 
 the broader sterno-thyroid is certain to be seen. If the omo-hyoid is 
 coming up at this level, it lies external to the others. In such case it 
 is to be drawn out while the other two are pulled inwards, any of the 
 three being divided, on a director, if needful. At this stage one or 
 more of the inferior thyroid veins may come into view, much swollen. 
 The pulsation of the artery being felt for, or the flattened artery felt 
 slippiag beneath the finger when pressed upon, the sheath is to be 
 opened well to the inner side, retractors usually being required at this 
 stage. Care must be taken of the internal jugular, especially on the 
 left side, as, if distended, it may conceal the artery (p. 440). 
 
 When the carotid is sufl!iciently cleaned, the needle is passed from 
 without inwards, avoiding the recurrent laryngeal nerve behind by 
 keeping very close to the artery. 
 
 Temporary Ligature of the Carotid.— Mr. Rivington (p. 448) 
 and Mr. Treves* have drawn attention to this method, believing that 
 the ligature of main arteries is resorted to too often, as there is suffi- 
 cient evidence to show that in most cases it is only temjjorary arrest 
 of the current that is required. 
 
 This method should certainly receive a further trial, on account of 
 the risks of cerebral mischief after ligature of the carotid, and also 
 because, as Mr. Treves says, pressure upon the carotid cannot be suc- 
 cessfully maintained for a serviceable length of time. 
 
 The artery being exposed in the ordinary way, a thick piece of soft 
 catgut is passed round it and tied in a very loose loop. By pulling 
 on the loop, the blood-current is at once arrested, and restored when 
 the tension is relaxed. 
 
 The following are abstracts of the four cases given by Mr. Treves : 
 
 1. Probable Wound of Superior Thyroid Artery. — A young man was 
 admitted with a deep, profusely bleeding wound about the level of 
 the great cornu of the hyoid. A fragment of glass driven in by a 
 bursting soda-water bottle had been removed. The patient was 
 blanched and almost insensible. It being "obviously useless to 
 attempt to find the bleeding point while blood was welling up from 
 so deep a wound," Mr. Treves placed a temporary ligature round the 
 
 * Lancet, January 21, 1888, p. Ill, 
 
442 OPERATIONS ON THE HEAD AND NECK. 
 
 common carotid. Traction on this arrested all bleeding, and was 
 maintained for half an hour. On relaxing the catgut, no haemorrhage i 
 occurred. The loop was left in situ for four days, and then removed. 
 The bleeding was supposed to have come from the superior thyroid. 
 
 2. Hemorrhage from Internal Carotid. — A child, aged three, had 
 profuse haemorrhage from the right ear, and vomited blood. This 
 recurred, and the right common cargtid was ligatured, and the bleeding 
 ceased. The next day the saliie haemorrhage recurred, having evi- 
 dently been brought round by the left carotid. As there is no case on 
 record of recovery after ligature of both common carotids when the 
 interval between the occlusion of the two vessels was less than some 
 weeks, Mr. Treves simply placed a loop of catgut round the left 
 carotid, and had traction made on it. The child never bled again, but 
 sank exhausted six days after the second operation. 
 
 3. HEemorrhage, probably from External Carotid, after Impalement 
 with a Spike. — A man, aged forty-one, fell 26 feet upon a railing spike, 
 which, entering just in front of the left ear, passed through the upper 
 jaws, and entered the mouth through the hard palate on the right side. 
 After removal of the spike, blood welled uj) freely from the wounds 
 and nose. Traction made on a catgut loop passed round the common 
 carotid arrested this. A weak pulse could be felt in the temporal on 
 the fourth day, and on the seventh the loop was removed. The case 
 did well. It is not stated how long traction was maintained. 
 
 4. Haemorrhage during an Operation. — In this case the loop was 
 placed around the artery prior to removing a large malignant tumor 
 of the neck. Very free bleeding occurred during the operation, but 
 was always checked by traction on the loop. Without this the opera- 
 tion would have been very difficult. 
 
 Old Operation for Ligature of the Common Carotid.— 
 This, perhaps the most formidable operation in surgery, was success- 
 fully made use of by Prof Syme * in a case of aneurism the result of 
 a stab. The patient was aged twenty. The aneurism, about the size 
 of an orange, extended between the trachea and sterno-mastoid, and 
 downwards close to, or rather under, the clavicle. Nearly at its centre 
 was a cicatrix. It was increasing in size, and, other treatment having 
 failed, it was decided to perform the old operation, it being evidently 
 impossible to apply a ligature below the aneurism. 
 
 " I pushed a knife through the cicatrix, and followed the blade with 
 the forefinger of my left hand so closely as to prevent any efi'usion of 
 blood. I then searched through the clots and fluid contents of the sac 
 for the wound of the artery, and found that pressure at one part made 
 the pulsation cease. Keeping my finger steadily applied to this point, 
 
 * Observ. in Clin. Surg,, p. 154. 
 
LIGATUEB OF THE COMMON CAEOTID. 443 
 
 I laid the cavity freely open both upwards and downwards, turned out 
 the clots, and sponged away the blood so as to get a view of the bottom, 
 which presented the smooth, shining aspect of a serous membrane, 
 without the slightest indication of either the artery or vein that could 
 be seen or felt. In order to make the requisite dissection, I next 
 attempted to close the orifice by means of forceps, but found that it 
 had the form of a slit, which could not be thus commanded. It was 
 also so near the clavicle that pressure could not be employed below it, 
 and, to my still greater concern, lay on the inner or tracheal side of the 
 vessel, so that the compression required for its closure, instead of being 
 backwards on the vertebrje, was outwards upon the vein. In these 
 circumstances it seemed proper, so far as possible, to lessen the op- 
 posing difficulties, and I therefore ran a bistoury through the skin and 
 the sternal portion of the sterno-mastoid. I then seized the edge of the 
 slit in the artery, as it lay under my finger, with catch-forceps, and 
 desired them to be held so as to draw the vessel towards the trachea ; 
 I then carefully scratched with the point of a knife until the arterial 
 coat was brought into view at its external edge, a little above the 
 aperture, where a ligature was passed by the needle, and tied. I re- 
 peated the same procedure below the wound, and, when it was com- 
 pleted, had the satisfaction of finding that my finger could be with- 
 drawn without the slightest appearance of bleeding, instead of the 
 tremendous gush which had previously attended its slightest displace- 
 ment. The ligatures separated on the tenth day, and the patient 
 recovered completely." 
 
 Prof Syme considered this by far the most arduous operation he 
 had undertaken, from the fact that " the shghtest displacement of one 
 hand must have instantaneouly caused a fatal haemorrhage from the 
 carotid artery, and a wrong direction of the needle by the other, to the 
 smallest possible extent, would have given issue to an irrepressible 
 stream from the jugular vein." 
 
 Mr. Erichsen * gives the following graphic picture of the difficulties 
 of the operation : " The hemorrhage having been completely arrested, 
 either by compression of the artery above the tumor, or by pressure 
 of the fingers at the opening leading into the tumor,t you lay it open 
 freely and completely, turn out the coagula, and syringe away any 
 dark or fluid blood which may be there. You then open the interior 
 
 * Lancet, 1868, vol. ii. p. 505. 
 
 t Mr. Erichsen thus puts Prof. Syme's practical point-" to make a small opening 
 into the tumor, an opening just sufficient to enable you to insinuate your fingers, and 
 so to work your whole hand gradually into the tumor in that way, so that the entrance 
 of the hand may plug up the opening into the sac; to feel with your fingers for the 
 opening into the artery, and to get your fingers against that, so as to restrain the flow 
 of blood from it, before the rest of the sac is laid open." 
 
444 OPERATIONS ON THE HEAD AND NECK. 
 
 of the aneurism. But what is that interior ? It is not the interior of 
 a smooth sac, but it is a large ragged cavity with masses of coagulum 
 or soHd fibrin sticking to it in different directions, with the remains, 
 perhaps, of an old sacculated aneurism at the bottom, with a quantity 
 of plastic matter infiltrating the tissues around it, with the anatomical 
 relations of the parts utterly and completely disturbed and destroyed, 
 with great thickening and solidification of the parts around from the 
 pressure to which they have been subjected in consequence of the 
 effusion of plastic matter. So you have a large cavity with an opening 
 at the bottom of it, the opening leading to the artery somewhere or 
 other, but the position of the artery more or less disturbed, more or 
 less masked and obscured by these masses of coagulum, by this plastic 
 infiltration, by this thickening and cohesion of the tissues to one 
 another around it. The r.ext thing is to pass the ligature around the 
 artery. Now, the artery does not lie exposed in this sac; quite the 
 contrary. You have to scrape, or to dissect, or cut through the poste- 
 rior wall of the sac, which always overlies the artery. That consti- 
 tutes the great difficulty of the operation — to open up this posterior 
 wall in a proper direction, and to get the needle round the part with- 
 out wounding the contiguous vein, or transfixing the artery, or doing 
 damage to the neighboring parts. The best way of doing that, un- 
 doubtedly, is to introduce a large steel probe or a metallic bougie into 
 the opening into the artery, and to use that as a guide to the situation 
 of the vessel. You may use a large one so as to plug up the opening.* 
 .... You then clear the vessel as well as you can — the coats are gen- 
 erally thickened and diseased in the vicinity of the aneurismal tumor 
 — and you pass a good double ligature around it." 
 
 DiflBculties and Possible Mistakes during Ligature of the 
 Common Carotid. 
 
 1. Altered condition of the soft parts — e.g., matted and oedematous 
 from the close contiguity of an aneurism, from previous trial of 
 pressure ; or loaded with blood or inflammatory products, as in the 
 case of a wound. 
 
 2. Presence of an aneurism which encroaches upon the site of 
 incision. 
 
 3. Not hitting the edge of the sterno-mastoid. This muscle may 
 be drawn over the artery if the chin be too much forced to the opposite 
 side. The chin should be kept about midway between the acromion 
 and the episternal notch of the opposite side (Barwell). 
 
 4. Great enlargement of the superior and middle thyroid veins.f 
 
 * In one case, as stated by Mr. Erichsen, Mr. Birkett used a large bougie as a guide. 
 
 t Mr. Barwell (Intern. Encycl. Surg., vol. iii. p. 499) says that the superior thyroid 
 vein, very full and turgid, sometimes runs before, more often behind, the carotid. " I 
 suppose it is the effect of the ansesthetic which causes this to swell to the size of a cedar 
 pencil." 
 
I.IGATUEE OF THE COMMON CAROTID. 445 
 
 5. An enlarged and overlapping thyroid gland. 
 
 6. A large internal jugular overlapping the artery. 
 
 7. Opening the sheath towards its outer side, and so coming down 
 upon, and perhaps injuring, the vein.* 
 
 8. Including one of the nerves f which are in relation with the 
 artery— e.gr., the descendens noni, the vagus, or the sympathetic. 
 
 Causes of Failure and Death after Ligature of the Com- 
 mon Carotid. 
 
 1. Cerebral complications— e.gr., impaired nutrition and softening. 
 Mr. Erichsen J thinks that " cerebral symptoms " (he does not say 
 whether he means fatal ones or no) are liable to occur in 25 per cent. 
 of ligatures of the common carotid. The symptoms of these cerebral 
 complications may come on almost at once or some days after the 
 operation. Mr. Erichsen divides them into two sets— (1) the early 
 ones, resulting from the too small supply of arterial blood, viz., syn- 
 cope, twitchings, giddiness, impaired sight, and hemiplegia; (2) after 
 the above have been present for a few days, and softening has taken 
 place, convulsions and death ensue. § 
 
 It would be, perhaps, worth while, in view of the above mortality, 
 to try pressure before resorting to the ligature, in order that the oppo- 
 site vessels may become enlarged. Pressure could only be kept up, 
 without an ansesthetic, for a few minutes at a time, and care would 
 have to be taken not to apply it at the intended site of ligature. 
 
 * On the dead body, especially, there is a risk of mistaking the flaccid jugular for 
 fascia, and opening it, unless the sheath has been opened over its front and inner part, 
 as should be always the practice. 
 
 f "The descendens noni lies usually on the outer part of the sheath, and will rarely 
 be endangered if that structure is opened as above described ; but it is well to see that 
 it is out of the line taken by the director; if its absence there be verified, it need not 
 be hunted up elsewhere. The pneumogastric lies in the interval between the artery 
 and vein in the back part of, but not loose in, the sheath ; each of the vessels, as well 
 as the nerve, has a compartment, strongly walled, to itself; while the sympathetic, 
 behind the sheath, is also separated by a thick fascia from the vessels. If these 
 anatomical positions be maintained, both nerves are safe. Young operators are some- 
 times made anxious and embarrassed by unnecessary cautions, yet sometimes the parts 
 do not quite maintain their proper positions. Hence it is well, before tightening the 
 ligature, to see that it includes the artery only." — Baewell {toe. supra cit.). 
 
 X Surgery, 7th edition, vol. ii. p. 92. In his calculations Mr. Erichsen includes four- 
 teen cases of ligature of the innominate, though not one of the thirteen fatal cases 
 died from cerebral trouble. Mr. Barwell (loc. supra cit.) argues, from the fact that in 
 no case of ligature of the innominate — an operation which cuts off all the right blood- 
 supply — have cerebral symptoms supervened, that there must be some other cause than 
 brain anaemia for these complications. 
 
 J Mr. Barwell is of opinion that a large majority of the cases in which so-called 
 cerebral symptoms supervened from the seventh to the tenth day were cases of pysemia, 
 and in some cases detachment of minute portions of clot may have been the cause. 
 
446 OPERATIONS ON THE HEAD AND NECK. 
 
 2. Cellulitis and septic complications. 
 
 3. Recurrent pulsation. In most cases this is due to blood finding 
 its way round from the opposite side. The pressure, however, in cases 
 of aneurism, having been relieved, coagulation, as a rule, takeg place, 
 though slowly. 
 
 In a smaller number of cases the recurrence of the pulsation has 
 been of a more permanent kind, from the ligature becoming loosened 
 or dissolved, especially when catgut has been used. 
 
 4. Suppuration of the sac. Mr. Erichsen states that this is not very 
 uncommon. " In the majority of cases the patient eventually does 
 well." 
 
 5. Hsemorrhage. This has never been a common complication, 
 owing to the absence of branches. It may take place from the site of 
 ligature * or from a suppurating sac. It should be still more rarely 
 met with in the future, owing to the modern treatment of wounds. 
 
 6. Low forms of lung-inflammation. Mr. Erichsen states that these 
 are not uncommon. He attributes them to diminished freedom of the 
 respiratory movements owing to the disturbed circulation in the 
 brain and medulla. 
 
 LIGATURE OP THE EXTERNAL CAROTID (Fig. 89). 
 
 This operation has not received the attention which it deserves, 
 having been too often set aside for the easier operation of ligature of 
 the common trunk. 
 
 Mr. Cripps,t discussing the ligature of the external carotid in the 
 treatment of hsemorrhage from punctured wouirds of the throat and 
 neck, states that the objections raised to the above operation are : 
 
 1. The fear of secondary hajmorrhage from the seat of ligature due 
 to the close proximity of its larger branches. 
 
 In answer to this he refers to M. Guyon's J collection of twenty -seven 
 cases of ligature of the external carotid, to which he adds three. In 
 only one case of these thirty did secondary hajmorrhage occur. Larger 
 statistics than these have been furnished by Dr. Wyeth, of New York. 
 He states that, of sixty-seven cases in which the external carotid .alone 
 was tied, three died, and that all these fatal cases were from gunshot 
 
 * This danger would seem to increase the lower down the ligature is placed. Mr. 
 Barwell says that the only fatal ease of secondary hsemorrhage he has had in this 
 operation followed the ligature of a carotid with catgut close above the sterno-clavicular 
 joint. It is not stated whether the wound was aseptic throughout or not. 
 
 t Mrd. Ohir. Trans., vol. Ixi. p. 234. 
 
 % Mem. de la Soc. de C'hir., vol. vi. According to Prof. Agnew (Prin. and Praat. of 
 Surg., vol. i. p. 636), out of nineteen cases of ligature of the external carotid only one 
 proved fatal from haemorrhage, and none from causes which could properly be at- 
 tributed to the operation. 
 
LIGATURE OF THE EXTERNAL CAROTID. 447 
 
 injuries in military practice. One of these fatal cases died on the 
 table from the effects of haemorrhage before the ligature could be 
 applied. In the other two the cause of death is not given. Of the 
 sixtj'-seven cases, haemorrhage occurred after ligature in five, none of 
 which proved fatal. In four of these the bleeding was noted as 
 occurring at the seat of lesion beyond the ligature. In one the point 
 of bleeding is not given. The artery was tied on both sides in two 
 patients and both recovered. 
 
 Dr. Bryant, of New York,* states that he can add sixteen cases to 
 the above sixty-seven, and that in only one of these did the subse- 
 quent death bear the least relation whatever to the operation itself 
 
 •2. The futility of the operation, should the wounded vessel be the 
 internal carotid. 
 
 Mr. Cripps answers this objection by comparing the rareness of a 
 wound of the internal carotid with one of the external or its branches. 
 He points out that, of eighteen cases in which the bleeding vessel was 
 identified, the internal one was wounded twice alone and once in con- 
 junction with the external.t 
 
 3. The external carotid is less easy to ligature than the common. 
 
 This objection will not be considered for a moment by a surgeon 
 who knows his anatomy, and who is in the habit of operating. 
 
 The advantages of the operation are : 
 
 1. That circulation through the brain is not in the least interfered 
 with. Consequently, one large element of danger is avoided (p. 445). 
 
 2. The incision made over the external carotid will also expose the 
 bifurcation and the internal carotid, and may thus lead to a direct 
 exposure of the wounded vessel. 
 
 Indications. 
 
 i. Wounds of the Trunk and of its Branches. — This subject has been 
 already alluded to (p. 434). While it cannot be denied that the easier 
 operation of ligature of the common trunk has answered in some of 
 these cases, it has also certainly failed repeatedly. Considering the 
 rarity of wounds of the internal carotid, the surgeon will do more 
 wisely, in the case of a wound over the carotid area, to expose and tie 
 
 * Ann. of Surg., August, 1887, p. 122. In this fatal case both external carotids had 
 been tied to check the rate of progress of malignant disease of the lower jaw, floor of 
 mouth, and tongue, which had been operated on repeatedly vTithout success. 
 
 t Mr. Cripps's list is interesting to the surgeon. In the first 10 it is to be presumed' 
 that ligature of the external carotid would have been the wiser course. In 2 the 
 bleeding came from the external carotid; in 1, the lingual; in 1, the facial; in 1, 
 a tonsillar branch ; in 1, a branch in the parotid gland ; in 2, the internal maxillary ;. 
 in 1, the inferior dental ; in 1, the middle meningeal ; in 1, the vertebral ; in 2, the 
 internal carotid ; in 1 the external also was wounded ; in 1 the source was close to 
 the bifurcation; in 2 the common carotid, at the point of bifurcation, was wounded ; 
 in 1, the ascending pharyngeal. 
 
448 OPERATIONS ON THE HEAD AND NECK. 
 
 the external carotid low down in any cases of doubt, that the trunk 
 and the internal carotid may be exposed as well, if needful. 
 
 Mr. Rivington has recorded * an interesting case of a wound of the 
 external carotid by a stab in the parotid region giving rise to recurrent 
 attacks of haemorrhage, and treated successfully by temporary f liga- 
 ture of the common carotid and ligature of the external carotid at the 
 seat of injury. 
 
 A man, aged thirty-one, was admitted into the London Hospital 
 with three wounds, one severing the lobule of the left ear and passing 
 into the parotid gland below the zygoma, a second behind the ear, and 
 a third over the mastoid process. Haemorrhage, occurring about a 
 week later, was stopped by pressure. Erysipelas followed, and an ab- 
 scess was opened in front of the ear. About three weeks after the 
 accident, hasmorrhage again occurred, being brought on by a fit of 
 coughing, blood running out from all the incisions. Though it was 
 again arrested by pressure, Mr. Rivington judged, from the size of the 
 stream and the force of the jet, that the injured vessel must have been 
 the external carotid on the parotid gland. 
 
 On account of the difficulty of securing the artery at the seat of 
 injury, and the amount of blood which would be lost before this could 
 be accomplished, and not being able to rely upon pressure on the 
 common carotid during the operation, Mr. Rivington cut down first 
 on the common trunk at its bifurcation J and placed a temporar}' liga- 
 ture of catgut round it, tying this lightly so as to stop the current of 
 blood, but not to divide the inner and middle coats. 
 
 The openings in the parotid region being explored and clots turned 
 out, a little below the angle of the jaw was found a hole from which 
 some blood issued in a feeble stream. The external carotid was liga- 
 tured above and below this spot. The ligature in the main trunk was 
 then untied, and left in situ for use if needed. All bleeding had ceased 
 and there was no recurrence. The patient made a good recovery, 
 .«ome weakness of the face muscles having almost disappeared when 
 he left the hospital two months after the accident. 
 
 Mr. Rivington draws attention to the advantage of the temporary 
 ligature on the main trunk, rendered very evident by the fact that • 
 immediately before the operation, when the sponge was removed arte- 
 rial blood spirted out in a lively jet, whilst after the ligature a languid 
 stream only issued, from the distal side of the hole in the external 
 carotid. He further points out that the employment of temporary 
 
 * Clin. Soc. Trans., vol. xvii. p. 79. 
 
 f Some cases in which Mr. Treves has more recently made use of this step are given 
 at p. 441. 
 
 X It remained uncertain whether this temporary ligature was placed on the external 
 or the common carotid. 
 
LIGATUEE OF THE EXTERNAL CAROTID. 
 
 449 
 
 ligatures, either lightly tied or left in situ for use in case of need, is 
 capable of wider application in the treatment both of hfemorrhage and 
 of aneurisms. 
 
 ii. Aneurism by Anastomosis of Scalp and Side of Plead and Neck 
 (Fig. 88).— Here the ligature of the external carotid should only be 
 made use of as an adjunct to local treatment, or where this has failed. 
 
 If the growth is not too large, it should be excised with antiseptic 
 precautions, tying each vessel as it is cut. The operation may be 
 rendered partly, if not entirely, evascular, by the use of stout india- 
 rubber bands passed round the back of the head and the lower jaw, 
 with pledgets of lint over the main vessels— e(/., temporal or external 
 carotid, posterior auricular, and occipital. Another method is one 
 made use of by Mr. Hutchinson* in the removal of an enormous 
 fibro-cellular tumor of the scalp— viz., a Petit's tourniquet passed 
 around the back and sides of the head and lower jaw (p. 151). 
 
 If the above are not applicable, the external carotid may be tied 
 preliminary to removing 
 
 the tumor. When this is ^i°- ^^• 
 
 being effected, any skin 
 that is not too much in- 
 volved should be pre- 
 served. If this is impos- 
 sible, the growth must be 
 taken away with the skin 
 over it, the vessels being 
 secured as cut. Every 
 pains must be taken to 
 keep the wound aseptic, 
 and thus promote rapid 
 granulation-healing, com- 
 pleted by skin-grafting. 
 
 If the tumor cannot be 
 excised, it should be 
 treated by underrunning 
 the main vessels of sup- 
 ply with pins, in order to 
 bring about their closure 
 and ultimately the oblit- (Fergusson.) 
 
 eration of the growth. 
 
 The case from which Fig. 88 is taken was that of a woman, aged 
 twenty-two, who was thus treated by Sir W. Fergusson.f The com- 
 
 * Land. Hosp. Heps., vol. ii. See also the cases referred to above, p. 151. 
 t Practical Surgery, 4th edition, p. 162, Fig. 73. 
 
 29 
 
450 OPERATIONS ON THE HEAD AND NECK. 
 
 mon carotid had been previously tied by Mr. Storks, but the vessels 
 slowly increased in size. Long needles were passed under and through 
 the vessels at the most prominent points, being sufficiently strong to 
 bear the pressure made by twisting strong threads about them over 
 the included vessels and scalp. At some points sloughing occurred, 
 elsewhere ulceration loosened the needles, and throughout the parts 
 interfered with there was inflammation and induration. In about 
 three weeks, as anticipated, haemorrhage took place. Digital pressure 
 was made use of till fresh needles were introduced and the old ones 
 withdrawn, when threads were again applied and the bleeding arrested. 
 Further inflammation and obliteration of the vessels ensued, repeated 
 hsemorrhages were arrested in a similar manner, the formidable affec- 
 tion being ultimately completely obliterated. 
 
 In a similar case it would probably be wiser to tie the external car- 
 otid before inserting the pins. 
 
 The following case, published by Mr. Wood,* is an excellent in- 
 stance of the same treatment aided by the antiseptic advantages of the 
 present day : 
 
 A man, aged thirty-seven, had a pulsating tumor in the right parie- 
 tal region of the size of a hen's egg, with a bruit, together with a pul- 
 sating swelling running forwards to the left orbit, the eyeball being 
 pushed forwards, while a loose, pulpy, nsevoid condition extended 
 into the occipital region. With antiseptic precautions, stout steel pins 
 were run under the right supra-orbital, temporal, and occipital arte- 
 ries. The left occipital and temporal had to be occluded before the 
 pulsation stopped, and four pins were also passed under the swelling 
 itself and its neighborhood. The pins were passed quite down to the 
 bone, and were made to emerge clear beyond the vessels. These were 
 compressed with silk over thick india-rubber pads, which served to 
 tighten up the pressure as the pins cut through. About an hour after 
 the operation intense neuralgic pain in the occipital region was expe- 
 rienced from inclusion of the nerve. The antiseptic precautions were 
 stopped in ten weeks, and the patient was quite cured without any 
 bleeding, suppuration, or sloughing, save, to a very limited extent, at 
 one spot. 
 
 As these cases are most obstinate, my readers will excuse me if I 
 draw their attention to another case proving that ligature of the ex- 
 ternal carotid (even if performed on both sides) is not likely to be 
 successful without local treatment as well — viz., either underrunning 
 the vessels with pins, or excision. It is recorded by Dr. Bryant, of 
 New York.f The patient, aged twenty-four, had a well-defined pul- 
 
 * Lancet, 1881, vol. ii. p. 255. 
 
 f Annals of Surgery, August, 1887, p. 116, 
 
LIGATURE OP THE EXTERNAL CAROTID. 451 
 
 sating tumor at the site of a healed scalp-wound in front of the left ear. 
 The trunk and branches of the temi^oral and the occipital were con- 
 cerned in the growth. As this was rapidly increasing, the left external 
 carotid was tied with catgut about half an inch above its origin. 
 Tying the lingual artery also provided a branchless portion of the 
 external carotid about an inch in extent. The ascending pharyngeal 
 was sought for, but not found. All pulsation was at once checked, 
 and the growth was also reduced to about one-third of its previous 
 size. The operation was antiseptic throughout, and when the dress- 
 ings were changed for the first time in ten days, a slight return of 
 pulsation was noticed in the tumor. A month after the operation, 
 pulsation, thrill, and bruit were nearly as strong as before, and it was 
 decided to attack the tumor itself in preference to tying tlie occipital 
 and temporal branches or the right external carotid. The arterial 
 circulation was admirably controlled by surrounding the head with 
 two strong rubber bands, beneath which compresses were placed at 
 the points where arteries passed to supply the scalp. Dr. Bryant has 
 found eight other cases of ligature of the external carotid for the cure 
 of aneurismal tumors of the head, face, and parotid gland, in two of 
 which both the vessels were tied simultaneously. This latter pro- 
 cedure is not reported to have been successful in either case. Of a total 
 of nine cases, only one, a traumatic aneurism of the parotid, was cured 
 by ligature alone. 
 
 Thus it would appear that local remedies — viz., excision and under- 
 running, aided by ligature of the chief feeding arteries — are most 
 likely to be successful in this disease, which so often baffles treatment. 
 Ligature of the external carotid, on one or both sides, will fail, owing 
 to the free collateral circulation, if tried by itself even in recent trau- 
 matic cases without much general dilatation of the vessels. If used 
 at all, it should be so as an adjunct and a preliminary step to dimin- 
 ish the vascularity of the tumor before this is dealt with locally by 
 the methods above indicated. 
 
 iii. Aneurism of the External Carotid. — The treatment of this rare 
 condition has been already discussed at p. 432. 
 
 iv. As a Preparatory Step to extirpating Malignant Tumors of the 
 Upper Jaw, Pharynx, etc., or as a PaUiative Step where the above 
 Extirpation cannot be attempted.— This question has already been 
 discussed at p. 437. The following cases, just pubhshed,* are of 
 interest as bearing on this matter. In each of these cases repeated 
 operations had been performed for removal of malignant disease in- 
 volving the lower jaw, floor of the mouth, and more or less of the 
 tongue. Rapid recurrence had taken place in each case, until, the use 
 
 * Dr. Bryant, Ann. of Surg., August, 1887, p. 121. 
 
452 OPERATIONS ON THE HEAD AND NECK. 
 
 of the knife no longer seeming feasible, the only course seemed to be 
 starvation of the growth. Accordingly this was attempted by simul- 
 taneous ligature of both external carotids, by incisions in the usual 
 place, the enlarged lymphatic glands found being removed- When 
 the carotids were reached, most unusual anomalies were found. The 
 right common carotid bifurcated beneath the posterior belly of the 
 digastric, which was divided to admit of passing the ligature. On the 
 left the bifurcation was behind the hypo-glossal nerve, which was 
 drawn down, and the ligature then passed just below the digastric. 
 The lingual and facial branches were not seen on the right side, but 
 this caused no apprehension, as the facial was said to have been tied 
 some months before, during removal of the diseased submaxillary 
 gland on that side. On the left side the branches of the external car- 
 otid were normal. The operations were antiseptic throughout. The 
 malignant growth diminished in size rapidly, the discharge became 
 scanty, thin, and watery, and the ability to speak and swallow im- 
 proved quickly. On the fifth day a portion of the growth on the right 
 side sloughed out, leaving an aperture bounded by sloughy tissue, at 
 the bottom of which could be seen necrosed bone in the lower jaw. 
 Nine days after the operation profuse htemorrhage took place, with a 
 fatal result. This hgemorrhage was caused by sloughing of some of 
 the diseased starved tissue, into which the trunk common to the facial 
 and lingual passed. 
 
 In the second case of Dr. Bryant no htemorrhage or sloughing fol- 
 lowed on the ligature of the external carotids. For two months the 
 state of the patient was much improved, the growth showed but little 
 tendency to increase, and the pain and dysphagia did not return- 
 Then profound cancerous cachexia set in, with emaciation and loss 
 of strength, beyond which there is no note of the patient. 
 
 V. Haemorrhage from Middle Meningeal Artery after trephining. — 
 This matter has been fully considered at p. 178, where it is shown 
 that severe hfemorrhage is not uncommon after a wounded middle 
 meningeal has been exposed by trephining, but that the bleeding will 
 usually yield to measures short of ligature of the external carotid. 
 
 Guide. — The anterior border of the sterno-mastoid above the hyoid 
 bone. 
 
 Relations. — The external carotid extends from the upper border 
 of the thyroid cartilage to a point midway between the external audi- 
 tory meatus and the condyle of the jaw ; beyond this point it is con- 
 tinued on as the temporal, having just before given off the internal 
 maxillary. In the first part of its course the external is somewhat 
 nearer the middle line than the internal carotid, and is more superfi- 
 cial than this throughout. 
 
LIGATURE OP THE EXTERNAL CAROTID. 
 
 453 
 
 In Front. 
 Skin ; fasciae ; platysma ; nerves from transverse cervical 
 
 and facial ; superficial veins. 
 Lingual and facial veins. 
 Digastric and stylo-hyoid. 
 Parotid, facial nerve ; temporo-maxillary and other 
 
 veins. 
 
 Inside. ' 
 Pharynx. 
 Hyoid bone. 
 Ramus of jaw. 
 Parotid. 
 
 External 
 carotid. 
 
 Outside. 
 
 Parotid, 
 
 Temporo-maxillary vein, when 
 this descends to join the in- 
 ternal jugular. 
 
 Behind, 
 Parotid gland, 
 Superior laryngeal, 
 Glosso-pharyngeal. 
 Stylo-glossus and stylo-pharyngeus. 
 
 The veins in relation with the. external carotid vary a good deal. 
 But, in addition to the lingual and facial crossing it, a number of 
 veins joining the external and anterior to the internal jugular may' 
 form a kind of jjlexus round the artery, and the temporo-maxillary 
 may descend outside the artery to join the internal instead of the 
 external jugular. 
 Branches : * 
 Anterior. Posterior. Ascending. Terminal. 
 
 Superior Auricular. Ascending Temporal. 
 
 thyroid. Occipital. pharyngeal. Internal 
 
 Lingual. maxillary. 
 
 Facial. 
 Operation. — This is performed at two spots : 
 a. Below the digastric (Fig. 89). 
 h. Above this muscle, behind the ramus of the jaw. 
 a. Below the Digastric. — This is the operation more frequently 
 performed in order to cut off the blood-supply through all the 
 branches of the artery. Though these are so numerous, arid vary 
 
 * While this is a common arrangement, it is by no means the only one. Very fre- 
 quently one trnnk gives off two or three arteries. Sometimes all the branches, save 
 the two terminal, arise very close together, the external carotifl constituting them an 
 arterial axis. It is the presence of these branches which enables the snrgeon to 
 decide whether he is dealing with the external or internal carotid. 
 
454 
 
 OPERATIONS ON THE HEAD AND NECK. 
 
 somewhat, there is usually a spot, varying from J to f inch, between 
 the superior thyroid and the lingual on which a ligature may be 
 safely placed, especially if the superior thyroid and Unguals are liga- 
 tured as well (p. 451). 
 
 The position of the patient's head and the surgeon being the same 
 as in the operation on the common trunk, an incision 2i to 3 inches 
 
 Fig. 89. 
 
 Ligatiire of the temporal, facial, external carotid, and occipital artery is shown here. In the 
 ligature of the external carotid, the angle of the jaw, digastric, an^ opened deep cervical fascia 
 are seen above. Overlying the artery is an enlarged lymphatic gland ; outside it is the inner 
 edge of the sterno-mastoid ; the facial vein crosses it, and descemding to join this on the inner 
 side is a large communicating branch from the internal maxillary vein. The occipital artery is 
 shown ligatured behind the mastoid process. The edges of the cut posterior half of the sterno- 
 mastoid are shown in the upper and lower parts of the wound. Above the artery, under the 
 upper part of the thread, is a part of the splenius capitis, cut. The vessel itself rests on some 
 fascia continuous with that over tlio complexus. 
 
 long is made, in the line of the artery, from the angle of the jaw to the 
 upper border of the thyroid cartilage, about i inch in front of the 
 anterior border of the sterno-mastoid. This incision should divide 
 
LIGATURE OF THE INTERNAL CAROTID. 455 
 
 skin, fasciae, and platysma ; any superficial veins being secured, the 
 cellular tissue in front of the muscle is opened up, and the posterior 
 belly of the digastric or the hypo glossal sought for as guides to the 
 vessel. In doing this the sterno-niastoid should be drawn outwards, 
 any large veins— e.g., facial or lingual— pulled aside with a strabismus 
 hook or secured with double chromic gut ligatures before division. 
 The muscle or the nerve being defined, the pulsation of the artery is 
 felt for below them, and the vessel carefully cleaned just above the 
 thyroid cartilage. The use of the steel director or knife should be 
 most cautious on the outer side of the artery, where lie, below, the 
 internal jugular and internal carotid. At the .same time the presence 
 of the descendens noni on the artery is to be remembered, and that of 
 the superior laryngeal nerve running obliquely downwards and 
 inwards behind the vessel. The needle should be passed from with- 
 out inwards. The superior thyroid and lingual should be ligatured 
 at the same time, and the ascending pharyngeal if it can be found. 
 
 b. Above the Digastric, behind the Ramus of the Jaw.— 
 This operation has the disadvantage of probably entailing the division 
 of important branches of the facial nerve. 
 
 The head and shoulders being duly raised and supported, the sur- 
 geon makes an incision downwards from the tragus of the ear, just 
 behind the ramus of the jaw, dividing the skin and fasciae. The 
 sterno-mastoid must be now drawn outwards and the digastric and 
 stylo-hyoid downwards, and it will probably be needful to divide 
 these latter muscles partially in order to secure the artery before it 
 enters the parotid gland, this structure being drawn upwards and 
 forwards. 
 
 The needle -may be passed from either side as is most convenient to 
 the surgeon. 
 
 Several veins communicating between the facial and the external 
 jugular will probably cross the line of incision, and must be dealt 
 with. 
 
 LIGATURE OF THE INTERNAL CAROTID. 
 
 Indications. — These are extremely few. 
 
 1. Wounds, usually Stabs. — The following striking case is quoted 
 by Dr. Lidell,* and reflects the greatest credit on the medical men 
 concerned : 
 
 On July 31, 1869, a man was wounded in the neck, at the angle of 
 the lower jaw, by the large blade of a pocket-knife, which penetrated 
 several inches, opening the internal carotid. Alarmed by the tremen- 
 dous outjets of arterial blood, Dr. Denning, in whose drug-store the 
 
 * Intern. Encyd. of Surg., vol. iii. p. Ill ; Amer. Journ. Med. Sei., January, 1879, pp. 
 142, 143. 
 
456 OPERATIONS ON THE HEAD AND NECK. 
 
 stabbing occurred, at once compressed the carotids. Happening to be 
 close at hand, Dr. A. T. Lee promptly cut down upon the artery by 
 the usual incision, exposed it- by careful dissection, found the bleed- 
 ing-point, and applied a ligature on the cardiac side of it. Haemor- 
 rhage now occurring from the upper end was arrested by a ligature 
 on the distal side of the wound. The patient was now pulseless, and 
 death was considered imminent, but, under energetic stimulation 
 with whisky and ammonia, the circulation soon became good, and the 
 patient made a good recovery, being in active work nine years later. 
 
 2. Aneurism.* — If this is non-traumatic f in origin and sacculated, 
 the decision as to treatment, if pressure has failed, must lie between 
 the Hunterian operation of ligaturing the common carotid, or, if the 
 artery is sound, and if there be room above as well as below the aneu- 
 rism, of placing ligatures above and below the sac, and opening this 
 to turn out the clots. But one or both of these conditions may very 
 likely be absent. 
 
 If the aneurism be traumatic in origin, resulting from a stab or 
 gunshot injury in the neck, or if, in spite of other treatment, it is 
 steadily increasing, the only operation likely to avail is the old one. 
 
 The following cases are excellent instances of the difficulties which 
 may be met with in these cases, and how they should be met : 
 
 Dr. Prewitt, of St. Louis,J has recorded the following most interesting 
 case of traumatic aneurism following a gunshot injury : A negress, 
 aged seventeen, was shot with a revolver bullet, which entered the 
 cheek over the malar bone and passed backwards. Profuse hasmor- 
 rhage took place at once from the wound of entrance, there being none 
 of exit. This was controlled by pressure. A swelling quickly ap- 
 peared between the ramus of the jaw and the mastoid process, which 
 three months later was found to project into the pharyngeal cavity, 
 crowding the tonsil over the middle line and resting against the uvula.§ 
 
 * Anenrisin of the internal carotid liere refers to the cervical part of the artery. 
 The treatment of orbital aneurism, which often depends on arterio-venous communi- 
 cation (traumatic or idiopathic) between the internal carotid and the cavernous sinus, 
 has already been considered at p. 432. 
 
 f The rareness of disease, and thus of idiopathic aneurism, here is well known. 
 
 I Trans. Amer. Surg. Assoc, vol. iv. p. '2'S'S. 
 
 ^ With reference to this tendency of internal carotid aneurisms to project inwards, 
 Dr. Prewitt thus quotes from Prof. Agnew {>Siir<jery, vol. i. p. 591) : "The deep situ- 
 ation of the artery, covered as it is externally by the stylo-hyoid, stylo-pharyngeus, 
 and stylo-gloKsus muscles, and by dense aponeurotic structures, which extend down to 
 the styloid process, prevents any very marked prominence of such a tumor on the sur- 
 face of the neck, and, as the artery is separated from the pharynx only by the mucous 
 membrane and the constrictor muscle, its extension inwards becomes an anatomical 
 necessity. Indeed, in this peculiarity lies the chief diflerence between aneurism of the 
 internal carotid and aneurism situated at the division of the common trunk " 
 
LIQATTJEE OF THE INTERNAL CAROTID. 457 
 
 Externally the swelling reached from' the temporal bone to the hyoid. 
 Expansile p\ilsa.tion, well-marked bruit, and thrill were present. Sense 
 of taste was lost in the right side of the. tongue, which was atrophied, 
 and, when protruded, inclined to the right. Pressure on the common 
 carotid arrested pulsation in the tumor, and caused some decrease in 
 size. There was no perceptible difference in the right and left tem- 
 poral pulses; the pupils were equal. There was persistent headache, 
 and sometimes roaring in the right ear. Difficulty in swallowing had 
 existed from the first. The general condition was unsatisfactory. 
 
 It was decided to tie the common carotid at once, l^ut though the 
 pulsation and thrill in the sac seemed arrested at first, they returned 
 in a few minutes. It was then decided, as a forlorn hope (because the 
 diagnosis had placed the opening of the sac close to the carotid 
 foramen), to extend the incision upwards in front of the tragus to de- 
 termine the feasibility of laying open the sac and tying the vessel upon 
 the distal side of it. 
 
 A cautious dissection * at the back and upper part of the sac showed 
 that this filled all the space between the mastoid process behind and 
 the condyle and ramus of the jaw in front, the sac seeming also to 
 blend with the skull or to be closely adherent to it. A little reflection 
 made it apparent that any attempt to deal with the sac after the 
 method of Mr. Syme would in in all probability prove disastrous, as 
 it would almost certainly be found that there was no portion of the 
 artery between the carotid foramen and the sac to be tied. The wound 
 was washed out with bichloride solution, drained, and closed. On the 
 evening of the eighth day, there having been pyrexia and free suppu- 
 ration of the wound in the interval, haemorrhage took place from the 
 sac. The wound was enlarged, and search made with the finger for 
 the orifice of the artery or the carotid foramen. The search being 
 fruitless, and it seeming certain that laying open of the sac or re- 
 moval of the finger would be followed by speedily fatal hajmorrhage, 
 the sac was strapped with strips of lint rolled in iodoform. Hicmor- 
 rhage did not recur, but the patient died exhausted twenty-five days 
 after the first ojaeration. 
 
 The autopsy was conducted under great difHculty, but it was thought 
 that it was made out that the opening in the artery was close to the 
 carotid foramen. Death seemed largely due to septic causes, e.g., 
 thrombosis of the inferior petrosal and of the lateral sinuses. 
 
 Dr. Prewitt points out that such an aneurism might be mistaken for 
 
 * It was suggested by Prof. Agnew, at tlie disciis?ion on this paper, that the jaw 
 should have been divided and the pieces pulled aside to facilitate further dissection, but 
 Dr. Prewitt found that the jaw and sac were closely adherent, and, even if separation 
 could have been effected, there would have been no artery above that could have been 
 tied. 
 
458 OPERATIONS ON THE HEAD AND NECK. 
 
 one of the occipital, vertebral, and perhaps of the internal maxillary 
 or one of its branches. The chief diagnostic points are the projection 
 into the pharynx, the evidence of pressure on- the vagus and glosso- 
 pharyngeal (p. 456), and the exclusion of the vertebral, by the effects 
 of pressure below the sixth cervical vertebra (p. 461). He also shows 
 by several cases that aneurism of the internal carotid has repeatedly, 
 owing to the interference with speech and swallowing, the pain in the 
 neck, and the difficulty in opening the mouth, been taken for tonsillar 
 abscess, and with fatal results. One of these cases may be quoted 
 here : 
 
 A man, aged twenty-eight, was shot, on September 30, 1879^ through 
 the right infra-orbital region. No haemorrhage. At the end of a week 
 the swelling in the face had entirely subsided, but tumefaction of the 
 right side of the neck remained. On the eighth day the patient was 
 out. On the fifteenth he called at Dr. Lee's office, and complained of 
 inability to speak or swallow, and also of severe pain in the right side 
 of the neck, which he said he could not bend. His appearance was 
 that of a man suffering from severe tonsillitis. With considerable 
 difficulty Dr. Lee succeeded in opening the patient's mouth enough to 
 permit of limited inspection. The tonsils and soft palate were so 
 swollen as to preclude inspection of the pharynx. On the hard palate 
 there was a small firm tumor about the size of a hickory-nut. Think- 
 ing this might be the ball surrounded by inflammatory products, an 
 exploratory incision was made. On the removal of some clots of blood, 
 there was a gush of arterial blood. In consequence of the struggles 
 of the patient. Dr. Lee was unable to control the haemorrhage, and 
 death ensued in a few minutes. 
 
 In the discussion which followed on Dr. Prewitt's paper, the follow- 
 ing case of traumatic aneurism of the internal carotid following a stab 
 in the neck w^as related by Dr. Briggs, of Nashville : 
 
 A man, aged twenty-three, had an expansile tumor in the left parotid 
 region, encroaching on the throat, causing difficulty in swallowing. 
 There was a loud bruit, and pulsation in the swelling was lessened by 
 pressure on the common carotid. A small cicatrix pointed to the re- 
 ceipt of a stab six weeks before. 
 
 Acting on the principle that a traumatic aneurism is simply a 
 wounded artery, and should he treated as such. Dr. Briggs performed 
 the old operation. A knife being pushed into the most prominent 
 part of the swelling, this opening was plugged with a finger, which np- 
 pearetl to find the wound in the artery. The opening being enlarged 
 upwards and downwards, lar^e clots were removed, followed by a gush 
 of arterial blood, which was arrested by stuffing the wound with 
 spon<i:es. The incision being prolonged downwards, the common 
 carotid was tied. On the removal of the sponges the hasmorrhage was 
 
LIGATURE OF THE INTERNAL CAROTID. 459 
 
 as violent as before, and was only arrested by the pressure of a finger 
 in the sac. While this was kept up, the tissues were scratched through, 
 and a ligature placed above and below the opening. Though the in- 
 cision measured 8 inches, there was scarcely sufficient room. At the 
 bottom of the wound the styloid process could be seen, and just ante- 
 rior and internal to it the ligatures on the internal carotid. The pa- 
 tient made a good recoverjr. 
 
 It will be seen that the two cases of Dr. Prewitt and Dr. Briggs differ 
 widely. Though both were traumatic, in one there was room to place 
 a distal ligature,* in the other there was not. The fact that, in the 
 latter, hamorrhage did not recur for the twenty- five days in which the 
 patient lived after plugging the sac, leads one to hope that plugging 
 with aseptic gauze, firmly and carefully against the base of the skull, 
 might be successful in such another case, if the wound could be kept 
 aseptic, and the dysphagia met by tube-feeding. 
 
 LiA^E AND Guide. — These are practically the same as those given for 
 the common carotid. The internal carotid lies outside and rather be- 
 hind the external carotid. Soon after its commencement it becomes too 
 deeply placed to admit of ligature. 
 
 Relations in the Neck : 
 
 In Front. 
 Skin ; fasciae ; platysma. 
 
 Sterno-mastoid ; stylo-glossus ; stylo-pharyngeus. 
 Glosso-pharyngeal nerve. 
 
 
 Parotid 
 
 gland. 
 
 
 
 
 
 Outside. 
 
 
 
 I 
 
 nside. 
 
 
 Internal 
 
 Vagus. 
 
 jugular. 
 
 
 Internal 
 carotid. 
 
 Behind. 
 
 Pharynx. 
 
 Ascending 
 
 Tonsil. 
 
 phary: 
 
 ngeal. 
 
 
 
 Rectus capitus anticus major. 
 Superior laryngeal nerve. 
 
 
 
 Operation. — This is much the same as that for Egature of the ex- 
 ternal carotid. The artery can only be tied in its first and more su- 
 perficial part. It here lies outside and rather behind the external 
 carotid. 
 
 Thus the incision should be made along the anterior border of the 
 
 * Dr. BriggR, in replying (p. 256), said that, thongh the opening in the internal 
 carotid was very clcse to the caroti 1 canal, not more than •] inch from it, the operation, 
 was not so very difficult. 
 
460 OPERATIONS ON THE HEAD AND NECK. 
 
 sterno-mastoid, and not just in front of it, the centre of the incision 
 lying about i inch above the upper border of the thyroid cartilage. 
 The sterno-mastoid being defined, and the cellular tissue opened up 
 in front of it, the same superficial structures will be met with as in 
 the external carotid (p. 45ij. When the carotids are found, the ex- 
 ternal should be drawn inwards, and the internal outwards, the 
 digastric being pulled upwards. The needle should be passed from 
 without inwards, avoiding the internal jugular and the vagus. 
 
 LIGATURE OF THE VERTEBRAL ARTERY. 
 
 Indications. 
 
 (1) Wounds, (2) Traumatic Aneurisms, may be considered together. 
 There is liable to be much obscurity as to whether it is the vertebral 
 or some other artery — e.g., inferior thyroid, ascending cervical, common 
 carotid, or, if higher up, the occipital which is attacked, and further, 
 when it is decided that it is the vertebral artery, it is by no means 
 easy to carry out satisfactory treatment. The best course is to enlarge 
 the wound, and to decide, with the finger, the relation of the wounded 
 vessel and of the haemorrhage to tlie transverse processes of the ver- 
 tebrte. The direction of the wound, and the effect of pressure below 
 and above the level at which the vertebral ceases to be compressible 
 — i.e., aViove the "carotid tubercle " (rkfe infra) — will als'j be helpful. 
 
 If the wound is low down, there are between 2 and 3 inclies of the 
 artery available for ligature, and this should be placed above and 
 below the wound (p. 464 i. But if, as is more frequent, the wound is 
 higher up in the neck, it will be almost impossible, even after exposing 
 and clipping away the anterior roots of the transverse processes, to 
 find and secure the arter}', and the best course will be to plug the 
 wound, as successfully done by Dr. Kocher, of Berne.* This case is 
 usually described as one of traumatic aneurism, but it is doubtful how 
 far this word should be applied to it. 
 
 A man, aged forty-eight, had tieen stabbed in the neck. Daily 
 h£emorrhage.s, often profuse, took place for three weeks, in spite of 
 plugs of cbajpie soaked in perchloride of iron. On admission into 
 the hospital a wound was found about an inch to the left of the spine, 
 at the level of the fifth and sixth cervical vertebne. Through the 
 wound was seen a swelling, feebly pulsating. (_>n remo'\'ing coagulum 
 and openin'j up the wound, free arterial ha?morrhage came from a 
 cavity about the size of a small apple, at the bottom of which trans- 
 verse processes could Ije felt. The Ijleeding came both from the central 
 and peripheral ends of the artery, between the transverse processes of 
 
 * Langenbeck's Arrh.f Klin. Clu'r., Bd. xii. ?. '-07. A full abstract of the paper is 
 given in the Syd. .S'oc. Birn. Rctr., 1^71-7:2, p. 2iJ2. 
 
LIGATURE OF THE VERTEBRAL ARTERY. 461 
 
 apparently the fifth and sixth vertebrso. As a ligature could not be 
 applied, a pea-like bit of charpie, soaked in solution of iron perchloride, 
 was introduced between the transverse processes. Carbolized dress- 
 ings were applied, and the head kept fixed with a stiff collar. On 
 removal of the plug on the fourth day, partly with a stream of water, 
 partly with forceps, no bleeding followed. The patient was discharged 
 cured in five weeks, having had a slight attack of erysipelas. 
 
 In the above paper Maisonneuve is said to have tied both the verte- 
 bral and inferior thyroid arteries and removed a bullet. The haemor- 
 rhage was arrested, but death occurred from purulent infiltration into 
 the spinal canal. This appears to have been a case of ligature of the. 
 artery before its entrance into the vertebral canal. 
 
 Aneurisms of the vertebral are always traumatic. There are about 
 twenty-four* cases on record of aneurisms and wounds of this vessel. 
 The situation varies much. Usually it is high up, near the mastoid 
 process.! 
 
 The difficulty of diagnosis of wounds of the vertebral and other ar- 
 teries, and their results, have been already alluded to. Mr. Holmes J 
 states that there are eleven cases in which the carotid has been tied 
 for wound or aneurism of the vertebral, of course with no advantage. 
 This mistake seems to have arisen from forgetfulness of the fact that 
 while pressure on the common carotid against the transverse process 
 of the sixth cervical vertebra will check all pulsation in the carotid, 
 the branches of the carotid, and aneurisms situated on them, it will 
 also check pulsation in a vertebral aneurism. Mr. Holmes points out 
 that the above " carotid tubercle " is higher up than is usually sup- 
 posed, being situated 2 to 3 inches above the clavicle, and he lays 
 down the rule that when a traumatic aneurism is situated in the course 
 of the vertebral, and its pulsations are commanded, however com- 
 pletely, by pressure on the common carotid low in the neck, it ought 
 not to be treated as being carotid, or as affecting a branch of the 
 carotid, until it is clearly proved that its pulsations are stopped by 
 pressure applied above the level at which the vertebral ceases to be 
 compressible — i.e., above Chaseaignac's carotid tubercle. Ligature of 
 the vertebral artery in the first few inches of its course being so very 
 
 * Barbieri, of Milan, quoted by Kocher (toe. supra cit), has collected sixteen ; Pilz 
 (Langenbeck's Arch.f. Klin. Chir., Bd. ix.) has gathered together four. Then there 
 is Kocher's, one by Liicke in the same Arch., Bd. viii. s. 78, and the American case 
 given below. 
 
 t In nine, according to Kocher, the wound was at or above the second cervical vei- 
 tebra ; in two, " at the upper part of the neck ;" in six it was below the second cervical 
 vertebra. In four of the latter it was in the neighborhood of the external carotid ar- 
 tery and its branches ; thus in one the wound was at the angle of the jaw. 
 
 i " Boy. Coll. Surg. Lectures" : Lancet, July 26, 1873. 
 
462 OPERATIONS ON THE HEAD AND NECK. 
 
 rarely available, compression of the artery low down, with the aid of 
 an ansesthetic if needful, and with the additional help of direct press- 
 ure or cold on the aneurism above, should be made use of. 
 
 Dr. Weir {New York Archives of Medicine, 1884) records a case of a 
 man stabbed on the right side of the neck, about f inch below the ear, 
 just in front of the sterno-mastoid. A traumatic aneurism, believed 
 to be of the vertebral, slowly developed. Digital pressure over the 
 carotid tubercle was made use of, and in three hours the tumor was 
 cured. 
 
 If pressure fails, and if the aneurism increases in size, the surgeon 
 must decide between running the risk of injecting ergotine, or throwing 
 in coagulants, or opening the swelling and plugging it. In the latter 
 case aseptic gauze strips — viz., iodoform or sal alembroth — should be 
 made use of in preference to the perchloride of iron. The gauze 
 should be carried into the aneurism, the wound being opened suffi- 
 ciently freely to allow the surgeon to see what he is about, and the 
 head should afterwards be kept rigidly still.* 
 
 (3) Ligature of the Innominate Artery, either at the same time to 
 prevent Secondary Haemorrhage, or, later on, to arrest this when it 
 has occurred at the seat of Ligature owing to the Reflux of Blood from 
 the Subclavian. — This matter has been alluded to at p. 478, where the 
 case in which Dr. Smyth, of New Orleans, ligatured the vertebral for 
 secondary hsemorrhage after ligature of the innominate is alluded to. 
 
 (4) Epilepsy. — Dr. Alexander, of Liverpool, has performed this 
 operation in thirty-six cases, after the first case usuallj' tying both 
 arteries simultaneously. The following! is his opinion of the value 
 of the operation : 
 
 The operation was performed in the hope that a lessened supply of 
 blood to the hinder brain and spinal cord would result in a diminution 
 or cessation of the epileptic convulsions, it being expected that the 
 diminution would be more permanent to the parts supplied after liga- 
 ture of the vertebrals than after ligature of other vessels, on account of 
 the absence of anastomosing branches, and the restraints to dilatation 
 of the unligatured vessels by the long canals through which the vessels 
 pass. For a time these expectations were realized, but soon relapses oc- 
 curred, and in May, 1884, an analysis of thirty-six cases showed only 
 eight cases which have had so few fits since operation that they may be 
 practically considered cured. Eleven were for several months so much 
 improved that they seemed to be cured; and, although the fits have 
 recurred in all, yet the improvement is still distinctly manifest in 
 many. In sixteen cases there did not seem to be any decided im- 
 
 * In one case related hy Koeher the nerves lying behind the artery were injured, 
 and, in another, dangerous inflammation of the spinal meninges took place, 
 f Diet, of Surg., vol. ii. p. 786. 
 
LIGATURE OF THE VERTEBRAL ARTERY. 463 
 
 provement. Three died out of the thirty-six — one from hsemorrhnge, 
 one from embolism, and one from pleurisy. All the cases operated on 
 were chronic, hopeless epileptics, many of whom had become, gradu- 
 ally, mentally affected. None of the latter were permanently bene- 
 fited to any practical extent. On account of the uncertainty as to 
 what cases will derive benefit from the operation, Dr. Alexander has 
 ceased to recommend or perform the operation. As far as he can at 
 present see, this chapter of surgery may be closed. 
 
 Kelations, — The vertebral artery, the largest and usually the first 
 branch of the subclavian, arises from the upper and back part of the 
 artery, and ascends at first a little outwards and backwards to reach 
 the foramen in the transverse process of the sixth* cervical vertebra. 
 Traversing these foramina, it passes through that of the axis; it then 
 bends outwards and upwards to reach that of the atlas, and then 
 passing backwards lies in a deep groove on the posterior arch of the 
 atlas behind the articular process, beneath the sub-occipital nerve. In 
 this position it lies in the sub-occipital triangle. Finally, it pierces 
 the posterior occipito-atloid ligament and dura mater, and running 
 upwards and forwards through the foramen magnum, winds round to 
 the front of the medulla to join its fellow and form the basilar at the 
 lower border of the pons Varolii. 
 
 Behind. 
 
 Cervical nerves (in vertebral canal). 
 Sympathetic plexus. 
 Outside. Inside. 
 
 Scalenus anticus and Longus coUi. 
 
 phrenic nerve. 
 
 Vertebral artery. 
 
 In Front. 
 Internal jugular. 
 Inferior thyroid. 
 Thoracic duct (left side) crossing from within 
 
 outwards. 
 Vertebral vein. 
 Sympathetic plexus. 
 
 Operation. — The head being suitably raised and turned slightly 
 over to the opposite side, an incision, 3 inches long, is made along the 
 outer border of the sterno-mastoid, extending to the clavicle. In 
 deepening this incision, the external jugular must be looked out for, 
 running parallel, here, with the outer border of the muscle. When 
 
 * Sometimes through the fifth or seventh. 
 
464 OPERATIONS OX THE HEAD AND MCCIC. 
 
 the deep tut^cia is divided, the stemo-iiuistoid, toiiether with the vein, 
 is to be drawn inwards, the ineision heiiiii' prolonged along the elavi- 
 ele, and some of the clavicular lilues detaelied iVoni tJie hone if need- 
 ful. The surgeon then, working with the narrow point of a steel 
 director, carefully opens up the deep connective tissue, and endeavors 
 to define the interval between the scakauis aiitieiisand the longus colli 
 muscles; as the outer border of the fornu>r njusele corresponds with 
 that of the sterno-niastoid, this muscle nuist be well retracted inwards. 
 In defining the vertebral arti'rv as it lies betwc<>n the scalenus and 
 longus colli, the presence of the phrenic nerve lying on the scalene. 
 the pleura internally, the internal jugular, inferior thyroid, and the 
 vertebral veins over the vessel, with the thoracic duct crossing it, on 
 the left side, from within outwards, must all be borne in mind, these 
 structures being drawn to either side, as is convenient, with strabismus 
 hooks. The needle is then passed from witliout inwards, thviug to 
 the deep position of the artery, a good light is essential, and the head 
 must be manipulated so as to relax tlie dee[i parts as is required. 
 The anterior transverse tubercle in the sixth cervical vertebra is a 
 good guide in cases of difficulty ; below it, the pulsation of the artery 
 should be felt. In cleaning the artery previous to passing tlic liga- 
 ture, the fibres of the sympathetic must lie disturbed as little as pos- 
 sible. Tem]HU'ary i>aralysis from the interference with these fibres is 
 almost certain, and innnediate contraction of the mrrcspouding pupil 
 is of very frequent occurrence, and may be rcgardeil as a pretty cer- 
 tain indication that the vessel has been seeurt'd. 
 
 Another method of securing the vertebral is by making incisieuis as 
 in Mott's operation for tying the innominate (p. 4i^0\ dividing both 
 heads of the sterno-niastoid, retleeting these, finding the carotid sheath, 
 turning this, together with the stcvno-hyoiils and sterno-thyroids, in- 
 wards, thus exposing the longus colli, and so finding the artery in the 
 interval between this muscle and the scalenus anticus. 
 
 It has been suggested by Dietrich to tie the vertebral artery between 
 the atlas and axis. This operation would prevent the retlux of blood 
 from above after a wound or traunuitic aneurism below had been 
 [>lugged ; but, however feasible as a dissecting-room operation, it 
 would be one of great difficulty on the living, owing to the depth and 
 small part of the artery which is to be tied. 
 
 LIGATURE OF SUBCLAVIAN. 
 
 As it is very doubtful whether ligature of the first part is a justifia- 
 ble operation even in these days of improveuunits in aseptic surgery 
 anil of new ligatures, tlie operations on tiu' second and third parts 
 will be (k-scribcil first, tlie two being taken togetlu-r, as one operation 
 
LIGATURE OF THE SUBCLAVIAN. 465 
 
 is often only an extension of tlie other. The operation on the first 
 part will then be more briefly alluded to (p. 475). 
 
 LIGATURE OF SUBCLAVIAN IN ITS SECOND AND 
 
 THIRD PARTS (Fig. 87). 
 Line. — From the curved and short course of this vessel no definite 
 line can be given. 
 
 Guide. — The chief point to remember is the outer margin of the 
 sterao-mastoid, as this corresponds to the outer border of the scalenus 
 anticus, which has to.be defined and then traced down to the tubercle 
 on the first rib, the part of the artery to be tied lying on the upper 
 surface of this bone outside and behind the muscle and the tubercle. 
 Relations (third part) : 
 
 In Front. 
 Skin ; fascia; ; platysma ; branches of cervical 
 
 plexus. 
 Venous plexus — viz., external jugular ; supra- 
 scapular ; posterior scapular ; transverse 
 cervical ; branch from cephalic. 
 Transverse cervical and supra-scapular arte- 
 ries. 
 Cellular tissue and fat. 
 Nerve to subclavius. 
 Subclavian vein (below). 
 
 Above. Behind. 
 
 Omo-hyoid. Subclavian First rib. 
 
 Cords of brachial plexus. (*ird part.) 
 
 Relations (second part) : 
 
 In Front. 
 Skin; fasciae; platysma. 
 Sterno-mastoid. 
 Scalenus anticus. 
 Phrenic nerve. 
 Above. Below. 
 
 Subclavian artery rieura. 
 
 (second part). 
 
 Cords of brachial 
 plexus. 
 
 Behind. 
 Scalenus medius. 
 Collateral Circulation. 
 
 When a Ligature is applied to the Third or Second Part. — Three main 
 sets of vessels* are here employed — viz., 
 
 * Key, Ouy's Honp. Reports, 1836. A case in which the subclavian artery had been 
 tied for axillary aneurism twelve years previously. 
 
 30 
 
466 
 
 OPERATIONS ON THE HEAD AND NECK. 
 
 Above. 
 
 The supra-scapular, 
 The posterior scapular, 
 
 The superior intercostal, 
 The aortic intercostals, 
 The internal mammary, 
 Numerous plexiform vessels 
 passing through the axilla 
 from branches of the sub- 
 clavian. 
 
 with 
 
 with 
 
 Below. 
 The acromio-thoracic, the 
 infrascapular, subscapu- 
 lar, and dorsalis scapulae. 
 
 The long thoracic, and sca- 
 pular arteries. 
 
 with Branches of the axillary. 
 
 When a Ligature is applied to the First Part— The collateral circula- 
 tion may be carried on by the superior anastomosing with the inferior 
 thyroid, one vertebral with its fellow, the internal mammary and su- 
 perior intercostal with the long thoracic and scapular arteries, and the 
 princeps cervicis with the profunda cervicis.* 
 
 Indications. 
 
 i. In some cases of axillary aneurism — i.e., those in which, owing 
 to the pain, the irritability of the patient, the depth of the artery, the 
 rapid increase of the aneurism, pressure is not available.f With 
 regard to the operation of ligature of the subclavian for axillary 
 aneurism, it should be remembered that the mortality is high. Mr. 
 Holmes I thus explains this fact: In the first place the procedure re- 
 sembles Anel's operation almost as much as Hunter's. Hence sup- 
 puration of the sac from loose formation of clot, and secondary haem- 
 orrhage from disease of the artery, may be anticipated. Again, the 
 ligature must be placed in the immediate vicinity of large branches. 
 Then, again, the deficient formation of laminated clot is further 
 favored by the absence or loose structure of the aneurismal sac and 
 by the want of resistance in the parts which surround it. Mr. Erich- 
 sen,§ also, alludes to the unfavorable results after ligature of the sub- 
 clavian for axillary aneurism : i.e., out of forty-eight cases, twenty- 
 three were cured and twenty-five died ; and attributes the high mor- 
 tality chiefly to three causes — viz., (1) inflammatory changes within 
 the chest; (2) suppuration of the sac; (3) hi-emorrhage. See below, 
 p. 470, when the chief points in the after treatment are given. 
 
 * Smith and Walsh am, p. 38. 
 
 f See the conclusions on axillary aneurism formulated by Mr. Holmes in his " Lec- 
 tures at the College of Surgeons," p. 107. 
 J Syst. of Surg., vol. iii. p. 109. 
 ? Surgery, vol. ii. p. 212.. 
 
LIGATURE or THE SUBCLAVIAN. 467 
 
 ii. Cases of subclavian and subclavio-axillary aneurism not amen- 
 able to other treatment; or where the aneurism, especially if subcla- 
 vio-axillary, is small in size (not larger than a hen's egg), of recent 
 duration, and distinctly traumatic in origin. Mr. Poland,* in his 
 report on subclavian aneurism, gives nine cases of recovery and 
 twelve cases ending fatally after ligature of the second or third por- 
 tions of the subclavian for subclavian or subclavio-axillary aneurism. 
 With regard to the nine successful cases Mr. Poland raises a very im- 
 portant question. Was the aneurism developed in a healthy artery ? 
 If so, the success is explained. In three the aneurism was entirely 
 local, independent of general arterial disease. In two this was doubt- 
 ful. In four the origin was spontaneous. Whether general atheroma 
 existed here must remain uncertain, as the patients recovered, and the 
 artery, where tied, was healthy. " We can only say this, that sub- 
 clavian aneurism in its early stage, occurring in persons of the early 
 or middle period of life, without any indication of disease of the heart 
 or large vessels, may and does recover, and that a cure may be effected 
 by means of a ligature of the third or second portion of the artery, 
 notwithstanding the disease is one of spontaneous origin, and there- 
 fore presumed to be indicative of arterial disease." In these successful 
 cases the size of the aneurism in no case exceeded that of a hen's egg, 
 and the duration of the cases was short, being under four and a half 
 months. 
 
 Of the twelve unsuccessful cases of subclavio-axillary aneurism, 
 there was good reason to believe that in ten at least an atheromatous 
 condition of the arteries existed. The size of the aneurism was, in all 
 the cases save one, larger than in the first group. 
 
 iii. As a distal oiDeration, together with ligature of the common 
 carotid for some cases of aneurism of the innominate and aorta. See 
 p. 493. 
 
 iv. Preparatory to such operation as removal of the scapula (pp. 
 141, 144). 
 
 V. For wounds of the subclavian itself— e.(/., stabs. This is very 
 rarely called for. 
 
 Operation for Ligature of the Third or Second Portion 
 of the Subclavian (Fig. 87). — These two will be considered together, 
 as one operation is but an extension of the other. 
 
 The patient being turned over on to the sound side, propped up 
 with pillows at the edge of the table, the head drawn over to the 
 opposite side, the shoulder on the side of the aneurism is depressed 
 as strongly as possible, so as to open out the posterior triangle. The 
 surgeon then, standing in front of the shoulder, draws the skin down 
 
 ' * Ouy's Hosp. Beports, 1871. 
 
468 OPERATIONS ON THE HEAD AND NECK, 
 
 over the clavicle with his left hand, and makes an incision, 3 inches 
 long, over this bone between the sterno-mastoid and trapezius, divid- 
 ing skin, fascia3, and platysma. The soft parts being now allowed to 
 glide up, the incision should lie * inch above the clavicle, the external 
 jugular vein thus escaping injury, for as this vein perforates the deep 
 fascia just above the clavicle, it cannot be drawn down with the skin, 
 superficial fascia, and platysma. If more room is required, owing to 
 the elevation of the clavicle or the presence of an aneurism, the above 
 muscles must be divided, and a longitudinal incision made upwards, 
 at right angles to the inner end of the first, and a triangular flap raised 
 outwards and upwards. 
 
 When the superficial parts have been sufficiently incised, the deep 
 fascia is carefully opened at the inner end of the incision and laid open 
 on a director, and the areolar tissue beneath, which varies much in 
 density and the amount of fat which it contains, scratched through in 
 a direction aiming for the outer edge of the scalenus anticus, which 
 corresponds to the outer margin of the clavicular part of the sterno- 
 mastoid. As soon as the deep fascia is divided, the presence of the 
 following complications must be remembered and provided for. The 
 soft tissues may be much matted, cedematous, and altered owing to 
 previous use of pressure or inflammation set up around a rapidly 
 growing aneurism. The venous plexus formed by the external jugular 
 receiving the supra-scapular and transverse cervical veins, and often 
 the posterior scapular and a branch over the clavicle from the cephalic 
 as well, may be much engorged. Any one or more of these veins 
 which are in the way should be drawn aside with a strabismus hook 
 or aneurism needle, or divided between two chromic catgut ligatures. 
 Owing to the free anastomoses, this latter course is to be adopted 
 without hesitation if needful. It cannot be insisted upon too strongly 
 that a bloodless wound will best enable the surgeon to reach this often 
 most difficult artery, and a bloodless wound is best secured by tying 
 beforehand every vein which cannot be drawn out of the way, and by 
 using a fine-pointed steel director as much as possible after the deep 
 fascia is opened. 
 
 As a rule the transverse cervical artery is above the incision, and 
 the supra-scapular below it, under the clavicle, but occasionally one 
 or both of these may be found lying across the field of operation, and 
 must then be drawn aside with a strabismus hook. While the veins 
 may be ligatured without hesitation, the arteries must be preserved 
 intact, that the collateral circulation may not be interfered with (p. 
 466). 
 
 The position of the omo-hyoid is altogether inconstant, and may be 
 neglected. 
 
 The outer edge of the scalenus anticus being defined by scratching 
 
LIGATURE OF THE SUBCLAVIAN. 469 
 
 through the cellular tissue, this muscle is to be traced downwards to 
 the scalene tubercle on the first rib, immediately above and behind 
 which landmark lies the artery. One of the lowest cords of the bra- 
 chial plexus will now come into view, and must not be mistaken for 
 the artery, a contingency otherwise not unlikely to happen, as the 
 lowest cord is in close contact with the artery, and may receive pulsa- 
 tion from it* A little cleaning will show the fasciculation of the 
 nerve, while the artery is closer to the rib, and is flat, not rounded, 
 when rolled under the finger.f By compressing the artery betweeu 
 the needle passed beneath it and his forefinger, and noting the result 
 of this pressure on the aneurism and the pulse below, the surgeon will 
 clear up any doubts as to whether he has the artery or no. 
 
 The position of the artery being made sure of, the sheath J is opened 
 with the point of the knife, the artery cleaned, and the needle passed 
 from above downwards and from behind forwards. This b^st avoids 
 the worst risk — i.e., of including a nerve cord. The needle should be 
 kept most carefully close to the vessel, and not dipped suddenly or 
 used with any force; otherwise the pleura or subclavian vein may be 
 injured. § 
 
 The artery, before the ligature is tightened, will be inspected with 
 some anxiety as to its condition — whether normal in size and struct- 
 ure, or if dilated, thickened, or thinned. || If much alteration is found, 
 
 * Mistaking a cord for the artery, or tying the two together, has happened to 
 excellent surgeons. Thus, in a case under the care of Mr. Green, of St. Thomas's Hos- 
 pital, one of the cords was included in the ligature. The agony produced was extreme ; 
 the man did not cry out, but the expression of his face was something most appalling. 
 The ligatrtre was immediately loosed, and the artery aione tied, and all the frightful 
 symptoms disappeared. The man made a good recovery, and was seen many years 
 afterwards perfectly well (Poland, loe. supra cit., p. 83). 
 
 t Another fallacy about the pulsation is its variableness. Sometimes it is violent 
 and excited ; at others, as in the case of a dilated and diseased artery, or one much 
 handled in the operation, almost imperceptible. 
 
 X A process of deep cervical fascia which the vessel brings out from between the 
 scaleni, and one which varies much in density. 
 
 I The surgeon should be provided with needles of different curves and a silver probe 
 with a large eye. As pointed out by Sir AV. Fergusson [Surgery, p. fj07) with his 
 attention to details in operations, the eye of the needle should always be close to the 
 point, that the ligature may be at once seized with forceps as soon as it appears under 
 the vessel, the difficulties at this stage of the operation being not only the surrounding 
 parts of importance, but also the fact that in this case the handle cannot be depressed 
 as'freely as in operations on most other arteries, and thus it is difficult to make the 
 point rise above the vessel. 
 
 II In a case of Liston's the vessel was dilated, thick, and soft, "aptly enough com- 
 pared to the finger of a buckskin glove." The patient, aged forty-three, died of ha-mor- 
 rhage on the fourteenth day. In a patient of M. Jobert's (Poland, loc. supra cit., p. 
 110) "the vessel was found enormously large, equal to the size of an aorta; it was 9 
 lines in diameter throughout, pulsation being very marked." 
 
470 OPERATIONS ON THE HEAD AND NECK. 
 
 the surgeon should carefully divide the outer half of the scalenus 
 anticus on a director with a blunt-pointed bistoury, sponging the 
 wound absolutely dry so as to watch for the phrenic nerve, which, if 
 seen, should be drawn inwards with a strabismus hook. 
 
 If the artery is found diseased here also, the surgeon should use a 
 flat ligature of ox aorta or kangaroo-tail tendon, and endeavor so to 
 adjust the tightening of the ligature as not to divide both the internal 
 and middle coats (p. 482). 
 
 In cases where the wound is a very deep one, care must be taken 
 while making the second knot that the first does not slip. The liga- 
 ture having been tightened and cut short, drainage is provided and 
 the wound carefully closed and dressed. The limb is then bandaged 
 with cotton-wool and kept somewhat supported, and the temperature 
 maintained with hot bottles if needful. 
 
 The Chief Points in the After-treatment are — u.) keeping 
 the wound rigidly aseptic, (ii.) meeting haemorrhage, (iii.) meeting 
 suppuration of the sac, (iv.) combating the stiffness and weakness of 
 the limb which sometimes follows on ligature of the main trunk. 
 
 (i.) This need not be further alluded to in a work like this, but it 
 cannot be too strongly insisted upon that, if the high mortality (p. 
 466) which has hitherto attended this operation is to be reduced, it 
 is mainly to keeping the wound aseptic throughout, and thus to early 
 primary union that we must look. 
 
 (ii.) The risk of hsemorrhage is so great that the surgeon should 
 always endeavor to prevent it by trying to obtain early and firm 
 closure of the wo\ind as just indicated, and by keeping the patient 
 absolutely quiet till all is soundly healed. When once hsemorrhage 
 occurs, the outlook is very grave. The treatment must vary according 
 to the size of the wound which remains. If there be only a sinus, firm 
 pressure must be made over the dressings by well-adjusted bandaging, 
 aided by a heavy bag of shot or a truss-like instrument adjusted for 
 the purpose.* 
 
 If the wound is larger, and perhaps septic and sloughj', an anaes- 
 thetic should be given, and, any clots being removed, the wound 
 should be gently but thoroughly swabbed over with a solution of zinc- 
 chloride (gr. 20 or 40 to water gj), the wound then dried, dusted with 
 iodoform, and pressure applied as above; or the wound may be 
 plugged with strips of one of the antiseptic gauzes, or with sjsonges 
 of appropriate size and texture which have been kept in a solution' of 
 carbolic acid (1 in 40), and are now wrung dry and dusted with iodo- 
 form, silk being attached to the deeper ones before they are inserted. 
 
 * In a lai'ge hospital, where relays of assistants are available, digital pressure may 
 be made use of. 
 
LIGATUKE OP THE SUBCLAVIAN. 471 
 
 The patient should be kept as quiet as possible with morphia ; the diet 
 should be restricted and given at regular intervals, and without stim- 
 ulants unless absolutely required. The cases collected by Mr. Poland* 
 show that, while haemorrhage may occur as early as the eighth day, 
 it may be deferred till the twenty -sixth or forty-sixth day, the ligature 
 having come away on the twentieth day in either case. In neither of 
 these two latter cases had the wound healed : in the first the patient 
 had been allowed to get up ; in the second, pygemia was present. 
 
 The same writer f thus sums up the sources of hajmorrhage after 
 ligature of the third and second portions of the subclavian : 
 
 (a) From the sac, either primary from puncture in the operation, or 
 secondary from ulceration or rupture at an early period, or later after 
 inflammation and suppuration and giving way of the sac. 
 
 (6) Prom the ligatured part, in consequence of non-obliteration of the 
 artery when the ligature is becoming detached, the hjemorrhage being 
 generally from the peripheral end of the artery tied. It may be due 
 also to an unsound state of the coats of the artery, such as dilated, 
 thinned coats or atheromatous degeneration. 
 
 It is worth remembering that this hasmorrhage is, in exceptional cases, 
 recovered from. Mr. Poland J quotes four cases from the collection of 
 Kocher which recovered after the use of styptics, pressure, and cold, 
 and adds one under the care of Sir W. Fergusson,§ in which the 
 haemorrhage was arrested promptly and for good by pressure applied 
 immediately by the patient's wife. 
 
 (iii.) Suppuration of the sac. The frequency of this untoward 
 accident has been already alluded to (p. 466). It is due to the close 
 proximity of the ligature to the sac, without any intervening branch, 
 whereby the necessary coagulum is but ill-formed and loose, acting as 
 a foreign body, and setting up irritation, inflammation, and its con- 
 sequences. 
 
 Every endeavor should be made to prevent its occurrence by for- 
 bidding all handling of the aneurism. 
 
 If evidence of it occur, and the swelling, which has at first dimin- 
 ished in size, again about the second or third week steadily increasing 
 in size, becomes tense and painful, but without pulsation, it must be 
 opened by a sufficiently free incision, carefully emptied of pus and 
 clots, drained, and well-adjusted pressure applied. If the wound has 
 not healed, and particularly if it has become septic, hsemorrhage is 
 extremely likely to occur after opening the sac — an ominous compli- 
 
 * Loc. supra cit., pp. 116, 117. 
 
 f Loc. supra cit., p. 125. 
 
 J Loc. supra cit , p. 1 27. 
 
 ? Edin. Med. and Surg. Journ., 1831, p. 309. 
 
472 OPEBATIOXS OS THE HEAP AXD NECK. 
 
 cation, which can only be met by plucr'/ing with aseptic sponge or 
 gauze, and using firm pressure (p. 470;. 
 
 (iv.j Atrophy, stiffness and weakness of the limb. These must be 
 met by warmth, ase of electricity, and, above all, by per^everingly 
 used massage. 
 
 The condition which is so common in the lower extremit}' after an 
 analogous operation (see Ligature of External Iliac , in which the 
 limb long remains in a state not far removed from gangrene, is much 
 less common in the upper extremity. 
 
 Diflaculties and Accidents which may be met with, and 
 Points to avoid, during the Operation. 
 
 1. Sterno-mastoid and trafjezius well developed along the clavicle. 
 
 2. A short full neck with much fat both above and beneath the 
 deep fascia. 
 
 3. Clavicle much pushed up. This may be due to the way in which 
 the patient has carried his shoulder to relieve the painful pressure on 
 the brachial plexus, or to the pre-euce of an aneurism. 
 
 4. The arterv may be displaced. Tiiis deviation from it- asual 
 course rnay be acc^uired, as in a ca-e of Warren's,^- where the left sub- 
 clavian was rai-ed and displaced by a curvature of the -pine in a 
 woman ajed thirty, the subject of an aneurism (attribut'^d to .strain), 
 about the -ize of a pi2e jii- kj,;. jus: above the scapular end of the 
 clavicle. Ligature w:t- performed by an inci-ion made obliquely from 
 the outer edjre of the sterno-mas'oid toward- the acromio-clavicalar 
 joint, the pulsation of the artery being the guide. Congenital de%Ta- 
 tions which have been met with are the artery perioratin2 the scalenus 
 anticu-. or lying in front of it. or, as usual, behind thi- muscle, but 
 now closely accompanied by its vein. 
 
 5. The soft parts infiltrated, cedematous. or matted to^^ether owin? 
 to the presence and irritation of an aneurism, aided, perhaps, by pre- 
 viou- attempt- at cure by pressure. 
 
 6. Great en/ori'cment of the vein^ met with here, due' to the piresence 
 of an aneurism and increa-rl by the an -liietic. 
 
 7. Aneurismal sac very prominent and liable to be punctured in the 
 operation. This accident took place even in the hand- of the elder 
 Travels. The =ac wa= as large as a swan'^ ei'sr. and pulsatini' -tron^ly. 
 The patient died on the third day after the operation with elusion into 
 the riitlit fileura. The ligature wa- firmly -reated on the arterv at the root 
 fif the sac and adjoininu' the outer ed_'e of the scalenus. The s.k- had 
 a pouch-like enlargement upward-, which closely overlaid the artery 
 on the pectoral side ; and this, having l.»een penetrated in tlie [tassage 
 of the needle, had occasioned the pr^ 'fuse arterial haemorrhau'e without 
 
 Quoted by Poland ,loc. supra eii., p. 77). 
 
LIGATURE OF THE SUBCLAVIAN. 473 
 
 saltus, which was not arrested by the tightening of the ligature, and 
 which was only controlled by introducing a sponge tent into the wound. 
 The same accident is stated by Mr. Erichscn to have happened to Cusack 
 while ligaturing the subclavian for a diffused aneurism of the axillary 
 artery, though this can scarcely be correctly called a wound of the sac. 
 The alarming gush of blood which took place was arrested by plug- 
 ging the wound, but the haemorrhage recurred fatally on the tenth day. 
 
 8. Wound of the supra-scapular artery necessitating ligature of this 
 branch. As a rule this artery lies too low down to be injured— a com- 
 plication to be extremely deprecated, as it is one of the chief channels 
 by which the collateral circulation is established (p. 465). In about 
 one out of every three cases the posterior scapular will be found to 
 arise from the third part of the subclavian as a separate branch. 
 Erichsen* advises, if this condition be met with, that the hgature be 
 applied as far as possible " to the proximal side of the branch. If 
 necessity obliges the ligature to be applied close to the branch, it is 
 perhaps safer to tie this also, as the anastomosis of vessels in this region 
 is so abundant that the risk of gangrene from the obliteration of a 
 single branch would be very small." But, according to the post- 
 mortem examination of a case in which Mr. Key had tied the artery 
 twelve years previously for axillary aneurism, the posterior as well as 
 the supra-scapular are very important channels by which the blood 
 is carried into the axillary through the infra-scapular {Giufs Hosp. Re- 
 ports, 1836). 
 
 Any artery crossing the subclavian should be, normally, the trans- 
 verse cervical. This or any other vessel which may be an artery 
 should always be drawn aside with a strabismus hook. 
 
 9. Pulsation in the artery, weak or deficient, or, on the other hand, 
 excited and tumultuous (p. 469). 
 
 10. Including a cord of the brachial plexus (p. 469). 
 
 11. Injuring the pleura. This has happened on several occasions 
 during the passage of the needle round the artery, owing to the close 
 proximity of the serous membrane to the vessel, and the difficulty in 
 passing the needle, especially when the clavicle is much raised, ren- 
 dering it impossible to pass the needle from below, and thus away 
 from, the pleura. 
 
 Erichsenf considers inflammation of the contents of the thorax to 
 be the most frequent cause of death, proving fatal in 1 out of every 
 2.5 cases. This is not pyasmic, but arises from causes essentially con- 
 nected either with the operation or with the aneurism itself " These 
 are referable to three heads. (1) Septic inflammation of the deep 
 areolar tissue at the root of the neck may extend to the airterior medi- 
 
 * Surgery, vol. ii. p. 208. t ^o<'- supra cit., vol. ii. p. 212. 
 
474 OPERATIONS ON THE HEAD AND NECK. 
 
 astinum, the pleura, and pericardium." . ..." (2) The sac may, by 
 its pressure inwards, encroach upon, and give rise to inflammation of, 
 that portion of the pleura which corresponds to its posterior aspect. 
 This occurred in a case in which Mayo, of Winchester, operated, and 
 is more liable to happen if suppuration have taken place in the sac; 
 when this occurs, adhesion may take place between this and the 
 pleura, or even the tissue of the adjacent lung, and the contents of the 
 suppurating tumor may be discharged into the pleural cavity or air- 
 tubes, and so coughed up. Of this curious mode of termination there 
 are at least two cases on record — one by Bullen, in which the patient 
 recovered ; the other by Gross, in which the patient died from the 
 escape of the contents of the sac into the cavity of the pleura. (3) 
 Division of the phrenic nerve would necessarily, by interfering with 
 the respiratory movements, induce a tendency to congestion and 
 inflammation of the lungs, and although such an accident must be a 
 very rare one in cases of ligature of the subclavian for axillary aneu- 
 rism, yet it undoubtedly has occurred, as I have myself witnessed in 
 one case." 
 
 12. Injuring or including the nerve to the subclavius in the ligature. 
 This nerve, derived from the junction of the fifth and sixth cervical, 
 usually gives a filament to the phrenic. If, as occasionally happens, 
 this filament is replaced by a nerve constituting an important part of 
 the origin of the phrenic, injury to it will be followed by urgent and 
 speedily fatal dyspncea. 
 
 13. Injury to the subclavian vein. This is rare, as the vein lies 
 below and well away from the artery. But if ligature was called for 
 in a case in which the vein accompanied the artery between the sca- 
 lenes, this deviation would prove embarrassing. 
 
 I have spoken at p. 470 of division of the scalenus anticus if the 
 surgeon does not find the part of the artery beyond this muscle 
 healthy. It is not needful to speak at length and separately of this 
 step, as it is a mere extension of the operation for ligature of the third 
 part, the muscle being also only divided in part. Mr. Poland * points 
 out that, of eight cases in which the scalenus was partially divided, 
 five recovered, and that of these five recoveries the operation was on 
 the left side. These cases thus fully prove that a ligature may be 
 ])laced on the second part of the artery without fear of want of throm- 
 bus formation or of injury to important parts. f 
 
 * Loc. supra cil., p. 128. 
 
 f As shown by Mr. Poland {loc. supra cil., p. 129), the remarks of Porter are scarcely 
 borne out on tlie numerous and great perils of this operation — viz., the phrenic nerve 
 on the scalenus anticus ; the thoracic duct lying, on the left side, at the inner edge 
 of the muscle; the fact that three large branches are usually given off by the subcla- 
 vian while it is between the scaleni ; and the close proximity of the first dorsal nerve 
 behind the artery. 
 
LIGATURE OF THE SUBCLAVIAN. 475 
 
 LIGATURE OF THE FIRST PART OF THE SUB- 
 CLAVIAN.* 
 
 As this operation has been performed by surgeons of the highest 
 eminence, and as it affords good practice on the dead subject, it will 
 be given here. It seems most doubtful, however, whether the im- 
 provements of modern surgery aided by recently introduced ligatures 
 will ever render this a successful operation, failing, as these advantages 
 almost certainly will, to meet that secondary ha3morrhage which has 
 proved so fatal from the distal side of the ligatvire, owing to the facility 
 with which the numerous collaterals bring in blood to this spot. 
 
 Mr. Erichsen, who gives what he calls an " appalling " table of four- 
 teen cases, all fatal, condemns the operation as " bad in principle " 
 and " most unfortunate in practice," and considers that it should " be 
 banished from surgical practice." 
 
 Eelations. — These, owing to the greater depth of the artery on the 
 left side, must be given separately. 
 
 In Front. 
 Skin; fasciae. 
 
 Sterno-mastoid ; sterno-hj'oid ; sterno-thyroid. 
 Internal jugular and (often) vertebral vein. 
 Vagus ; phrenic ; cardiac nerves. 
 
 Eight subclavian (first part). 
 
 Behind. 
 Recurrent laryngeal; sympathetic. 
 Longus colli ; pleura (and beneath). 
 
 In Front. 
 Sterno-mastoid ; sterno-hyoid ; sterno-thyroid. 
 Pleura; lung. 
 
 Vagus ; phrenic ; cardiac nerves. 
 Internal jugular; innominate veins. 
 Common carotid. 
 Outside. Inside. 
 
 Pleura. Trachea. 
 
 Left subclavian OLsophagus ; thoracic 
 
 (first part). duct. 
 
 Behind. 
 Sympathetic. 
 
 CEsophagus ; thoracic duct. 
 Longus colli. 
 
 * These remarks refer to the right subclavian. A ligature has certainly once been 
 placed on the first part of the vessel on the left side, Dr. Kodgers, of New York being 
 
476 OPERATIONS ON THE HEAD iND NECK. 
 
 Operation. — This resembles ligature of the innominate. The fol- 
 lowing account is taken from Mr. Barwell :* 
 
 A triangular flap having been turned upwards and outwards, and 
 both heads of the sterno-mastoids divided, the anterior and, if need- 
 ful, the external jugular veins are secured with double chromic-gut 
 ligatures, and cut. The fascia over the sterno-hyoid being exposed, 
 " the director, after a little opening in the aponeurosis has been made, 
 can be insinuated behind that muscle, which also must be severed. 
 It is well now to look and feel for the carotid artery before going on 
 to divide the sterno-thyroid, whose outer edge covers that vessel, and 
 never, as far as my experience of the dead subject goes, conceals the 
 subclavian."! The finger of the operator, after division of the sterno- 
 hyoid, readily detects the longitudinal course and pulsation of the 
 carotid, and may with ease push the edge of the sterno-thyroid from 
 off its sheath inward, in which position the muscle should be held 
 with a blunt hook. When thus the sheath of the vessel is brought 
 into view, the operator should look for the large veins that always, 
 but more especially if there have been dyspnrea, overlie it. Choosing 
 a vacant spot, he merely nicks the loose structure in which they lie, 
 and then pushes them up and down, tearing the cellular tissue a little, 
 till the dense fibrous sheath is bared suflficiently — first, to have a small 
 opening made in it, and then to be slit up. This should be done on 
 the front and inner aspect. Now, at this part, the vein diverges a little 
 from the artery, so as to leave a triangular interval, through which 
 the vagus runs. A blunt hook is placed over this, and it is to be 
 drawn with the jugular vein gently outward. The next point is to 
 find the subclavian. To do this the operator must remember that the 
 usual description and delineation of the innominate bifurcation is in- 
 correct. It is generally depicted as if the two branches rose side by 
 side and almost at right angles to each other. In reality, the subcla- 
 vian sjjrings behind the carotid, and the angle between the two vessels 
 is very acute. Therefore, to detect the subclavian, the operator must 
 place his finger at the back and outer part of the carotid, when, 
 passing it down, he comes, generally a few lines above the clavicle, to 
 the slightly divergent pulsating line of tlie subclavian, which lies 
 deeper than the carotid liy the whole diameter of that vessel. 
 
 the operator, and losing his patient from hsemorrhage on the fourteenth day. Mr. 
 Erichsen {toe. supra cit.) states that ISir A. Cooper failed in an attempt to secure the 
 vessel, and that he is said to have wonnded the thoracic duct. See also Mr. Banks's 
 remarks, p. 539. 
 
 * fiilcrn. Enryrl. Surg , vol. iii. p. 513. 
 
 f "The mere divisimi of the mnscle is in itself unimportant, but there lies behind 
 it a plexus of large veins passing from the thyroid body to the internal jugular, gen- 
 erally distended by the dyspnoea accompanying aneurism at the root of the neck. 
 Their division causes profuse bleeding and subsequent difficulty in recognizing the 
 deeper parts." 
 
LIGATURE OF THE INNOMINATE. 477 
 
 In selecting the spot for placing the ligature, it is well not to put it 
 quite close to the bifurcation, but also not too near the border of the 
 scaleni, lest the recurrent laryngeal or the phrenic should be injured. 
 The vagus and the jugular vein should be kept, not too forcibly, out- 
 wards, and the needle should be passed from below, while with his 
 left forefinger the surgeon gently presses the pleura downward and 
 outward. Some obstruction behind the artery will very likely be 
 encountered, but it is better gently and patiently to overcome this, and 
 never on any account to attempt to pass the needle the other way ; for 
 if -this be attempted, the point of the instrument is certain to penetrate 
 the pleura. Having now passed and tied the ligature, the surgeon 
 should consider the advisability of also securing the vertebral. It lies 
 in the groove between the longus colli and scalenus, so that the jugu- 
 lar vein must now be held inwards ; the dissection already made will 
 have so nearly exposed the artery that a few touches with a director 
 will lay it sufficiently bare to allow the passage of the needle. The 
 position of the phrenic nerve on the anterior scalene, outside and a 
 good deal in front of the vessel, guards it against much risk of injury, 
 but still it mtist be carefully avoided. The operator must not mistake 
 the inferior thyroid (which is, however, much smaller, and usually at 
 this part external) for the vertebral* itself 
 
 LIGATURE OF THE INNOMINATE (Figs. 87, 90). 
 
 Owing to the fatality of this operation, the question arises whether 
 it is justifiable or no. There have certainly been eighteen cases, and 
 in only twof have the patients survived. 
 
 The extreme danger of the operation is due partly to difficulties 
 which may be met with at the time of its performance — difficulties 
 which have driven most skilful surgeons to abandon the operation — 
 but chiefly to the frequency of secondary ha;morrhage. 
 
 In an operation which must be performed at so long intervals it 
 will be some time yet before we know how far modern antiseptic 
 surgery is able to diminish the above mortality, with the absence or 
 diminution of suppuration, the more rapid healing, the firmer throm- 
 bosis, and the improved ligatures. Sir J. Lister, speaking of antisep- 
 tic ligatures in 1869, wrote thus sanguinely : " For my own part, I 
 should now without hesitation undertake ligature of the innominate, 
 
 * " In certain cases the aneurismal sac overlying tlie vertebral artery renders it inac- 
 cessible." 
 
 t One of these is the well-known case of Dr. Smyth, of New Orleans [Syd. Soc, 
 Bien. Retr., 1865-66, p. 346). The other, under the care of Mr. Mitchell Banljs, has 
 never been published. I am enabled, through his courtesy, to give this case below, p. 
 484. Another case has been briefly published by Prof. Durante, of Kome {Lancet, 
 1887, vol. i. p. 876), before the wound was soundly healed. If the termination of this 
 case has been published, it has escaped me. 
 
478 OPERATIONS ON THE HEAD AND NECK. 
 
 believing that it would prove a very safe procedure." Two cases have 
 recently been fully reported — viz., Mr. Thomson's and Mr. Bennet 
 May's. In spite of all the care taken, and the use of modern ligatures, 
 neither case ended successfully. Mr. Thomson's case died on the 
 forty-second day, of hemorrhage, which began on the thirtieth day. 
 It was believed that the sinus which resulted from the drainage-tube 
 became septic, and that the pulse had ulcerated into the innominate 
 at a point quite unconnected with the ligature, the latter, ox aorta 
 furnished by Mr. Harwell, having disappeared. Mr. May's case died 
 of secondary hasmorrhage on the nineteenth day, caused by the large 
 and very hard knot, which had been tied in the ligature used, ulcer- 
 ating into the vessel (p. 483). 
 
 At the present time, till we have further evidence bearing on the 
 influence of modern surgery on this operation, we may say that there 
 are cases which are clearly most inappropriate, and that there are cer- 
 tain special precautions which should not be neglected during and 
 after the operation. 
 
 First, as to selection of cases, the following words of Mr. Holmes* 
 should be remembered. The operation '' should never b* performed, 
 however, unless the artery can clearly be felt healthy behind the 
 sterno-clavicular joint,t or the tumor is so plainly limited as to afford 
 a very reasbnable hope that it will be found so. In cases of tubular 
 enlargement of a long tract of artery in the neck, it is more than use- 
 less to expose an artery which will probably be found so diseased as 
 either to prevent the operator from the attempt to tie it, or to give way 
 and occasion fatal bleeding within a few hours if it be tied."J 
 
 The following are amongst the precautions indicated : 
 
 1. Rigid antiseptic precautions persevered with till the wound is 
 soundly closed. 
 
 2. Use of a flat ligature in securing the innominate — viz., one of 
 ox aorta or kangaroo tail — with care, if possible, that the knot is not a 
 hard one and does not press strongly on the side towards the artery. 
 
 3. Securing the carotid artery at the same time,§ and the vertebral 
 either then or a few days later. 
 
 * Syst. of Surg., vol. iii. p. 112. 
 
 t As Mr. Holmes remarks in a foot-note, "If the shape of the bones or joints is 
 altered, it is clear that the aneurism arises in the thorax." 
 
 I It is, however, very remarkable thjit in the cases of Porter and Aston Key, 
 though it was found impracticable and undesirable to ligature the artery owing to its 
 diseased and dilated condition, such changes were set up in the vessel by the exposure 
 and manipulation as to lead to gradual cessation of the pulsation in the aneurism in 
 one case and its diminution in the other. 
 
 § Ligature of the common carotid at the same time as the innominate will not nec- 
 essarily prevent hflemorrhage, as was shown by Smyth's case, in which the carotid 
 was tied at the same time as the innominate. Hsemorrhage occurred on the fourteenth 
 
LIGATURE OF THE INNOMINATE. 479 
 
 4. Closing the wound as thoroughly as possible, so as to prevent 
 formation and collection of discharges. 
 
 ^ Mr. Thomson, in his exhaustive account of his own case, states 
 his belief that the fatal ulceration into the innominate was brought 
 about by decomposition of discharges collecting at the bottom of the 
 sinus left by the drainage-tube. This decomposition was, he thinks, 
 due to the difficulty of keeping the dressings firmly on a movable 
 part like the neck, to the fact that the skin heals much more quickly 
 than the deep parts, and that the clavicle assists in preventing the soft 
 parts coming together. He would, in future, use carefully adjusted 
 sponges and shot bags over them. 
 
 6. Keeping the patient absolutely at rest till the wound is soundly 
 healed, morphia being used subcutaneously, and any tendency to 
 cough checked at once if possible. 
 
 Line and Guide.— The vessel, 1 to 2 inches long, extends along a 
 fine drawn from the middle of the junction of the first with the 
 second bones of the sternum to the right sterno-clavicular joint (Hol- 
 den). Its point of bifurcation varies somewhat. 
 
 Relations : In Front. 
 
 , Sternum ; sterno-hyoid ; sterno-thyroid. 
 
 Left innominate and right inferior thyroid vein. 
 Inferior cervical branch of right vagus. 
 
 Outside. Inside. 
 
 Right innominate vein. Left carotid. 
 
 Right vagus, 
 rleura. Innominate artery. 
 
 Behind. 
 Trachea. 
 
 Collateral Circulation. — These are thus given by Sir W. Mac- 
 Cormac (Ligature of Arteries, p. 75) : 
 
 Cardiac Side. Distal Side. 
 
 C First aortic intercostal, with Superior intercostal of sub- 
 
 clavian. 
 Upper aortic intercostals, with Thoracic branches of axil- 
 lary and intercostals of 
 internal mammary. 
 Phrenic, with Musculo-phrenic of internal 
 
 mammary. 
 Deep epigastric, with Superior epigastric of in- 
 
 ternal mammary. 
 
 day, and was repeated at intervals. The vertebral was ligatured on the fifty-fourth 
 day, and recovery ultimately took place. 
 
 a 
 a 
 
 Si 
 
480 
 
 OPERATIONS ON THE HEAD AND NECK. 
 
 Free communication of vertebrals and internal carotids of opposite 
 sides inside the skull. Communication of branches of opposite ex- 
 ternal carotids in the middle line of the face and neck. 
 
 Operation (Figs. 87, 90).— The patient, having been brought into 
 as satisfactory a condition as possible by preparatory treatment, the 
 head, body, and arm are placed as in ligature of the subclavian (p. 
 467). The surgeon, standing in front, makes an incision* along the 
 inner third of the clavicle, and another along the anterior border of 
 the sterno-mastoid, meeting the first at an acute angle, each incision 
 
 Fig. 90. 
 
 Above, tbe two heads of the sterno-mastoid, the sterno-hyoid and sterno-thyroid are seen re- 
 flected. Two inferior thyroid veins cross the innominate. Another large vein is drawn down 
 by the strabismus lioolt. 
 
 being upwards of 3 inches long. The flap thus marked out is dis- 
 sected up, the sternal and clavicular heads of the sterno-mastoid di- 
 vided, and the sterno-hyoids and sterno-thyroids are carefully cut 
 through on a director. During these preliminary steps, one or two 
 small arteries may be divided and some enlarged veins connected 
 with the inferior thyroids drawn aside or tied with double ligatures, 
 and, in reflecting the above-mentioned flap, the presence of the ante- 
 rior jugular passing outwards beneath the sterno-mastoid just above 
 the clavicle must be remembered. 
 
 * This incision was made use of by Mott when he tied the artery in 1818. It ap- 
 pears preferable, as giving much more room, to any other. 
 
LIGATURE OF THE INNOMINATE. 481 
 
 The above muscles, when cut, being carefully held out of the way 
 and a layer of deep cervical fascia varying in strength divided, the 
 pulsation of the carotid is defined, and its sheath opened to the inner 
 side and as low down as possible. 
 
 Other guides will be found, in the trachea and the subclavian, to 
 lead the finger down to the innominate, the horizontal incision being 
 prolonged a little internally or externally as the case may need. 
 
 The carotid being traced down, the innominate will be found bifur- 
 cating into the carotid and subclavian (Fig. 90). It is now that the 
 real difiicultiee may be met with. (1) Owing to engorgement of the 
 venous circulation, increased by the ana?sthetic, the internal jugular 
 and innominate vein may be so much enlarged as to protrude into the 
 wound. (2) An aneurism may have reached under the artery and 
 flattened it out so as to make it difficult of recognition. The cellular 
 tissue around the vessel and between it and the sternum may be so 
 matted with adhesions as to make it difficult to define the artery and 
 its important relations on the right side — viz., vagus, pleura, and right 
 innominate vein. (3) The artery itself may be enormously diseased 
 and ex2)anded. . 
 
 In tracing down the innominate itself, the surgeon must keep his 
 steel director most carefully on the front of the artery. In following 
 the vessel down behind the sternum in order to find a site for his 
 ligature, he will be aided by slightly flexing the head and by a laryn.- 
 geal mirror. The cleaning the artery must be done with the utmost 
 caution, especially on the outer side, owing to the important strucr 
 tures lying there ; of these the innominate vein and the vagus may be 
 drawn outside, but it is only Ijy keeping the director or needle-point 
 very close to the artery here that injury to the pleura can be avoided. 
 
 If there is doubt as to the position of the artery, pressure with the 
 finger behind the vessel against the sternum will arrest the pulsation 
 in the carotid and the aneurism. 
 
 The needle should be passed from without inwards and a little from 
 below upwards to avoid the pleura. In this case, as in that of the 
 subclavian and other deep-seated arteries, the surgeon will do well to 
 provide himself with needles of different curves, or with a silver probe 
 sufficiently flexible to take any curve and with a large eye close to the 
 point (p. 469). 
 
 The question now arises what ligature is best suited to a large 
 trunk like this, with blood forcibly impelled into it by the closely ad- 
 jacent heart, and with collateral circulation certain to be set up 
 quickly along the carotid and vertebral. This point is at present un- 
 settled. It is probable that stout silk or chromic gut, though properly 
 prepared and used with every antiseptic precaution, will be inefficient. 
 For in so large a vessel very considerable force will be required to 
 
 31 
 
482 OPERATIONS ON THE HEAD AND NECK. 
 
 close it and stop its current, the artery offering much resistance and 
 its pulsation being very strong; thus it is probable that any round 
 ligature will have to be applied so tightly as to divide the two inner 
 coats and thus weaken, probably fatally, an artery which has to bear 
 the strain of such strong pulsation before the wound can heal and the 
 parts consolidate around the ligature. 
 
 On the other hand, the value of the more recently introduced ani- 
 mal ligatures — viz., ox-aorta, kangaroo-tail, or whale tendon — though 
 probably superior, is not yet established. It is probable that there is 
 much less risk of their dividing the two inner coats, and there is every 
 reason to expect that, if properly prepared, their contact with the soft 
 tissues they surround will be harmless and unirritating ; that, infil- 
 trated by wandering cells, they will be gradually absorbed, new rings 
 of fibrous tissue forming in their place.* But as yet we do not know 
 whether all these ligatures are free from a tendedcy to slip prema- 
 turely, from the knot becoming soft or united. Again, as pointed out 
 by Mr. Heath, though these ligatures are flat before application, we 
 are by no means safe in assuming that, as the ligature is tightened, 
 there is no flat edge pressing in against the vessel. While, if there be 
 a greater demand for these ligatures, they will no doubt be prepared 
 in a reliable form, at present the surgeon must be prepared for the fol- 
 lowing accident, which happened to Mr. May. 
 
 The needle — an old-fashioned silver one, flexible, well rounded at 
 the point, and with a large eye — having been passed satisfactorily 
 round the vessel, " was threaded with a small cord, to which a strip of 
 ox-aorta material, kindly sent me by Mr. Barwell, was attached, and 
 by it pulled through. In tightening the tape, I had to draw the ends 
 with very considerable force to stop the pulsation, the vessel offering 
 great resistance and pulsating with great force. Just at the critical 
 moment, however, the material gave way and broke across, and a sec- 
 ond piece introduced in a similar manner suffered the same fate. I 
 then endeavored to imitate the principle of the flat ligature by using 
 a cord made up of five or six medium-sized threads of catgut. This 
 bore the strain very well, and, after tightening with sufficient force to 
 completely stop pulsation in the tumor and branches of the carotid, I 
 drew on the ends still further to allow of some subsequent relaxation 
 in fixing the knot. At the same time I endeavored to avoid crushing 
 the coats of the artery. The ligature was secured with a third knot, 
 and cut short." The patient died of ha3morrhage on the seventeenth 
 day, and it was found that this very precaution, taken with all care 
 and thoughtfulness by Mr. May, had tended to bring about the fatal 
 result. " The ligature still retained a firm hold on the vessel ; one or 
 
 * See the case of ligiitiu'e of tlie innominate and first piirt of the subclavian by Mr. 
 Banks (p. 484). 
 
LIGATURE OF THE INXOMINATE. 483 
 
 two of the threads were partially absorbed and softened, but others 
 scarcely changed. The knot, unfortunately very large and hard, was 
 quite unaltered. Under the knot, in the front of the vessel and in the 
 line of a fold or bend of its wall, was the obvious source of the h;em- 
 orrhage, in the form of a ragged hole about the size of a small pea ; 
 this opened into the vessel on both sides of the ligature." Mr. May 
 goes on to say that the further appearances were instructive in view of 
 the debatable questions surrounding the use of animal ligatures. . . 
 With the exception of the hole corresponding to the knot, no part 
 of the arterial wall was injured or -divided, though under the ligature 
 itself the wall was thinner than elsewhere. The inner coats were in- 
 tact. It was obvious that the small chink which remained between 
 the crumpled-up folds of the vessel, the remainder being occluded bj' 
 adhesion of the inner coats, was closed by a moderately firm clot. A 
 similar clot with conical end extended along the distal side of the 
 artery nearly to its bifurcation. On the heart side there was a thin 
 diaphragm of clot with a conical end, but it extended a very inconsid- 
 erable distance. As the bulk of the haemorrhage no doubt occurred 
 here, some of the clot nray have got carried out during life. The hole 
 in the wall of the artery having been closed, it was shown, by injecting 
 water, that the vessel was wholly occluded at the seat of ligature. 
 
 The ligature being tied and cut short, the surgeon will have to 
 decide whether he will be satisfied with tying the main trunk, or 
 whether he will place ligatures on other vessels also — e.g., upon the 
 carotid and vertebral — in order to prevent the risk of that secondary 
 haemorrhage which has almost invariably taken place on the distal 
 side of the ligature owing to the facility with which blood is brought 
 into the branches of the subclavian through reflux currents along the 
 vertebral, common carotid, inferior thyroid, etc. 
 
 Until further use of the fiat animal ligatures has shown how far we 
 can rely upon these, and their effect upon the vessel so far to strengthen 
 it as to prevent its giving way, it will be wiser to secure the common 
 carotid, and also the vertebral by an extension outwards of the hori- 
 zontal incision if needed, and finding these vessels by the steps given 
 at pp. 441,463. 
 
 These vessels being tied, the wound is carefully cleaned and dried, 
 haemorrhage most scrupulously stopped, a drainage-tube inserted, and 
 the wound carefully closed. If the patient will bear it, the limb, pre- 
 viously wrapped in cotton-wool, should be secured to the side and 
 chest, and every attempt made, by elastic bandaging and aid of a shot- 
 bag, to keep the dressings firmly in place, and thus jjromote, from the 
 first, steady adjustment of the parts and sound healing. Morphia 
 should be used as freely as is safe, to diminish, as far as possible, the 
 sensibility of the patient to the irksomeness of his position. The 
 
484 OPEKATIONS ON THE HEAD AND NECK. 
 
 slightest tendency to cough should be treated at once. The absolute 
 need of rest and quiet should be enforced upon the patient until the 
 wound is soundly healed. 
 
 While these sheets are passing through the press, I am enabled, 
 through the courtesy of Mr. Banks, to give an abstract of a most in- 
 teresting case of right subclavian aneurism, in which the innominate 
 and, subsequently, the first part of the subclavian were tied. Owing 
 to the exceeding rareness of recovery after ligature of the innominate, 
 and the survival of a patient for thirty-six days after the placing of a 
 ligature round the first part of his subclavian, it is to be hoped that 
 this most instructive case will soon be published in extenso. 
 
 J. B., aged fifty, was admitted iiito the Liverpool Royal Infirmary, 
 February 10, 1883, with well-marked symptoms of aneurism of the 
 third part of the right subclavian. Attempts to treat the patient by 
 rest, etc., having failed, owing to his obstinately persisting in getting up, 
 the innominate and common carotid were tied, February 26, with the 
 strictest antiseptic precautions. The earlier stejDS presented nothing 
 remarkable. " Unluckily, the bifurcation was quite i inch lower than 
 it ought normally to be, and this caused some difficulty in getting 
 the aneurism needle round the vessel. I used a needle of the ordi- 
 nary kind, having a large curve, and threaded with silk. There was 
 about a minute of rather anxious work while the needle was being 
 tickled through the tissues surrounding the vessel, a proceeding which 
 was accomplished solely by feeling, as the artery lay too deep for me to 
 see anything that could aid me. By means of the silk thread, a stout 
 kangaroo tendon ligature was pulled beneath the vessel, then tightened, 
 three knots being placed upon it. I applied the amount of force 
 which I thought would be necessary completely to occlude the artery, 
 but not to damage its coats, and I felt very certain that I had made a 
 thorough and satisfactory ligature of the arterj'. Whether I really 
 
 did so or not is a question The aneurism ceased to pulsate. I 
 
 next proceeded to pass a ligature round the common carotid 
 
 Being engrossed in this, I took no further notice of the aneurism. But 
 those who were assisting saw that, after an interval of about two min- 
 utes, a certain amount of pulsation returned in the aneurism. I 
 imagined that this must have arisen from the retrograde circulation 
 along the common carotid and subclavian, and so proceeded at once 
 to tighten the ligature (another kangaroo tendon) round the former 
 vessel. As soon as this was done, the pulsation in the aneurism again 
 became practically imperceptible." 
 
 A slight return of pulsation was noticed in the evening of the 
 operation. 
 
 The restlessness and irritability of the patient during the first few 
 days were frightful. He tossed about the bed, moved his arm as much 
 as the bandages would allow, loudly demanded stimulants, and swore 
 
LIGATURE OF THE INNOMINATE. 485 
 
 at everybody about him. He was not, however, in the least feverish 
 or delirious. Practically there was never any suppuration, and the 
 extensive wound healed by primary union. All dressings were dis- 
 continued on the thirteenth day, and the patient, who had insisted 
 on getting up on the ninth, went out on the twentieth day with the 
 wound sound. 
 
 Unhappily, the pulsation feebly present in the aneurism on the 
 evening of the operation became strong and accompanied with thrill 
 by the third day. Pressure with a bag of shot was tried, but the 
 patient, by his unruly behavior, did all he could to prevent any con- 
 solidation occurring. When the patient went out the aneurism was 
 quite as soft, and the pulsation and thrill quite as obvious as before. 
 It very soon decidedly increased, spreading out under cover of the 
 trapezius and pushing inwards the scalenus anticus. "At the end of 
 five weeks it became clear that either the aneurism must be left alone 
 and the man abandoned to his fate, or that something more must be 
 done. But what? Galvano-puncture and the introduction of wire 
 or other material into the sac have not proved of sufficient utility to 
 entitle them to be considered satisfactory methods of treatment at the 
 present moment, whatever may become of them in the future. Liga- 
 ture of the first part of the axillary on the distal side of the tumor is 
 not any l:)etter. To lay open the aneurism and attempt to secure the 
 artery on either side of the aneurismal opening would almost certainly 
 have been fatal on the spot. To go down through the old cicatrix in 
 search of the innominate, with a view of tying it a second time, 
 seemed very impracticable. Besides, I could not be any more certain 
 of curing the aneurism the second time than the first. The only thing 
 that remained was to tie the first part of the subclavian. Sixty-seven 
 days after the ligature of the innominate I performed this operation, 
 not using the spray during the dissection, lest it should obscure one's 
 vision, but turning it into the wound after the vessel was tied. By 
 this date the tumor had so increased in size that there was just room 
 on its inner side, and no more, to get at the artery. An incision was 
 made along the hinder margin of the sterno-mastoid, and another ex- 
 tending from it outwards along the clavicle. After getting through 
 the superficial structures, the clavicular portion of the sterno-mastoid 
 was divided, and the internal jugular was followed down to its junc- 
 tion with the subclavian. Here, in consequence of the matting 
 together of parts as a result of the first operation, it became almost 
 impossible to know what one was dealing with, and an unpleasant 
 accident occurred. I tore across a vein of some size close to the point 
 where it entered the angle of junction of the jugular and subclavian. 
 Instantly a rushing and hissing noise showed that some air had got 
 into the venous trunks, and for a brief space the situation was uncom- 
 
486 OPERATIONS ON THE HEAD AND NECK. 
 
 fortable. A finger was put on the aperture, and to our relief the 
 patient showed no signs of being in any way affected by the occur- 
 rence. The aneurism covered by the thin fibres of the scalenus anticus 
 next came into view. My colleague, Mr. Harrison, gently but steadily 
 pushed this outwards with a couple of fingers, and in the very limited 
 space between this and the internal jugular I proceeded to search for 
 the artery, guided by its pulsation. Very slowly, and after an infinity 
 of anxious picking and teasing (for one dared not use a knife), this 
 was exposed about i inch from the aneurism. The vessel was obvi- 
 ously thinned and dilated, and this added immensely to the danger 
 of passing the aneurism needle beneath it. The needle was threaded 
 with a silk ligature, which drew after it a double catgut ligature. The 
 loop of this being divided, the artery was secured by both portions 
 lying side by side. The knots were drawn very gently, with the in- 
 tention of merely closing the artery and not of injuring any of its 
 coats. The aneurism at once became still. 
 
 "A very few lines have sufliced to describe this operation, but it 
 took more than an hour to perform, while the difficulty, danger, and 
 anxiety that attended it are almost impossible to describe. Owing to 
 the fact that the parts had already been interfered with, there was a 
 great deal of thickened and cicatricial tissue present. Cutting this 
 was out of the question, as it was impossible to say what was adherent 
 to or mixed up with it. It had, therefore, to be pulled asunder fibre by 
 fibre, with the aid of strong forceps and a dissecting tool. As the 
 operation advanced, the depth at which one had to work became 
 greater and greater, while, in order clearly to make out the various 
 structures, the wound had to be kept absolutely free from blood. 
 Sometimes minutes would be lost in picking up some trifling vessel 
 from which just enough blood would keep welling to obscure the 
 wound. The space in which anything could be done was of the most 
 limited descrijition, and surrounded by dangers on every hand. To 
 the outer side was the bulging aneurism, to the inner was the internal 
 jugular, below lay the subclavian vein, and immediately beneath the 
 
 artery itself was the pleura Compared with this performance, 
 
 tying the innominate was a mere surgical amusement, and I should 
 never care to repeat it again." 
 
 The patient rallied well from the operation, but a few days later 
 developed an attack of broncho-pneumonia, which exhausted him ex- 
 tremely. He slowly rallied from this, but the wound gaped widely. 
 It ultimately healed, save for a sinus, which admitted a probe deeply. 
 On the twenty-third day the patient got up, and by the thirty-first 
 day had been out in the open air. On the evening of this day haem- 
 orrhage occurred from the sinus, frequent recurrences took place, and 
 the patient died on the thirty-seventh day after the operation. By 
 
LIGATURE OF THE INNOMINATE. 487 
 
 the fourth day the aneurism had no trace of pulsation, and was small 
 and hard * 
 
 Causes of Death after the Operation.-It may be expected 
 that most of these will, with antiseptic precautions, disappear, viz. : 
 
 1. Suppurative cellulitis and mediastinitis. 
 
 2. Lung trouble— e.gf., bronchitis, pleuro-pneumonia. 
 
 3. Pericarditis. 
 
 There still remains the terrible complication of secondary haemor- 
 rhage, which has occurred, as yet, in almost every case, and has always 
 proved fatal, save in the case of Dr. Smyth. 
 
 Secondary hsemorrhage may occur up to the sixtieth day, as in 
 Graefe's. It has already been discussed" how far modern surgery is 
 likely to prevent this, and certain precautions have been enumerated 
 at p. 478. The treatment as shown is mainly preventive. When once 
 bleeding has occurred, httle can be done beyond tying the vertebral 
 and common carotid, if this has not already been done, and plugging 
 the wound with antiseptic gauze (iodoform or sal alembroth), and 
 putting on pressure with shot-bags. 
 
 On the frequency of this complication the following remarks by 
 Dr. Sabine are of interest : 
 
 " The source of hfemorrhage and consequent failure is obvious. It 
 came from the distal side of the ligature, and especially from the sub- 
 clavian In the majority of cases the artery is not more than 1 '» 
 
 inch between its origin and point of bifurcation. What, now, could 
 be supposed to be the result of ligature of an artery so short, and at 
 the same time situated so near two currents of blood— viz., that through 
 the aorta, and that which would pass from the carotid into the sub- 
 clavian ? Fatal hfemorrhage, either from the distal or proximal side 
 of the ligature, according to its seat. If the ligature be placed near 
 the origin, it would be impossible for a clot to form on its proximal 
 side, owing to the full current of blood passing through the aorta, 
 though there might be one on the distal side. On the other hand, if it 
 were placed near the point of bifurcation, though a clot would in all 
 probability be formed on the proximal side, as ha.ppened in three of 
 the cases already cited, and nearly in a fourth, none would be formed 
 on the distal side, more especially in the subclavian, for in two of the 
 
 cases, and nearly in three, the carotid was obliterated 
 
 " The third place where a ligature might be placed is midway 
 between the point of origin and that of bifurcation. In this case there 
 would be a very great chance of neither a proximal nor a distal clot 
 being formed. It allows only J to I inch on either side of the liga- 
 ture, a space too small to render the formation of clots at all probable 
 
 * The notes of this case contained no mention of an autopsy. 
 
488 OPERATIONS ON THE HEAD AND NECK. 
 
 in an artery as large as the innominate. It is thus seen that, in what- 
 ever situation a ligature be placed, secondary haemorrhage will almost 
 inevitably occur, and probably from the distal side, because a ligature 
 could not, without very great difficulty, be applied much below the 
 bifurcation, and hence there would be sufficient space for a proximal, 
 but not for a distal, clot." 
 
 SURGICAL INTERFERENCE IN ANEURISMS OF THE 
 INNOMINATE AND AORTA. 
 
 In spite of the amount of work done in this direction, the question 
 how far any surgical interference is justifiable remains unsettled. The 
 importance of the subject, the difficulties with which it is beset, justify 
 an allusion to it in this place, it being understood that the question 
 of surgical treatment only arises either when a sufficient trial of med- 
 ical treatment has failed, or when the time for this has gone by, and 
 the distress of the patient justifies resort to uncertain operations in 
 the hope of giving relief rather than of bringing about a cure. 
 
 The advisability of resorting to surgical means will be considered 
 under the heads of — A. Diagnosis ; B. Treatment, the latter including 
 — (i.) Ligature; (ii.) Introduction of Foreign Bodies; (iii.) Galvano- 
 puncture. 
 
 A. Diagnosis between Innominate and Aortic Aneu- 
 risms. — It is well known how extremely difficult this matter is; the 
 expression of a confident opinion is, too often, quite out of the ques- 
 tion (p. 490). While a precise diagnosis is usually impossible, no 
 pains should be spared in going into all those points which may help 
 in deciding how far the aneurism is probably limited to the innomi- 
 nate or to the aorta, and, in the case of this vessel, which piece of the 
 arch is chiefly encroached upon, for it is only by paying attention to 
 the above points that answers can be given to the two questions which 
 arise — viz. (1) Is any operation justifiable at all? (2) If an operation 
 is justifiable, what is it to be ? 
 
 Chief Points to pay Attention to in Diagnosis. 
 
 1. The Position of the Aneurism. — This is obviously only of value in 
 a few cases, when the patient is seen early, or when he can be relied 
 upon for an intelligent history of his case. Mr. Wardrop's rule was, 
 that innominate aneurism first presents itself to the inner side of the 
 right sterno-mastoid, carotid aneurism in the interval between the two 
 heads, and a subclavian one to the outer side of the muscle. Mr. 
 Barwell* writes of the first of the above thus: "The tumor of an 
 innominate aneurism generally occupies the episternal notch, but 
 chiefly on the right side, and, even though it may not rise high, takes 
 
 * Intern. Encycl. Surg., vol. iii. p. 507. 
 
SURGICAL, IKTERFEREXCE IN THORACIC ANEURISMS. 489 
 
 up the whole breadth of this space. On gently pressing the finger 
 backward and downward, the rounded margin of the sac can be felt. 
 After a little time the sternal end of the clavicle protrudes abnormally, 
 and partakes in the pulsation (communicated), while the sternal and, 
 afterwards, the clavicular portion of the sterno-mastoid are also pushed 
 forward. Not unfrequently the first costal cartilage, outside where it 
 joins the sternum, is also abnormally prominent, and throbs with the 
 beat of the tumor." 
 
 Mr. Heath thus describes * the possible points of appearance of an 
 aortic aneurism : " If on the ascending jiortion of the arch, the sac 
 presses against the sternum, producing gradual absorption of the wall 
 of the chest, and communicating a marked impulse to the right side 
 of the sternum as high as the sterno-clavicular joint, which may be 
 invaded by the tumor in the later stages. If on the transverse portion 
 of the arch, the sac encounters but little resistance in an upward 
 direction, and hence is apt to invade the inter-clavicular notch, to 
 compress the trachea and occasionally the oesophagus, and to produce 
 marked spasm of the larj^nx by interference with the left recurrent 
 laryngeal. When a sac of this kind rises into the neck, it is a matter 
 of uncertainty to which side it should be allotted, since a tumor pro- 
 jecting most to the right by no means necessarily originates on the 
 right side, and vice versa.'''' 
 
 2. The Pulse.— If a decided diminution is found in the right radial 
 and carotid, the aneurism is probably of the innominate; but an 
 aortic aneurism near the root of the innominate will bring about the 
 same result. 
 
 3. Pressure Symptoms. — These will vary with the position as well as 
 the size of each form of aneurism. Thus in innominate aneurism 
 pressure symptoms will vary according as it is high up or low down, 
 and pressing inwards or outwards. As to oedema, the value of this 
 must remain undecided while surgeons hold such opposite views. 
 Thus Mr. Heath f and Mr. Erichsen J speak of a?dema of the right side 
 of the neck and upper limb as first noticed. Mr. Barwell,§ on the 
 other hand, speaking more particularly of the low form of innominate 
 aneurism (usually combined with aortic disease), writes : " The point 
 to be especially remarked is this— the pulsation, dulness, abnormally 
 loud heart sound, etc., are on and to the right of the middle line ; the 
 venous congestions are on the left side of the body, nor does the right 
 
 participate till late in the disease When the right side is also 
 
 involved, the aneurism will have become large." 
 
 * Diet, of Surg., vol. i. p. 81. 
 f Loc. supra cit. 
 t Surgery, vol. ii. p. 75. 
 I Loc. supra, cit. 
 
490 OPERATIONS ON THE HEAD AND NECK. 
 
 I cannot find that the other pressure symptoms— viz., laryngeal or 
 tracheal dyspncea, irregularity of the pupil— are really distinctive be- 
 tween innominate and aortic aneurism. 
 
 Mr. Barwell considers that the following combinations of symptoms 
 " furnish remarkably positive evidence " in aortic aneurism : " For 
 instance, pressure wholly and entirely on the right bronchus ; conges- 
 tion of both arms and both sides of the head and chest; tumor symp- 
 toms, chiefly about the second space and rib, considerably to the right 
 of the sternum; heart displacement, if any, directly outward; the 
 pulses equal, with very slight sphygmographic change — perhaps a 
 rather sloping up-stroke, usually a blunt, flat apex, absence, partial or 
 total, of dicrotic wave, but undulatory character of whole down-line 
 — indicate disease of ascending aorta. Congestion of the left arm, 
 supra- clavicular region, and side of the head; aneurismal character 
 of right pulse (radial and carotid) ; tumor symptoms a little to the 
 right of the sternum, and probably some tracheal dyspnoea, are symp- 
 tomatic of aorto-innominate aneurism. Modification of left radial 
 pulse, affection of left vocal cord, left venous congestion, tracheal 
 dyspnoea, and obstruction of air to both lungs, with tumor symptoms 
 on and to the left of the median line, mark disea%se of the transverse 
 aorta. Obstruction to the entrance of air to the left lung alone, with 
 pains at the back and along the intercostals, is indicative of disease 
 of the third part of the arch." 
 
 4. Displacement of the Heart Downwards. — The more marked this is 
 the greater is the probability that the aneurism is aortic. 
 
 DiflQculties and Fallacies in the Diagnosis. 
 
 1. The proximity of the heart. " When there is a bruit, it is ex- 
 tremely difficult to distinguish w^hether it is limited to the tumor or 
 is propagated into it from the cardiac valves ; whether the pulsation is 
 limited to the neck, or extends also into the thorax; and whether one 
 only of the large vessels is implicated, or whether others of the great 
 arteries in the neighborhood, or the whole trunk leading from, the 
 heart, may not be diseased and dilated." 
 
 2. " The growth of aneurisms in the cellular tissue of the medias- 
 tinum and root of the neck is so free that instances have been observed 
 of aneurisms of the arch of the aorta causing compression of the sub- 
 clavian and carotid, without any disease of those vessels ; while, on 
 the other hand, if the aneurism approaches the tubular shape, the 
 pulse may be unaffected in the branches, though the trunk is exten- 
 sively diseased " (Holmes*). 
 
 3. The distribution of the branches of the aorta may be anomalous.! 
 
 * Syat. of Surg., vol. iii. p. 14. 
 
 f Mr. Holmes quotes the following instructive case: In a patient in whom, from 
 other symptoms, there was no difficulty in diagnosing an aneurism of the arch of the 
 
SUKGICAL INTERFERENCE IN THORACIC ANEURISMS. 491 
 
 _ The following remarks of Mr. H. Morris on a case of aortic aneurism 
 illustrate the extreme difficulty of diagnosing here : " No one who ex- 
 amined this woman questioned that the aneurism was innominate, and 
 some very capable diagnosticians considered it to be a simple sacculated 
 aneurism of that vessel. Even after dissection it was impossible to 
 make out its true character until the sac had been laid freely open in 
 front and the innominate artery behind. The situation and outline 
 of the tumor, the pain in the shoulder and over the right side of the 
 head and neck, led to the diagnosis of innominate aneurism. The 
 origin of the disease from the aorta might have been suspected if more 
 weight had been given to the severe gnawing pain across the front of 
 the chest suffered at the onset ; to the dilated veins on the right side of 
 the upper part of the chest; to the equality of the radial pulses; to 
 the absence of any cough, dyspncea, and throat dryness, of any 'de- 
 flection of the trachea, of any numbness or loss of power in the right 
 arm (such frequent symptoms in innominate aneurism) ; and to the 
 fact that aortic aneurism causes tumors in the neck." 
 
 B. Treatment. 
 
 I. Ligature.* 
 
 Aids in selecting Cases fitted for Operation.— Mr. Barwell,t 
 writing on innominate aneurisms, has formulated the following 
 aphorisms : 
 
 i. An aneurism commencing suddenly, especially if traceable to 
 some traumatism or over-exertion, is more likely to be benefited by 
 operation than one arising gradually and without assignable mechan- 
 ical cause. 
 
 ii. Distinct sacculation is a most desirable condition ; fusiform dila- 
 tation of the innominate indicates almost certainly a similar condition 
 of the aorta and widespread arterial disease. 
 
 iii. If symptoms show the aortic arch to be also affected, the disease 
 should be limited — that is, should not extend along the transverse 
 portion. It should be of the sacculated variety, not a general dilata- 
 tion of the whole calibre. Absence of any other aneurism, esjDecially 
 of the rest of the aorta, must be ascertained. 
 
 iv. Absence of rasp-sound along the aorta, or any other indication 
 of extensive atheroma, should be verified. 
 
 V. Aortic incompetence, unless very slight, is a decided objection, 
 as is also mitral disease or considerable hypertrophy of the heart. 
 
 aorta, one circnrastance was difficult to account for, viz., that while the pulse in the 
 right carotid was unaffected, that in the right wrist was imperceptible. After death 
 the right subclavian was found to be the last branch of the aorta. Passing between the 
 aneurism and the spine it had been compressed, while the carotid was unaffected 
 
 * Many of the remarks below apply also to the two other methods of surgical inter- 
 ference — introduction of foreign bodies into the sac and galvano-puncture. 
 
 t Loc. supra cit., p. 520. 
 
492 OPERATIONS ON THE HEAD AND NECK. 
 
 vi. The patency of the vessels leading to the brain should be inves- 
 tigated by making a few seconds' pressure on the carotids alternately 
 and then simultaneously. 
 
 vii. Absence of visceral disease must be ascertained. 
 
 Before deciding to recommend operative interference in these 
 aneurisms, the surgeon should, I think, consider most carefully the 
 following points, which appear to me to be the outcome of recorded 
 cases : 
 
 1. It is possible that too much importance has been attached to a 
 very few successful cases, and that too little attention has been given 
 to the fact that numerous unsuccessful cases have occurred which 
 have never been published. 
 
 2. It is certain that, in some cases, operative treatment may not 
 only fail to check the progress of the aneurism, but may actually and 
 decidedly hasten the fatal issue. This grievous result may not only 
 be brought about by the difficulties of the operation itself, but also by 
 this special and untoward result which is common to all operative 
 treatment here — viz., that, as in these aneurisms the contiguous part 
 of the large vessels (aorta especially) is often extensively diseased, 
 and as other aneurisms may be present, ligature of one vessel, by 
 checking the flow of blood at one part, may throw the current sud- 
 denly upon another, perhaps unfit to bear the strain, or, from its rela- 
 tions, more likely to produce grave pressure-symptoms.* 
 
 " If the enormous difficulty of diagnosis, the great risks of the opera- 
 tion, the possibility of spontaneous improvement, if not of cure, and 
 of palliation by rest and diet, and also the fatal results of recorded 
 operations, be taken into due consideration, it seems that the distal 
 ligature on the right side should be limited to desperate cases, and 
 then performed only with the expectation of relief, not of cure" 
 (Morris f). 
 
 Contraindications to Operative Interference.— Mr. Barwell 
 {loc. supra cit., p. 528) lays down the following : (1) \^'hen tumor 
 symptoms reach widely on both sides of the middle line; (2) when, 
 with paralysis of the left vocal cord, there is obstruction of the right 
 bronchus; (3) when there is evidence of considerable aortic incom- 
 petence ; (4) when there is mitral disease or considerable cardiac 
 hypertropliy ; (5) when there is, in the course of the aorta, the rasping 
 sound of calcification or advanced atheroma, more particularly if the 
 
 * Thin rapid extension of the aneurism in anotlier direction after its original growth 
 has been checked by operative interference is well shown by a case of Dr. Churton's 
 (Clin. Soc. Trans., vol. xix. p. 261) in which, subsequently to galvano-pnncture, the 
 blood-pressure found out other weak spiits in addition to the original aneurism, thus 
 bringing about other saccular projections and fatal rupture into a bronchus. 
 
 f Loc. supra cit., p. 103. 
 
SURGICAL INTERFERENCE IN THORACIC ANEURISMS. 493 
 
 superficial vessels are rough and rigid ; (6) when there is pain about 
 the spine and intercostal nerves ; (7) when there is obstruction of the 
 left bronchus only; (8) M'hen there is pressure on the left apex, and 
 expectoration of frothy blood. 
 
 Choice of Vessel.— Question of Simultaneous or Consecu- 
 tive Ligature.— I have no space here for quoting statistics, which 
 are, after all, of inferior value to the authoritative opinion of those 
 who have worked most at this subject. The earliest and foremost of 
 these is Mr. Holmes ; as it is to his opinions that English surgeons 
 will naturally turn, the most important of liis recent views arc given 
 here. 
 
 1. " One thing, I think, has been fully proved— viz., that the dis- 
 tinction wliich was so much insisted on between aortic and innomi- 
 nate aneurism is of less importance in regard to the distal operation 
 than used to be taught, and that a case of innominate aneurism which 
 otherwise seems appropriate for operation need not be rejected be- 
 cause it is suspected or known that the aorta is also involved. It has 
 also been satisfactorily proved that aneurisms jourely aortic have been 
 much benefited by distal operations. It remains to inquire what 
 cases should be selected, and what arteries should be tied in each case." 
 
 2. " To my mind the clearest evidence of benefit has been in the 
 case of ligature of the left carotid in the treatment of aneurism aifect- 
 ing the transverse part of the arch." In a case of this kind it was 
 the evident extension of the tumor up the neck and towards the 
 trachea which made Mr. Holmes think that the ligature would prove 
 beneficial, and the result even surpassed his expectations, the patient 
 being alive and in tolerable health five and probably seven years 
 after the operation. Thus Mr. Holmes, considering that the ajoplica- 
 bility of the distal ligature depends largely on the observed growth 
 of the tumor, would think ligature of the subclavian justifiable if, in 
 innominate or mixed aneurism, the tumor was making rapid advance 
 under the sterno-mastoid. He also draws attention to the importance 
 of estimating pressure signs as indicating extension of the aneurism, 
 as evidenced by the condition of the veins, the breathing, the pupils, 
 etc. (p. 494). 
 
 3. With regard to operations on the right side in cases of innomi- 
 nate or mixed innominate and aortic aneurism, opinions vary as to 
 whether the carotid or subclavian should be tied simultaneously or 
 whether the carotid should be tied first. Mr. Holmes, who holds this 
 latter view, evidently thinks that ligature of this vessel may be suffi- 
 cient without any consecutive ligature of the subclavian, unless indi- 
 cations arise — e.g., the manifest growth of the subclavian portion of 
 the sac, or the effect of compression of the subclavian in diminish- 
 ing the size or the pulsation of the tumor. 
 
494 OPERATIONS ON THE HEAD AND NECK. 
 
 Mr. Holmes's chief reasons for preferring ligature of the carotid 
 alone as a first step are — (o) that while the number of cases of si- 
 multaneous ligature is much the larger, the most striking instances of 
 success have followed ligature of the right carotid alone ; (b) in some 
 cases, where ligature of the subclavian has been also resorted to later, 
 the aneurism was already diminishing and becoming firmer after liga- 
 ture of the carotid ; (c) the simultaneous ligature of two such vessels 
 as the carotid and the subclavian may be a very formidable undertak- 
 ing from the prolonged dissection and difficulties with the auEesthetic ; 
 {d) as ligature of the left carotid has proved sufficient in aortic aneu- 
 rism, a similar step should be tried on the right side in innominate 
 aneurism. 
 
 Mr. Barwell* goes a good deal further, and thus summarizes the 
 principal points which he believes will serve to guide the choice of the 
 surgeon. Time alone will show how far each is reliable. 
 
 1. For Ligature of Left Carotid. — Tumor S3anptoms upon and some- 
 what, but not far, to the left of the middle line, and rising into epis- 
 ternal notch, or beneath left sterno-mastoid. Left venus congestion ; 
 alteration of left carotid, and, to a much less degree, of left radial 
 pulse. Paralysis of left vocal cord ; obstruction to entrance of air, 
 equal on both sides of chest; sometimes alteration of left pupil. 
 
 2. For Ligature of Right Carotid and Subclavian. — Tumor symptoms 
 on right of middle line. Marked changes in right radial and carotid 
 pulse. Venous congestion on right side, affecting first, and chiefly, 
 head and neck. Afterwards, with increase of tumor, right arm and 
 chest and right vocal cord may be paralyzed. 
 
 Tumor symptoms on right of and upon middle line, running up to 
 sterno-clavicular joint and episternal notch ; venous congestion on 
 left side ; alteration of right pulse (radial and carotid) ; tracheal 
 dyspnoea. 
 
 Tumor further to the right, and lower (second space) ; congestion 
 equal on both sides ; no marked diff'erence between the two pulses ; 
 heart displacement, chiefly outwards. 
 
 Pressure on right bronchus; left lung perfectly free; with puerile 
 respiration and perhaps emphysema. 
 
 With any of these conditions, changes of the right pupil may be 
 combined. 
 
 3. Dovhfful Signs only to he Read by the Light of other Symptoms. — 
 Venous congestion on the left side, tracheal dyspnoea, dysphagia. 
 
 Another interesting and unsettled question bearing on this matter 
 of ligature of large vessels near the heart is the most appropriate 
 material for ligature. t While it is probable that ligatures of kan- 
 
 * Loc. supra cit., p. 328. 
 
 t See also the remarks at p. 4S1. 
 
SURGICAL INTERFERENCE IN THORACIC ANEURISMS. 495 
 
 garoo-tendon and ox-aorta are superior to silk or catgut, as the above 
 large, strong, slowly-absorbing bands, as they disappear, seem to leave 
 a ring of organized tissue behind them, it is improbable that the 
 greater security which they give is due to their not dividing the inner 
 and middle coats. Mr. Holmes* points out that while a case of Mr. 
 Barwell's shows that the ox-aorta may be so tied as not to divide the 
 inner coat, other cases show that this ligature may produce as perma- 
 nent and complete obliteration as any silk ligature ; moreover, a case 
 of Mr. Barwell's proves that in attempting not to divide the inner 
 coat, the surgeon may fail to close the vessel at all, a serious objection 
 to the proposal of tying arteries without division of the inner coat. 
 
 Facts which show that the resort to Ligature has been 
 justifiable. 
 
 1. Solidification and diminution in the size of the swelling. 
 
 2. Diminution of pulsation. In one case of Mr. Barwell's,! a month 
 after simultaneous ligature of both arteries for innominate aneurism 
 the swelling again began to increase and the solidifying tumor to 
 soften, pulsation also recurring ; this went on for about two weeks, 
 when the swelling again solidified and decreased, recovery ultimately 
 taking place. 
 
 3. Improvement in dyspnosa, dysphonia, and dysphagia. 
 
 4. Regain of power over a limb. 
 
 5. Expectoration of muco-purulent discharge which has been accu- 
 mulating in the lungs owdiig to interference with expiration from 
 pressure on the trachea. 
 
 II. Inteobuction of Foep:ign Bodies into the Sac. — This method 
 was origipally brought before the profession by Mr. Moore,! who in- 
 troduced 26 yards of fine wire iron into an aortic aneurism. No relief 
 followed, inflammation of the sac set in, and the patient died five days 
 later. 
 
 More recently Dr. Cayley has published a similar case in which 40 
 feet of wire were introduced by Mr. Hulke. Some relief was given to 
 the pain, and some consolidation had evidently taken place, but ex- 
 tension followed in another direction, causingurgent tracheal dyspnoea. 
 On this account wire was introduced a second time, 34 feet being got 
 in. Death followed nine days later. Owing to this material being 
 considered too irritating, it has not been much used. 
 
 Other surgeons have made use of catgut and horsehair, but with 
 
 *■ Land. Med. Eecord, 18S5, p. 53. Mr. Holmes also observes; ''Mr, Barwell's liga- 
 ture is, no doubl, flat when laid on a table, but when tied it is hard to see how its sharp 
 edges can be prevented from impinging on the vessel, and, if they do, they will prob- 
 ably cnt the middle coat." 
 
 t Mtd. Chir. Trans., vol. Ixviii. p. 130. 
 
 t Med. Chir. Trans., vol. xlvii. p. 129. 
 
496 OPERATIONS ON THE HEAD AND NECK. 
 
 these less irritating substances the great difficulty is to get much into 
 the sac, as they readily bend on themselves in the cannula * In the 
 summer of 1887, in a patient of Dr. Pye Smith's, with a large aortic 
 aneurism coming through the chest wall, I introduced about 40 feet 
 of horsehair by means of an ingenious method suggested to me by Dr. 
 Perry. No good was done, the patient dying shortly after, worn out 
 with pain. The post-mortem examination showed that the clot 
 formed by the horsehair was too localized to have effected much in 
 the huge cavity formed by the aneurism. 
 
 Another method, that of introducing very fine needles, is, I think, 
 more deserving of trial. Suggested by Mr. Moore, it has been tried 
 by Mr. Heath and Mr. Puzey.f The former made use of it in a trau- 
 matic aneurism of the subclavian, where amputation at the shoulder- 
 joint had failed. Three pairs of sewing needles were introduced into 
 the tumor, making each pair cross within the sac ; they were not with- 
 drawn until the fifth day, by which time considerable clotting had 
 taken place. The aneurism gradually became solid ; but bronchitis 
 supervened, and the patient sank seventeen days later. Mr. Puzey 
 followed Mr. Heath's plan in an aneurism of the innominate, but, no 
 apparent efi'ect taking place at the end of four or five days, other 
 needles were inserted as the first were withdrawn, but at different 
 parts of the swelling. This procedure being carried out for several 
 weeks, the aneurism finally almost disappeared behind the sternal 
 end of the clavicle. Unfortunately, the needles set up some chronic 
 cellulitis, septicaemia followed with vomiting, and fatal rupture of 
 the sac. Mr. Puzey thinks this case affords a warning against pushing 
 this treatment too far, and that it would be better to wait .patiently 
 the results of the first introduction of the needles before proceeding 
 to insert others. 
 
 If the introduction of foreign bodies be resorted to, antiseptic pre- 
 cautions I should, as far as possible, be made use of. The following 
 directions for the use of wire ai'e given by Mr. iIoore:§ " Choose wire 
 which is stiff enough to pass the cannula without bending, but so fine 
 as to bend easily when pressed against the wall within the aneurism. 
 Provide a straight short cannula of thin silver, sharply pointed at one 
 end, expanded at the other, and let its tube be somewhat larger than 
 is sufficient to give ready passage to the wire. Let there be also a 
 
 ■" I know of one caRe in which specially prepared very long pieces of catgut were 
 introdnced into an aneurism in the neck. At the post-mortem some of these were 
 found to liave passed on, lieyond the aneurism, into the splenic artery. 
 
 t Art. "Acupuncture,'' Did. of Snnj., vol. i. p. 25. 
 
 X Mr. Hulke in his case, in order to cleanse the steel wire thoroughly, etc, and thus 
 to get rid of (lie risks of jiysemia, soaked it for twelve hours in strong liquor potassffi; 
 strict antiseptic precautions were used, including the passage of the wire between car- 
 bolized sponges. 
 
 ? Loc. supra cit., p. 135. 
 
StTKGICAL INTERFERENCE IN THORACIC ANEURISMS. 497 
 
 thicker wire which fills the cannula, and is flattened at the end. This 
 is for use as a probe. Puncture with the cannula some part of the 
 aneurism which shall not be opposite to the presumed situation of the 
 aperture from the artery. Introduce the probe, and ascertain the 
 position and size of the arterial opening, as well as the dimensions of 
 the aneurism itself. This would determine the directions in which 
 the fine wire should be introduced and the quantity which the aneu- 
 rism might be expected to hold. Push in the fine wire, directing its 
 point against the opposite wall of the sac, and, whilst introducing 
 more, divert the end of the cannula. The wire must bend from its 
 fixed extremity in a curve determined by the direction given by the 
 cannula. Continue to introduce wire and to move the cannula, and 
 coils of wire will be formed of any required shape and in any part of 
 the sac. In withdrawing the cannula the wire must not be suffered 
 to remain in the puncture ; if it did so, the issue would probably be 
 fatal hemorrhage. The last part of the wire must be pushed fairly 
 into the aneurismal cavity with the flat end of the probe. The can- 
 nula may then be withdrawn upon the probe, on the removal of 
 which, last of all, the skin should slip back again over the tumor, and 
 the puncture in the sac would not correspond in that of the skin. 
 The puncture might be covered with collodion." 
 
 III. Galvano-puncture. — This method has for its object the pro- 
 duction of clotting without the risks and difliculties connected with 
 the introduction of foreign bodies. Like the latter, it has scarcely 
 had a fair trial, being too often not made use of till the size attained 
 by the aneurism forbids any hope of cure, and almost of relief. 
 
 Points, to pay attention to —(1) To avoid production of heat, 
 pain, and sloughing of the skin, the current* used should be a com- 
 paratively weak one. As an ansesthetic is not usuallj^ required, the 
 time occupied may be considerable. (2) The needles should be of 
 steel, as fine as is consistent with perforating the tissues, in order to 
 diminish pain, haemorrhage, and risk of sloughing. f (3) To avoid 
 the same risks, the needles should be insulated within about i inch of 
 their points by two layers of spirit varnish. (4) As it has been proved 
 that the effect of electrolysis on blood at the positive pole is a fairly 
 firm and tenacious dark clot, while the negative rather produces a 
 pinkish frothy substance, it seems wiser to connect the needle or 
 
 * Dr. McCall Anderson, in a most successful case {Lancet, 1873, vol. i. p. 261), em- 
 ployed four to six cells of a Stohrer's battery. In a case of Dr. Ord {Lancet, 1880, vol. 
 ii. p. 450), followed by temporary benefit, six to eighteen cells of a Foveaux's battery 
 were used. Dr. Bastian {Brit. Med. Journ., 1873, vol. ii. p. 595) made use of five tO' 
 eleven cells of the same battery. 
 
 t With this object, Dr. Bastian used a small hare-lip pin. Dr. Duncan's needles, 
 as made by Weiss, seem very large. 
 
 32 
 
498 OPERATIONS ON THE HEAD AND NECK. 
 
 needles introduced into the sac with the positive pole, while a large 
 sponge wrung out of warm salt-water is connected with the negative 
 pole and applied to the chest-wall near the swelling. (5) A sitting 
 should not be prolonged over thirty or forty minutes. The punctures 
 had best be closed by collodion. (6) The operation should not be re- 
 peated too soon, time being allowed for all local reaction to cease and 
 for consolidation of the coagulum to occur, which often takes some 
 time. 
 
 Drawbacks and Dangers. — (1) As pointed out by Mr. Holmes, 
 " it is a radical defect of this method that it acts by inducing ' passive ' 
 coagulation of blood in the sac. Hence, it is inherently uncertain, 
 liable to cause relapse by the melting of the coagulum, or inflamma- 
 tion by its too sudden deposition. Again, it is very liable to set up 
 inflammation in the walls and contents of the sac. Then, too, the 
 needles sometimes produce eschars at the points of their insertion, and 
 thus give rise to consecutive hsemorrhage. In fact the cases are few 
 in which a perfectly happy result has been obtained, but some of 
 these are worthy of particular attention. 
 
 Amongst these is a case of Ciniselli (Holmes, loc. supra cit), in which 
 an aneurism of the ascending aorta, quickly increasing, pushing out 
 the third and fourth ribs, with powerful pulsation, rapidly diminished 
 with much solidification after galvano-puncture for forty minutes, the 
 patient resuming his work as a coachman ten weeks later. In Dr. 
 McCall's case the aneurism was a small one, about 3i inches in diam- 
 eter; after galvano-puncture on three occasions, the swelling was only 
 about one-quarter of its previous size, and for the most part very solid. 
 In a case of Dr. Carter's {Lancet, 1878, vol. ii. p. 761), an aneurism of 
 the thoracic aorta appearing in the right sub-clavicular region, and 
 accompanied by much pain, was treated by galvano-puncture on three 
 occasions with very great relief, the pulsation becoming almost imper- 
 ceptible and the pain disappearing. 
 
 In deciding between the introduction of foreign bodies {e.g., wire) 
 and the use of galvano-puncture, I think (1) That the use of needles 
 (p. 496) deserves a further trial ; (2) That there can be no doubt as to 
 ithe superiority of galvano-puncture over the use of wire or catgut. 
 Eveaa when some material is found less irritating than wire and not so 
 flexible as catgut or horsehair, and therefore more manageable, gal- 
 vano-p.uncture will, probably, still be safer and more resorted to. 
 
 It is clear, however, that, if anything like prolonged relief is to be 
 given, such operations must be resorted to at an earlier date than has 
 hitherto been the case, and I would again draw attention to the 
 remarks at p. 492 (a point to which attention has not been sufiiciently 
 directed), that surgical interference may, in cases of large aneurism, 
 do more harm than good by diverting the blood-current from the 
 origmal aneurism into some outlying and unsuspected secondary sac. 
 
PART III. 
 OPERATIONS ON THE THORAX. 
 
 CHAPTER I. 
 
 REMOVAL* OP THE BREAST (Figs. 91, 92). 
 
 Indications. — The following remarks must be considered to refer 
 to that most common and important of diseases — carcinoma. 
 
 As recurrence after operation is, sooner or later, practically certain 
 in the great majority of cases,t a careful and judicious selection 
 of cases is of the utmost importance. For such a purpose cases of 
 carcinoma of the breast fall into the three following groups : 
 
 A. Cases to which an Operation is altogether unsuited, or especially douU- 
 ful and (in many) dangerous.— (1) The very aged, e.g., after sixty ; not 
 only are the aged less healthy, but they are less troubled by the 
 cancer, and more resigned. (2) The unhealthily fat J and plethoric. 
 (3) Habitual over-eaters. (4) Tipplers on the sly. (6) The subjects 
 of a confirmed bronchitis, and weak heart. (6) Subjects of decided 
 albuminuria, cirrhosis or diabetes. (7) Extensive disease of the skin, 
 accompanied by scattered tubercles or cedema, and, worst of all, a 
 brawny, leather-like, greasy condition of the skin, with firm oedema 
 and open sebaceous glands, approaching the condition of cancer en 
 cuirasse. (8) Quick growth, with rapidly increasing fixity. (9) Supra-- 
 
 * Owing to the limitation of my space, I have been unable to deal with other less 
 important operations on the breast. 
 
 f "As certain as anything in surgery" (Sir James Paget). 
 
 X Sir James Paget, from whom several of the above have been taken, thus writes 
 (Glin. Lecls. and Essays, p. 14) : The over-fat are certainly a bad class, especially when 
 their fatness is not hereditary, but may be referred in any degree to their overeating, 
 soaking, indolence, and defective excretions. The worst of this class are such as have 
 soft, loose, flabby, and yellow fat, and I think you may know them by their bellies 
 being pendulous and more prominent than even their thick subcutaneous fat accounts 
 for, for this shape tells of thick omental fat and, I suppose, of defective portal circula- 
 tion.'' Some earlier remarks of Sir James may here be quoted : " Such people must 
 be carefully managed ; not fed too well ; not kept too long in bed ; not allowed to 
 retain their refuse ; and mere bigness must not be taken for plethora." 
 
600 OPERATIONS ON THE THORAX. 
 
 clavicular disease * (10) A young patient, especially with a volumi- 
 nous breast,! a rapidly increasing growth, and a bad family history, 
 (11) Of course, the presence of carcinoma elsewhere— e.gr., uterus— or 
 secondary deposits. 
 
 B. Coses in which an Operation is indicated. — (1) Cases somewhat ad- 
 vanced in life, for the younger the patient the more active is the can- 
 cer. (2) Especially if patients who are on in years are thin and dry 
 and tough, clear-voiced and bright-eyed, with good pulses and diges- 
 tion, and no cough or wheezing. (3) Small breasts and little fat. (4) 
 Where the growth is circumscribed with distinct outline. The worst 
 defined tumors are the worst for recurrence. (5) Where the growth is 
 very hard. The " stoniest " growths are usually the slowest. (6) Skin 
 not involved. (7) Absence of fixity. (8) Either no axillary glands, 
 or but very few involved. (9) Rate of progress slow, and family his- 
 tory good. 
 
 C. Cases in which an Operation is douhtfid. — These lie intermediate 
 between A and B, both as to general and local points. 
 
 Questions which the Surgeon may be asked, or which he 
 may have to put to himself. 
 
 1. How long will my patient live if I do not operate f This can only be 
 answered approximately by considering the average duration of life 
 from the earliest discovery, in cases of scirrhus. This is about two 
 years and a half.J 
 
 * If other points are favorable, and if it seems justifiable on account of pain, threat- 
 ening ulceration, etc., to give the patient temporary relief by the removal of the breast, 
 enlargement of glands here need not deter the surgeon ; when the disease has been 
 removed below from the breast and theaxilla, the supra-clavicular glands will, I believe, 
 be found to enlarge slowly, and as the space which contains them is large, they do not 
 become adherent quickly. I have twice within the last four years operated in cases 
 in which these glands ware slightly involved. In one the patient lived three years, 
 in the other fourteen months, after the operation. 
 
 f The larger and the more vascular the breast, and the more abundant the fat, the 
 more difficult will it be to make certain of extirpating not only the growth, but also 
 every atom of the breast. 
 
 i Mr. Sibley {Med. diir. Trans., vol. xlii.) gives thirty-two months; Mr. M. Baker 
 {ibid., vol. xliii.) gives forty-three months. Mr. Beck (Diet, of Surg., vol. i. p. 18.5), 
 apparently quoting from Prof. Gross, divides the course of an ordinary scirrhns of the 
 breast, unrelieved by treatment, into these three stages: First, when the disease is lim- 
 ited to the breast, the duration of this first stage averaging fourteen months. Secondly, 
 the stage of the skin and the axillary lymphatics, taking in the average from fourteen 
 to twenty months. Thirdly, the stage of ulceration and general infection usually 
 taking from the twentieth to the twenty-seventh month to close the case in death. In 
 atrophic scirrhus the average duration of cases not operated on is given as eighty-two 
 months, patients having been known to survive fifteen or even twenty years. With 
 encephaloid cancer the average duration is under a year. Even after removal of the 
 breast it is said to be onlv sixteen months and a half. 
 
REMOVAL OF THE BREAST. £01 
 
 2. How long will she live if I do operate ? If the discovery and the 
 operation are early ones, three years and a half may be hoped for, in 
 cases operated on, from the first discovery to the close. Mr. Sibley 
 (toe. supra cit.) gives fifty three months; Mr. M. Baker fifty-five 
 months. 
 
 3. What is the average date of recurrence after operation f About a 
 year. Mr. Sibly gives Qoc. supra cit.) fourteen, Mr. M. Baker thirteen, 
 months. If anything, the above averages are probably too favorable : 
 while the extremes vary from two months to ten years, more than 
 half return within twelve months ; about two-fifths return in six 
 months. 
 
 4. \nat are the risks of the operation itself f In other words, what are 
 the risks that the patient, instead of dying in one or two years of the 
 disease, may die in one or two weeks of the operation? In most 
 cases, with careful after-treatment, the risks are slight. The deaths 
 from operation are mainly due — (o) to septic causes and blood-poison- 
 ing — e.g., erysipelas, pytemia, etc. ; or (6) to lung-trouble — e.g.., bron- 
 cho-pneumonia. This being so, the mortality formerly given has 
 been much diminished of late years by the improvements of modern 
 surgery.* 
 
 Fresh statistics, to be of any value, will be required of this operation, 
 performed with modern completeness and with strict aseptic precau- 
 tions maintained throughout. 
 
 Reasons which may make a Patient wish for an Opera- 
 tion beyond making a mere Prolongation of Life. — These may 
 be : (a) Relief from pain,t which otherwise increases daily ; the mis- 
 ery of waking every day to the consciousness of an incurable disease ;J 
 
 * Sir James Paget and Mr. Ericheen gave 10 percent. ; Mr. Bryant, 6 per cent. ; Dr. 
 Stettegart, giving the statistics of operations performed from 1873 to 1876 in one of the 
 hospitals at Berlin, gives a mortality of 7 per cent, where the breast alone was re- 
 moved, and 23 per cent, where the breast was removed and the axilla cleared out as 
 well (Lang. Arch., Bd. xxiv. 1879). These statistics, nowadays, require revision. 
 
 t The uncertainty of the pain attendant on cancer of the breast is well known. Al- 
 most always absent for the first year or more, save when the bosom is handled, pain 
 may scarcely be present from first to last. More frequently after the above dates the 
 pain becomes increasingly dull and heavy, then more and more lancinating; finally, 
 when the growth is ulcerating, a hot burning sensation is substituted for, or added to, 
 the lascinating pain (Paget, Surg. Path., pp. 646, 647). Thus, while the growth is 
 small and can be removed with good hope, the patient refuses operation because she 
 cannot believe in cancer without pain. Later on, when she seeks relief from her pain, 
 all hope of giving permanent relief has usually passed away. 
 
 t Sir C. Bell's vivid picture of the advanced stage of cancer of the breast may be 
 quoted here. It should stir up in every mind an earnest desire to secure earlier oper- 
 ations. " The general condition of the patient is pitiable. Sufiering much bodily, 
 and everything most frightful present to the imagination, a, continual hectic preys 
 upon her, which is shown in increasing emaciation. The countenance is pale and 
 
502 OPERATIONS ON THE THORAX. 
 
 the sometime loathsomeness; the restlessness for cure (Paget). (6) 
 The return of the disease in the scar is often less greivous than the 
 original disease— i.e., the induration, ulceration, excavation are slower 
 and less marked than in the breast-tissue.* (c) Death by deposits in 
 the viscera, these being unseen, is less distressing to the patient than 
 death by the original cancer in the breast, which is always under her 
 eyes, (rf) The patient may have especial reasons for wishing to live 
 and get about in comparative comfort for a year or so.f 
 
 Operation (Figs. 91, 92). — The chief objects to be bore in mind 
 throughout the operation are — 
 
 1. To get away every atom of the disease. — The main diffi- 
 culties in securing this are — -(a) The fact that while cancer may be 
 actually declared in the tumor only, yet the whole breast is in a pre- 
 cancerous condition, and one on which cancer may easily supervene 
 if an atom of the gland is left behind. (6) Owing to the amount of 
 fat which is often present, it is very difficult to make sure that every 
 particle of gland-tissue has been removed, especially when the parts 
 are obscured with blood. 
 
 2. To remove entirely the lymphatic tract between the 
 breast and the axilla. 
 
 3. To clear out the axilla. — This should be done as a regular 
 thing in every case of cancer of the breast, whether any glands can be 
 felt or no. 
 
 X The parts having been well cleansed, including the axilla, and this 
 
 anxious, with a slight leaden hue ; the features have become pinched, the lips and nos- 
 trils slightly livid ; the pulse is frequent; the pains are severe. In the hard tumors 
 the pain is stinging or sharp ; in the exposed surface it is burning and sore. Pains, 
 like those of rheumatism, extend over the body, especially to the back and lower part 
 of the spine; the hips and shoulders are subject to these pains. Successively the 
 glands of the axilla and those above the clavicle become diseased. Severe pains shoot 
 down the arm of the affected side. It swells to an alarming degree and becomes im- 
 movable. At length there is nausea and weakness of digestion; a tickling cough dis- 
 tresses her ; severe stitches strike through the side ; the pulse becomes rapid and 
 fluttering, the surface cadaverous, the breathing anxious, and so she sinks " (Med. Chir. 
 Trans., vol. xii. p. 22.S). 
 
 * While this is correct, local recurrence, as being constantly visible to, and dwelt on 
 by, the patient, is much to be deprecated. If only is was more the custom to operate 
 very widely and deeply, and without attempting much primary union (p. 559), local 
 recurrence would be almost unknown, 
 
 f Thus, in a case mentioned by Sir B. Brodie (Led. on Path, and Surg., p. 202), he 
 declined at first to operate on a lady with a scirrhus of the breast on the point of ulcer- 
 ating. In a few weeks the patient returned, begging to have the breast removed, that, 
 her life being rendered more comfortable and active, she might accompany in society 
 an only daughter. The operation was successfully performed, and at the end of twQ 
 years the patient died of secondary pleuritic efTusion. 
 
 X Important points in the preliminary treatment are regulating the patient's diet, get- 
 ting rid of her refuse, and treating any bronchitis, however slight this may appear to be. 
 
REMOVAL OP THE BREAST. 503 
 
 space shaved, the patient's neck and abdomen well protected with 
 mackintoshes, the arm is carried away from the side and an elliptical 
 incision is made from a point close to the sternum, passing along the 
 lower border of the breast, and then somewhat upwards towards the 
 axilla. An assistant standing opposite to the surgeon now draws up 
 the breast, while the surgeon, taking the edge of the cut skin with his left 
 finger and thumb, dissects this off in a downward direction till he is 
 well below the lower limit of the breast* Spencer Well's forceps 
 bemg applied to any spouting vessels, an assistant makes sponge- 
 pressure on this flap, and draws the breast somewhat down, while the 
 surgeon makes another elliptical incision, starting from the same 
 point as the first, but passing upwards along the upper limit of the 
 breast, and then descending somewhat to meet its fellow just below 
 the tendon of insertion of the pectoralis major. While the breast is 
 drawn downwards by the assistant who is making pressure on the 
 lower flap to prevent bleeding, the surgeon raises an upper flap in the 
 same way as the lower, taking care to get above the upper limit of the 
 breast, and in either case keeping the point of the knife towards the 
 skin and not towards the breast, but not sufficiently so to make "but- 
 ton holes." 
 
 Opportunity may be taken here to refer to these elliptical incisions, 
 and the flaps which are raised thereby. I am strongly of opinion 
 that the way in which they are often planned and carried out is not 
 only futile, but highly perilous. What is far too often done, is, by 
 means of such elliptical incisions, to include the nipple and a very 
 shght margin of skin on either side. The breast is then quickly re- 
 moved without any due precaution as to getting above and below its 
 limits; the wound comes, without any trouble, excellently together; 
 nothing could look better at the time, but in a few months the disease 
 inevitably reappears. I believe that we should do much better in 
 these days of antiseptic surgery and skin-grafting if we reverted to the 
 ancient method of deliberately sweeping away the whole breast and 
 all the skin over it. But as this proceeding requires too much cour- 
 age, especially in the theatre of a large hospital, to allow of its being 
 adopted, at all events at present, the surgeon should take care that he 
 does not fall into the opposite extreme for the sake of turning out a 
 neatly finished operation. The elliptical incisions should be carried 
 very wide of the nipple, close to the lower and upper limits of the 
 breast, and the flaps should be reflected well beyond the breast limits. 
 No skin that is even doubtful should be hesitated over for a moment. 
 
 * While the surgeon must get beyond the breast so as to make sure of removing all 
 of it, he shoiid not carry his knife farther down than is needful, otherwise discharges 
 will pocket here, and may travel backwards around the ribs, pointing at the angle of 
 the scapula (p. 507 j. 
 
504 OPEEATIONS ON THE THORAX. 
 
 In cases of any standing, all the skin over that half of the breast, in 
 which the cancer is, had better go. It may be answered to this that 
 there will be a wound left, gaping more or less widely. This objection 
 can be met, to a large extent, by following the steps detailed below. 
 But if a gaping wound has, after all, to be left, while it does not look 
 so well at the time, it will give a far better result afterwards. 
 
 Bearing on the above, the following remarks may be quoted, coming 
 as they do from one who, in his day, had a vast experience of cancer 
 of the breast, the late Mr. C. Moore, of the Middlesex Hospital.* 
 
 " Taught, without doubt by foregoing failures, our surgical ances- 
 tors adopted a method of operating which might well have been 
 expected to prove effectual against a local recurrence of the disease. 
 They transfixed the base of the mamma, and, raising it with ligatures, 
 swept off the whole organ, together with all the skin that covered it. 
 The proceeding had a barbarous appearance enough, but it was prom- 
 ising, and if their knowledge of the disease had led the surgeons of 
 the time to adopt it before the skin was hopelessly infiltrated, they 
 must have met with more success than they appear to have done. 
 Postponing, however, all operation until the skin was brawny and 
 filled with tubercles, and the deeper textures were involved without 
 limit, they failed too often, with even such extensive cutting as they 
 adopted, to comprehend the entire disease. It was a mistaken kind- 
 ness which led to a change of this mode of operating. Under the 
 influence of a clergyman, who expressed what must have been a pre- 
 vailing horror at such Amazonian surgery, the practice was changed 
 to an incision in the integument, which was reflected in flaps, and 
 brought together again in flaps, after the removal of the cancerous 
 tumor. 
 
 " There would have been no diminution of suffering by this pro- 
 longation of the operation, and what was gained by it in neatness was 
 lost in life. With the remains of the breast, as well as in their own 
 texture, the -flaps enfolded fragments of diseased substance, and can- 
 cer soon reappeared. It was an operation proper to innocent tumors, 
 which can be removed without the needless mutilation of extirpating 
 the breast, but was quite inapplicable to eases of mammary cancer." 
 
 The incisions having been made as directed, widely separated from 
 each other, the flaps cleared off' till the limits of the breast above and 
 below and at the sternal and axillary ends are clearly definea, all 
 freely bleeding points secured, the surgeon proceeds (Fig. 91), with his 
 finger or the handle of the scalpel, to strip the breast from off the 
 cellular layer which unites it to the pectoral muscle. Two precautions 
 should be taken here : (1) to define the lower border of the muscle, 
 
 * Inadequate Operations on Cancers. 
 
EEMOVAL OF THE BREAST. 
 
 505 
 
 otherwise it is very easy to strip up some of the fibres of this muscle 
 also as well as the breast over it ; (2) to remember that when, as is 
 often the case, this muscle is soft and probably fatty, it is very easy 
 to detach some of the fibres even when the breast is not adherent to 
 the muscle. If it be found, especially in a case of any duration, that 
 
 Fig. 91. 
 
 ■^ 
 
 J*-v 
 
 >- 
 
 
 •^- V 
 
 ' m 
 
 ''k, 
 
 rt i 
 
 
 the cancer has involved any part of the muscle, any fasciculi should 
 be cleanly removed from their sternal to their axillary attachments, 
 cutting across them at these points, and stripping them up cleanly 
 with a director ; any muscular vessels which need it are now tied. 
 
 The breast being removed, any remaining bleeding points should be 
 secured, and it may be here said, once for all, that, in removal of a 
 breast, vessels will be met with chiefly at the four following points : 
 (1) In the cut edges of skin ; (2) coming through the pectoralis major ; 
 (3) at the outer edge of the pectoralis major, coming through the ser- 
 ratus magnus ; (4) at the axillary end of the incision, branches from 
 the external mammary and sub-scapular, this latter being usually the 
 largest of all. 
 
 The wound left by the removal of the breast being covered over 
 with lint wrung out of 1 in 40 carbolic solution, the surgeon should in 
 every case of cancerous breast prolong his incision into the axilla 
 along the lower border of the pectoral major, and thence through the 
 skin up to the biceps, so as to expose the cavity freely. A few light 
 touches of the knife open the deep fascia, and the tip of the finger 
 then loosens the glands and further explores the cavity. During this 
 stage the arm is drawn more and more above the patient's head, so 
 as to open out the axilla. 
 
506 
 
 OPEEATIOXS ON THE THORAX. 
 
 Not only every gland that can be felt or seen should be removed, 
 but also every atom of fat that can be got out of the axilla. In this 
 substance lie lymphatic glands, which otherwise will be surely left 
 behind, and by its removal a source of tedious suppuration, which is 
 always liable to follow on disturbance of fat, will be avoided. 
 
 In removing the fat and glands after loosening them and freeing 
 them with the finger, steel director, or blunt dissector, everything 
 which feels like a pedicle, everything which does not shell away 
 quickly, should be divided, below a pair of Spencer Wells' forceps, 
 and the upper end tied, or secured, if preferred, with double chromic- 
 gut ligatures passed with an aneurism-needle. 
 
 Every precaution must be taken not to rupture the axillarj^ vein, 
 an accident best avoided by remembering its position, by using no 
 sharp instrument, and working without any undue tearing or force. 
 The large subscapular vein nearly always requires ligature, and if 
 this, or any other branch, is torn away close to the axillary vein, an 
 
 Fig. 92. 
 
 To show the position of the chief glands and vessels in the axilla. (After SSdillot.) 
 
 accident which here, as in branches of the internal jugular, is not at 
 all unlikely to happen if undue force is used, or if the parts are made 
 adherent by growth, most embarrassing haemorrhage will take place. 
 This is only to be met by taking up the aperture with a ligature around 
 it, if this be feasible, or by ligaturing the vein above and below. 
 When the axilla seems to be thoroughly cleared out, attention must 
 
REMOVAL OF THE BREAST. 507 
 
 Still be paid to the following points : (a) The edges of the pectoraUs 
 major and minor, as glands are met with here between the two mus- 
 cles (Fig. 92) ; (b) the under surface of the pectorals ; (c) the apex of 
 the axilla. To reach enlarged glands in either of these two latter 
 situations, both pectorals must be divided near their insertions, com- 
 pletely if necessary. Such a step will cause additional hemorrhage, 
 probably from the long thoracic and muscular branches, and will 
 call for thorough drainage and greater attention still to keeping the 
 wound sweet. It is, however, far better to face these than to run the 
 risks, inevitable otherwise, of leaving mischief behind which the 
 surgeon will never again have so favorable a chance of attacking, or of 
 doing harm to the large vessels, by working in the dark. 
 
 If at any stage of cleaning out the axilla the axillary vein is so 
 embedded in the malignant deposit that this cannot be removed with- 
 out taking away a part of the vein also, this may be done without 
 hesitation, two chromic-gut ligatures being first applied.* 
 
 The wound is now thoroughly sponged out, all haemorrhage finally 
 arrested, and due drainage provided for. In doing this it is often ad- 
 visable not only to pass a drainage-tube from end to end of the wound, 
 but also to puncture the lower flap, if this is large, near its attached 
 border, and to bring out here another drainage-tube, with one end in 
 the axilla, otherwise tension, and burrowing of discharges, which may 
 travel round to the back along the ribs, requiring fresh administra- 
 tion of anaesthetics and free openings, are very likely to occur. 
 
 Due drainage being provided for, the surgeon sees how far he will 
 be able to close the wound. And without describing an easy case, I 
 would say at once that it is often possible, by paying attention to the 
 following details, when the arm is brought down, to unite a wound, 
 perhaps completely, in which any attempt to close the edges appears 
 at first quite hopeless. To begin with, a very large number of sutures 
 should be used, upwards of twenty-four perhaps in a widely gaping 
 wound, so that the tension shall be distributed as evenly as possible 
 over a large number instead of falling heavily upon a few. Secondly, 
 Sir J. Lister's leaden button-suturesf should be used wherever much 
 
 * In two cases in which I was compelled to remove a portion of the axillary vein 
 between two ligatures, the resulting oedema and trouble were much less than I ex- 
 pected; in one case they could scarcely be said to occur at all. 
 
 t These are oval discs of lead from 1 inch to IJ inch long, perforated in the centre, 
 and having the two sides turned up in the form of projecting wings. They are applied 
 as follows: The free end of a stout piece of wire is passed through the hole in a 
 button, and secured by twisting it round the wings ; the other end of the wire is then 
 threaded on a needle, which is made to enter and emerge an inch pr more above and 
 below the margin of the wound; the wire is then threaded through a hole in a second 
 button, and when two or three such pairs of buttons are in place, each pair is pressed 
 firmly against the flaps by an assistant, while the surgeon twists the wire round the 
 
508 OPEEATIONS ON THE THORAX. 
 
 tension is needed. Numerous other sutures must be employed as 
 well, a dozen or more of stout carbolized silk or wire, and the rest of 
 fine silk or horsehair soaked in carbolic acid. The wires of the 
 buttons should be cut usually on the second or third day after the 
 operation. All of them should not be cut at the same time, and, with 
 regard to these and other sutures, it is not necessary to disturb the 
 wound by removing the sutures. Judicious cutting of those on which 
 the tension is too great is all that is required at first. 
 
 The wound being finally cleansed, the drainage-tubes syringed 
 through to free them of clots, a little iodoform is dusted into the 
 axilla, strips of gauze, and then a piece of appropriate size and thick- 
 ness, are laid over the wound, the arm and forearm brought across 
 the chest, and a large gauze dressing thus applied. A large square 
 piece has a hole cut in it near the upper left or right corner according 
 to the breast removed, the arm and forearm being brought comfort- 
 ably across the chest, the hand is passed through the hole, which is 
 next slid over the limb till it is well up in the axilla, the hole being 
 sufficiently far from this side of the dressing to allow it to reach well 
 into the scapular region. The dressings are then kept in situ by 
 bandaging round the abdomen and chest, and over the clavicle and 
 point of the shoulder, the object being to distribute the discharges as 
 evenly as possible, and to meet their tendency to come through at 
 three spots — viz., at the lower border of the dressings, at the sternal 
 end of the drainage-tube, and behind the axilla. It is well, before 
 the arm and forearm are shut in, to dust on a little zinc-and-starch 
 powder over the elbow and palm, especially when the weather is hot 
 and the skin delicate, owing to the irritation of the perspiration 
 which is thus shut in. 
 
 I prefer to keep my patients as much propped up as possible, and 
 turned on the sound side, thus facilitating drainage from, and early 
 closing of the axillary end of the wound where cellular tissue has 
 been much opened up. 
 
 Question of the Need of Removal of the Whole Breast, 
 and of Clearing out the Axilla in Every Case of Cancer.— It 
 will be gathered from the above account that I here follow, and would 
 advise others to follow, Mr. Banks, whose views on this matter have 
 been so clearly and vigorously put forward.* 
 
 It is only right to remind my readers that these views have been 
 
 wings of the second button, so as to keep the stitch securely in position. The object 
 of these sutures is to relax the parts, the strain being, by the leaden discs, distributed 
 over a considerable surface, and the risk of the sutures cutting out too soon diminished. 
 * Bnt. Med. Journ., 1882, vol. ii. p. 1138 ; address before the Harveian Society 
 (ibid., 1887, vol. i) ; Liv. Med. Cliir. Journ.., 1883. 
 
REMOVAL OP THE BREAST. 509 
 
 lately criticized with much ability by Mr. Butlin* While I am well 
 aware of the weight that is due to his opinion as that of a very high 
 authority on malignant disease, the following are my reasons for dif- 
 fering from him : 
 
 Mr. Banks holds most strongly that in every case of cancer of the 
 breast — (1) The whole breast, the skin over it, the fascia over the pec- 
 toral muscle, and (if at all suspicious) the fibres of this muscle should 
 be removed. (2) The axilla should be cleaned out whether any en- 
 larged glands can be felt or no. 
 
 Mr. Butlin (toe. supra cit, p. 375) considers that (A) the practice 
 of removing the whole breast is " theoretically and practically 
 wrong," and again (p. 375), he believes this wholesale method of 
 treating cancer of the breast "to be unscientific and needlessly cruel 
 to many women." Amongst his reasons put forward with much 
 ability and carefulness for preferring a more partial operation are — 
 
 1. With regard to recurrence. " Certainly, in the vast majority 
 of instances, there is nothing to lead one to believe that the new 
 growth arises in the outlying lobules of the mammary gland, or in 
 any remains of the parenchyma of the gland." If this view be cor- 
 rect, it must be allowed that extensive oj^erations with a view of re- 
 moving all the breast are needless, and deserve Mr. Butlin's condem- 
 nation quoted above. But with our ignorance as to how exactly 
 cancer recurs in the breast, can it be said to be correct? I venture, 
 with all respect, to hold a totally different opinion on this most car- 
 dinal point. I hold, with Dr. Creighton,t that, in the great majority 
 of cases, cancer here is a disease of a breast becoming obsolete, or 
 actually so ; that one result of this is that the atrophying acini become 
 so disordered as to allow their epithelium to escape into, and infect, 
 the surrounding connective tissue. Though the exact way in which 
 this disbandment of the epithelium is started is unknown, it is a most 
 important step, the connective tissue of people after middle life being 
 unable to resist the encroachments of epithelium. J It is this which 
 not only may start a carcinoma, but which makes it so difficult to 
 prevent its recurrence, unless by early and complete operations, be- 
 cause the connective tissue goes widely beyond the breast. 
 
 On this account, beUeving that the whole breast is, in the great 
 majority of cases, in a condition to become carcinomatous, and that 
 thus partial operations are liable (especially when the coarse fat, 
 which is often so abundant, and the haemorrhage in the operations are 
 remembered) to leave behind potential foci of disease, I consider that 
 
 * Opei: Surg, of Mai Dis., p. 375 et seq. 
 
 f Contrib. to the Physiol, and Pathol, of the Breast. 
 
 X Other instances are seen in the lip and penis. 
 
510 OPERATIONS OK THE THORAX, 
 
 more wholesale operations are, in these days of modern surgery, the 
 reverse of " unscientific and needlessly cruel to many women." 
 
 2. With regard to the severity. There can be no doubt that the 
 more extensive operations are the more severe. I doubt, however, 
 very strongly whether, at the present day, with earlier operations, a 
 wise selection and preparation of cases, with the antiseptic precautions 
 at our command, aided by subsequent skin-grafting, the mortality 
 will be largely increased. If there must be an increase, the gravity 
 of the disease for which the risk is run, and the object that is in view, 
 must not be forgotten. 
 
 3. The mutilation. All will agree with Mr. Butlin when he 
 writes, p. 382, " I believe it affects women much more than we, and 
 even they, perhaps, are inclined to admit, and it is not improbably 
 one amongst several causes which lead them to conceal the presence of 
 a tumor of the breast until long after the period at which it may hope- 
 fully be removed." While this is a matter which must be sorrowfully 
 remembered, and its explanation weighed with due reverence when a 
 surgeon is inclined to blame his patient for having concealed her dis- 
 ease, I think that another and more potent reason usually leads women 
 to defer the operation until the setting in of the second stage and the 
 commencement of pain, and that is, the widespread knowledge of the 
 frequency of cancer here, and the failure of operations to exterminate 
 the disease. If only we could show better results, and, though not a 
 believer in any extensive curing of cancer, I believe that we can do so by 
 combining earlier operation, a wise selection of cases, going very wide 
 of the disease, and paying strict attention to antiseptics throughout, 
 women would, I think, come forward more readily for treatment with 
 that calm good sense in which, in addition to quiet patience, they too 
 often surpass us. 
 
 (B) That the axilla should be cleared out in every case.— 
 I advocate this strongly, for two reasons : (a) While I am aware that 
 in some cases of cancer of the breast the glands are never implicated 
 at all, while the disease recurs inveterately in the scar made for the 
 removal of the breast, I believe strongly that, in the great majority of 
 cases, to clear out the axilla is the wiser course, for if the surgeon 
 wait, as Mr. Butlin (p. 383) advises, till the glands are obviously en- 
 larged, or till there is fulness not amounting to actual proof of en- 
 largement, he will often wait till it is too late — i.e., till not only the 
 glands, but the connective tissue and fat of the axilla, are implicated 
 as well, and till the supra-clavicular glands have had time to become 
 infected, though not visibly enlarged. (6) I do not consider, with the 
 surgerj' of the present day, that opening up the axilla adds to the 
 severity of the operation. If good drainage and those antiseptic pre- 
 cautions which have been so often mentioned are duly attended to, 
 the axillary wound heals rapidly. 
 
PARACENTESIS OF THE CHEST. 511 
 
 CHAPTER II. 
 
 PARACENTESIS AND INCISION OF THE CHEST. 
 RESECTION OP RIBS. 
 
 PARACENTESIS AND INCISION OP THE CHEST. 
 
 Indications for interference in pleuritic effusions. Before interfering 
 operatively, the surgeon has two points to consider. I. Whether 
 fluid is present. II. Whether it is purulent or not. My space 
 will only allow of my dealing with the second of these points. 
 
 II. Is the fluid purulent or not ? The importance of clearing 
 up this point is manifest from the fact that if pus is present it is very 
 rarely absorbed ; it may burst into the lung, may burrow about, 
 making its way externally, causing hectic, caries, and lardaceous 
 disease. 
 
 A. Exploratory puncture (vide sit'pra). A large hypodermic syringe 
 and needle should be used, absolutely clean, pervious, and the needle 
 sufficiently long and not too flexible. A grooved needle should never 
 be trusted to. It is readily plugged by a pellet of fat, and thick pus 
 will not flow along it. 
 
 B. Presence of pyrexia and hectic. This is not always reliable. 
 Fallacies : (a) They may be absent, or little marked, in empyema, 
 especially in long-standing cases, the alteration of the pleura or the 
 degree of tension preventing absorption. (6) Well-marked pyrexia 
 may be present in serous effusions; thus, in these, the evening tem- 
 perature may reach 101°.* 
 
 C. The aspect of the patient. The tint is often ana?mic and earthy 
 in long-standing empyema, and the finger-ends, especially in children, 
 clubbed.f 
 
 D. Age. Empyema is common in children % and young adults. 
 
 E. Rigors. These are often slight, irregular, and may occur only 
 towards evening. In children they are often absent throughout. 
 
 F. Any preceding disease. Empyema is not unfrequent after scar- 
 let fever, measles, childbirth, pyasmia, small-pox, and especially 
 typhoid fever. The onset of the empyema is most insidious and often 
 overlooked. If a patient during convalescence seems to go back, loses 
 
 * In 1886 I tapped the chest of one of our students, under the care of Dr. Pye Smith, 
 whose temperature was 103° The fluid was serous, and after the single aspiration a 
 good recovery took place. 
 
 t "If a child be seen with general pallor and finger-clubbing, one ought to think 
 of empyema rather than of the other causes of clubbing— viz , chronic bone diseaes, 
 bronchiectasis, and congenital heart-disease" (Barlow). 
 
 % In children the pleura seems to have a tendency to form pus (Goodhart). 
 
512 OPERATIONS ON THE THORAX. 
 
 his appetite, any embarrassment of the breathing must be at once 
 looked for, and empyema suspected. 
 
 G. GEdema. This is often absent, though pus is present. 
 
 H. Other signs, especially in children, must be remembered — viz., 
 unexplained and obstinate diarrhcea, emaciation, etc. 
 
 Treatment of Non-purulent Serous Effusions.— Question 
 
 of operation. If medical treatment— e.g'., absorbents and diuretics, 
 counter-irritation, dry, nutritious diet, etc. — fail, two questions arise : 
 A. What is the danger of leaving the fluid? B. What is the risk of 
 paracentesis ? 
 
 A. Danger of leaving the fluid. 
 
 1. There is the risk of sudden death when a large, quiet effusion 
 persists.* 
 
 This risk is greatest in left-sided effusions which displace the heart 
 and cause bending of the inferior vena cava. 
 
 2. There is the risk of the lung being more andenore tied down by 
 adhesions— e.g-., when much lymph has formed. 
 
 3. There is the risk of engorgement of the sound lung, especially 
 if the patient is submitted to a chill. 
 
 4. There is the risk of slow pus-formation, especially in a patient 
 much let down, where the effusion is secondary to some other.disease, 
 and where sucli a case gives the history of a chill. 
 
 B. The risks of paracentesis. 
 
 1. Shock. This is especially probable in delicate patients with a 
 nervous dread of the operation. 
 
 2. Syncope. A special cause of this is perhaps alteration of the po- 
 sition of the heart and large vessels by removal of the supporting 
 fluid. 
 
 Dr. Moxon showed that the effect of the effusion varied with the 
 side affected. Thus an effusion into the right chest not only pushes 
 the heart over to the left, but also compresses the right auricle, and so 
 shuts off blood from the heart, thus tending to produce syncope from 
 cardiac anaemia. Effusion on this side also tends to make lateral 
 pressure on the inferior vena cava, which is the more readily bent 
 over, as it has just passed through a rigid ring. Effusion into the left 
 chest drives the heart over to the right, and, pressing on the left auricle, 
 distends the right side of the heart, by impeding the passage of the 
 blood into the left ventricle, and thus tends to bring about syncope 
 from cardiac plethora. There is also a tendency for the right lung to 
 
 * I think it is Dr. Clifford Allbutt wlio records the case of a girl who had been 
 brought to the Addenbrooke Hospital with a large, quiet, serous effusion. Having got 
 out of the cart which had brought her, she was walking slowly across the green in front 
 of the hospital, when, without a cry or a stagger, she was seen to fall dead. 
 
PARACENTESIS OE THE CHEST, 513 
 
 become oedematous and crepitant, owing to its being engorged with 
 blood. 
 
 3, Embolism from detachment of clots in the pulmonary veins. 
 That this is a real risk is shown by a case of Sir B. Foster's, in which 
 clots dislodged from the right pulmonary veins caused embolism of 
 both renal and iliac arteries, with a fatal result from albuminuria, sup- 
 pression of urine, and gangrene. 
 
 Both 2 and 3 may perhaps be prevented by not drawing off all the 
 fluid, and drawing it off slowly. 
 
 4. CEdema of the lung. This is an undoubted danger. Shortly 
 after the tapping (the effusion being usuallj^ a large one), urgent 
 dyspnoea comes on with frothy, serous expectoration rich in albumen. 
 Death usually takes place in about twenty-four hours. Dr. Dufiin's 
 explanation of this is probably the correct one. The compressed lung, 
 after the removal of a large effusion, corresponds to a limb after the 
 use of Esmarch's bandage — i.e., the vaso-motor nerves are paralyzed; 
 thus, when the lung expands, sudden stress is thrown on toneless ves- 
 sels, hence the transudation of sero-albuminous fluid, equivalent to the 
 oozing so common after removal of the bandage. 
 
 Indications for Paracentesis in Non-purulent Effusions. 
 
 1. Threatened failure of the heart's action, shown by the failing 
 pulse, the extremities growing cold, etc. 
 
 2. In all cases, and at any date, when the fluid is so copious as to 
 compress the opposite lung. The base of this should be carefully 
 watched, and expectoration noted. 
 
 3. In all cases where, with a large effusion, there have been one or 
 more attacks of orthopnoea. Relief will be most emphatically called 
 for when, with this history, the patient lives some distance off, when 
 he is no longer young and the chest no longer yielding, or when the 
 opposite lung is at all cedematous. 
 
 4. In all cases in which a pleuritic effusion, occupying half one 
 pleural cavity, has existed three or four weeks, and shows no sign of 
 progressive absorption. 
 
 Paracentesis for Serous Effusions.— Site of puncture. This 
 is decided by : (1) Physical signs. (2) The result of the exploring 
 needle. Common sites are : (a) The sixth space in front of the pos- 
 terior axillary fold, a spot which has the advantage of being thinly 
 covered, and where the ribs are well apart. (6) In the seventh, eighth, 
 and ninth space behind, in the scapular line. The eighth space is 
 here very frequently used. 
 
 The patient being turned somewhat over on to his sound side, if he 
 can bear this, and brought to the edge of the bed, or, if he must^ be 
 raised, so supported that he can be readily lowered in case of faint- 
 ness, the surgeon, having seen that the spot chosen for puncture is 
 
 33 
 
514 OPERATIONS ON THE THOKAX. 
 
 cleansed from any poultice debris, etc., and that his aspirator is thor- 
 oughly clean and in good working order, fixes his nail just above the 
 lower rib, and holding the needle so that it cannot penetrate too 
 deeply, plunges it straight into the pleural cavity, and brings his 
 needle into connection with the vacuum. If the skin is very thick, 
 and the needle slender, it is well just to make a puncture with a scal- 
 pel-point. In either case it is the skin-wound which pains. 
 
 The following practical points should be remembered : (1) Not 
 to catch the needle on a rib, a mistake which is easy when the ribs are 
 close together. (2) To be sure and enter the chest cavity, a thickened 
 pleura or false membranes sometimes interfering with this. (3) 
 Avoiding injury to the lung, by not plunging the needle in too deeply, 
 or by guarding the point when it has entered. Usually the lung is at 
 a considerable distance, but when the collection is a localized one, 
 this accident may easily take place. (4) The fluid should not be 
 drawn off too quickly or completely ; if successive vacua are required, 
 the later exhaustions should not be too complete. The patient should 
 always be warned against making any sudden movement or deep in- 
 spiration. If the flow stops suddenly, it may be due to a kink in the 
 tube, or to a pellet of lymph plugging the needle. The flow should 
 always be stopped at once — (a) if the patient faints, this being due 
 sometimes merely to the withdrawal of a large amount of fluid, some- 
 times to the consequent displacement of viscera ; (6) if any blood sud- 
 denly appears in the fluid, this coming usually from the rupture of 
 vascular adhesions, more rarely from a wound of the lung ; (c) if an 
 irritating cough is set up, this being due sometimes to the unfolding 
 of a temporarily compressed lung. 
 
 When the needle is withdrawn, the puncture should be at once 
 closed with collodion and iodoform. 
 
 If an anaesthetic is asked for, it may generally be safely given with 
 attention to the precautions given below (p. 516). But, as a rule, the 
 pain is so momentary that this is not needful. I have been disap- 
 pointed with the results of injection of cocaine. With a nervous 
 patient the spot may be marked by a freezing mixture of ice and salt, 
 or with the ether-spray. A little stimulant should be given before and 
 after the operation. 
 
 EMPYEMA. 
 
 The frequency of this in children * has been already alluded to. 
 
 At this time of life the prognosis is good, as the lungs are free from 
 morbid changes. The formation of pus may be very rapid at this 
 early stage of life, pus being present by the fourth, fifth, or seventh 
 
 * Out of forty-four and sixteen consecutive cases of pleuritic effusion at Great Or- 
 rnond Street, Dr. Barlow found twenty-seven and fourteen to be purulent. 
 
EMPYEMA. 515 
 
 day. The importance of this is considerable. With pus, lymph is 
 present also, and thus— (a) the pleura is soon altered, thickened, and 
 less prone to heal ; (6) the lung becomes tied down ; (c) the drainage- 
 tube is readily blocked ; (d) this lymph leads to subdivision of the 
 cavity, and so to difficulty of thorough drainage and obliteration. All 
 this shows the necessity of early and free incision. 
 
 Another important point is, that pus in the pleural cavity is fre- 
 quently localized and encysted in children. This is not uncommon 
 in the middle third of the thorax, the pus being hmited above by ad- 
 hesions, and below by the fixing of the lower lobe to the chest wall. 
 Thus at this spot loud bronchial breathing and modified resonance 
 may be present. Finally, in children small multiple collections are 
 not uncommon. 
 
 The surgeon will very likely be asked the question, whether the pus 
 need be withdrawn, if it will not be gradually absorbed. The chances 
 of this are extremely small, and the risks of leaving it very great. 
 They are — (a) external perforation, leading to the unfavorable results 
 of insufficient drainage, caries, and amyloid disease. The most likely 
 sites are : In front, above and below the nipple ; antero-laterally, in 
 the fifth space, just outside the rib cartilages. (6) Lung perforation, 
 leading to gangrene and hectic, (c) Tuberculosis, if the belief is cor- 
 rect that an old empyema, even if caseated and inspissated, is still 
 infective. 
 
 Treatment of Empyema. 
 
 A. Simple Puncture with Aspirator or Fine Trocar.— This 
 is seldom curative. It is justifiable in a few conditions — (a) if the 
 patient is very young or very timid ; (6) if the collection is very small, 
 or multiple ; (c) if the patient is healthy, the pus sweet, and the re- 
 filling slow ; (d) punctures may " coax pus to the surface " (Good- 
 hart). Patients thus treated should be watched for some time. In a 
 few cases preliminary aspiration is very useful — e.g., in very large em- 
 pyemata of sudden formation. Here a free incision may be followed 
 by urgent dyspnoea from displacement of viscera. 
 
 B. Sub-aqueous Drainage. — This method, formerly much in 
 use, is now rarely seen. One end of a long piece of india-rubber tubing 
 is introduced, through a large cannula, into the chest, while the other 
 end dips into some antiseptic solution. Advantages: (1) The method 
 is simple and little painful. (2) The tube is usually well tolerated, 
 and (if secured) follows the movements of the patient. (3) The 
 drainage can be made gradual and adapted to the expansion of the 
 lung. (4) It is readily converted into a siphon for washing out the 
 chest. I look upon this last as of very doubtful advantage, believing 
 that if the pus is fetid a free opening should be made at once, and if the 
 pus is sweet washing out is meddlesome and risky. The disadvantages 
 
516 OPERATIONS ON THE THORAX. 
 
 are— (1) The tube, necessarily small, is easily blocked. (2) Ulcera- 
 tion soon takes place around the tube, and thus air enters, or the tube 
 slips out. It is allowable in children, or in very nervous patients, 
 where the collection is not great ox of long standing, and the lung will 
 therefore be able to expand gradually. 
 
 C. Incision. — This is the method most frequently required, espe- 
 cially in adults, when the pus is thick and caseous, when it is fetid, 
 and when it re-accumulates after aspiration quickly. The advantages 
 are, the free drainage which it gives, and the facilities for'washing out 
 the pleural cavity (if this is required). The disadvantages are, its 
 severity and the tendency to close. The question will often arise 
 whether a single or a double opening is required. A single opening is 
 usually sufficient in children and in young adults, owing to the 
 healthy condition of the parts, and the natural tendency to oblit- 
 eration of the cavity. The sites usually chosen are the eighth or 
 ninth space in the scapula line, or in the same spaces anterior to and 
 below the scapula angle. I prefer the latter in adults, as the chief 
 part of the opening is anterior to the latissimus dorsi, an incision 
 through this muscle, in adults, having certainly the risk of causing 
 oozing afterwards, which may be very serious in a weakly patient. 
 A double opening is occasionally required— e.g'., in very large cavities in 
 adults, when the pus is fetid ; when the case is of very long standing; 
 when the ribs are very close together ; when the pus is pointing high 
 up and anteriorly, and thus the drainage is inadequate. 
 
 The Chief Points of Importance in Incising an Empyema 
 are the following : Amongst the first will arise the question of giving 
 an anesthetic. Speaking from an experience of thirty-one cases, in 
 twenty-seven of which an antesthetic was given, I believe that an 
 anffisthetic may be safely given in the vast majority of cases. On the 
 whole, I think that chloroform is the most suitable, on account of the 
 greater struggling (undesirable with viscera displaced), the dyspnoea 
 from the mucus set up, and the subsequent bronchitis after ether, but 
 I am certain that the way in which the ana?sthetic is given is of more 
 importance than the anicsthetic itself 
 
 Of the twenty-seven cases alluded to above, I have only known bad 
 results follow the anfesthetic once — a case of large empyema with pyo- 
 pneumothorax. The heart was displaced to the right side, the face 
 and lips somewhat cyanotic, the extremities cold, and the pulse almost 
 imperceptible. Although the dangers of an ansesthetic were put before 
 him, the patient insisted on having one administered. On the whole, 
 I thought ether the safest, because of the condition of the pulse. It 
 was administered carefully, but caused coughing. The pus was thus 
 sucked into a bronchus, up into the trachea, and thence drawn down 
 
EMPYEMA. 517 
 
 to the opposite lung, causing death rapidl^^ Artificial respiration 
 expelled, during expiration, pus from the trachea. 
 
 As this patient was almost moribund before the operation, I now 
 much regret the giving of an anajsthetic. It would doubtless have 
 been wiser to have refused one, and trusted to minimizing the shock 
 by exhibiting a stimulant, and by a rapid operation. A year later I 
 was asked by my old friend Dr. Goodhart to operate on a somewhat 
 similar case in Clinical Ward. This patient was also young, and there 
 was here, too, a communication with the lung, the pus being, in this 
 case, also, fetid, but the pulse was good and there was no cyanosis. 
 Chloroform being given, the empyema was incised by Mr. Nicholson, 
 the clinical assistant, under my supervision. Chloroform in this case 
 was taken well, the discharge quickly became sweet with iodoform 
 dressings frequently renewed, and the patient made a rapid recovery. 
 
 The injection of cocaine is worth a trial, but, as I have stated above, 
 it has disappointed me. While an anaesthetic is only really necessary 
 where two openings have to be made, or where a rib is to be resected, 
 yet its administration in capable hands is usually so safe that I always 
 make use of it. 
 
 The patient being supported over the edge of the bed or table, partly 
 rolled over on to the sound side, or, if this is impracticable, being 
 suitably propped up, the surgeon, having cleansed the part, fixes a 
 finger-nail just on the upper margin of the lower rib in the space 
 chosen, and makes an incision down to the muscles for I2 to 2 inches, 
 just above his nail. This incision having exposed the muscles, a steel 
 director is driven through into the chest-wall, care being taken not to 
 plunge it too deeply. A pair of dressing-forceps is then run along 
 the director and opened widely both horizontally and vertically. 
 Owing to the gush of pus which is now violently expelled, it is well 
 to throw a piece of lint, out of carbolic solution (1 in 20), over the 
 wound, while the pus is escaping.* The opening is next thoroughly 
 dilated by one or two aseptic fingers, and the size of the cavity, the 
 
 * Occasionally, if the patient struggles, air is drawn into the pleural cavity after the 
 escape of the pus, and then is expelled into the connective tissue of the wound, con- 
 stituting emphysema. This will all pass oif spontaneously. I have very recently met 
 with a case of much more marked emphysema under the following conditions : Being 
 asked by my colleague Dr. Pitt to incise the chest of a child who, after lobar pneu- 
 monia of the right lung, had rapidly developed empyema on the same side, I noticed 
 that, after the usual incision at the angle of the scapula, the usual violent outgush of 
 pus— itself free from blood— was immediately followed by frothy blood and a markedly 
 emphysematous condition of the wound. I believe that here the lung-tissue, damaged 
 by previous inflammation, had given way when the pressure of the fluid upon it was 
 removed. A few days later it was evident that the lung had become adherent around 
 the incision, which communicated freely with an opening in it, and that the emphy- 
 sema had subsided. The case did well. 
 
S18 OPERATIONS ON THE THORAX. 
 
 proximity of the lung, and the degree of granulation-formation all 
 investigated. A. large-sized drainage tube is then inserted, and care- 
 fully secured in situ. One of the simplest, and, at the same time, an 
 entirely efficient plan, is to pass two loops of silk through the outer 
 end of the tube with a needle, knot these loops, and then place in 
 them bundles of gauze strips. After a few days a smaller size, of the 
 shape (on a large scale) of a tracheotomy tube, may be worn. 
 
 Htemorrhage during the operation is usually slight, and gives no 
 anxiety afterwards. If any point give trouble, resisting ligature, after 
 picking up the tissues with Spencer Wells's forceps, a pair of these left 
 on for twenty-four hours will probably meet the case, or a bit of a rib 
 quickly resected will give access to the bleeding-point. The impor- 
 tance of not cutting through a thick muscle like the latissimus dorsi 
 has already been alluded to (p. 616). 
 
 The opening must be sufficient, and, if there is any doubt about 
 this, a part of a rib should be resected without hesitation, especially 
 where these are very close together, or where the pus is foul {vide 
 infra, p. 521). 
 
 If the question of washing out the cavity arise, probably from the 
 discharge being foul, it should be remembered that this proceeding, 
 however gently done, has occasionally brought about grave and even 
 fatal results very suddenly. Whether these have been due to absorp- 
 tion, reflex nervous disturbance, or to dislodgment of thrombi, is 
 uncertain, but it is beyond question that in several cases symptoms 
 of impending collapse, and even death, have followed on washing out 
 an empyema, and that, too, in a patient who is well on in convales- 
 cence. Again, it cannot be too strongly insisted upon that foetor calls 
 for a freer opening, not for washing out. If, however, it is decided to 
 make use of injections, dilute and bland ones — e.g., Condy's fluid — 
 should be used, and these should be run in with a funnel and tubing, 
 and not thrown in with a syringe. A long period of drainage is 
 often needed in adults, while in children the tube can be quickly 
 shortened. In both sufficient tubing should be retained to keep 
 the opening patent, as long as any discharge remains. 
 
 During the prolonged after-treatment everything should be done 
 to improve the general health. Change of air is here a cardinal 
 point, first, getting the patient from' his room, then outside the 
 house, and lastly, if possible, to the seaside.* 
 
 * "Last, and most important of all — unfortunately for hospital patients a treatment 
 that cannot often be utilized — comes Margate air. Any seaside air is beneficial, but, 
 weather and season permitting, I do not believe there is any corner of England so 
 quickly restorative to children with empyema as that in which Margate and Broad- 
 stairs are situated ; and, personally, I set more store by a change of this kind after the 
 first three or four weeks have passed than in any continuation of antiseptic dressings " 
 (Goodhart, Dis. of Children, p. 345). 
 
EMPYEMA. 519 
 
 A point of no small importance in the after-treatment, especially 
 in young subjects -with flexile spines, is to encourage early, system- 
 atic, deep breathing, and gymnastic exercises, and thus to promote 
 expansion of the chest, and so to minimize that sad sequela of 
 empyema, irremediable lateral curvature. 
 
 Before leaving the subject of the operative treatment of empyema, 
 a few words should be said about the dressing of these cases. This 
 should be strictly antiseptic from first to last. The spray is advisable 
 in hospital practice, but not essential if strict attention be paid to 
 more important details — i.e., cleansing the parts incised, disinfection 
 of instruments, taking care that the pus escapes under an antiseptic 
 atmosphere, p. 517, a sufficiently free opening, adequate drainage, 
 abundant dry, aseptic gauze dressings, changed twice perhaps in the 
 first twenty-four hours, and then daily for the first week. Later on, 
 when the patient is going away to the seaside, he can easily be in- 
 structed to remove and cleanse daily the short piece of drainage-tube 
 which keeps the external opening patent, and to apply over the 
 sinus a dressing of boracic-acid lint and carbolized tow, with a pinch 
 of iodoform dusted on. 
 
 Complications of Empyema and Reasons for Cases not 
 Doing Well. 
 
 1. Persistent septic condition, in spite of two openings, free drain- 
 age, etc. 
 
 2. Tubercular disease. 
 
 3. Lung mischief on the opposite side — e.g., broncho-pneumonia, 
 bronchitis. 
 
 4. Long duration of the case before it came under active treatment, 
 a free incision being deferred, or aspiration dallied with. 
 
 5. Caries of the ribs. Multiple spontaneous openings, with burrow- 
 ing sinuses beneath the skin. 
 
 6. Age. From the feebler powers of repair, and the more rigid 
 condition of the chest as life advances. 
 
 7. Size of the empyema. The smaller and the more localized the 
 collection, the better the prognosis. 
 
 8. Collection of pus forming in the opposite pleura. 
 
 9. Mr. Godlee (Diet, of Surg., vol. i. p. 459) reminds us that a curious 
 compHcation of septic cases— viz., cerebral abscess— has been noticed 
 in a sufficient number of instances to make it impossible to overlook 
 the possible association of one with the other. Judging from Dr. 
 Fagge's remarks on thoracic disease as a cause of cerebral abscess 
 (Prin. and Pract. of Med., vol. i. p. 546), it would appear that disease 
 of the lung itself is oftener the primary lesion upon which the abscess 
 of the brain is dependent. 
 
520 OPEEATIONS ON THE THORAX. 
 
 RESECTION OF RIBS. 
 
 Indications. — These are chiefly : 
 
 A. Caries of ribs* 
 
 B. In certain cases of empyema. 
 
 A. In obstinate caries, where more than one rib is affected, where 
 previous treatment, including gouging, fails, resection should be at 
 once performed. It is a very simple operation in these cases, as the 
 soft tissues are nearly healthy and the periosteum is retained. 
 
 An incision, about 2 inches long, being made over the centre of 
 the carious rib, and the muscles peeled off with a blunt dissector, the 
 periosteum is next incised, and separated from the upper and under 
 surface with an elevator, blunt and slightly curved, so as to pass 
 readily under the rib and lever it upwards. The rib being thus raised, 
 it is easily divided at one limit of its exposed part, either with a 
 narrow-bladed saw or with slightly curved cutting forceps. The soft 
 parts are next peeled away from the under surface, and the rib 
 divided at the corresponding spot and removed. 
 
 B. In certain cases of empyema — e.g., (1) when the drainage is in- 
 sufficient, the discharge foul, in spite of one or two free openings ; 
 
 (2) when the ribs are too close together, for a tube of sufficient size ; 
 
 (3) when an empyema cavity still persists, though sweet, in spite of 
 free incision, good drainage and careful dressing. In the first two 
 classes of cases removal of a small piece of one or two ribs will be 
 sufficient, but in some of these latter cases the operation M'ill necessa- 
 rily be a much more severe one. When called to a case of persistent 
 sinus and discharge after the incision of an empyema, the surgeon on 
 examination may find that the cavity which remains is small, and 
 that the discharge is due to a persistent sinus only. This should be 
 dilated up with laminaria tents, part of a rib removed, and both sinus 
 and cavity thoroughly scraped out with sharp spoons. 
 
 But in the majority of cases of long-standing empyemata the con- 
 dition of things is not so simple and so easily dealt with. Oblitera- 
 tion has taken place often very imperfectly, owing to the lung not 
 being able to expand, to the ribs having fallen in all they can, to the 
 
 * In this most tedious affection, prone to resist other treatment and often provoca- 
 tive of hudaceous disease, resection of the ribs should be resorted to much oftener than 
 has hitherto been the case. Apart from cases of " strumous " origin, I have r&sected 
 p.arts of the fourth, fifth and sixth ribs, l<eeplng up persistent mammary sinuses, and 
 thought to be due to old abscess of the breast. la another patient I twice resected ribs 
 In operations for extirpation of cancer of the left breast. Strict antiseptic precautions 
 can alone justify this, as the sal alembroth dressings were placed in Immediate contact 
 with the lung and pericardium. The patient is as yet without further recurrence, tea 
 months after the resection of the ribs and six years after the primary operation. 
 
EESECTION OF EIBS. 521 
 
 diaphragm having risen, and the opposite lung, heart, etc., having 
 come over as far as they are able, while the cavity, often large, which 
 thus results, is lined with much thickened scar-like tissue, covered 
 with granulations of but poor vitality. Here portions of several ribs 
 must be removed and the operation perhaps repeated, in order that the 
 walls of the cavity may still further collapse, and thus obliterate the 
 cavity while an opportunity is given for exploring this thoroughly. 
 
 The spot chosen for the resection of the ribs should be, as far as 
 possible, opposite to the lung which can expand no more, and the 
 pieces of ribs removed should correspond as closely as may be to the 
 anterior and posterior limits of the cavity which it is desired to close. 
 
 It has been thought by some that the amount of rib to be removed 
 should correspond pretty closely to the distance between the two 
 pleurffi. Thus it may be needful, especially in an adult, to remove 
 pieces of five or six ribs, 3J inches being removed from some and 1 to 
 li inch from others. 
 
 Dr. Fenger, of Chicago (Med. News, November 13, 1882), finds first 
 the shape and extent of the cavity. He considers that a cavity which 
 extends transversely requires resection of a large piece of one or of a 
 few ribs, the largest piece taken being that from the rib which overlies 
 the centre of the cavity. A vertical cavity covered by five or six ribs 
 will need resection of small pieces of several ribs, from f to 2i inches 
 of bone being removed. 
 
 The ribs to be resected may be exposed in one of two ways. One, 
 and I consider this the safest, is to make two or three incisions, two 
 being usually sufficient, and to raise flaps comparatively small in size. 
 The other is to raise a single large flap, containing in it any muscles 
 — e.g., pectoralis major and serratus magnus— which overlie the ribs 
 to be removed. This latter plan has the high authority of Mr. Godlee, 
 who has done much to introduce this operation into English surgery, 
 and who has had much practical experience at the Brompton Hospital. 
 While desirous of attaching all proper weight to the above opiiiion, I 
 am obliged to differ from it. The operation is one of considerable se- 
 verity, the patient, as a rule, far from a strong one ; thus I prefer to use 
 the operation of multiple small flaps, rather than one large one, on 
 account of the hemorrhage being much less, and, what there is, more 
 easily dealt with. 
 
 In raising his large flaps, Mr. Godlee does not think it worth while 
 to spend much time in trying to stop the hffimorrhage, which is often 
 free at this stage, as it is very difficult to do so, and as it will cease 
 after removal of the ribs. While this last remark is quite true, I look 
 upon the hfemorrhage which must occur with large flaps as not a light 
 matter in the patients with whom we have to deal. 
 
 I much prefer, in removing four or five ribs, to make one incision 
 
522 OPERATIONS ON THE THORAX. 
 
 between two, deal with these, and then to make another over the 
 centre of the three which remain. Small incisions being made at right 
 angles to the long ones, flaps of skin and fascia, parallelogram in shape, 
 are raised, the muscles are then peeled off each rib with a blunt dis- 
 sector or slightly curved elevator. Care must now be taken to leave 
 the periosteum on the rib, and by no means to strip it off. If it be left 
 behind with the muscles, it will throw out callous material, which will 
 be as unyielding as the bones removed. The elevator is then slipped 
 under the rib, run along close to its posterior aspect, to one limit of its 
 bared surface, and the rib divided here either with a narrow strong- 
 backed saw — an osteotomy saw or a FergusBon's jaw-saw answers the 
 purpose excellently — or with cutting forceps. The rib being then 
 raised up when cut is divided again at a corresponding spot, and as 
 many as it is desired treated in the same way. Each piece of rib 
 should show clean-cut surfaces at either end, and be covered with 
 periosteum. 
 
 Mr. Godlee advises removing as much as possible of the thickened 
 pleura, which is now exposed, and, with it, any periosteum which has 
 been left behind. Some square inches of this may be taken away 
 without fear of serious hfemorrhage, if it is snipped through gradually 
 with curved blunt-pointed scissors, the vessels met with being easily 
 secured. 
 
 The cavity may now be thoroughly explored with the finger or a 
 soft catheter. If very foetid it may be mopped out, gently, with a 
 solution of zinc chloride (gr. xx-3j), though it is best to dispense 
 with this, if possible, from fear of coming in contact with important 
 parts, such as the j^ericardium, root of the lung, etc. It is preferable, 
 in cases of fcEtor, to blow in iodoform mixed with finely powdered 
 boracic acid. Drainage-tubes are then inserted, if needful, and if a 
 large flap has been raised, this is secured in situ, with a few points of 
 suture. If, on the other hand, as recommended here, multiple small 
 flaps have been raised, no sutures should be inserted, as primary union 
 cannot take place, and discharges might be pent up. 
 
 The wound, at the bottom of which probably lies the lung covered 
 over only with visceral pleura, is lightly filled with strips of aseptic 
 gauze and boracic-acid lint, and salicylic wool or carbolized tow re- 
 tained with a many-tailed bandage. If strict precautions are taken 
 by cleansing the instruments, covering over the wound with carbolized 
 lint whenever practicable, the spray need not be used, and a source of 
 chill and shock thus avoided. 
 
 With regard to the date at which ribs should be partially resected 
 in long-standing cases of empyema, most surgeons who have seen 
 much of these troublesome cases will, I think, agree that the operation 
 should be performed as soon as the natural powers of obliteration are 
 
DRAINAGE OF LUNG-CAYITFES. 523 
 
 at a standstill, care being taken that the patient has recovered from the 
 effects of the first operation and perhaps recruited his strength in the 
 meantime at the seaside. 
 
 Estlander, who first introduced this operation, advises, on the other 
 hand, that the operation should not be made use of too early, as he 
 considers it essential that the two layers of pleura should be changed 
 into thick, firm connective tissue, for the operation to succeed. Thus 
 an interval of six or eight months after the formation of the empyema 
 would seem, according to this view, to be the proper time for resection 
 of ribs ; but, on the other hand, too unyielding a condition of the chest 
 walls, too thick a layer of scarred pleura and pyogenic membrane are 
 conditions not to be waited for. 
 
 CHAPTER III. 
 
 DRAINAGE OF LUNG-CAVITIES. 
 
 Indications. — Operative interference is justifiable where there is a 
 lung-cavity due to bronchiectasis, gangrene,* or hydatid, and most of 
 the following conditions are present. 
 
 When previous treatment has failed, when it is evident that the 
 cavity is insufficiently drained through a bronchus,t and the conse- 
 quent abundant muco-purulent, foetid expectoration exhausts the pa- 
 tient, with harassing cough, irritative diarrhoea, and commencing 
 hectic. When the cavity is limited and can be accurately localized, J 
 when the surrounding lung-tissue is not yet infected, and the opposite 
 lung is healthy. When the cavity is sufficiently near the surface to 
 be got at, and when it is in a region that can be safely attacked. § 
 When that part of the pleural sac which overlies the lung-cavity is 
 obliterated. 1 1 
 
 * Mr. Godlee (Lancet, 1887, vol. i. p. 459) is of opinion that most gangrenous abscesses 
 are the result of acute pneumonia, and situated near the bases. The occasional exist- 
 ence of a foreign body as a cause of the trouble — viz., a piece of bone or a blade of 
 grass, etc. — should not be forgotten. 
 
 t If the surgeon wait too long in dealing with a gangrenous abscess, fretid fluid 
 from this may, by getting into the bronchi, reach the other lung and set up most 
 serious damage there. 
 
 J In other words, when the whole bronchial tree is not dilated in one and perhaps 
 both lungs (Dr. Williams, Med. Chir. Trans., vol. Ixix. p. 317). 
 
 § Drs. Fenger and Hollister, of Chicago [Amer. Journ. Med. Sci., 1882, vol. ii. p. 370, 
 a paper which will well repay reference), point out that a cavity covered by the scap- 
 ula, or in the supra-scapular region, must be at present considered inaccessible. Access 
 can be best got from the mammary and axillary regions. 
 
 !| This point is of the greatest importance, chiefly from the probably foul nature of 
 the cavity contents, and the risk of setting up a foetid pyo-pneumothorax when the 
 
524 OPERATIONS ON THE THORAX. 
 
 The two American writers just quoted show that adhesions may 
 be expected when the abscess cavity is large, or where several attacks 
 of disease have occurred in that part of the lung in which the cavity 
 now exists. If the surgeon is in doubt as to the condition of the 
 pleura here, he should make an incision down to the intercostal 
 muscles, pass a needle into the lung, and watch it during respiration. 
 If it does not move synchronously with this, there are certainly ad- 
 hesions, and the lung may be cut into without fear. 
 
 The coexistence of empyema, of pleurisy, of a tendency to general 
 bronchitis, will be examined into, and the amount of each and the 
 importance in prognosis dulj' weighed. Finally, come more general 
 points — e.g., the age of the patient and the history must be con- 
 sidered. 
 
 In endeavoring to estimate the size of the cavity before exjDloring 
 it, the following possible fallacies will be remembered : 
 
 Dr. Williams {loc. supra cif.) points out (1) that the empyema which 
 invariably accompanies the globular form of bronchial dilatation, 
 often entirely masks the physical signs of a cavity, even when the 
 patient's sensations and the amount and character of the expectoration 
 point to the presence of a bronchiectasis ; (2) that the character of 
 the cavernous sound heard over bronchial dilatation is so jarring in 
 tone that it is audible over a far larger area of chest-wall than that 
 immediately overlying the cavity. On this account the size of the 
 bronchiectasis is often thought to be larger than it eventually proves 
 to be. This jarring note is more common in bronchiectasis associated 
 with interstitial pneumonia and fibrosis, than in the globular bronchi- 
 ectasis accompanied with chronic bronchitis and empyema. 
 
 Mr. Godlee, in his lectures, to which I have already referred, shows 
 that the amount of expectoration is no criterion as to the size of the 
 cavity, as each pellet irritates the bronchi in its way over them, and 
 causes a great secretion of mucus.* 
 
 Operation. — The anffisthetic should be given slowly to avoid 
 coughing, and the patient kept on his back as much as possible, these 
 two precautions being intended to prevent fluid, coughed out of the 
 cavity, dangerously obstructing the bronchi. 
 
 If the exact position of the cavity is doubtful, a preliminary aspira- 
 tion or exploring trocar-puncture f should be made use of. 
 
 lung-cavity is opened, and even graver and much more urgent danger from cutting 
 into a healthy pleural cavity. 
 
 * Thus, he has cured by incision a. cavity which, really holding only an ounce, 
 caused expectoration of more than a pint. 
 
 f With reference to this step, Mr. Godlee's remark should be remembered. " It ig 
 impossible to penetrate the lung with any amount of accuracy or definiteness, because 
 it recedes before even the sharp point of a needle.'' 
 
DRAINAGE OF LUKG-CAVITIES. 525 
 
 An incision IJ inches long* is then made, taking the needle or 
 trocar, if used, as a guide, in the middle of an intercostal space down 
 to the muscles, which are next torn through. The lung-tissue with 
 the overlying pleura f is, perhaps, best opened with a medium-sized 
 trocar and cannula, and the opening then dilated with dressing- 
 forceps. The finger is then gently inserted to ascertain whether any 
 dead cast-off lung-tissue % is present, and to find out the lowest point 
 at which to make a counter-opening.§ 
 
 A full-sized drainage-tube should be inserted, soft, for fear of 
 haemorrhage from friction and ulceration, and sufficient aseptic dress- 
 ings, iodoform or sal alembroth gauze with salicylic wool applied. 
 
 As a cavity which gives unequivocal evidence of its existence may 
 be missed || by making one puncture and then incising at that spot, 
 and as the exploring finger or director may push the cavity to one 
 side, the lung should be explored at several spots if needful. If the 
 pleura is not adherent over the cavity, it will be but little good 
 stitching the lung so as to obliterate the pleural sac here, as stitches 
 so used are very difficult of insertion and soon cut out (Godlee). If 
 any foul fluid escape into the pleural cavity, this must be treated 
 like an empyema (p. 516). 
 
 Haemorrhage is not commonly met with after puncturing the lung, 
 as this is probably solidified and altered round the abscess cavity. If 
 
 * It is wise to make a sufficiently free incision to prevent the risk of subcntaneous 
 emphysema. In one case foetid emphysema took place and disappeared. 
 
 f In addition to the aids already given for deciding as to whether the pleura is 
 adherent or not, the state of the intercostal spaces may help, i.e., whether they are 
 depressed on deep breathing. 
 
 X Eokitansky (Path. Anat. : Syd. Soc. Trans., vol. iv. p. 96) speaks of having met 
 with a walnut-sized piece of dead lung in circumscribed gangrene of that viscus. 
 Wagner [Berl. Klin. Woch., September 6, 1880) removed a piece of gangrenous lung- 
 tissue by an opening made for evacuating an empyema, the patient recovering. In 
 some cases broken-down lung-tissue may be all that is met with ; very little fluid, 
 if any, being present. 
 
 § It is wiser to make two openings, one at the most superficial part; then from 
 this to explore the cavity and to try and find the lowest part for making a counter- 
 opening, and thus to secure complete evacuation. Simple drainage with a single 
 opening is often not sufficient, washing out being usually required to arrest the foetor. 
 If this washing out be done from a single opening, the fluid, having no escape, irritates 
 the bronchi and sets up much cough. The counter-opening is best made on some 
 unyielding body, such as a sound. Occasionally the cavity comes to the surface at 
 several points. 
 
 II It is possible that, after such, a fruitless exploration and the insertion of a 
 drainage-tube, pus may burst into it, as happened in Dr. Cayley and Mr. Gould's 
 case {Med. Chir. Tram., vol. Ixvii. p. 209), but this did not happen in a case of Mr. 
 Godlee's, though the patient recovered. While the puncture may yield no fluid, gas 
 may escape, showing that gangrenous lung has been reached. 
 
526 OPERATIONS ON THE THORAX. 
 
 it be severe, the cavity must be plugged with aseptic gauze. When 
 any rotten lung-tissue has been removed with the finger, hsemorrhage 
 is to be expected. 
 
 If the cavity be due to a hydatid, the cyst-wall may perhaps be 
 expelled when coughing is set up by the incision of the cavity. If it 
 does not so come away, it should be removed, if this can be effected, 
 without setting up hsemorrhage. A good instance of how large cavi- 
 ties in the lung may be, when due to this cause, is given by a case of 
 Dr. Fenger's (Land. Med. Rec, 1881, p. 327), in which he successfully 
 operated by an incision in the third space (through adherent pleura), 
 on a large gangrenous cavity in the right lung, reaching from the 
 second to the fifth rib, and from the sternum to the posterior axillary 
 line. 
 
 After-treatment. — The cavity should be syringed out with a 1 in 
 50 solution of carbolic acid, till fester disappears, and then with 
 thymol lotion. The drainage-tube must be retained until the cavity 
 has almost completely closed — i.e., until the discharge has almost, and 
 the expectoration has quite, stopped. If the tube be removed too 
 early, refilling up of the cavity, with return of fever, nausea, expec- 
 toration, etc., are certain. Moreover, as the external opening tends to 
 close before the cavity is obliterated, any foul remaining matter which 
 does not escape will be drawn into the bronchi and set up diffuse 
 bronchitis and broncho-pneumonia. 
 
 The general health must be sustained, and every attempt made to 
 secure fresh air, whether in the patient's room, or by getting him as 
 soon as possible into another room, and out-of-doors. 
 
 Even if the operation does not save life, it may make the remainder 
 much more comfortable both to the patient and his friends. 
 
 Dangers and DiflBculties in Opening a Lung-Oavity. 
 
 1. Dyspncea, coughing and choking expectoration with the anaes- 
 thetic, p. 524. 
 
 2. Pleural adhesions absent, p. 524, or so soft that they easily break 
 down the lung, thus being pushed away from the ribs (Godlee). 
 
 3. Missing the cavity and damaging healthy lung-tissue. This is 
 best avoided by careful preliminary use of an aseptic fine trocar or 
 large morphia-needle. 
 
 4. Getting, as a result of the operation, diffuse broncho-pneumonia, 
 pleurisy, pleuro-pneumonia, in the lung operated on or its fellow. 
 
 5. Severe hajmorrhage, causing much trouble, owing to the htemop- 
 tysis, with the anesthetic (Godlee), and later on setting up septic 
 inflammation of the lung. 
 
 6. Finding a large branching cavity, with numerous caverns, 
 difficult or impossible to drain. 
 
 7. If the bronchi are dilated and contain fluid similar to a cavity, 
 
DRAINAGE OF LUNG-CAVITIES. 527 
 
 this may be drawn from a bronchus by preliminary puncture. This 
 is then mistaken for a cavity, and cut down upon, 
 
 8. A cavity near the root of the large vessels. 
 
 9. Much consolidation of the lung-tissue over the cavity. 
 
 10. As a result of the operative interference, secondary rapid 
 sloughing and gangrene of the lung may follow. 
 
 This seems to have happened in an interesting case reported by 
 Dr. J. Smith, of Halifax (Lancet, 1880, vol. ii. p. 86). Decided relief 
 and improvement followed on the opening of what was apparently a 
 large cavity, but death took place in about a fortnight.* 
 
 * The conclusions with which Mr. Godlee (Lancet, 1887, vol. i. p. 718) sums up his 
 most valuable lectures on this obscure and diiBcnlt subject may be quoted here ; " 1. 
 Gangrenous cavities should always be sought, and, if possible, opened; and the prog- 
 nosis, if the operation be successful, is not bad. 2. The same may be said in regard to 
 abscesses caused by the rupture of purulent collections from other parts into the lung, 
 at least as regards the pulmonary complication. 3. Abscesses connected with foreign 
 bodies must be opened, and, if the body be not found, it must be remembered that, if 
 of any considerable size, it probably lies pretty near the middle line. If possible, these 
 cases should be treated early by tracheotomy and incision. 4. Bronchiectatic cavities, 
 when single (a very rare condition), will be cured by operation. When multiple 
 (a very common condition), they offer but small chance of relief by our present surgi- 
 cal methods. Still, for the rea.sons stated, an attempt may be made to open the main 
 one, if such is to be found, but only if the pleura has been ascertained to be adherent. 
 5. Tubercular cavities should only be opened in cases where the cough is harassing 
 and the cavity single. Injections may be used to relieve symptoms, but cannot be 
 expected to be curative." 
 
PART IV. 
 
 THE ABDOMEN, 
 
 CHAPTER I. 
 
 LIGATURE OF VESSELS. 
 
 EXTERNAL ILIAC. COMMON ILIAC. INTERNAL ILIAC. 
 ABDOMINAL AORTA. GLUTEAL. SCIATIC. 
 
 LIGATURE OF THE EXTERNAL ILIAC (Fig. 93). 
 
 Indications. — Chiefly : 
 
 1. Some cases of aneurism of the upper part of the femoral, or of 
 the femoral encroaching on the external iliac itself.* Thus, ligature 
 of this vessel is indicated where pressure, rapid or gradual, has failed 
 to command the circulation, where it is intolerable, where it cannot 
 be made use of owing to the abundance of fat, from failure of pulse 
 and breathing under an antesthetic, or from the height at which the 
 aneurism involves the external iliac,t where the patient from chronic 
 bronchitis is quite unfit for a prolonged trial of continuous pressure 
 under an anaesthetic, or in cases where the increase of the aneurism 
 is very rapid. 
 
 Before deciding on relinquishing the idea of pressure for ligature, 
 the surgeon should refer to a paper by Mr. "Wheelhouse (Clin. Soc. 
 Trans., vol. vii. p. 67). This case is one of the most interesting in all 
 surgery. The patient, a publican, and syphilitic, had previously been 
 cured by Mr. Wheelhouse of a right-sided popliteal aneurism,J by 
 
 * Mr. Holmes (B.C.S. Lect. : Lancet, 1873, vol. i.) shows that in ilio-femoral aneu- 
 risms it is often very difficult to say wliether the aneurism is or is not limited to the 
 iliac or femoral — i.e., whether it is wholly above or below the place where the deep 
 epigastric and circumflex iliac come off, or whether the mouths of these vessels open out 
 of the sac. In the former case the aneurism would be purely iliac or femoral; in the 
 latter, iliofemoral. 
 
 f It being increasingly diEBcult to apply pressure in these cases without dangerous 
 interference with the peritoneum and its contents. 
 
 J It is very possible that the strain thrown on the artery above during the treatment 
 by pressure on the femoral was the cause of the aneurism higher up. The liability 
 
LIGATURE OP THE EXTERNAL ILIAC. 529 
 
 means of continuous pressure for eight hours with a Porter's femoral 
 compressor. A few months hiter he was admitted into the Leeds 
 Infirmary with a large right iliac aneurism * reaching from Poupart's 
 ligament to within 2 inches of the umbilicus, and extending outwards 
 almost to the spine of the ilium. The swelling, about the size of a 
 small cocoanut, was hard and firm below, soft above ; it appeared to 
 be wholly connected with the external iliac, but to extend above and 
 overlie the common iliac. Pressure could not be made on the latter 
 vessel sufficient to stop the beating, as the tumor was too much in 
 the way, but it was easily controlled by pressure on the abdominal 
 aorta. The patient was kept under the influence of ether for five 
 hours, Lister's tourniquet being very slowly screwed down just over 
 the umbilicus. By the end of the time the patient was black in both 
 limbs, and blue as far as the tourniquet. This had been slightly 
 relaxed twice. No other unpleasant symptoms arose during the whole 
 time. A quarter of an hour was taken in relaxing the pressure — a 
 quarter turn of the handle being made every minute. The tumor had 
 ceased to pulsate and was firm and hard. Pulsation gradually 
 recurred with nearly its old force, but was less " distensile," and 
 slowly ceased altogether, an excellent recovery being made. 
 
 In the same volume of the Clinical Society's Transactions (p. 56) is 
 a case of a large diffuse femoral aneurism, in which Mr. Barnard Holt 
 made use of continued pressure, by means of tourniquets applied 
 alternately to the external and common iliacs, the pressure being kept 
 up for fifty -two hours, with varying alterations of the tourniquets, and 
 intervals of consciousness (for about half an hour) to allow of the 
 patient taking brandy, Liebig, and arrowroot.f Chloroform was given 
 
 of patients with one aneurism to develop another may often baffle the surgeon. Mr. 
 Glutton [Brit. Med. Journ , 1880, vol. i. p. 441 ) records a case in which a femoral aneu- 
 rism was cured by the use of Esmarch's bandage applied up to the tumor, and a P^tit's 
 tourniquet adjusted over the brim of the pelvis. Tlie first attempt lasted an hour; at 
 the .second trial the Esmarch was removed in an hour, and the tourniquet continued 
 for nine hours, ana?sthetics not being given. The aneurism ceased to pulsate and began 
 to shrink, but still fluctuated. Nine days after leaving the hospital, the patient died 
 suddenly of an aortic aneurism rupturing into the pericardium. 
 
 * Dr. Diver, of Southsea, has put on record a case in which the external iliac was tied 
 in a case in which a popliteal and inguinal aneurism coexisted on the right side. Gan- 
 grene followed, a line of demarcation forming in the lower third of the leg. Amputation 
 through the thigh was performed, and the patient recovered. A similar case of double 
 aneurism is reported by Mr. Hilton (Med. Chir. Trans., vol. ii. p. 309). A tourniquet 
 was first applied to the right common iliac for six hours without eflect on the aneu- 
 risms. A second trial of pressure was made, later on, with a tourniquet again on the 
 common iliac and one on the femoral at the apex of Scarpa's triangle. In about nine 
 hours both aneurisms were cured. Chloroform was used on both occasions. 
 
 f If sickness occurs with the anaesthetic, nutrient enemala should be given. 
 
 34 
 
530 OPERATIONS OX THE ABDOMEN. 
 
 throughout, and cure seems to have been probable ; the last report 
 behig that "the patient left the hospital, walking well with the aid 
 of one crutch."* 
 
 In ruptured f femoral aneurism the old operation (facilitated by 
 the application of a tourniquet above) would usually be indicated, 
 but Mr. Southam has briefly reported J a case in which he tied the 
 external iliac successfully in a patient whose femoral aneurism sud- 
 denly ruptured and became diffuse. The effused blood was quickly 
 absorbed, and there was never any tendency to gangrene. Complete 
 power over the limb was regained. 
 
 2. Wounds. — A wound of the external iliac is so rare as to be almost 
 unknown. § It has been frequently tied for haemorrhage from parts 
 below — e.g., for secondary haemorrhage after wounds of the femoral 
 high up, after ligature of the femoral, and after amputation at or near 
 the hip. The futility || of this treatment is shown by a table in which 
 
 * Cases of Dr. Mapother's and Mr. Holden's, in which ilio-femoral aneurisms were 
 cured by pressure on the common iliac and the aorta, will be found, recorded by Dr. 
 Mapother, in the Dub. 3fed. Press, March '29, 1865, and by Mr. Holden, in St. Barthol. 
 Hasp. Reports, vol. ii. p. 190 ; Syd. Soc. JBien. Eetr., 1865-6, pp. 306, 307. In Dr. 
 Mapother's case, instrumental pressure on (he right common iliac (about 1 inch below 
 and J inch to the right side of the umbilicus) kept up for twelve hours under chloro- 
 form had failed. A second attempt, with a Signorini's tourniquet on the end of the 
 abdominal aorta, and a Skey's tourniquet on the femoral just as it left the sac, pressure 
 being kept up for four hours and a half, made the tumor solid and pulseless. Two 
 rigors followed, and a carbuncle formed at the site of the first compression. In Mr. 
 Holden's patient the aneurism was also large, and double aortic valvular disease was 
 present. Chloroform was given here continuously for an hour and a half, and then 
 with cautious intermissions, owing to the state of the pulse and breathing, for the rest 
 of the treatment, which lasted four hours. 
 
 f In an interesting case recorded by Dr. Sheen of Cardiff {Brit. Med. Journ., 1882, 
 vol. ii. p. 720), the femoral aneurism, for which the external iliac was tied success- 
 fully, changed its shape suddenly, having burst some of its coats, apparently, but not 
 all, on the day of operation. 
 
 X Brit. Med. Journ, 1883, vol. i. p. 818. 
 
 ? The only case with which I am acquainted is one quoted by Mr. Erichsen from 
 Velpeau (Nouv. Elan, de Med. Oper., t. i. p. 175), in which the above French surgeon 
 was suddenly called upon to tie the external iliac for a knife-wound. Though there 
 had been no preliminary dilatation of the collateral circulation, either by pressure or 
 by the presence of an aneurism, the result was successful. 
 
 II It is fair to state that Mr. Bartleet, of Birmingham, published a case in which the 
 external iliac was tied successfully after secondary hsemorrhage from the common 
 femoral, the latter having been tied for aneurism of the femoral artery. Previous to 
 ligature of the external iliac, " sponge-jiressure" and pressure by means of a Martin's 
 bandage were tried, but no details are given. It is noteworthy that the catgut ligature 
 applied to the femoral in this case came away on the seventh day (the first day of the 
 ha'morrhage) unabsorbed, and surrounding a small slough of the artery. It had been 
 tied ''tightly." 
 
LIGATUEE OF THE EXTERNAL ILIAC. 531 
 
 Dr. Otis* gives a summary of twenty -six cases in which the external 
 iliac was tied for such cases as the above. Of these, twenty-three 
 ended fatally, a mortality of 88.4 per cent. The uselessness of trust- 
 ing to ligature of the external iliac in such cases, instead of either 
 securing the wounded vessel itself, or trusting to well-applied pressure, 
 was long before this insisted on by Guthrie.f This question is alluded 
 to again below, but in proof of the above statement one of the Ameri- 
 can cases X may be mentioned here, in which ha?morrhage returned 
 after ligature of the external iliac and was arrested by well-applied 
 pressure. The patient had been wounded, January 15, 1865, by a 
 minie ball, entering at the upper and inner part of the thigh, and 
 emerging near the knee. The wound becoming sloughy, haemorrhage 
 occurred from the wound — March 23 and 31 — and the external iliac 
 was tied. April 21. Hasmorrhage recurred from the upper gun-shot 
 wound, and was successfully restrained by a horseshoe tourniquet, 
 constantly kept on for two weeks, when it was omitted, without any 
 subsequent haemorrhage. The wounds were now healing kindly, when- 
 — May 31 — dysentery set in, carrying off the patient, June 15, two 
 and a half months after the operation of ligature. 
 
 3. Elephantiasis. — Ligature of the external iliac or femoral (when 
 the condition of the soft parts admit of it) has been extolled by some 
 surgeons in the treatment of this affection. § A larger experience 
 shows, however, that when cases thus treated are watched, the cures 
 cannot be relied upon as permanent. Moreover, too little value has 
 been attached, in reported cures by ligature of the main vessel, to. the 
 thorough rest and elevated position entailed by tying the artery. || 
 
 * Med. and Surg, History of the War of the Rebellion, pt. iii. p. 788. 
 
 t Wounds and Injuries of the Arteries, Lects. v. and vi. 
 
 J Otis, loc. supra cit., p. 40. 
 
 ? An apparently successful case is reported by Mr. Leonard, of Bristol. Measure- 
 ments are given nearly three years after the operation, showing that the success was 
 then maintained. Five years later the patient reported that " his leg was much the 
 same" as at the last report. Bandaging does not appear to have been made use of 
 here. Prof. Buchanan (Brit. Med. Journ., November 23, 1867; Syd. Soc. Bien. Retr., 
 1867-8, p. 300) reports a case, seven months after the operation, apparently cured by 
 ligature of the external iliac, after failure of rest and methodical compression (this was 
 before the introduction of Martin's bandage). Three months later it is candidly stated 
 that the disease had recurred to a considerable degree. Dr. White, of Harvard Uni- 
 versity (Intern. Encyel. of Surg., vol. ii. p. 631), quotes Wernher (reference not given) 
 as having followed up thirty-two cases ; in all there was an immediate reduction of size, 
 but the relief was permanent in three only. Dr. Pinnock, of Melbourne (Lancet, 1879, 
 vol. i. p. 44), gives a case in which no permanent benefit followed on ligature of the 
 femoral artery. 
 
 II A severe case of Mr. Whitehead's is briefly reported in the Brit. Med. Journ., 
 1882, vol. ii. p. 1043. The disease had lasted seventeen years, and had been associated 
 with attacks of erysipelas. "The treatment (successful) had consisted in rest, massage, 
 
532 
 
 OPERATIONS ON THE ABDOMEN. 
 
 This operation should, I think, be reserved for those cases (which 
 will be very few) in which Martin's bandages cannot be applied owing 
 to cracks, foul ulcers, or burrowing sinuses. Here the ligature may 
 be used after explaining its risks to the patient, but only as a subsidi- 
 ary measure. The bandage will have to be used as weU later, and 
 persisted in, during the day at least, probably for life. 
 
 4. As a distal operation in aneurism of the common iliac, ligature 
 of the external iliac, has been so unsuccessful here as to call for no 
 further comment. 
 
 Surgical Anatomy. 
 
 Extent. — From the lumbo-sacral articulation to a point just 
 internal to the centre of Pouisart's ligament Length. — About 4 
 inches. 
 
 Surface Marking. — From a point an inch below and to the left of 
 the umbilicus to a point just internal to the centre of Poupart's 
 ligament. 
 
 Relations. 
 
 In Front. 
 Peritoneum, small intestines. 
 Iliac fascia. 
 
 Lymphatic glands and vessels. 
 Genito-crural nerve (genital branch). 
 
 Spermatic vessels 
 
 1 
 
 Crossing artery near Poupart's liga- 
 
 Circumflex iliac vein J 
 
 ment. 
 
 
 Outer Side. 
 
 
 
 Inner Side. 
 
 Psoas (above). 
 
 E: 
 
 eternal iliac 
 
 Iliac fascia. 
 
 Iliac fascia. 
 
 
 artery. 
 
 Vein. 
 
 
 Behind. 
 
 
 
 Iliac fascia. V 
 
 as deferens (dipping 
 
 
 Vei 
 
 in (above). 
 
 from internal ring 
 
 
 Psoas (below). 
 
 to pelvis). 
 
 Collateral Circulation. 
 
 
 
 Deep epigastric 
 
 with 
 
 Internal m 
 
 ammary and lower 
 
 
 
 intercostal and lumbar. 
 
 Deep circumflex iliac 
 
 with 
 
 Ilia-lumbar 
 teal. 
 
 , lumbar, and glu- 
 
 Gluteal and sciatic 
 
 with 
 
 Internal an 
 flex. 
 
 d external circum- 
 
 Comes nervi ischiadici 
 
 with 
 
 Perforating 
 funda. 
 
 branches of pro- 
 
 elastic pressure, compression of the femoral artery, and rubbing down the tubercles with 
 pumice-stone. The Ijnee, which had become flexed and ankylosed by bony union, was 
 straightened by sawinfj through the site of the original joint." 
 
IJGATUEE OF THE EXTERNAL ILIAC. 533 
 
 Obturator 
 
 with 
 
 Circumfiex arteries and epigas- 
 tric. 
 
 Internal pudic 
 
 with 
 
 External pudic. 
 
 Operation. — (1) By the lower and more transverse incision of Sir 
 A. Cooper. (2) By the higher and more vertical incision of Abernethy. 
 The two are compared at p. 535. 
 
 (1) Incision of Sir A. Cooper.— This is the method more frequently 
 made use of. The diet having been limited, and the bowels having 
 been freely moved for some days before the operation, the parts shaved 
 and the hip slightly* flexed, an incision is made 4 inches long (4i to 
 5 if there be very much fat, or if the parts are pushed up by a con- 
 tiguous aneurism), parallel with Poupart's ligament, and nearly an 
 inch above it, commencing just outside the centre of the ligament and 
 extending outwards and upwards beyond the anterior superior spine.f 
 The superficial fascia and fat, varying in amount, being divided, and 
 the superficial circumflex iliac vessels secured, the external oblique 
 both fleshy and aponeurotic is cut through, and then the fleshy fibres 
 of the internal oblique and transversalis. This is done either by using 
 the knife alone, lightly and carefully, or by taking up each layer with 
 forceps, nicking it, and slitting it up on a director. If the wound be 
 sponged carefully,! ^ layer of cellular tissue can usually be seen be- 
 tween the muscles however thin they are. Any muscular branches 
 should be secured with Spencer Wells' forceps as soon as cut; and in 
 pushing a director beneath the muscles as little damage as possible 
 should be done, owing to the proneness to cellulitis later on, and to 
 the proximity, in a thin patient, of the peritoneum. The fascia trans- 
 versalis when exposed, will be found to vary a good deal in thickness 
 and in the amount of fat which it contains. It is to be divided very 
 carefully ,§ and the extra-peritoneal fat, if present, will next come into 
 
 * So that the skin may not be too much relaxed before being incised. Later on to 
 relax the parts, the hips may be more strongly flexed. 
 
 t The incision may have to be made higher than usual, owing to the upward exten- 
 sion of the aneurism, to enable the surgeon to tie either the upper part of the external 
 or the common iliac. On this point see the remarks on the comparison of Cooper's 
 and Abernethy's operation, p. 535. Often in these cases of upward extension of the 
 aneurism the sac is found to involve the lower part of the artery, and to have over- 
 lapped the upper portion. 
 
 X In some cases where the circulation has been much interfered with by an 
 aneurism, most copious haemorrhage, especially venous, has been met with in the 
 fearlier steps of this operation. 
 
 § Dr. Sheen {he. supra cit.) thus writes of the accident which may happen here: 
 " I made the incision somewhat too high, and, in consequence, opened the peritoneum, 
 which I mistook for transversalis fascia. Even then I was in a little doubt, because 
 some (omental) fat presented itself, which very much resembled the fat seen in the 
 
534 
 
 OPERATIONS ON THE ABDOMEN. 
 
 view. First one and then two fingers being introduced, the peritoneum 
 is to be gently stripped up from the iliac fossa towards the middle line 
 —i.e., upwards and inwards as far as the inner border of the psoas * 
 In doing this, care must be taken, especially in the dead body, not to 
 separate the iliac fascia and the vessels from their position on the 
 
 Fig. 93. 
 
 Ligature of the external iliac artery. The peritoneum is held out of the way above and at the 
 two angles of the wound. Below are seen, from without inwards, the lliacus, psoas, genito-crural 
 nerve, the artery (with a ligature beneath it), and the vein. • 
 
 The incision below is that for ligature of the common femoral. 
 
 psoas, not to tear this muscle, and not to lacerate the peritoneum. As 
 soon as the peritoneum has been well raised, an assistant keeps this 
 and the upper lip of the wound well out of the way by means of broad 
 retractors. The surgeon then feels for the pulsation of the artery on 
 
 previous case (fat around the vessel), but in pusiiing this up gently, a knuckle of bowel 
 came into view, which settled the matter.'' The wound in the peritonseum was sewn 
 up with two fine carbolized sutures, and the case did perfectly well. 
 
 * Great care is needed here if the peritoneum is adherent. This condition, when 
 present, is usually found above. It is especially likely in long-standing cases, and 
 where the aneurism has caused irritative and inflammatory changes. By some it iS 
 held that the transversalis fascia can always be stripped up along with the peritoneum. 
 As this fascia is thickened and attached, close to Poupart's ligament, to form the deeper 
 crural arch and front of the femoral sheath, it is very doubtful if it can ever be de- 
 tached unless it is divided or torn through. The latter is very easy on an aged corpse. 
 
LIGATURE OF THE EXTERNAL ILIAC. 535 
 
 the inner border of the psoas, and carefully opens the layer of fascia 
 which ties the vessel to the psoas and forms a weak sheath to it. This 
 should be done IJ inch above Poupart's ligament * and the needle 
 passed from within outwards, carefully avoiding the vein on the inner 
 side and the genito-crural nerve outside and in front. In difficult 
 cases the ligature must mainly be passed by touch, but a free incision, 
 adequate use of retractors, and light thrown in by a large mirror, will 
 very often allow the surgeon to see what he is doing. The effect of 
 tightening the ligature being satisfactory, it is cut short and dropped 
 in, the cut muscles are then brought together with chromic gut cut 
 short, sufficient drainage provided, and the superficial wound closed. 
 The parts must be kept relaxed by propping the chest up slightly and 
 flexing the knees over a pillow, but too much flexion of the groin is 
 to be deprecated as causing a deep sulcus from which discharges will 
 escape with difficulty. The limb is evenly bandaged from the toes 
 upwards, raised and kept covered in cotton wool, with hot bottles 
 placed in the bed.f In case of threatening gangrene, assistants should 
 persevere in a trial of friction of the limb from below upwards. Where 
 there is a history of syphilis, appropriate remedies should be given 
 after the operation. 
 
 (2) IxcisiON OF Abernethy.— In his first operation this surgeon 
 made his incision in the line of the artery for about three inches, com- 
 mencing nearly 4 inches above Poupart's ligament. Later on he 
 modified his incision by making it less vertical, and more curved, with 
 its convexity downwards and outwards, and extending between the 
 following points — viz., one about 1 inch internal and 1 inch above the 
 anterior superior spine to IJ inch above and external to the centre of 
 Poupart's ligament. 
 
 The respective advantages and disadvantages of the methods 
 of Cooper and Abernethy appear to be the following : Cooijer's is rather 
 the easier, interfering as it does with the peritoneum less, and lower 
 down. It is most suitable to those cases which do not extend far, if 
 at all, above Poupart's ligament. The risk of ventral hernia would 
 appear to be less. On the other hand, where the extent to which the 
 aneurism reaches upwards is not exactly known, Abernethy's opera- 
 tion, hitting off the artery, as it does, higher up, or some modification 
 of that given (p. 547) for ligature of the common iliac will be found 
 preferable. 
 Difficulties and Possible Mistakes. 
 1 Too short an incision. Here, as in colotomy and other deep 
 
 * So as to lie well above the origin of the deep epigastric, which usually comes off 
 J or J inch above Poupart's ligament. The absence of any other branch shonld, if 
 possible, be verified. 
 
 f If the patient be restless, as in delirium tremens, a long splint should be applied. 
 
536 OPERATIONS ON THE ABDOMEN. 
 
 operations on the abdominal wall, every layer must be cut to the full 
 extent of the superficial ones. Otherwise the operator will be working 
 at the bottom of a conical, confined wound. 
 
 2. A wrongly placed incision— i.e., one which, by going too near the 
 middle line, opens the internal abdominal ring, or which, if too low, 
 may come too near the cord. 
 
 3. Disturbing the planes of cellular tissue needlessly or roughly. 
 
 4. W'ounding the peritoneum, owing to a hasty incision through a 
 thin abdominal wall, by rough use of a director, especially if the 
 peritoneum is adherent in the neighborhood of the sac, or fixed with 
 the transversalis fascia. The peritoneum is often difficult to dis- 
 tinguish : it is bluish in aspect, but of course not smooth, but covered 
 with cellular tissue which connects it to the extra-peritoneal fat. 
 
 5. Stripping up the peritoneum roughly and too far. 
 
 6. Detaching the artery from the psoas. 
 
 7. Lacerating the psoas. 
 
 8. Tying or injuring the vein. 
 
 9. Including the genito-crural nerve. 
 
 10. An abnormal position of the artery. This may be due to an 
 exaggeration of that naturally tortuous condition of the artery which 
 is especially likely to be met with in patients advanced in life. 
 Another unusual cause of displacement may be met with in extrava- 
 sated blood, when an aneurism has given way. Sir W. Fergusson 
 briefly reported (Brit. Med. Journ., 1873, vol. i. p. 286) an instance of 
 this kind, in which the sac gave way after repeated manipulation. 
 Much venous hiemorrhage was met with during the first incisions and 
 evidence of extravasated blood deeper down. On reaching the peri- 
 toneum, a novel feature presented itself Instead of the iliacus* lying 
 uninjured before the operator, it seemed as if the aneurism had burst 
 at the back, and a great infiltration of blood had taken place into the 
 substance of the iliacus. No trace of the artery could be seen, nor 
 could it be felt anywhere. On pushing his finger deeply in towards 
 the middle line close upon the bladder, Sir W. Fergusson came upon 
 the artery, with little pulsation and quite at the inner side of the 
 swollen ilicacus. Pulsation in the aneurism ceased as soon as the 
 ligature was tightened. How the case ended is not stated. 
 
 Causes of Failure and Death. 
 
 1. Gangrene. In some cases, where the limb does not become 
 gangrenous, the vitality is very feeble and requires much attention. 
 Thus, in Mr. Rivington's case (Clin. Soc. Trans., vol. xix. p. 45), loss of 
 sensation was noticed on the fourth day, followed by paralj'sis of 
 most of the muscles. Though gangrene did not appear, and the 
 
 * Probably the ilio-psoas is intended here. 
 
LIGATURE OP THE EXTERNAL ILIAC. 537 
 
 patient survived five and a half months, the limb was " on the verge 
 of gangrene," as shown by sores appearing on the heel and great toe * 
 
 2. Secondary hasmorrhage. This is especially likely if the wound 
 becomes septic, and if catgut is used. This fatal result may I:ie long 
 deferred ; thus, in Mr. Rivington's case (loc. supra cit), the patient died 
 of secondary hajmorrhage five and a half months after the operation ; 
 the wound had been found septic at the first dressing, catgut was 
 used. Early recurrence of pulsation may be ominous of secondary 
 hemorrhage. In a case of Sir A. Cooper the haemorrhage which 
 proved fatal a fortnight after the operation was found to be due to 
 a large collateral — viz., an abnormal obturator arising immediately 
 above the site of ligature (Roux, Parallele de la Chir. Anglaise avec la 
 Ghir. Frangaise, etc., pp. 278, 279). 
 
 3. Cellulitis. Septicajmia. Pya3mia. Owing to the number of 
 planes of cellular tissue met with here, any needless or rough disturb- 
 ance of the parts, inadequate drainage, or a septic condition super- 
 vening, are extremely to be deprecated. The wound should be 
 opened up at once if any collection of fluid is suspected. 
 
 4. Peritonitis. 
 
 5. Tetanus, from including the genito-crural nerve. 
 
 6. Phlebitis and secondary haemorrhage from injury to the external 
 iliac vein. 
 
 7. Suppuration of the sac with its attendant dangers of septic in- 
 fection and secondary hfemorrhage.t 
 
 This accident is far from uncommon in cases of inguinal aneurism 
 after ligature. No pains should be spared to prevent its occurrence 
 by taking every step to keep the wound strictly aseptic from first to 
 last, and thus to secure early and sound healing. Absolute rest 
 should also be enforced upon the patient. If suppuration take place 
 it will usually be within two months of the date of ligature. The 
 symptoms need not be alluded to here beyond pointing out that 
 pulsation is one of very grave omen. When it is evident that suppu- 
 ration, if not established, is inevitable, the surgeon should so arrange 
 his time as to choose a suitable occasion both as to assistance and 
 a good light, for interfering. Allowing the supjjurating sac to open 
 spontaneously should not be thought of, not only because of the risk 
 of haemorrhage, the want of preparation, etc., but because septic in- 
 
 * In one of Dr. Sheen's cases already referred to, four days after the operation a 
 large patch of skin on the outer side of the thigh was noticed to be darkish in color, 
 and 10 pit on pressure, though normal as to sensation. The case did quite well. 
 
 t Very occasionally secondary haemorrhage may take place to a slight amount, and 
 leave off spontaneously. Thus, in one of Dr. Sheen's cases, five weeks after the opera- 
 tion " about an ounce of bright- red blood came from the slight remaining wound, and 
 a slight oozing again after a few days, but there was no further haemorrhage." 
 
538 OPERATIONS ON THE ABDOMEN. 
 
 fection is now made very probable. The operative steps are much 
 the same as in the old operation for aneurism, for which the reader is 
 referred to p. 554. It may be here pointed out that in this case there 
 is more chance of the hasmorrhage taking the form of a general oozing 
 from the sac, and not that of a gush or spirt of blood. Moreover, if 
 the collateral circulation has been well established, there is also the 
 probability of the sac being fed by some additional branch, which, 
 perhaps, entering deep down, may be a cause of much embarrassment. 
 
 8. Recurrence of pulsation. 
 
 This is especially likely to occur when a catgut ligature has been 
 used and given way, owing to its being softened by suppuration. 
 Over-free collateral circulation will cause recurrence of pulsation 
 quickly, and melting down of soft coagulum (this appearing to be all 
 that the blood can do in the way of clotting) will bring about the 
 same cause of failure later on. 
 
 In these cases, the following courses are open in the matter of the 
 external iliac — viz., well-adjusted and carefully maintained pressure, 
 and the old operation. Ligature of the vessel lower down — i.e., between 
 the first and the aneurism — and amputation are not available here.* 
 
 Two other conditions which may supervene and prove troublesome 
 should be mentioned here, viz. : 
 
 9. Formation of a ventral hernia. This should be prevented as far as 
 possible by ensuring primary union, and by the use of deep chromic 
 gut sutures in the cut muscles. Later on, if this complication occur, 
 an appropriate belt should be worn. 
 
 10. Coming away of the ligature long after the operation through a 
 persistent sinus or reopened wound. This may happen, even in a 
 wound kept sweet from first to last, if a silk ligature has not been 
 properly carbolized, or if one of too close texture is used. See the 
 foot-note, p. 404. 
 
 LIGATURE OF THE COMMON ILIAC (Fig. 94). 
 
 Indications. — Very few : 
 
 1. Aneurisms. Especially those inguinal aneurisms which affect 
 the external iliac on its upper part, above the origin of the deep epi- 
 gastric, occupying the iliac fossa and lower part of the abdomen. 
 When such aneurisms are progressing steadily, when they have re- 
 
 * In one case {Syd. Soc. Bien. Betr., 1873-4, p. 220) after ligature of the external 
 iliac for a femoral aneurism with catgut, and premature absorption of this on the fifth 
 day (the wound suppurated freely, and antiseptic precautions do not appear to have 
 been talcen), pulsation returned, and tlie swelling enlarged. The patient was operated 
 upon again, and a stout carbolized hempen ligature made use of, one end being left 
 long. Though, owing to the close matting of parts, the peritoneum was wounded 
 twice, and intestines and omentum protruded, the patient recovered. 
 
LIGATURE OF THE COMMON ILIAC. 539 
 
 sisted a trial of pressure, and are not thought amenable to the old 
 operation, ligature of the common iliac is indicated. 
 
 The following remarks by one of the chief living authorities on 
 aneurism, Mr. Holmes,* will aid the surgeon in coming to a decision 
 in this most miportant matter : 
 
 "Allowing that an iliac aneurism is amenable to all three methods 
 of treatment, the Hunterian, by ligature of the aorta or common 
 ihac; the old operation, by laying open the sac and securing the 
 artery or arteries opening into and out of it; and the method of com- 
 pression applied to the aorta or common iliac— I think no one could 
 deny that the number of cures by the latter method bears a very 
 large proportion to the number of cases treated, while the cures by 
 the Hunterian method are very rare, and the other method is as yet 
 pretty nearly untried. 
 
 "But this is far from settling the question ; compression, doubtless, 
 often succeeds, but it also often fails. It is not without its risks. It 
 usually requires the prolonged use of chloroform, and this cannot 
 always be borne by the patient. 
 
 " The question of applying the old method in preference to the 
 Hunterian in those cases (rare, it may be, but which must sometimes 
 be met with) in which pressure has failed, is one which Mr. Syme's 
 brilliant operations have put in a totally new light. And I must say, 
 for my own part, that looking at the awful mortality which has 
 attended the ligature of the common iliac for aneurism, and the uni- 
 form fatality of the same operation on the aorta, I think Mr. Syme's 
 suggestion ought to be put to the test of more extended experience, 
 although the facts and reasonings which I have adduced will show 
 that I am not insensible to the risks which attend the performance 
 of the operation, to the probability of secondary haemorrhage, and to 
 the extensive injury which must be inflicted upon parts in the imme- 
 diate neighborhood of important organs." 
 
 Mr. Holmes, then, in proof of the great fatality of the Hunterian 
 operation on the common iliac, quotes the list collected by Dr. Stephen 
 Smithjf in which, out of fifteen cases in which that vessel was tied for 
 aneurism, only three can be reckoned as definitely cured. 
 
 Mr. Holmes's belief that subsequent experience has not been more 
 favorable, is supported by a table of 65 cases, tabulated by Dr. Pack- 
 ard.J Of these 65 cases, no fewer than 51 died, only 14 recovering, 
 giving a general mortality of 78.46 per cent. § 
 
 * E.C.S. Lectures {Lancet, 1873, vol. i. p. 297). 
 
 + Amer. Journ. Med. Sci., July, 1860, vol. xl. 
 
 X Trans. Amer. Surg. Assoc., vol. i. p. 234. Sixty-seven cases are given, but the 
 result is not stated in two. 
 
 § Grouping these cases into classes, after Dr. Smith's example, in order to obtain 
 more satisfactory deductions, Dr. Packard concludes as follows: (i) Those cases in 
 
540 OPERATIONS ON THE ABDOMEN. 
 
 Mr. Holmes goes on to discuss the old operation, and in answer to 
 the objection that, though the Hunterian operation has been attended 
 with " awful mortality " here, we are not made more secure by oper- 
 ating on an artery, perhaps not much more than 3 inches lower down, 
 and already involved in disease, writes : " I repl}', that if we grant the 
 artery where it is involved in the sac to be healthy enough to bear the 
 ligature, many advantages may be found in the old operation over 
 
 that of Hunter First, the clot is removed, and the sac laid 
 
 open ; consequently, that softening of clot and inflammation of a 
 closed sac lying in proximity to the peritoneum, which is so surely 
 fatal, is obviated. Next, the ligature will probably be placed on the 
 external iliac instead of the common, and thus the chances of gan- 
 grene will be greatly diminished, since the internal iliac and its 
 branches are left open. Thirdly, the artery is tied at a point where 
 most likely the peritoneum and viscera have been pushed away from 
 it by the sac, so that there is less risk of hurtful interference with these 
 latter in the operation. And, lastly, the total excision of the tumor 
 precludes any such relapse as occurs sometimes after the Hunterian 
 operation. 
 
 " Against these advantages must be set the undoubted risks of sec- 
 ondary haemorrhage, even in cases where the immediate dangers of 
 the operation have been surmounted. What this risk is we have no 
 means of judging until our experience of this operation becomes 
 greater ; but I am under the impression that Mr. Syme much under- 
 rated it, in consequence of having operated chiefly upon traumatic 
 aneurism." 
 
 Farther on,* Mr. Holmes writes, while " maintaining that the old 
 doctrine on which the superiority of Hunter's operation is based, is 
 quite true in general, I should have no objection in the particular in- 
 stance of iliac aneurism, to follow Mr. Syme's practice; at least until 
 further experience of it should show that it is wrong: only the less 
 dangerous expedient of rapid compression of the trunk-artery under 
 chloroform, or gradual compression, with or without chloroform, 
 should first be tried." 
 
 The same authority when, later on, discussing the value of pressure, 
 brings out the following facts. That while rapid compression under 
 
 which the operation was done for the arrest of hiemorrhage: 22 case's, of which 19 
 died and 3 recovered; mortality, 80.36 per cent, (ii) Those in which it wa.s done for 
 the cure of anenrism : 35 citses, of which 24 died and 9 recovered, the result not being 
 stated in 2; mortality in 33 case'i, 72.72 per cent, (iii) Those cases in which tumors 
 simulating aneurism led to its performance: 5 cases, 4 of which died and 1 recovered. 
 (iv) Those in which the vessel was secured to prevent haemorrhage during the removal 
 of a morbid growth: 3 cases, all of which died. 
 * Loc. supra cit., p. 367. 
 
LIGATURE OP THE COMMON ILIAC. 541 
 
 CSS 
 
 IS 
 
 chloroform is a mode of treatment by which most gratifying succcs^ 
 has been obtained in iliac as well as aortic aneurism, it exposes the 
 patient to serious dangers. Amongst these are enteritis and peritonitis 
 from bruising of small intestine, mesentery, meso-colon, and sympa- 
 thetic ; hematuria ; failure of pulse and breathing when the pad is 
 screwed down. On account of these very real dangers, which every 
 dexterity may not obviate, Mr. Holmes advocates a trial of gradual 
 compression, as safer, though less efficient, and he points out that the 
 relations of the common iliac are less complicated than those of the 
 aorta, and, " as we get further to one side there is more chance for the 
 intestines to slip out of the way."* 
 
 2. Wounds. These may be gunshot or bayonet wounds, or knife 
 stabs of the vessel itself, or the internal iliac or its branches, usually 
 the latter. The haemorrhage calling for ligature seems to be usually 
 secondary .f Gunshot wounds of the common iliac have a fresh in- 
 terest now, owing to the recent advances in surgery in the treatment 
 of gunshot wounds of the abdomen. 
 
 Dr. S. Smith J gives two cases of ligature of the common iliac for 
 wounds, the one from a musket-ball which injured the vessel itself, 
 passed through the intestines and lodged in the sacrum. The opera- 
 tion was performed by opening the peritoneal cavity. Peritonitis soon 
 set in ; secondary haemorrhage recurred repeatedly, and the case ended 
 fatally on the fifteenth day. The other case is of great interest, as the 
 common and internal iliac were here tied for severe heemorrhage after 
 a stab in the inguinal region. A large quantity of blood was found in 
 the peritoneal cavity, and the patient died ten hours after the operation. 
 At the autopsy it was found that the deep epigastric was the wounded 
 vessel. 
 
 Dr. Otis§ records four cases of ligature of the common iliac during 
 the late American war. In one, a gunshot wound, in which the ball 
 entered the groin and came out at the buttock, the external iliac was first 
 tied, the repeated hasmorrhage being believed to be from the profunda, 
 but as the bleeding persisted and evidently came from the sciatic, the 
 wound was prolonged and the common iliac tied. Both ligatures 
 
 * Mr. Plolmes draws attention also to tliis most important point — i.e., that rapid co- 
 agulation in an aneiirisnQal tumor cannot be regarded as in itself a means of cure, but 
 only as the commencement of a process which, if not interrupted, may result in cure, 
 and that thus, while pulsation may diminish soon after a trial of compression, it may 
 not absolutely cease for quite a month. 
 
 t It would naturally be thought that haemorrhage from a wound of the common iliae 
 would be fatal before a ligature could be applied. Dr. Otis gives a case in which this 
 vessel was wounded by a ball entering from the buttock through the sacro iliac syn- 
 chondrosis. Death took place from hasmorrhage on the second day. 
 
 } Avier. Journ. Med.Sci., 1860, vol. xl. p. 17. 
 
 § Med. and Surg. HiMory of the War of the JR.bellion, pt. ii. p. 333, 
 
542 OPERATIONS ON THE ABDOMEN. 
 
 came away, and the operation-wound healed, but the patient died 
 about three months later of exhaustion, associated, apparently, with 
 necrosis in the gluteal region. 
 
 In the second case the common iliac was tied for a gunshot wound 
 believed to be of the gluteal artery, in which the hemorrhage was not 
 arrested by tying the internal iliac. The hajmorrhage recurred and 
 death took place two days later. The third case was one of diffuse 
 aneurism of the right buttock and iliac fossa resulting from a bayonet 
 stab in the former region. Death took place four days later from 
 gangrene of the sac. The old operation is considered by Dr. Otis to 
 have been preferable in this case, but as the post-mortem showed that 
 the anterior trunk of the internal iliac had been wounded, within the 
 sacro-sciatic notch, by the bayonet, it is difficult to see how the case 
 could have been treated save by ligature of the internal iliac, either 
 outside or within the peritoneum, and then by opening and filling the 
 aneurismal sac with aseptic gauze or sponges. The fourth case was 
 one of aneurismal varix of the femoral vessels from a punctured 
 wound 2 inches below Poupart's ligament. In this case, owing to the 
 impossibility of separating the peritoneum, this was incised and the 
 common iliac thus secured. Peritonitis proved fatal four days_ later. 
 Here ligature of the artery lower down, above and below the original 
 seat of injury, would have been better treatment. 
 
 3. For the arrest of haemorrhage apart from aneurism. Such cases 
 may be met with after amputation near the hip, followed by secondary 
 hsemorrhage from the branches of the internal iliac in what is usually 
 the posterior flap. 
 
 Mr. Listen * published a case of this kind in which, after amputa- 
 tion below the trochanter minor for necrosis of the femur, hsemorrhage 
 occurred from the stump on the seventh day. As this could not be 
 arrested the common iliac was tied, but the patient died twenty -four 
 hours later. 
 
 Dr. Packard f treated a somewhat similar case in the same way, suc- 
 cessfully. This case is especially interesting as the hfemorrhage oc- 
 curred from branches of the internal iliac after a Furneaux Jordan's 
 amputation, a method which is coming largely into vogue now, and 
 which would usually be expected to do away with the above risk.J 
 Haamorrhage occurred from the stump on the sixth day, and as this 
 could not be arrested by pressure the common iliac was tied. The 
 patient ultimately did well. 
 
 * Lond. Med. Gaz, April 24, 1830. 
 
 f hoc. supra cit., foot-note, p. 539. 
 
 X In Dr. Packard's case the Furneaux Jordan's amputation was performed probably 
 higher up than usual, owing to osteo-myelitis, after a previous amputation for growth 
 at about the middle of the thigh. 
 
LIGATURE OF THE COMMON ILIAC. 543 
 
 It will not, it is hoped, seem a hasty criticism on the above if I say 
 that in future cases opening up the flaps and plugging with aseptic 
 gauze,* or the application for some days of Spencer Wells's forceps, 
 aided by even pressure on the flaps and pressure on the common or 
 external iliac, would be preferable to submitting, the patient to the 
 severe and risky operation of ligature of the common iliac. 
 
 4. For pulsating tumors simulating aneurism. As these growths 
 from the iliac fossa and the walls of the pelvis have been found to be 
 malignant, it is of the utmost importance to form a correct diagnosis 
 in these cases, and thus save a patient who has a certainly fatal dis- 
 order from being submitted to an operation which is most dangerous 
 and almost certain to be useless.! As mistakes have, however, been 
 made in these cases by excellent surgeons,^ the chief points of diag- 
 nosis, as given by Mr. Holmes,§ may be briefly mentioned here : (1) 
 The bruit is usually less well marked ; (2) The pulsation is less heav- 
 ing and less expansive ; (3) The condition of the bone with which the 
 swelling is connected ; thus, a plate of bone may be found in the 
 supposed aneurismal sac; the supposed aneurism maybe found both 
 on the gluteal and the iliac aspects of the pelvis, the bone being ex- 
 panded by the growth ; (4) The cancerous cachexia is usually present, 
 and perhaps secondary growths as well. 
 
 5. For hsemorrhage, not the result of a wound. Ligature of the 
 common iliac has been employed in some cases of this nature, usually 
 secondary hsemorrhage after ligature of the external iliac, the gluteal 
 and sciatic, or after rupture of the external iliac. Ligature of the 
 main trunk has been so fatal in these cases that it ought to be aban- 
 doned, carefully applied pressure aided by plugging with aseptic 
 gauze, or the old operation being certainly preferable. 
 
 Mr. Morrant Baker has put on record || a case of great interest in 
 diagnosis, in which an abscess. from sacro-iliac disease ulcerated into 
 branches of the internal iliac artery, and when opened gave rise to 
 hfemorrhage calling for ligature of the common iliac : A gardener, 
 aged seventeen, had felt pain a month previously while digging. A 
 tense, elastic swelling, distinctly fluctuating, and acutely tender, occu- 
 
 * Wrung out of turpentine if the parts are sloughy (p. 423). 
 
 f In Guthrie's case, a pulsating tumor in the right bultook, the size of an adult 
 head, diminished by one-half in a month. Two months later it again enlarged, and 
 the patient dying, eight months after the operation, an immense encephaloid tumor 
 was found occupying the right iliac region. 
 
 J E.g., Guthrie (Lmid. Med. Oaz., vol. ii. 1834) ; Stanley (Med. Gfiir. Trans., vol. 
 xxviii.) ; Moore (ibid., vol. xxxv.). 
 
 i Syst. of Surg., vol. iii. pp. 44, 145. The reader should also consult Mr. Holmes's 
 article, "On Pulsating Tumors which are not Aneurismal, and on Aneurisms which 
 are not Pulsating Tumors " (St. George's Hasp. Reports, vol. vii.). 
 
 II St. Barthol. Hasp. Reps., vol. viii. p. 120. 
 
544 OPERATIONS ON THE ABDOMEN. 
 
 pied all the right buttock. It was opened, and a small stream of 
 apparently arterial blood escaped without jets. On further explora- 
 tion the finger entered a large cavity between the iliac bone and the 
 glutei. The ihac fossa was full and tense, and on examination, per 
 rectum, a swelling, was found in the right ischio-rectal fossa. On 
 enlarging the gluteal wound a steady stream of arterial blood welled 
 up through the great sacro-sciatic foramen. This was firmly plugged 
 and the common iliac tied. On removing the plug some bleeding 
 still occurred, but was easily arrested. The gluteal wound became 
 offensive, and this region, together with the upper part of the thigh, 
 became gangrenous, the leg and foot remaining unaffected. The 
 patient died forty hours after the operation. 
 
 Post mortem the sacro-iliac joint was open and the neighboring 
 bone diseased. The remains of a large abscess was found involving 
 the branches of the internal iliac. There was no trace of aneurism. 
 
 Surgical Anatomy. — The common iliacs coming off on the left 
 side of the fourth lumbar vertebra, incline downwards and outwards 
 to divide, opposite to the lumbo-sacral intervertebral disk, into the 
 internal and external iliacs. The right is rather the longer and more 
 oblique of the two. Their length is usually H inch. Their branches 
 are few and small — viz., to the ureter, psoas muscles, glands, etc. The 
 iliacs become increasingly tortuous with age : a point of importance in 
 tying the vessel on an aged corpse. 
 
 Line. — One drawn from a point li inch below and a little to the 
 left of the umbilicus to the centre of Poupart's ligament, the line 
 curving a little outwards in its course, will represent the course of the 
 artery with sufficient accuracy. 
 
 Guide. — The above line is the only surface guide : more deeply the 
 lumbo-sacral articulation and the psoas muscles are useful guides, 
 esjjecially in a thin subject.* 
 
 Relations : 
 
 In Feoxt. 
 
 Peritoneum ; small intestine ; csecum and 
 
 apiDendix, sometimes. 
 Ureter. 
 Sympathetic. 
 
 Outside. Inside. 
 
 Psoas. Left common iliac vein. 
 
 Vena cava. 
 
 T>' u-i- „„ ,„„„ Right common 
 
 Right common iliac artery. 
 
 iliac vein. 
 
 * Attention has been drawn to the need of employing touch, as well as sight, in tlie 
 ligature of these large trunks (p. 534). 
 
LIGATURE OF THE COMJVION ILIAC. 545 
 
 Behind. 
 
 Right and left common iliac vein. 
 
 In Front. 
 
 Peritoneum ; small intestine. 
 
 Sympathetic. 
 
 Ureter. 
 
 Superior luemorrhoidal artery. Rectum. 
 Outside. 
 
 Psoas. Left common 
 
 iliac artery. 
 
 Behind. 
 Left common iliac vein. 
 
 Collateral Circulation.— The chief vessels concerned here are : 
 
 Above. BELo^v. 
 
 Internal mammarj^ and 
 
 lower intercostals, with Deep epigastric. 
 
 Lumbar, with Ilio-lumbar and circumflex 
 
 iliac. 
 Middle sacral, with Lateral sacral. 
 
 Superior hemorrhoidal, with Inferior and middle hajm- 
 
 orrhoidal. 
 
 In addition, the pubic arteries anastomose behind the symphysis. 
 
 Operations (Fig. 94). — The common iliac may be tied by opera- 
 tions based upon one of two incisions. (1) An anterior abdominal by 
 which the vessel is approached more directly from the front ; an in- 
 cision based upon those for tying the external iliac, and made use of 
 by Dr. Mott, of New York, who first tied this vessel in 1827. (2) A 
 posterior abdominal, or loin incision, by which the vessel is reached 
 from behind ; a method made use of by Sir P. Crampton, of Dublin, in 
 1828, and by Mr. Stanley at St. Bartholomew's, in 1846 (Fig. 94). 
 
 (1) Anterior Abdominal Incision. — The preparatory treatment is here 
 the same as that for the external iliac. The parts being shaved and 
 cleansed, a curved incision, 5 to 8 inches long, according to the amount 
 of fat, the development of the body, and the size of the aneurism, is 
 made, commencing just outside the centre of Poupart's ligament and 
 IJ inch above it, then carried outwards, reaching towards the crest of 
 the ilium, then upwards towards the ribs, and finally curving inwards 
 towards the umbilicus, till sufficiently free to admit of the necessary 
 manipulations for reaching the artery. The three abdominal muscles 
 are cut through, either on a director, or with careful, light sweeps of 
 
 35 
 
546 OPERATIONS ON THE ABDOMEN. 
 
 the knife, till the fascia transversalis is reached ; any vessels which 
 bleed * being at once secured with Spencer Wells's forceps. The fascia 
 transversalis, which may generally be known from the peritoneum 
 by the layer of extra-peritoneal fat, which usually intervenes between 
 the two, is then picked up and divided on a director, at the lower part 
 of the wound where it is best marked.f The peritoneum is next raised 
 upwards and inwards, first one finger, and then more, being insinuated 
 towards the middle line until the psoas is reached. On the inner side 
 of this muscle the artery will be found, the external iliac being traced 
 up if needful. In order to aid the surgeon in the difficulties which 
 are now met with, owing to the artery lying at the bottom of a very 
 deep wound, the abdominal walls should be relaxed by bending up 
 the thighs, the wound sponged thoroughly dry, and light thrown in 
 by a reflector if needful. Care will, of course, have been taken to 
 divide every layer from end to end equally, and thus to avoid a coni- 
 cal hole of a wound. The position of the vessel having been made 
 out, it is to be cleaned with a director, especial care being taken on 
 the right side, as here both the common iliac veins lie behind the 
 artery. The needle should be passed from within outwards. 
 
 (2) Posterior Incision, partly in Abdomen, partly in Loin. — This 
 operation will be best given in the words of Sir P. Crampton,J who 
 first introduced it : 
 
 " The first incision § commenced at the anterior extremity of the 
 last false rib, proceeding directly downwards to the ilium ; it followed 
 the line of the crista ilii, keeping a very little within its inner margin, 
 until it terminated at the superior anterior spinous process of that 
 bone ; the incision was therefore chiefly curvilinear, the concavity look- 
 ing towards the navel. The abdominal muscles were then divided to 
 the extent of about an inch, close to the superior anterior spinous pro- 
 cess, down to the peritoneum ; into this wound the forefinger of the 
 left hand was introduced, and passed slowly and cautiously along 
 the line of the crista ilii, separating the peritoneum from the fascia 
 iliaca. A probe-pointed bistoury was now passed along the finger to 
 its extremity, and by raising the heel of the knife, while its point 
 rested firmly at the end of the finger as on a fulcrum, the abdominal 
 muscles were separated from their attachments to the crista ilii by a 
 single stroke. By repeating this manoeuvre the wound was prolonged 
 until sufficient room was obtained to pass down the hand between 
 the peritoneum and .the fascia iliaca. Detaching the very slight con- 
 
 * See note, p. 533. 
 
 f Dr. Liddell {Intern. Encycl. of Surg., vol. iii. p. 312) recommends that the separa- 
 tion of this fascia from the peritoneum should be begun at the upper part of the wound, 
 where the adhesion is slightest. 
 
 X Med. Chir. Trans., vol. xvi. p. 161. 
 
 § The patient would, of course, be rolled over on to the sound side. 
 
LIGATURE OF THE COMMON ILIAC. 
 
 547 
 
 nections which these p^rts have with each other, I was able to raise 
 up the peritoneal sac with its contained intestines on the palm of my 
 hand, from the psoas magnus and iliacus and internus muscles, and 
 thus obtain a distinct view of all the important parts beneath ; and 
 assuredly a more striking view has seldom been presented to the eye 
 of the surgeon ; the parts were unobscured by a single drop of blood ; 
 there lay the great iliac arterj^, nearly as large as my finger, beating 
 awfully, at the rate of two in a minute, its yellowish-white coat con- 
 trasting strongly with the dark blue of the iliac vein which lay beside 
 it, and seemed nearly double its size ; the ureter in its course to the 
 bladder lay like a white tape across the artery, but in the process of 
 separating the peritoneum, it was raised from it with that membrane 
 to which it remained attached. The fulness of the iliac vein seemed 
 
 Fig. 94. 
 
 Ligature of common iliac by a posterior inci.sion. Tliis would also be available for the 
 abdominal aorta. (Bryant.) 
 
 to vary from time to time, now appearing to rise above the level of 
 the artery, and now to subside below it. Nothing could be more easy 
 than to pass a ligature round an artery so situated. The forefinger of 
 the left hand was passed under the artery, which, with a little man- 
 agement, was easily separated from the vein; and on the finger 
 (which served as a guide) a common-eyed probe, furnished with a 
 ligature of moistened catgut, was passed under the vessel. A sur- 
 geon's knot was made in the ligature, and the noose gradually closed, 
 until Mr. Colles, who held his hand pressed upon the tumor, an- 
 nounced that all pulsation had ceased. A second knot was then 
 made and one end of the ligature cut off short." Unfortunately, the 
 
548 OPERATIONS OX THE ABDOMEN. 
 
 catgut of that day became quickly dissolved, pulsation returned in 
 the tumor within fifty hours of the operation, and on the tenth day 
 profuse secondary hemorrhage took place, death following imme- 
 diately. 
 
 Comparison of the Two Methods.— Sir P. Crampton thus 
 speaks of his own and Dr. Mott's operation ; " The operation of 
 tying the common iliac artery is not only a feasible but (when per- 
 formed in the manner described in this paper) an exceedingly easy 
 operation. The difficulties which Dr. Mott encountered, and which 
 prolonged the operation to nearly an hour,* are clearly referable to 
 the circumstance of his incision having been made too low. This, in 
 the first place, brought him in contact with the aneurismal tumor, 
 from which he was obliged, with great laljor and considerable risk, to 
 detach the peritoneum ; then he had the whole mass of the tumor 
 between him and the artery which he was to tie ; and, lastly, he had 
 the intestines pressing down upon him and producing such a compli- 
 cation of difiiculties as I believe few men but himself could have 
 encountered with success." 
 
 Mr. Skey t preferred the posterior incision for these reasons: (1) 
 It is a part less liable to consequent inflammation. { 2) The requisite 
 separation of the peritoneum is less extensive. (3) The artery is 
 brought better into view, the act of passing the needle around it being 
 made visible to observers around. (4) The line of the vessel is 
 suffi.ciently exposed to enable the operator to select his site of liga- 
 ture, to carry it higher or lower, or even, if necessary, to separate the 
 peritoneum from the aorta itself, and to pass a ligature around that 
 vessel at a sufficient distance from its bifurcation. (5) The formation 
 of a ventral hernia is not likely to occur. 
 
 To the above Mr. Skej' might have added that the posterior incision 
 gives far better drainage to the wound. 
 
 The diflBculties of the operation and the causes of failure 
 and of death are much the same as those already given in the 
 account of ligature of the external iliac (pp. 535, 586). 
 
 LIGATURE OF THE INTERNAL ILIAC. 
 
 Indications. — Very few and rare. 
 
 i. In some cases of gluteal and sciatic aneurisms. Mr. Holmes, in 
 the course of those lectures from which I have already quoted, lays 
 down conclusions which will very greatly help the surgeon in de- 
 ciding what form of treatment is best suited to these aneurisms. 
 They are (|Uoted Ix'luw under the heading of Ligature of the Gluteal 
 Artery (p. 552). 
 
 * Sir P. Crampton's operation was completed in twenty-two minutes, 
 f Oprraiirc Sunjery, p. 294. 
 
LIGATURE OF THE INTEBXAL ILIAC. 549 
 
 ii. Hemorrhage. This is most frequently met with in military 
 surgery after gun-shot wounds of the vessel itself, but more often of 
 one or more of its branches within the pelvis, the ball entering usually 
 from the front through the inguinal region, or behind through the 
 sacrum. Four such cases are given by Dr. Otis,* all being fatal 
 Two cases, in which this artery was tied for wounds of the sciatic 
 and gluteal respectively, are given by the above writer {op. cit, p. 332) ; 
 both were fatal from hasmorrhage. 
 
 Dr. Liddell,t who as U.S.A. Medical Inspector, saw much of mili- 
 tary surgery, gives the following advice in case of punctured wounds 
 of this artery or its branches : " The wound should be explored by 
 introducing a finger into it for the purpose of locating by touch the 
 precise point whence the blood issues by jets into the wound. If the 
 punctured artery is found to be external to the pelvis, the bleeding 
 point should be laid bare by enlarging and cleansing the wound, and 
 the vessel secured by ligatures placed on each side of the aperture. 
 But if it be shown by the occurrence of intra-pelvic extravasation of 
 blood, or by other signs, that the internal iliac-artery, or some branch 
 thereof, is wounded within the pelvis, it will be impossible to reach 
 and tie the punctured artery in the wound. Under these circum- 
 stances it sometimes becomes very difficult to decide what plan of 
 treatment should be adopted. . . . One thing," Dr. Liddell goes on 
 to say, " ought never to be done, that is, trusting to the use of iron 
 perchloride or persulphate. The first thing to be tried, in most cases, 
 is compression. It should be applied to the common iliac-artery, 
 and, at the same time, to the wound itself, if possible, with a vfew to 
 obtain coagulation of the blood in, and obliteration of, the wounded 
 artery. The very desperateness of these cases makes it all the more 
 necessary to use the compression faithfully, intelligently, and persist- 
 ently, otherwise a traumatic aneurism will form." 
 
 Surgical Anatomy.— A short trunk about IJ inch long, of large 
 size, the internal iliac given off opposite to the lumbo-sacral inter- 
 vertebral disk dips downwards and backwards as far as the uppei 
 part of the sacro-sciatic notch, where it gives off its anterior and pos- 
 terior trunks, a ligamentous cord also coming off from the bifurcation : 
 this cord, the remains of the obliterated hypogastric artery, usually 
 remains pervious as far in the bladder as one of the vesical arteries. 
 Line. — No distinct line or guide can be given for this vessel, owing 
 to its at once dipping into the pelvis, but it will be worth while tO' 
 remember that a line drawn with a slight curve outwards from a 
 point about an inch below, and a little to the left of, the umbilicus, 
 
 * Med. and Surg. History of the War of the Rebellion, pt. ii. p. 331. 
 f Intern. Emycl. of Surg., vol. iii. p. 12). 
 
650 OPERATIONS ON THE ABDOMEN. 
 
 to the centre of Poupart's ligament, gives sufficiently accurately the 
 line of the common and external iliac arteries : the internal is given 
 off about two inches from the commencement of this line,* 
 
 Relations : 
 
 In Front. 
 Ureter. 
 Peritoneum. 
 Rectum (left side). 
 Outside. Inside. 
 
 Right internal iliac vein. Pyriformis. 
 
 Obturator nerve. Internal iliac. Sacral nerves. 
 
 Behind. 
 Internal iliac vein. 
 Sacro-iliac synchondrosis. 
 Lumbo-sacral nerve. 
 
 Operation. — The preparatory treatment being the same as in 
 ligature of the external iliac (p. 533), the surgeon makes an incision 
 much as in the case of that artery, or else, in the words of Dr. Stevens 
 (who first tied the vessel successfully in 1812), " one about 5 inches 
 long, parallel with the deep epigastric artery, and nearly i inch 
 on the outer side of it." The peritoneum having been raised up, the 
 hips are well flexed, and the lips of the wound retracted as widely 
 as possible : the finger now finds the external iliac, and then by tracing 
 it up the internal iliac vessel. f The cord of the obturator nerve must 
 not be mistaken for this. J 
 
 The artery is now separated, partly with the finger-nail and partly 
 with the i^oint of the director, and the needle passed from within out- 
 wards, avoiding the vein and psoas muscle. It will be well to have in 
 readiness aneurism needles of different curves, and an ordinary silver- 
 eyed probe. 
 
 Ligature of the Internal Iliac by Laparotomy. — This method 
 has been advocated recently by Dr. Dennis, § of New York, on account 
 of the following advantages : (1) Laparotomy in no way increases the 
 dangers of the operation of ligature of the internal iliac. (2) Lapa- 
 
 * The origin of the arteries will be found nearly opposite to the centre of a line 
 drawn from the anterior superior spine to the umbilicus. 
 
 t The finger should be passed downwards and backwards towards the sacro-iliac 
 synchondrosis. 
 
 { In oases of doubt the artery should be compressed gently between the finger and 
 thumb. 
 
 i New York Med. Napf, November 20, 1886; Annak of Surgery, vol. v. No. 1, p. 55. 
 I am indebted to the latter periodical for the above account. 
 
LIGATURE OF THE GLUTEAL ARTERY. 651 
 
 rotomy prevents a series of accidents which have occurred during the 
 performance of the operation of ligature of this artery by the older 
 methods. Amongst these are, the division of the circumflex and epi- 
 gastric arteries, wounding the vas deferens, including the ureter in the 
 ligature, puncturing the iliac or circumflex veins, tying the genital 
 branch of the genito-crural, tearing the peritoneum, injury to the sub- 
 peritoneal connective tissue, celluhtis, purulent oedema, pelvic abscess, 
 septicemia, and py;cmia. (3) Laparotomy enables the surgeon to ap- 
 ply the ligature at a point of election, and to obtain information as to 
 the exact extent of disease in the main arterial trunk. (4) Laparotomy 
 occupies much less time for its performance, in order to secure the in- 
 ternal iliac, than was occupied by the older methods. 
 
 Three cases are given by Dr. Dennis, two of which occurred in his 
 own practice. (A) A woman, aged sixty, presented pulsatile tumors 
 in both gluteal regions, the tumors dating back a year and a half, £ind 
 pain three years back. The external parts being thoroughly purified, 
 a median incision was made from the umbilicus to the pubes ; the 
 pelvic viscera,* which would have hindered the operation, were drawn 
 out into warm, moist sponges and towels, the internal ihacs of both 
 sides ligatured with catgut, the viscera returned, the wound closed, and 
 aseptic dressing supplied. The patient died with suppression of urine, 
 and slight parenchymatous nephritis, on the third day. (B) A negro, 
 aged forty-six, had a right gluteal aneurism, the trouble dating back 
 seven months. By a curved lateral incision the abdomen was opened • 
 owing to the violent efforts of the patient, and the difficulty of manip- 
 ulation, a few coils of intestine were drawn out, a strong silk ligature 
 applied to the internal iliac, the parts cleansed, and the wound closed. 
 A cure followed. (C) A female, aged eighteen, had an aneurismal varix 
 of the left side, the trouble dating back many years. Under careful 
 antiseptic treatment the abdomen was opened, the incision finally ex- 
 tending from the symphysis to some distance above the umbilicus, the 
 intestines drawn out sufficiently to admit of exposure of the vessel, a 
 double twisted catgut ligature applied to the left internal iliac, the 
 bowels returned, and the wound treated as before. The patient rallied 
 quickly, and the bowels were moved normally on the fifth day : a slight 
 acute albuminuria, due to congestion of the kidney from the ligature 
 of the main trunk of the internal iliac, appeared on the following day, 
 but soon disappeared. The aneurism, togetlier with the aneurismal 
 varix, was perfectly cured. 
 
 LIGATURE OF THE GLUTEAL ARTERY. 
 Indications. 
 
 1. Stab. 2. Aneurism. 3. Hemorrhage after opening an abscess. 
 All are rare, especially the last. 
 
 * Probably small intestine occupying the pelvis is intended here. 
 
552 OPERATIONS ON THE ABDOMEN. 
 
 1. Stab.— The source of the bleeding from a stab in the buttock may 
 be very difficult to tell exactly. The surgeon must be guided by the 
 position of the exit of the gluteal and sciatic (pp. 553, 555) ; he will 
 remember the outline of the gluteus maximus, the lower border of this 
 muscle forming the fold of the buttock, the upper starting from the 
 crest about 2 inches in front of the posterior superior spine, and run- 
 ning' downwards and forwards to the great trochanter. Hsmorrhage 
 from a stab in the upper part of this muscle will probably come from 
 the gluteal ; if from the lower part, from the gluteal or sciatic. 
 
 2. Aneurism. — This affection is so rare that it will be sufficient to 
 quote the following conclusions of Mr. Holmes : * 
 
 (1) " Gluteal aneurisms, both traumatic and spontaneous, are very 
 favorably circumstanced for the treatment by either rapid or gradual 
 compression, applied to the aorta or common iliac." Mr. Holmes points 
 out that gluteal aneurism, if not ruptured, is usually of no great size, 
 and does not encroach upon the abdomen, and thus any part of the 
 common iliac or aorta is accessible to pressure. 
 
 (2) " If this treatment, with or without anaesthetics, does not succeed 
 by itself, it may be supjilemented Ijy coagulating injection or galvano- 
 puncture, while the patient is narcotized, and the circulation com- 
 manded." Of the two, Mr. Holmes prefers galvano-puncture.j 
 
 "(3) " When such treatment fails, and particularly in aneurisms with 
 imperfect or ruptured sacs, where it is not indicated, the internal iliac 
 must be tied when the surgeon thinks that he cannot find the artery 
 outside the pelvis. But when the artery is accessible, the old opera- 
 tion, or the operation of Anel, should be practiced, according to the 
 size and extent of the tumor."' 
 
 In deciding whether the aneurism is inside or outside the pelvis, the 
 surgeon will see if the pulsation can be commanded by pressure on 
 the artery above the aneurism, whether the latter can be lifted from 
 the bone, and also make an examination liy vagina or rectum. | 
 
 The old operation must always be formidable, and while modern 
 tourniquets may admit of efficient pressure, there is always the risk 
 of fatal ha-morrhage from the artery having retracted into the pelvis. 
 
 The method of Anel does not seem likely to be always useful: of 
 three cases, only one has been successful. 
 
 (4) " The ligature of the internal iliac is liable to failure in cases of 
 spontaneous aneurism from a diseased condition of the coats of the 
 artery, and should always be avoided when other means of treatment 
 are available." 
 
 * Hunt. Lect., Lancet, 1874, vol. ii. p. 70; Syst. of Siirrj., vo]. iii. p. 148. 
 + See the remarks on the introdnetion of foreign bodies and galvano-puncture, pp. 
 495, 497. 
 
 :|; An anaestlietic being given, and the liand pa-sed here, if needful. 
 
LIGATURE OF THE GLUTEAL ARTERY. 
 
 553 
 
 This method has proved fatal in about half the cases operated on. 
 The varying length of the artery, the proximity of the hgature in all 
 cases to large branches and to the sac, have all to l)e remembered. 
 
 Surgical Anatomy of Gluteal Artery.-A short, thick branch 
 from the posterior division of the internal iliac, this leaves the pelvis 
 above the pyriformis, through the sacro-sciatic notch. Immediately 
 after its exit it divides into a superficial and deep portion. The super- 
 ficial is mainly distributed to the gluteus maximus, the deep lies be- 
 tween the gluteus medius and minimus, and divides into two, the 
 upper branch running along the origin of the gluteus minimus, 'and 
 
 Fig. 95. 
 
 Ligature of the gluteal artery is shown above. The fibres of the gluteus maximus have been 
 separated, showing the medius beneath. The vessel has been secured close to the great sacro- 
 sciatic notch, before it divides into a superficial and deep part. The latter is not shown. Below 
 is shown the incision for stretching the great sciatic nerve, as it lies under cover of the ham- 
 strings. 
 
 the lower running obliquely across this muscle towards the trochanter 
 major. The gluteal nerve emerges just below its artery, and sends 
 branches with the deeper portion. 
 
 Line and Guide. — " If a line be drawn from the posterior superior 
 spine to the great trochanter, the limb being slightly flexed and rotated 
 inwards, the point of emergence of the gluteal artery from the upper 
 part of the sciatic notch will correspond with the junction of the upper 
 with the middle third of this line " (MacCormac, Lig. of Arts., p. 126, 
 Figs. 90 and 91). 
 
 Operation. — The patient being rolled two-thirds over on to his 
 fa,ce, the part well exposed and cleansed, the limb hanging over the 
 
554 OPERATIONS ON THE ABDOMEN. 
 
 edge of the table, an incision, 5 inches long, is made in a line running 
 from the posterior superior spine to the upper and inner part of the 
 great trochanter. This incision should run almost parallel with the 
 gluteus maximus. The fibres of this muscle being separated, between 
 adjacent fasciculi, with a director, a muscular branch should be found 
 and traced down to the exit of the artery. The gluteus maximus hav- 
 ing been relaxed, and the contiguous margins of the gluteus medius 
 and pyriformis separated with retractors, the surgeon, taking as his 
 guide the above line and the aperture of the great sacro-sciatic notch, 
 clears the artery as high up as possible, avoiding the nerve and the 
 veins, and dividing the adjacent muscles if needful. The ligature 
 should be applied as far within the notch as possible, almost within 
 the pelvis, as the gluteal divides immediately after its exit. 
 
 Old Operation. — The following is the account of Prof Syme's 
 case. The man had been stabbed in the buttock seven years before. 
 The aneurism measured more than 13 inches in both diameters ; this, 
 together with the great thinness and laxity of the coverings being 
 opposed to coagulation, led to the adoption of the old operation. 
 " The patiei:it having been rendered unconscious and placed on his 
 right side, I thrust a bistoury into the tumor, over the situation of the 
 gluteal artery, and introduced my finger so as to j^revent the blood 
 from flowing except by occasional gushes, which showed what would 
 have been the effect of neglecting this precaution, while I searched for 
 the vessel. Finding it impossible to accomplish the object in this 
 way, I enlarged the wound sufficiently for the introduction of my 
 fingers in succession, until the whole hand was admitted into the 
 cavity, of which the orifice was still so small as to embrace the wrist 
 with a tightness that prevented any continuous haemorrhage. Being 
 now able to explore the state of things satisfactorily, I found that there 
 was a large mass of dense fibrinous coagulum firmly imf)acted into 
 the sciatic notch, and, not without using considerable force, succeeded 
 in disengaging the whole of this obstacle to reaching the artery. . . . 
 The gentleman who assisted me being prepared for the next step of 
 the process, I ran my knife rapidly through the whole extent of the 
 tumor, turned out all that was within it, and had the bleeding orifice 
 instantly under subjection by the jjressure of a finger. Nothing then 
 remained but to pass a doul3le thread under the vessel and to tie it on 
 both sides of the aperture." The case did perfectly well * (Obs.in 
 Clin. Snrg., p. 169). 
 
 If, in the case of a stab, the haemorrhage continue after the ligature 
 
 * Nowadays tlie application of a Lister's tourniquet to the abdominal aorta wonld 
 facilitate matters. Another successful case is recorded by Mr. J. Bell {Priii. of Surg., 
 vol. i. p. 1801). 
 
LIGATURE OF SCIATIC ARTERY AND ABDOMINAL AORTA. 555 
 
 has been applied with the above precautions, and the gluteal has 
 evidentlj^ been punctured within the pelvis, the internal iliac must be 
 tied after the wound in the buttock has been firmly plugged with dry 
 gauze or boric lint and iodoform. 
 
 LIGATURE OP THE SOIATIO ARTERY. 
 
 Indications. — Stab. This operation is so very rarely required 
 that it may be very briefly described here. 
 
 Surgical Anatomy.— The sciatic artery emerges, together with 
 the sciatic nerve and the pudic artery, from the lower part of the 
 great sacro-sciatic notch below the pyriformis. 
 
 Guide and Line. — The limb being rotated inwards, a line is drawn 
 from the posterior superior spine to the ischial tuberosity. The exit 
 of the sciatic and pudic arteries corresponds to the junction of the 
 middle and lower thirds of this line. 
 
 Operation. — The sciatic artery may be found by one of two 
 incisions, («) by a horizontal one, about 5 inches long, made about IJ 
 inch below that for the gluteal artery, and, like that, parallel with the 
 fibres of the gluteus maximus. (b) By one made vertically in the 
 above given line. The deeper guides will be the margins of the 
 notches, or the great sciatic nerve. 
 
 LIGATURE OF THE ABDOMINAL AORTA. 
 
 Indications. — As this most rare operation has been fatal in every 
 one of the cases in which it has been performed (some nine or ten) * 
 its justifiability has naturally been called in question. On the one 
 hand, the desperate condition of the patients, the large amount of dis- 
 ease probably present in their arteries, hearts, etc., the large and rapid 
 blood current, the disturbance of very vital parts, and the risk of peri- 
 tonitis, all combine to render the probability of success extremely 
 small. On the other hand, recent improvements in surgery, the in- 
 troduction of better ligatures, the fact that in these cases life must 
 speedily end if nothing is done, and, perhaps, the fact that many of 
 the large operations of surgery have been unsuccessful at first, will 
 justify surgeons in again making trial of this forlorn hope, if they feel 
 certain that otherwise the case is quite hoj^eless. 
 
 The cases have mostly been those of iliac and inguinal aneurism, 
 in which other arteries have been tied without success. To justify 
 the epithet above given of " desperate," the first case, the well-known 
 one of Sir A. Cooper (in 1817),t may be alluded to. Here the patient 
 
 * In Erichsen's Surgery (vol. ii. p. 237) seven cases are given, but this list does not 
 contain either Dr. P. H. Watson's case nor the two of Czerny, though one of these is 
 mentioned later. 
 
 t Prin. and Pract. of Surg, (edited by Dr. Lee), vol. i. p. 228. 
 
556 OPERATIONS ON THE ABDOMEN. 
 
 had long suffered from an aneurism affecting the external and com- 
 mon iliac arteries, leading to sloughing of the skin and htemorrhage. 
 Sir Astley having failed in an attempt to perform the old operation, 
 owing to the artery lying so deeply, gave the patient " the only hope 
 of safety " which remained, by tying the aorta. As life was here pro- 
 longed for forty hours, and as in Monteiro's case death did not take 
 place till the tenth day, proof is given of the restoration of the collat- 
 eral circulation. As bearing on this point the words of Sir A. Cooper 
 are of great interest : " I knew that the aorta had been obliterated 
 within the cliest, and that the circulation had been carried on by the 
 intercostal arteries going from above to just below the spot where the 
 aorta was obliterated ; the insides of the ribs are covered with numer- 
 ous vessels. A gentleman of Dublin had a preparation in which the 
 aorta had been obliterated in the abdomen, and in this case the circu- 
 lation was carried on by the lumbar arteries going from above to below 
 the part where the vessel was obliterated."* 
 
 In addition to the above cases, in which the aorta has been tied in 
 cases of aneurism, it has been tied once for htemorrhage after a gun- 
 shot injury of the upper part of the thigh by Czerny of Heidelberg. 
 Hemorrhage continuing, the common femoral was tied, together with 
 the superficial femoral below the profunda. Bleeding taking place 
 again in six days, the common iliac was tied. The haemorrhage still 
 persisting, it was thought that the external iliac only had been tied, 
 and a ligature was next placed, by mistake, upon the aorta. The 
 patient lived twenty-six hours. The same surgeon during a nephrec- 
 tomy for a soft malignant growth of the kidney met with such uncon- 
 trollable ha?morrhage as to compel him to tie the aorta, the patient 
 dying soon after. 
 
 Surgical Anatomy. — The lowest part of the aorta — viz., that 
 between the bifurcation and the origin of the inferior mesenteric — is 
 that which should be chosen. f 
 
 The vessel may have in front of it the omentum, duodenum, mesen- 
 tery, small intestines, and more closely, the aortic plexus of the 
 sympathetic, and a layer of fascia of varying strength. To the right 
 
 * In comparing these inst:inces of the restoration ol' the circnlation, the one by dis- 
 ease and the other after the surgeon's liiralnre, the importance of the slow and gradual 
 process in the one case will not be lost, si;;ht of. Mr. Barwell (Intern. Encyd. of Surg., 
 vol. iii p. 481 ) alludes to the experiments of Pirogoff (Waller and von Giiife's Joum., 
 Bd. x.xvii. ». Vl'l) and a paper liy Kast (Zeit.f. Chir., \'>d. xii. s. 405) to show that,the 
 collateral circulation is estaiilished. .Sir A Cooper {loc. supra cil.) used to show in his 
 lectures an injected specimen from a dog which survived the operation. Beyond this 
 fact, however, no comparison can be made between the chance of survival of healthy 
 animals and that of patients reduced to such straits as tu call for this operation. 
 
 t Tliis interval varies in length from J inch to 2 inches. 
 
LIGATURE OF THE ABDOMINAL AORTA. 557 
 
 e 
 
 side lies the vena cava, and behind it are the left lumbar veins. Th„ 
 bifurcation is usually situated a little to the left side of the umbilicus 
 and about i inch below it. 
 
 Operation.— This may be performed (A) through, or (B) behind, 
 the peritoneum. In deciding which method to make use of, the 
 surgeon will be influenced by the extent to which he is convinced 
 that the improvements of modern surgery have lessened the risks of 
 interfering with the contents of the abdomen, and of dividing the two 
 layers of peritoneum; while the other course is open when the 
 amount of distension of the intestines, or any evidence of matting of 
 the structures of the abdominal wall (dating to any inflammation 
 about the aneurism, or to the use of pressure), would probably inter- 
 fere with stripping up the peritoneum. 
 
 A. Through the Perifoneuvi.— The bowels having been emptied as 
 much as possible, the skin cleansed, the shoulders raised, and the 
 knees slightly flexed, the surgeon makes an incision at least 4 inches 
 long, in the middle line, with its centre opposite to the umbilicus, 
 but curving a little to the left here, so as to avoid the round ligament 
 of the liver and the urachus. The linea alba being found and divided, 
 the fascia transversalis slit up, all hemorrhage must be arrested before 
 opening the peritoneum.* ^Mien this structure has been opened to 
 the whole extent of the wound retractors are inserted, and the small 
 intestine and mesentery drawn partly upwards and partly to the 
 sides, carbolized sponges being packed around, if needful, to keep 
 the above structures out of the way. The pulsation of the vessel is 
 now felt for, and the deeper layer of peritoneum carefully scratched 
 through. Care should be taken to disturb as little as possible the 
 aortic plexus f during this step, and in passing the needle, which 
 should be carried from right to left. 
 
 The ligature used should be one of the flat tape-like ones, of kangaroo- 
 tendon or ox-aorta. The passage of the needle may be attended with 
 much difficulty, J not only from the depth of the vessel, and from the 
 
 * In Mr. James's case (Med. Chir. Trans., vol. xvi. p. 10) a large quantity of blood 
 was found in the abdominal cavity. This had come either from a vessel in the pari- 
 etes, or from one wounded in the mesentery. 
 
 f Sir A. Cooper (he. svpra cit.) believed that his experiments on dogs proved that 
 inclusion of this plexus, and not the interruption of the circulation, was the cause of 
 the paralysis which followed the experiment. In Mr. James's case, when tlie ligature 
 was tightened, the patient complained of "deadness in the lower extremities." This 
 was soon followed by agonizing pain in the same parts, only relieved by death about 
 three hours after the operation. 
 
 X Thus, in Mr. James's case the aneurism-needle broke at its handle, the surgeon 
 having "little anticipated occasion for so much force." In one case the sac gave way 
 during the operation. 
 
558 OPEKATIONS ON THE ABDOMEN. 
 
 presence of intestines if distended and allowed to protrude into the 
 wound, but also from the denseness of the cellular tissue surrounding 
 the artery. 
 
 B. Behind the Peritoneum.- — This method should certainly be tried 
 in any future cases. The chief objection is the great depth at which 
 the artery is reached, but it is well worthy of notice that in Monteiro's 
 case, which survived ten days, this method was made use of. 
 
 The operation is performed on much the same lines as those already 
 given for ligature of the common iliac (p. 646). The incision should 
 be as free as possible, from the top of the tenth rib, curving somewhat 
 forward to the anterior superior spine.* The muscles and trans- 
 versalis fascia being cut through, the peritoneum is stripped up and 
 turned inwards, several large retractors placed in the wound, and the 
 rib dragged up and outwards. The common iliac being found this 
 vessel is traced up into the aorta (Fig. 94). 
 
 CHAPTEE 11. 
 
 OPERATIONS ON HERNIA.f — OPERATIONS FOR 
 STRANGULATED HERNIA -RADICAL CURE OP 
 HERNIA. 
 
 OPERATION FOR STRANGULATED HERNIA. 
 
 Chief Indications for Operation and Points to bear in Mind. 
 
 — While this is not the place for going into the above fully, a few 
 practical remarks on those indications usually given may be helpful 
 to some of my readers. 
 
 i. A lump in one of the openings more or less hard, tense and 
 tender, partly or completely irreducible, and with doubtful or no 
 impulse. 
 
 a. The swelling may be small and deep-seated, as in a small 
 bubonocele near the internal abdominal ring, or a tiny femoral in a 
 fat patient. 
 
 b. Two hernias may be present, both irreducible. The surgeon 
 should operate on the one which is the more tense and has the least 
 impulse, and the one which has most recently descended. If this fail 
 
 * If necessary, a horizontal one might be added, at right angles to the first, but the 
 rectus and the deep epigastric should on no account be interfered with. 
 
 f The different forms of liernia, (hose which present on the thigh as well as the 
 inguinal and umbilical varieties, will be considered here for the sake of convenience, 
 and because they are all abdominal in origin. 
 
STRANGULATED FEMORAL HERNIA. 559 
 
 to give relief, either the opi^osite swelling must be explored or abdom- 
 inal section performed in the middle line. This step will probably 
 allow of the opposite hernia being reduced from within, and at the 
 same time of any other possible seats of strangulation being exposed— 
 viz., the inner aspects of the deeper rings. 
 
 c. ^^'ith regard to the impulse, it is worth while to observe carefully 
 the point where this ceases. This point, probably, is over the site of 
 stricture, and should be about the centre of the incision. 
 
 (/. Sir J. Paget {Clin. LecL, p. 108) thus writes of the hardness of a 
 hernia : " In large hernia the hardness may chiefly be felt at and 
 near the neck and mouth of the sac, especially in inguinal herniaj, 
 and you must take care not to be deceived by a sac which is soft and 
 flaccid everywhere except at its mouth, for there may be strangulated 
 intestine in the mouth of the sac though the rest contain only soft 
 omentum or fluid not sufficient to distend it; nay, you must not let 
 even a wholly soft condition of the hernia, or an open external ring, 
 weigh down against the well-marked symptoms of strangulation, for 
 the piece of intestine at the mouth of the sac may be too small to 
 give a sensation of hardness, or the whole hernia may be omental." 
 
 ii. Constipation becoming absolute, even as to the passage of flatus. 
 It is well known that, occasionally, small scybalous motions may be 
 forced out by the straining of a patient with a strangulated hernia 
 anxious to get his bowels to act. It must be also remembered here, 
 and in intestinal obstruction generally, that the bubbling away of an 
 enema may stimulate the passage of flatus. 
 
 iii. Vomiting.* Especially if (a) this is changing from the early 
 rejection of stomach contents or bile to feculent fluid ; (5) even if it is 
 repeated only at long intervals, and all other signs are absent or little 
 marked ; (c) it must be remembered that vomiting may be stopped 
 by drugs, strangulation persisting. 
 
 iv. Tympanites and other evidence of peritonitis. 
 
 These will not, of course, debar the surgeon from operating, but 
 they will lead him to warn the friends that relief will probably come 
 too late. 
 
 STRANGULATED FEMORAL HERNIA (Fig. 96). 
 
 Operation. — The parts being shaved and cleansed with soap and 
 carbolic-acid lotion (1 in 60) or perchloride of mercury lotion (1 in 
 1000), a little iodoform rubbed in around the genitals, the limbs 
 being kejjt warm with blankets and a hot bottle or two, if the patient's 
 
 * Sir J. Paget {loc. supra cit., p. 112) says: " If I were asked which of the signs of 
 Btrangulatioii I would most rely on as commanding the operation, I should certainly 
 say the vomiting." 
 
560 OPERATIONS ON THE ABDOMEN. 
 
 vitality is low, and the knee flexed slightly over a pillow, an incision 
 li to 2 inches long is made vertically on the inner side of the swell- 
 ing* Some small branches of the superficial external pudic occa- 
 sionally require torsion or ligature. The cribriform fascia and the fascia 
 propria (femoral sheath and septum crurale) 
 are next divided in the same vertical line with 
 or without a director, according to their thick- 
 ness and the experience of the operator, all the 
 incisions made going quite up to and above the 
 top of the swelling, so as to lie over the seat of 
 strangulation, usually Gimbernat's ligament. 
 In the operation without ojDening the sac,t 
 the site of stricture must next be found. The 
 varieties here are best given in Sir James 
 Paget's words : J "In some instances, as you 
 trace up the neck of the sac, you find it tightly 
 banded across by the layer of fibrous tissue called Hey's ligament — 
 a layer traceable as a falciform edge of the fascia lata, where that 
 fascia, bounding the upper part of the saphenous opening, is con- 
 nected with the crural arch, and is thence continued to Gimbernat's 
 ligament. Sometimes a fair division of this layer of fibres up to the 
 
 edgeof the crural arch is sufficient to render the hernia reducible 
 
 But in more cases this is not sufficient, and you may feel the stricture 
 formed by bands of fibres which encircle the neck of the sac, and 
 which must be divided, band by band and laj^er by layer, till none 
 can be felt. These fibres are part of the deep crural arch. Very rarely, 
 however, even the division of these is not sufficient, for the stricture 
 is formed by thickening of the mouth of the sac itself. This con- 
 dition, which is a common cause of stricture in inguinal hernia, is 
 very rare in femoral ; but it certainly does occur, and in any case well 
 suited for the operation without opening the sac, you may try to thin 
 the mouth of the sac without opening it, and thus to make it exten- 
 
 * This incision is nsiially made in the ordinary way. A somewhat quicker method 
 is by incising or transfixing a fold pinched up at a right anj^le to the long axis of the 
 swelling, and held by the fingers of the surgeon and an assistant. Before beginning 
 the operation, the surgeon should always examine into the probable amount of fat, and 
 thickness or thinness of the hernial coverings. In the case of a large hernia turning 
 outwards and upwards, it may be well, at a later stage of the operation, if any addi- 
 tional exploration is required of doubtful contents, to convert the first incision 
 into a ^ 
 
 f Canes best suited for this plan are those where the strangulation has been short; 
 its symptoms not very severe — e.y., the vomiting only bilious ; where the hernia is 
 small in size and without mixed contents; where the patient is in good condition, and 
 any previous taxis has been gentle and brief. 
 
 J Loc, supra cii., p. 132. 
 
STRANGULATED FEMORAL HERKIA. 561 
 
 sible enough for the return of its contents. You may try this, but the 
 chances of success are small. You are much more Hkcly to cut into 
 the sac at some thin ])lace, and when you have done this you had 
 better enlarge the opening and divide the stricture from Avitliin."* 
 
 Operation by opening the Sac— In this and in the former case 
 much difficulty is occasionally met Avith in deciding as to whether 
 the sac is reached or no. The causes of difficulty here arc mainly— 
 (1) An altered condition of the soft parts from the pressure of a truss, 
 or from long strangulation ; (2) from meeting with fluid outside the 
 sac ; (3) from the extreme thinness of the patient, which leads to the 
 sac being reached unexpectedly ; (4) from the opposite condition, 
 much fat being met with in several of the deeper layers, making it 
 uncertain which is the extra-peritoneal layer, the fat in these cases 
 being often soft, and readily breaking down under examination; 
 (5) an apparently puzzling number of layers — this condition is 
 usually due to " hair-splitting " over-carefulness on the part of the 
 operator; at other times it is brought about hy a much thickened 
 fascia propriaf separated into imperfect layers by its softened con^ 
 dition or inflammatory matting; (6) by the absence of a sac. J 
 
 Aids ill recognizing the Sac in C'ctsa of Dijfic Ity. — Several of those 
 ordinarily given § — e.g., " its rounded and tense appearance, its fila- 
 mentous character, and the aborescent appearance of vessels on its 
 surface " — are, I think, quite fallacious. So, too, with regard to the 
 escape of fluid from the sac, for this is often dry in femoral hernise, 
 and occasionally fluid is met with before the sac is reached. A smooth 
 lining characteristic of its inner surface is more reliable, but the inner 
 surface of the fascia propria is sometimes remarkably smooth. Two 
 
 * In trying to divide points of stricture outside tlie eac, attention sliould be ]iaid to 
 the following; (1) First reaching the sac itself, if possible, by a careful division of 
 all the overlying structures in the vertical incision carried well npwards; (2) By 
 carefully drawing down the sac, so as to expose any fibres constricting its neck ; (3) 
 By gently insinuating the point of the director nnder any bands met with, 
 
 f The fascia propria, though sometimes of wafer thinness, may be much thickened 
 and difljcult of recognition. In Mr. Erichsen's words (Surgery, ^o\. ii. p. S21 ), " If 
 not unfreqnently happens that, after the superficial fascia has been divided, an oval, 
 smooth and firm body is exposed, which at first looks like the hernial sac or a lump of 
 omentum. This is in reality the fascia propria, thickened by the long-continued 
 pressure of the truss, and congested perhaps by the attempts at reduction ; and in the 
 midst of it the sac will at length be found, after thedissection has been carried through 
 several layers of this tissue. 
 
 % A sac is said to be absent in some cases of hernia of the ca?cum, and where the 
 patient has been operated on before. This, however, was not the case in three herni* 
 containing the caecum, and in two which had been operated on before, which came 
 under ray care. 
 
 I Erichsen, he. supra cit, 
 
 86 
 
562 OPERATIONS OX THE ABDOMES. 
 
 points remain which will help to solve the doubt— (a) To draw gently 
 down the doubtful structure, whether sac or bowel, and to examine 
 whether it is continuous above and below with the structures of the 
 abdomen and thigh, like the other coverings of the hernia, or whether 
 it has a distinct neck to be traced into the abdominal cavity ; (6) To 
 see if the point of a Key's director can be insinuated along this last 
 doubtful layer into, and moved within, the peritoneal cavity or no. 
 In a very few cases the surgeon, if still in doubt, incises carefully 'the 
 suspected layer, and tries if he can pass in a probe and move it from 
 side to side ; if this can be done, he is still outside the bowel, not 
 between the peritoneal and muscular coats of intestine. 
 
 The sac being carefully nicked with the scalpel-blade held horizon- 
 tally at a spot where it can best be pinched up with dissecting-forceps, 
 a matter of much difficulty at times owing to its tenseness, is slit up 
 on a director, and its contents examined. If omentum first present 
 itself, this is drawn to one side and unravelled, and intestine sought 
 for. This usually takes the form of a small, very tense knuckle, of 
 varying color and condition. If it will facilitate the manipulations 
 needful for reduction, the omentum may be first dealt with. (1) If this 
 be voluminous and altered in structure, it should be tied bit by bit 
 with carbolized-silk ligatures, and then cut away, the scissors being 
 applied so close to the ligatures as to leave holding-room, but no excess 
 to mortify or slough. After the return of the intestine, the omentum 
 is also replaced within the abdomen. (2) If the omentum is small in 
 amount and recently descended, it may be merely returned. (3) In a 
 few rare cases when the omentum is intimately adherent to the sac, and 
 the patient's condition does not admit of delay, the omentum may be 
 left iv siti(. As, however, this course very much interferes with the 
 satisfactory wearing of a truss, and as it is likely to lead to a fresh 
 descent of bowel, it should never, if possible, be followed. 
 
 Bcdiidion of the Inlc>-tiii('. — As soon as this is exposed, the surgeon 
 examines with the little finger-nail, or a Key's director, the tightness 
 of Gimbernat's ligament. In a few cases reduction may be at once 
 effected by gentle pressure backwards on the bowel with the tip of the 
 little finger. But in the large majority the above site of structure will 
 need division, a point requiring much carefulness for fear of injuring 
 the intestine or important surrounding structures. If the degree of 
 tightness of the parts admit of it, there is no director equally safe and 
 satisfactory as the index or littk' finger of the left hand passed up to 
 the stricture, and the nail-tij) insinuated beneath this, the hernia-knife 
 being introduced along the pulp of the finger (Fig. 97). But there is 
 rarely room for this, and a K(\y's director* must usually take the place 
 
 * Tlu.s director is broad, so as to prevent aiiv intestine curling over and reaching 
 the knife; blunt-pointed, so as not to damage the contents of the jieritoneal cavity; 
 
STEAKGULATED FEMORAL HERKIA. 663 
 
 of the finger. The tip of this instrument being insinuated into the 
 peritoneal cavity just under Gimbernat's ligament, the hernia-knife* 
 is introduced obliquely or flat-wise upon it, its end slipped under and 
 beyond the ligament, its edge turned towards the constricting fibres, 
 and a few of these cut through in an upward and inward direction by 
 
 Fig. 97.t 
 
 (FergusEon.) 
 
 a gentle movement of the wrist. In doing this it is well for the sur- 
 geon to draw down the edges nf the cut sac close to its neck, and to 
 ask an assistant to hold these, thus facilitating the passage of the di- 
 rector and the knife by preventing the sac falling into folds before 
 them. Occasionally also a knuckle of intestine persistently coils 
 over the edge of the director. This is best met by patience, by 
 drawing it out of the way by the carbolizcd finger-tip of an assistant, 
 or by pressing it down with the handle of a pair of forceps. 
 
 The direction and the extent to which the stricture must lie cut are 
 matters of much importance. The upward and inward line is the 
 only path of safety. Directh' outwards lies the femoral vein ; by cut- 
 ting upwards, the spermatic cord, and, if upwards and outwards, the 
 epigastric artery, would be endangered ; behind are the peritoneum 
 and pubes. The incision upwards and inwards must be of the nature 
 of a nick; otherwise, owing to the imperfect healing of this filirous 
 stricture, the ring will lie left large and gaping, thus facilitating the 
 re-descent of the hernia, and jiroducing much difficulty in fitting on 
 trusses, and causing certain discomfort and probable peril to the pa- 
 tient, especially if she belong to the poorer, hospital class. 
 
 Gimbernat's ligament having been carefully and sufhciently nicked, 
 the bowel is replaced either by gentle squeezing between the finger and 
 
 finally, its groove does not run quite np to the end, so that the knife-point shall be 
 stopped before it comes in contact with important parts. 
 
 * A curved one will be found most useful. The cutting-blade is usually too broad 
 and the tip too massive. On the other hand, a worn-down blade has been known to 
 break while dividing a tense Gimbernat's ligament. 
 
 t The cutting-blade of the knife shown here is needlessly long and unguarded. 
 
564 OPERATIONS ON THE ABDOMEN. 
 
 thumb, eo as to empty it of its contents, or with the pressure of the 
 httle finger; the sac should now be kept stretched with forceps so that 
 no folds interfere with the return of the bowel. If pressure on the part 
 of the intestine fail, it must be tried at another point. After the re- 
 duction of the intestine the tip of the little finger should be introduced 
 through the crural canal into the peritoneal cavity to see that the gut 
 is absolutely safe ; a little iodoform is then dusted on to the stumps of 
 omentum, and these too returned, if this has not been done. 
 
 If the patient's condition admit of it, if the hernia is not of a very 
 long standing, and if the surrounding parts are healthy, the sac should 
 next be taken away by carefully separating it with the point of a di- 
 rector from its attachments. Its neck is then ligatured with chromic 
 gut or carbolized silk* as high up as possible, and the rest cut away 
 '1 inch below this point. If the surgeon is at all doubtful about the 
 safe ligature of any stump of omentum, he should keep this down and 
 transfix it and the neck of the sac with a doulile chromic-gut ligature, 
 the ends of which are afterwards cut short. Sufficient drainage is now 
 provided by a small tube or a bundle of horsehair, and the superficial 
 wound closed. The dressings must be applied with sufficient care to 
 keep the wound secured from obviously close sources of contamination. 
 It is well to place a separate pad of carbolized tow or salycylic wool 
 over the anus and genitals, and to draw the water off before the patient 
 leaves the table. The thigh should not be kept too much flexed, other- 
 wise the escape of discharge from the drainage-tube will be interfered 
 with. 
 
 The account of an ordinary operation having been given, it remains 
 to consider certain complications. These are chietly : 
 
 1. Adhesions of Bowel to the Sac or Omentum. — The treatment of 
 this uncommon complication must vary with (a) the character and 
 position of the adhesions, (/5) the condition of the intestine, and (y) the 
 state of the patient. Owing to the difficulty of fitting on a truss if any 
 of the hernia is left unreduced, every attempt should be made to free 
 the contents by separating the adhesions with the point of a steel di- 
 rector, the finger-nail, or a blunt-pointed bistoury. When near the 
 neck they must always be divided, sufficiently nicked, or stretched. 
 No intestine and omentum if still adherent to each other should ever 
 be returned. A few cases remain in which adhesions should be left 
 alone. When gangrene is threatening, their presence, especially about 
 the neck of the sac, is the chief safeguard against extravasation into the 
 peritoneal cavity. In some cases of large hernia, if the patient is much 
 collapsed, as long as any recently <lescended loop is returned any long- 
 adherent intestine may l>e left. jVnd in other cases of collapse from 
 
 See foot-note, p. 404. 
 
STRANGULATED FEMORAL IIERXI \ . 565 
 
 delay of the operation, where there is much difficuUy in returning a 
 loop of intestine, especially if this is not in good condition, it may be 
 left, after the stricture lias been sulliciently divided. 
 
 ■2. Tightly constricted or (.Gangrenous Intestine. — In spite of all that 
 has been taught about the importance of early operations, eases do 
 still occur in which the advisability of returning the bowel seems 
 doubtful. In most cases of doubt, as long as the stricture is sufficiently 
 divided and the intestine placed only just within the crural ring (the 
 wound being left open and the sac not ligatured in these cases), the 
 interior of the abdomen is the liest place for the intestine. And this 
 is true of congested intestine, however deeply loaded with blood only, 
 as long as there is some shade of red jiresent. But on these ^joints 
 nothing will surpass the advice of Sir J. Paget:* "You are to judge 
 chiefly from the color and the tenacity. Use your eyes and your 
 fingers ; sometimes your nose ; very seldom your ears, for what you 
 may be told about time of strangulation, sensations, and the rest is as 
 likely to mislead you as to guide aright. As to color .... I ;im dis- 
 posed to say that you may return intestine of any color short of black, 
 if its texture be good ; if it feels tense, elastic, well filled out, and 
 resilient, not collapsed or sticky ; and the more the surface of the in- 
 testine shines and glistens, the more sure you may be of this rule. 
 When a piece of intestine is thoroughly black, I believe you had 
 better not return it, unless you can be sure that the blackness is wholly 
 from extravasated blood. It may not yet be dead, but it is not likely 
 to recover; and, even if it should not die after being returned, there 
 will be the great risk of its remaining unfit to propel its contents, and 
 helping to bring on death by what appears very frequent — distension 
 and paralj'sis of the canal above it. But, indeed, utter Idaekness of 
 strangulated intestine commonly tells of gangrene already ; and of this 
 you may be sure if the black textures are lustreless, soft, flaccid or 
 viscid, sticking to the fingers or looking villous. Intestine in this state 
 should never be returned. Colors about Avhich there can be as little 
 doubt, for signs of gangrene, are white, gray, and green, all dull, lus- 
 treless, in blotches or complete over the whole protruded intestine. 
 
 Then as to the texture of the intestine : it should be, for safety 
 
 of return, thin-walled, firm, tense, and ehistic, preserving its cylindrical 
 form, smooth, slippery, and glossy. The further the intestine deviates 
 from these characters, the more it loses its gloss and looks villous, the 
 more it feels sticky and is colla|3sed and out of the cylinder form, the 
 softer and more yielding, the more pulpy, or like wet leather or soaked 
 paper, the less it is fit for return. And when these characters are com- 
 bined with such bad colors as I have described, the intestine had 
 
 * Loc. supra cit., p. 138. 
 
566 OPEEATIOXS ON THE ABDOJIEX. 
 
 better be laid open, that its contents may escape extemall}' and do no 
 harm. 
 
 In other lon.e-standing cases of femoral hernia the chief stress of the 
 constriction is shown, not on a dying loop of intestine, but in ulcera- 
 tion, partial or nearly ring-like, at the neck of the sac, under the sharp 
 edo-e of Gimbernat's ligament. Where this condition, owing to the 
 duration of the case, is suspected, the intestine should be very gently 
 drawn down, and, if ulceration is found, laid open. If the mischief 
 is locabzed and the adjacent intestine fairly healthy and not fixed, it 
 will be well to stitch it to adjacent parts to prevent it slipping up into 
 the peritoneal cavity. 
 
 It has been much disputed whether, in these cases, when the 
 intestine is unfit to be returned, it is safe or needful to divide the 
 stricture in addition to laying open the intestine. On the one hand, 
 M. Dupuvtren, .Sir A. Cooper, Mr. Key, and Mr. Erichsen have advo- 
 cated this step lieing taken ; on the other, ;Mr. Travers and Sir W. 
 Lawrence were against it. The following words of a very brilliant 
 writer* will probably convince most that tliis step is not only injuri- 
 ous, but unneeded : " The only result of this is that the protecting 
 barrier which divides the still aseptic peritoneal cavity from the putrid 
 sac, is broken down, and putridity spreads upwards into the abdomen 
 and kills the patient by rapid septicemic poisoning. "Why break 
 down this valuable wall? If it is argued that, unless the stricture is 
 divided, the contents of the bowel cannot escape, then the reply is 
 that experience jjroves this to be utterly untrue. In a very short time 
 both flatus and fa?ces find their way out. As every one knows, the 
 nipping of the gut is not produced by a sudden narrowing of the 
 hernial aperture, but l\v a swelling of the loop of gut. . . . ^\'hen 
 the gut is slit up, its contents are set free, and its inflammatory juices 
 escape, with the result that its swelling goes down and room enough 
 is soon permitted for wind and fteces to jjass, more jDarticularly as the 
 tVeces are invariably C[uite liquid." 
 
 3. The treatiiicnt of artificial anus is considered together with resec- 
 tion of the intestine infra. It will suffice here to say that in cases 
 of hernia, owing to the condition of the intestine, the state of the 
 patient, and often the absence of needful pre[KU'ations and good light, 
 no attempt should be made to resect the damaged parts now. 
 
 4. Wound of Intestine. — This may be due to {a) carelessly incising 
 thin, soft parts ; (/') ureal difficulty in making out sac and intestine 
 in a fat ijatient, with the parts matted, esiieeially if the light is bad ; 
 {<:) to the intestine lieing allowed to curl over the edge of the director 
 
 * Jlr. M. Baiik^, CiiiiimI Xotcs on Two Yi:ars' Surgical Wor.': in the Liverpool Royal 
 Iiifirmanj, p. 9 i. 
 
STRAXGULATED FEMORAL HEKXIA. 567 
 
 while the stricture is being divided, or to this being cut with careless 
 freedom, or, lastly, to a loop lying out of sight just al.iove the constric- 
 tion, and to the hernia-knife coming in contact with this. Any l^ub- 
 bling of flatus or escape of lleces from the wound must lead to a 
 careful search for the opening. When this is found, it may usually 
 be tied up around a pair of dissecting-forceps with carbolized silk, the 
 ligature not being tied too tightly, and the ends cut short. If the 
 opening be larger, it should be closed by Lembert's suture (infra, 
 Figs. 106, 107). ^\'hichever method is used, the injured jDart should 
 be replaced just within the peritoneal cavity, and in a severe case the 
 sac should not be taken away nor the wound closed. The patient 
 should be kept under the influence of opium, and liquids restricted. 
 
 5. Wound of Obturator Artery. — The position of this vessel when 
 it rises by a common trunk with the deep epigastric instead of from 
 the internal iliac, which occurs in every 82 subjects (^Gray), may bear 
 a very important relation to the crural ring. In most cases when thus 
 arising abnormally, the artery descends to the oljturator foramen close 
 to the external iliac vein, and therefore on the outer side of the crural 
 ring and out of harm's way. In a small minority of cases,* the artery 
 in its passage downwards curves along the margin of Gimbernat's 
 ligament, and may now be easily wounded. 
 
 The treatment is mainly preventive — i.e., by making the smallest 
 nick possible that will be sufficient into any point of stricture, such 
 as Gimbernat's ligament, a point the importance of which has already 
 been alluded to (p. 563), and using a hernia-knife that is not over- 
 sharp. If the artery has probably been wounded, the following points 
 are of interest : (1) The hEemorrhage may not at once follow the 
 wound. It may not make its appearance till the bowel is all reduced, 
 or even until a quarter of an hour after the wound has been stitched 
 up. In one case, that of Dupuytren, no haemorrhage occurred, and 
 the division of the artery was discovered for the first time at the 
 autopsy three weeks after the operation. (2) It may occur when the 
 sac has not been opened. (3) As is shown by Dupuytren's case, it is 
 by no means a fatal accident. Very various means have served to 
 arrest the hsemorrhage. («) Pressure usually applied by a pad,t as in 
 the cases of Sir W Lawrence, Mr. Iley, and Mr. Barker. J (/3) Liga- 
 ture of the vessel, usually the proximal end. In five cases given by 
 
 * Sir W. Lawrence considered this risk to occur about once in a hundred times, 
 estimating the origin of the obturator with the epigastric to occur once in five, and the 
 descent of the artery on the inner side to take place once in twenty times. 
 
 t Or better, by pledgets of aseptic gauze or sponges dusted with iodoform, and 
 secured by silk. 
 
 t Clin. Soc. Trans., vol. xi. p. 180. This paper will well repay perusal. Most 
 of the above information is taken from it. 
 
568 OPERATIONS ON THE ABDOMEN. 
 
 Mr. Barker, this was Hiicc.cKsrnl in four; it is only hVaIcA in one that 
 thi; (lishil end waB also secured. 'J'lu; li.i^atni'e lias l)een ap[)lie'd in 
 some cases by continuing tlie wniiid upwards; in otliers by making 
 an incision parallel with i^)upart's ligament, as if for tying the exter- 
 nal iliac. This step could only be taken when the patieul's condition 
 was satisfactory, (y) l!y acupi-essure. 'I'iiis method was thiis niad(t 
 use of Ity Mr. Oorley: The ^ush of atierial ba:mon-ha,fi;e which took 
 place; the moment the inii^stiiie was I'l^turiied Avas controlleil by pass- 
 ing a curved needle through the ring, ami bringing it out immcdiah'Iy 
 above l'iiu])art's ligament, and jiassing a figiii-e-or-(;i^ht suture over it. 
 No reeui'i'eiiee of hariioirhage took jdace, but Ihe [laticnt died thirty 
 hours later. At the autopsy about 4 o/,s. of clot weie foumi in the 
 sub-serous tissue. 'J'lic obturator springing from the I'pigasti'ic, and 
 beiii;: abfiut the size of a, No. '■'> boiigii^, took the dangerous coui'se over 
 the neck- of the s;ic. 'J'hc; cii'diac end was occluded by clot. 1'he 
 distal end had retracted H inches from the enrdiac, and was open. 
 ThouLdi the needle had controlled the haauorrhage, itharl not included 
 the ai'tei'v. In two of Sir W . fv;! wi-ence's c:ises the fainting of the 
 patient a|ipr:ars to have di.'cided the cessiitioii of hainorrha!/e. Both 
 of these i-i-covcred. In the event of prcssurf.' failin,^'-, it might Ije worth 
 while-, before taking other steps, to try the ajijilieation of a jiair of 
 Spenc(;r Wells's f(jrcr>[is. These would be left in, situ for three or four 
 days, and would favor drainage. 
 
 STRANGULATED INGUINAL HERNIA (Fiirs. OS, 'M). 
 
 Operation. — In eonsiderin'j- this it will not be needful to go a'jaiii 
 into detail, as in the case of StriiiiLTulidi'd Femoral Ibrnia ; the i-ln'cf 
 points of difference and those of im|)0)-taiice will be considered c.n-e- 
 fully. 
 
 The ])arts lieiiig shaved and cleansed (]k i'M ), and the thi^h a little 
 flexeil. an incision 'J.^ inch long at first is madi- in the long axis of the 
 tumor, with its centre (in an ordinary scrotal e.ise *; o\'er the external 
 abdominal rin;,'-. This ineivjon maybe made eithei- by pinching up a 
 fold and cutting fr(jm within outwards, or by cutting, in the usual 
 way, from without iiiwaids. 'J'lie external pudics (both superior and 
 inferioi,! of'ieu now lerpiire li;:aluie i,v tor-ion. As the layers are 
 divideil, the- knife bemn kept strictly in the same line- throuudiout, 
 some arching fibres of the intia'-eolumnar fascia may lie sec-n above, 
 but tlie fii'st la,yer usually I'cf-oL^nized is the cremasti-ric fascia, often 
 nrjuch thickened. Afte-r this the I ransvcrsalis fascia. aKo ofti-ii thick- 
 eni.-d and vascular-looking, is slit u[i, and any extra-p(-ritonea,l fat 
 
 * In .1 Btrari;.;ulate(l Ijiiljoimcele tlie r,:uir<: of the iiii-ision hlioiild liu nve-r the 
 internnl alKloniirjal ring, and in the (li.-'-|)';r part of the incinioti llie dei-|) epigahtric 
 must l)i_- felt for and avoided. 
 
STRANGULATED INGUINAr. HERNIA. 
 
 569 
 
 overlying the grayish-blue sao looked for. The surgeon now sees if he 
 can find any constricting fibres outside the sac, and slits them up on 
 a director. The more voluminous the hernia the more important it 
 is to avoid exposure and manii)ulation of its contents by opening the 
 sac* But in the majority of cases of inguinal hernia the surgeon 
 must be prepared for opening the sac. As soon as this is done, with 
 the precautions already given (p. 5(V2), the contents arc examined, 
 
 Fig. 98. 
 
 (Ferguyson.) 
 
 omentum got rid of if this step will give more room, and the site of 
 stricture found M'ith the finger-nail or tip of the director. It is next 
 divided with the hernia-knife manipulated under it in a direction 
 directly upwards, so as to lie parallel with the deep ejDigastric, which- 
 ever side of the hernia this vessel occupies. f During this stage, the 
 steps given at p. 563 must be taken to avoid any injury to the intes- 
 tine. The constricting point being divided and dilated, the next step 
 
 * Tlie site of tlie stricture in inguinal hernia varies. In botli varieties, in old cases 
 of long duration, it is nsnally situated in the neck of the sac itself, owing to contrac- 
 tion and thickening of this and the extra-peritoneal tissue. In other cases of oblique 
 hernia the stricture is found in the infundibiiliform fascia at the internal ring, just 
 below the edge of the internal oblique in the canal, or at tlie external ring. In a 
 direct hernia the constricting point, if not in the sac, is probably caused by the fibies 
 of the conjoined tendon. In many cases the parts are so approximated and altered 
 that in the short time given by an operation it is not so easy to tell exactly in what 
 tissues lies the strangulation, as to relieve it. Finally, in many cases of young sub- 
 jects and acute strangulation, muscular spasm — e.g., of the internal oblique — must be 
 borne in mind. 
 
 f Of course, if the surgeon is certain that he is dealing with an oblique hernia, he 
 may cut outwards, and, in the ca.se of a direct hernia, inwards, so as to avoid the deep 
 epigastric. In all cases the cut should be of the nature of a nick dividing only tliose 
 fibres which actually constrict, any additional dilatation being usually now effected by 
 the tip of the director or finger. 
 
670 
 
 OPERATIONS ON THE ABDOMEN. 
 
 is reduction of the intestine. This, in bulky inguinal hernije, is 
 often a matter of difficulty and time. The chief causes of diflS- 
 culty here are — (1) A large amount of intestine, one or two coils of 
 small and some large intestine being not very uncommon. (2) The 
 distension" of these with flatus, etc. (3) Insufficient division of the 
 
 Fig. &P. 
 
 (Skey.) 
 
 stricture ; or there may be a point of stricture higher up than the one 
 divided, and overlooked. (4) During attempts at reduction one bit 
 of intestine may get jammed across the ring instead of slipping up 
 along it, and against this the rest of the contents are fruitlessly pressed. 
 (5) Folds of the sac may in much the same way block the opening. 
 
 Aids in DifQcult Cases.— First, that part which lies nearest the 
 ring should be taken — cij., mesentery Ijcfore intestine. After each part 
 is got up, ]iressure should be made on it for a few seconds before an- 
 other is taken in hand. If the surgeon find, after a while, that he is 
 making no progress with one end of a coil, he sliould take in hand 
 the other end, or another coil altogetlier if more than one is present. 
 During the manipulations the thigh should be flexed and rotated a 
 little inwards, ami the cut edges of the sac drawn tense with forceps, 
 so as to prevent any folding or pushing up of this before the intestine. 
 If the intestines are much distended, attempts should be made to 
 
STRANGULATED INGUIXAL HERNIA. 571 
 
 return some of their contents first into tiie alxlominal cavity. After 
 by gentle squeezing with the finger and tliuml), and careful pressure 
 upwards on each successive bit of intestine, it all ap[Mjars to be 
 returned, the little finger (aseptic) must be passe<l into the alxlominal 
 cavity to make certain that no knuckle remains in the canal or 
 internal ring. 
 
 Cases will occasionally be met with where, owing to the low con- 
 dition of the patient, the large amount of intestine down, its great 
 distension, its altered condition, still red and only congested, but 
 softened, with the peritoneal coat shaggy rather than lustrous, and 
 tending to tear easily, it is clear that reduction will not be effected 
 by manipulation only. The question now arises which of these 
 courses is the wisest — to make a small incision, empty the intestine,* 
 and then to suture after Lembert's method (Figs. 106, 107, infra), or to 
 tie up the opening, picked up on a pair of forceps, with carbolized silk,t 
 or to leave the intestine in the sac after a free division of the stricture. 
 The first of these can only he followed when the intestine is healthy, 
 and thus by peristaltic action the oiiening in the muscular coat will 
 be carried past that in the serous, the two not corresponding, and 
 when aseptic precautions have been carefully followed. If there is 
 any doubt about these, or if the intestine is much congested and 
 softened, the surgeon had best ])c content with a free division of the 
 stricture upwards and leave the intestine in the sacl This method 
 is, on the whole, the safer, but prevents, of course, any attempt at 
 relieving the patient, at one operation, by a radical cure. 
 
 During any prolonged manipulation of tlie intestines these should 
 be kept covered as much as possible b}' green protective wrung out of 
 warm boracic acid or carbolic (1 in 80j, or lint, the fluffy side being 
 
 * While the intestine is emptying, care mnst be taken to lead the contents well away 
 from the wound. 
 
 f The ends of this will be cnt sJiort, and the precautions given at p. 5fi6 in case of 
 wound of the intestine in herniotomy followed. 
 
 t This will all gradually and slowly return into tlie peritoneal cavity. On this point 
 the following case by South (Chdlus's Siiryery, vol. ii. p. 40) is of interest: "I know 
 by experience that if strangulation be relieved, it is of little consequence how much 
 intestine be down. In reference to this point, I recollect the largest scrotal rupture 
 on which I have operated, and in which, before the division of the stricture, tliere was 
 at least half a yard of bowel down, filled with air; and, after the stricture had been 
 cnt through, at least as much more thrust through, so that I almost despaired of getting 
 any back ; yet, after a time, I returned the whole. To my vexation, however, next 
 morning I found that my patient had got out of bed to relieve himself on the chamber- 
 pot, and, as might be expected, tlie bowel had descended, and in, such quantity that 
 the scrotum was at least as big as a quart pot, and the vermicular motion of the intes- 
 tine was distinctlj' seen through the stretched skin. Nothing furtlier was done than 
 to keep the tumor raised above the level of the abdominal ring, and by degrees it 
 returned, and the patient never had an untoward symptom." 
 
572 OPEUATIOXS ox THE ABDOMEN, 
 
 turned away from the bowel. I prefer also to stop the spray during 
 this sta,ue, if prolonged, and to keep the neck of the sac as much cov- 
 ered and protected as possible. It is wise also that the patient should 
 be well under the ana/sthetic now, and breathing quietly. If vomit- 
 ing occur, tlie surgeon must wait, Ivceping up pressure on what he 
 has reduced. When the intestine is all reduced, any ligatured stumps 
 of omentum are returned, and, if the condition of the patient admits 
 of it, the sac is ligatured, removed, and a few sutures inserted to close 
 the dilated canal and external al)dominal ring, the precautions as to 
 the cord and other points given at p. oS;-] being carefully followed. 
 
 In 2?roviding drainage after an operation on a large inguinal hernia, 
 where the parts have Ijeen much handled either before or during the 
 operation, I am sure it is well worth while to bring the lower end of 
 the drainage-tube out at the lower part of the scrotum, by means of 
 a counter-])uncture there, thus ensuring efficient escape of the dis- 
 charges, and syringing out of the wound if needful. 
 
 After thus considering the chief points in tlie operation, it remains 
 to draw attention to some special points connected with 
 inguinal hernia. 
 
 I. Varieties* — In addition to the oblique and direct varieties, both 
 of which are acquired, there are some others of much practical im- 
 portance — e.g., 
 
 (rt) The congenital. The tubular process of peritoneum is open 
 from abdomen to fundus scroti, and the contents lie in contact with 
 the testis. 
 
 (b) Hernia into the funicular process of peritoneum. Here the 
 tubular process of peritoneum is divided into a shut vaginal sac 
 below and an open funicular process above. Into the latter the con- 
 tents descend, but are not in absolute contact with the testis. 
 
 (c) Hour-glass contraction of the sac. Here the tubular process is 
 open as in (a), but an attemiDt at closure has brought about a con- 
 striction which may be at the external abdominal ring or lower down 
 in the scrotum. If the contents pass through this constriction, and 
 get low enough, they will be in actual contact with the testis. 
 
 ((/) Encysted hernia of the tunica vaginalis. Here the funicular 
 process is closed at its abdominal extremity — i.e., at either ring or in 
 the canal — and open l)elow to the testicle. Here the hernial protru- 
 sion as it comes down either ruptures the septum (when of sudden 
 descent), or gradually extends and inverts it, or comes down behind 
 it. Tliese are rare, but may be puzzling when they occur, as the 
 operator has more than one layer of peritoneum to incise before 
 
 * Tliese varieties are clearly descrilied by Mr. Birkett (Stjst. of Surg., vol. ii. pp. 
 798, 799, Figs. IGJ, 165). See also the diagrams in Mr. Bryant's Surgery (second 
 edition), vol. i. p. 601. 
 
STRANGULATED IJS'GUINAL HERNIA. 573 
 
 reaching the contents, two or three being met with according as the 
 descending hernia has brought a layer of parietal peritoneum with it 
 or no, and according as the septum has Ijcen ruptured or stretched. 
 
 That the above varieties have an importance bej'ond that of ana- 
 tomical puzzles is shown by the fact that in (6), (c), and ((0 strangu- 
 lation may be very acute and urgent. Again, though the defect is a 
 congenital one, the hernia does not, in many cases, make its appear- 
 ance till the patient has, in early adult life, been subjected to some 
 sudden strain. Finally, in these cases any prolongation of the taxis 
 will )je not only futile, but actually dangerous, owing to the tightness 
 of the strangulation and the facility with which, owing to tljo delicacy 
 of its adhesions, the sac may be separated or burst. 
 
 II. Rcdvction en masse, and, Allied Conditions. — These have been 
 commonly met with in inguinal hernia' owing to the loose connections 
 of the sac and, sometimes, to the force used in attempts at reducing 
 large specimens. Strangulation may persist after («) displacement, 
 or (b) rupture of the sac. In the former, the sac, still strangling its 
 contents at its neck, is displaced bodily between the peritoneum, 
 usually, and extra-peritoneal fascia. In the latter, the sac is rent, 
 usually close to its neck and at its posterior aspect, and some of 
 its contents are thrust through into the extra-peritoneal connective 
 tissue. The chief evidence of these accidents is — Though the swelhng 
 has disappeared, perhaps completely, this has taken place without 
 the characteristic jerk or gurgle. On close examination, though the 
 bulk of the hernia is gone, some swelling, often tender, is usually to 
 be made out, deep down, in the neigh l)orhood of the internal ring. 
 Above all, the symptoms persist, perhaps in an intensified form. 
 
 The treatment is immediate exploration of the inguinal canal and 
 the internal ring. If the cord is exposed, the whole sac has proba))ly 
 been detached. If any of the sac is left above, a rent in it should be 
 sought for. SujDposing the index finger, passed through the internal 
 ring, fail to find any swelling, aided by pressure from without, a ver- 
 tical incision must be added to the upper end of the oblique one, and 
 the neighborhood of the internal ring explored.* 
 
 III. Retained Testis simulating Hernia. — Such a testis, when in- 
 flamed, may closely simulate strangulated hernia. A testis, jDcrhaps, 
 has never descended ; a truss has been worn and laid aside. Tlie 
 patient presents himself with a tender swelling in one groin, with 
 indistinct impulse. The abdomen is tense and full, constipation is 
 present, and perhaps vomiting of bilious stuff. Such a swelling 
 should be explored and the testis removed, as it is certain, later on, 
 
 * As this will probably involve abdominal section, the stejis given further on 
 should be referred to. 
 
574 OPERATIONS ON THE ABDOMEN. 
 
 to cause serious trouble, even if the present urgent symptoms subside 
 witli palliative treatment. In other cases a retained testis maj' draw 
 down an adherent loop of intestine which may become actually 
 strangled* 
 
 STRANGULATED UMBILICAL HERNIA. 
 
 Two di4irict forms of strangulated hernia will be met with here. 
 One, more rare, is of small size, with a single knuckle of intestine 
 acutely strangled in the navel-cicatrix. The other, the more common, 
 is often huge, its contents mixed, intestine both large and small, and 
 omentum. Such hernia soon become, in part at least, irreducible ; 
 when in this condition, any unwise meal may readily bring about 
 obstruction, a condition requiring much care to tell from strangu- 
 lation. f In other cases a large irreducible hernia may easily become 
 strangulated from the descent of some additional loop of bowel. 
 
 Before proceeding to operate, it is well to bear in mind these ijradical 
 points: («) The sac usually communicates directly with the general 
 peritoneal cavity by a large opening. (;J) The contents are not only 
 mixed, but of long standing, and often adherent, (y) The patients are 
 often advanced in life, stout, flabby, and not unfrequently the sub- 
 jects of chronic bronchitis. (3) The coverings are ill-nourished, and 
 slough easily. 
 
 Operation. — The parts having been cleansed, and an antesthetic 
 administered, an incision 2 to 3 inches long is made over the lower J 
 part of the swelling in the middle line, the hernia being somewhat 
 pushed upwards to facilitate this. The thinness of the coverings must 
 be remembered, after the laj'er of subcutLineous fat has been divided. 
 
 ■* For fuller information on these mntters I wonld refer my readers to m_v article 
 on "The Disease of the Male Organs" (Syst. of Surfj., vol. iii. p. 471). 
 
 t Annongst the most imiiorlant points will be the vomiting, whether early in onset, 
 constant, and showing signs of becoming feculent ; the constipation, whether absohite, 
 even to the passage of flatns. In doubtful cat-es the rule should be to operate. " The 
 risk of operating on a hernia which is inflamed and not easily reducible is very small 
 in comparison with the risk of leaving one which is inflamed and strangulated ; and 
 even if yon can find reasons for waiting it must be with the most constant oversight, 
 for an inflamed and irreducible hernia may at any time become strangulated, and will 
 certainly do so if not relieved by rest and other appropriate treatment" (Sir J. Paget, 
 he. supra cit., p. 106). 
 
 J The lower part is here recommended because, in Mr. Wood's words {Intern. 
 EncifcL of Surg., vol. v. p. 1165), "the point of strangulation in an adult umbilical 
 hernia is most frequently at the lower part of the neck of the sac, where the action of 
 gravity, the dragging weight of the contents, and the superincumbent fat, together with 
 the pressure and weight of the dress or an abdominal belt, combine to press downwards 
 upon the sharp edge of the abdominal opening. It is here that adhesions and ulcera- 
 tion of the bowel are most frequently found, and here the surgeon must search for the 
 constriction in cases of strangulation." An incision here also gives better drainage. 
 
STRANGULATED UMBILICAL HERNIA. 575 
 
 Search should be made for any constricting; bands of fibres outside 
 the sac. If it be needful, the sac must be opened, Avith the knife held 
 horizontally, and slit up, care being taken now and throughout the 
 operation, in cases of large hernire, that protrusion of intestine be pre- 
 vented by the means given a little later. The contents having been 
 examined, any loops of intestine are gently displaced upwards, while 
 the surgeon turns the curved surface of a Key's director over the lower 
 edge of the opening, and, guiding the hernia knife on this, divides the 
 constricting edge downwards. If sufficient space is not given, the 
 downward nick may be repeated, or the director turned against the 
 lateral or upper aspects of the ring, and fibres here also divided. 
 
 Adhesions of the contents of the sac are not unfrequently met with, 
 If they are very close and dense, and if the condition of the patient is 
 unsatisfactorj', the surgeon should be content with a free division at one 
 or two places of the constricting ring, and with reducing any portion 
 of intestine that has clearly only recently come down, and leave the 
 rest undisturbed. 
 
 A complication of large irmbilical herniaB is thus well described by 
 Mr. Wood (foe. sitjyra cit., p. 1168) : 
 
 " In corpulent persons, in whom the operation has been delayed 
 until peritonitis has begun, the operator has frequently to contend 
 with a gush of bowels out of the abdomen. This should be restrained 
 by receiving them in warm towels wet with carbolic lotion, and ap- 
 plying pressure by the hands of assistants. If it can be managed, all 
 the operative proceedings within the sac should be done before such 
 a rush occurs ; but if a cotigh, or voniiting, or ansesthetic difliculty 
 occurs at this juncture, this is sometimes impossible, and the surgeon 
 is compelled to do the best he can. In such cases the operation be- 
 comes a formidable one indeed, and is comparable only to laparotomy 
 under conditions of distension of the intestines. The bowels and 
 omentum should always, if possible, be kept in the warm wet towels, 
 and not indiscriminately handled by the assistants, whose arms 
 should be bared, and well purified by carbolized lotion. The intestines 
 should always be returned before the omentum, which should, if pos- 
 sible, be spread out* over them before the stitches are applied." 
 
 All the intestine and the remains of the omentum, carefully liga- 
 tured, being returned if possible, the surgeon now, if the patient's 
 condition admits of it, removes the redundant sac and skin. The 
 opening into the peritoneal cavity being covered with a veil of car- 
 bolized lint, the sac is separated from its connections and cut away 
 
 * Mr. Wood prefers leaving the edge of the oraentiim so arranged as to become ad- 
 herent to the lower margin of the hernial opening, so as to prevent, if possible, any 
 future profrnsion, to tying it and cutting it short. 
 
576 OPERATIONS ON THE ABDOMEN. 
 
 close around the ring ; any blccding-points can now be arrested bj' 
 nunierons strong chromic-gut ligatures passed through the edges of the 
 ring so as to close it save at the lower part, where a good sized drain- 
 age-tube is left with its orifice flush with that into the peritoneal 
 cavity. The redundant skin is then cut away and the edges of the 
 wound brought together with stout silk or silver sutures. 
 
 It will lie seen from the above account that three methods may be 
 pursued in the reduction of a strangulated umbilical hernia : (1) The 
 division of the stricture outside the sac (p. 500). This should always 
 be tried, but is rarely successful here. (2) If the sac has to be opened, 
 the opening is made as small as possible, and the ring freely divided 
 at one or two points, but the contents disturbed as little as possible, 
 any recently descended intestine being returned, but thickened 
 omentum, adherent intestine, especially large, being left undisturbed. 
 (3) Free opening of the sac, examination and separation of its con- 
 tents, return of all intestine, and of omentum after ligature and 
 resection. 
 
 "While the third of these courses has the great advantage of leaving 
 the patient permanently in a more satisfactory condition, as it admits 
 of something like a radical cure,* the surgeon can only rightly decide 
 between this and the second course by a careful consideration of each 
 case. The following points may aid in judiciously selecting either 
 operation: (1) The size, bnig-standing, previous attacks, of incarcera- 
 tion and obstruction of the hernia, all these tending to bring about 
 adhesions t and alterations in the parts. (2) The condition of the 
 patient — viz., the degree of flabliy fatness, chronic bronchitis, probable 
 renal and hepatic disease, amount of depression by vomiting and pain. 
 (3) The facilities for carrying out during the operation, and, later, 
 strict aseptic i:)recautions. (4) The presence of the skilled help so 
 essentia] in these cases. (5) The way in which the anajsthetic is taken. 
 (6) The amount of experience of the operator. Thus a hospital sur- 
 geon frei^uently operating and with all instruments and assistance at 
 hand, may readily incline to one course, while the other may as wisely 
 be followed by a surgeon who has to oi^erate under very different cir- 
 cumstances. 
 
 * It will be remembered that it is not as essential to try and ensure a radical cure in 
 women of this age as in children and young male adults, with the prospect of a long 
 and active life before them. 
 
 t Mr. Clement Lucas (C'/m. Soc. Tnaia., vol x'lx. p. .5) advocated more radical meas- 
 ures, such as excision of the sac and redundant skin, with suture of the ring, in all cases 
 of umliilical hernia. Two successful cases are recorded, both excellent instances of this 
 treatment, and one of especial hilerest, as the patient had been-previously thrice tapped 
 for ascites, and the operation allowed three pints and a half of fluid to escape. 
 
STEANGULATED OBTURATOR HERXIA. 577 
 
 STRANGULATED OBTURATOR HERNIA. 
 
 This form of hernia has occurred too frequently to be entirely passed 
 over. It may be so readily and fatally overlooked that a few words on 
 its diagnosis will not be out of place. 
 
 (1) Position of the swelling. This appears in the thigh below the 
 horizontal ramus of the pubes, to the inner side of the capsule of the 
 hip. behind and just inside the femoral vessels, behind the jjectineus, 
 and outside the adductor longus. (2 ) On careful comparison of the 
 outline of Scarpa's triangles, a slight fulness^is found in one as com- 
 pared with the hollow in the other. (3) Pain along the course of the 
 obturator nerve, down the inner side of the thigh, knee, and leg. (4) 
 Persistence of symptoms of strangulation, the other rings being empty 
 or occupied by reducible hernia. (5) A vaginal or rectal examination. 
 
 Operation. — Two different ones present themselves: (i.) by cutting 
 down on the sac as in other hernise; (ii.) by abdominal section, and 
 withdrawing the loop from within. 
 
 (i.) It is noteworthy that this hernia was thus first successfully 
 operated on by a general practitioner, Mr. Obre. 
 
 The parts being duly cleansed and slightly relaxed, an incision is 
 made parallel to and just inside the femoral vein.* The saphenous 
 opening being probably exposed in part, the fascia over the pectineus 
 is next divided, the fibres of this muscle having been torn through 
 with a director,! the obturator muscle covered by its fascia and some 
 fatty cellular tissue is next defined, and the hernial sac probablj' now 
 comes into view, either between the muscle and the pubes, or between 
 the fibres of the muscle. If the case is a recent one, attempts are now 
 made to reduce the hernia without oj^ening the sac. If the sac has to 
 be opened, and any constriction divided, the knife should be turned 
 either upward or downwards, the latter being the easier if anj' con- 
 stricting fibres intervene between the sac and the bone. As the obtu- 
 rator vessels lie usually on one side or the other, a lateral incision 
 must be avoided. 
 
 Care must be taken to keep the femoral vessels drawn outward with 
 a retractor, while any branches of the obturator or anterior crural 
 nerve are drawn aside with a blunt hook, the same precaution being 
 taken with the saphena vein. 
 
 When by the passage of the little finger into the abdomen it is cer- 
 tain that the intestine is reduced, if the condition of the patient admits 
 
 * Mr. Birkett {loc. supra oil., p. 830) says the incision "may commence a little above 
 Poupart's ligament, at a point midway between the spine of the pubes and the spot 
 where the femoral artery passes over the ramns of that bone.'' 
 
 t If it will give more room, they may be divided transversely for IJ to 2 inches, as 
 in Mr. Obr^'s case. 
 
 37 
 
578 OPERATIONS ON THE ABDOMEN. 
 
 of it, the sac is separated and ligatured close to the thyroid foramen 
 and removed. Adequate drainage must be provided before closing, 
 
 the wound. 
 
 (ii.) The operation of abdominal section will perhaps be more 
 frequently performed in the future. An obturator hernia was thus 
 reduced by Mr. Hilton in a case which simulated intestinal obstruc- 
 tion. Some empty intestine being found and traced downwards, led 
 to the detection of an obturator hernia, which was reduced by gentle 
 traction aided by firm pressure made deeply in the thigh. The 
 patient, who was not operated on till the eleventh day, died, within 
 twelve hours of the operation, of rapid peritonitis, considered by Mr. 
 Hilton to be due to the operation. 
 
 Mr. Erichsen briefly mentions a case operated on by this means in 
 1884 by Mr. Godlee. The hernia was reduced without difficulty, but 
 the pstient, who was much collapsed at the time, died in about twenty- 
 four hours. 
 
 The duration of the hernia and the condition of the patient must 
 be considered in selecting one of the above operations. Where the 
 patient is much exhausted, the shock of an abdominal incision should, 
 I think, be avoided ; and where a much damaged intestine is present, 
 it may give way when withdrawn, causing extravasation into the 
 peritoneal cavity. 
 
 RADICAL CURE OF HERNIA. 
 
 Before describing the different methods, the following points claim 
 attention, and while the improvements of modern surgery have estab- 
 lished radical cure on a sound scientific basis, many questions remain 
 quite undecided. 
 
 Permanency of cure. Advisability or need of wearing a truss. 
 Term, " radical cure." Age. 
 
 On these points I would refer my readers to the writings of Mr. M. 
 Banks,* as one of the earliest and foremost workers at this subject, 
 and to the difficulty of some of his cases and the honest frankness 
 with which he has given his results. His experience is gained from 
 106 cases, 68 of which were without strangulation, while in 38 strangu- 
 lation was present. Of 66 of these cases in which he was able to 
 follow up the result, 44 were completely successful, 7 partially so- 
 le., though there was a distinct tendency to return, the hernia could 
 now be kept up by a truss, a thing impossible before. 
 
 Mr. Banks considers the term " radical cure " misleading. " It is 
 popularly understood that a patient upon whom a radical cure has 
 
 * Pamphlet, loc. infra cit.; Med. Times and Qaz., 1884 ; Bnt. Med. Journ., December 
 10, 1887. 
 
RADICAL CUI^E OF HERNIA. 579 
 
 been performed need never again wear a truss nor ever again be in 
 danger of his hernia coming down. This is, unfortunately, far from 
 being the case. The instances in wliich a light truss can be dispensed 
 with are the minority." 
 
 Other surgeons appear to hold a different opinion. Thus, Dr. 
 Macewen,* in a brilliant series of cases — 81 in all, in 29 of which 
 strangulation had been present — without any death, merely states 
 that 48 1 subsequently wore a pad or bandage. 
 
 Mr. Barker % has had no death in a series of 41 cases. Seven of 
 these were lost sight of; of the others recurrence had taken place in 5. 
 He does not recommend the use of trus.ses except in cases of umbilical 
 hernia. 
 
 Many other surgeons might be quoted as deprecating trusses alto- 
 gether, or any save of the lightest. 
 
 Turning to foreign surgery, we find Prof. Socin, of B&,le,§ bringing 
 forward an experience of 136 operations, 71 being for strangulation. 
 The mortality! I here was 3,6 per cent, for non-strangulated cases. 
 He considers that, after operation, the wearing of a truss is not per- 
 missible as long as a relapse has not occurred.^ 
 
 While it will be at once granted that any continuous pressure in 
 the form of a pad with a strong spring may tend to weaken the in- 
 
 * Brit. Med. Journ., December 10, 1887. 
 
 f In one of these the parts were firm ; in the others support was worn as a precau- 
 tionary measure, one patient being of lax habit, another having had a direct hernia 
 with a very wide opening, while the occupation of the third demanded much exertion. 
 
 % Brit. Med. Journ., December 3, 1887. Mr. Barker allows, however, that in one 
 recurrence the patient had been at very hard work, ever since the operation, without 
 a truss. 
 
 ? Beut. Zeit.j. Chir., 1886, Bd. xxiv. Hft. 3 and 4; Annals of Surgery. March, 1887. 
 
 II Prof. Socin agrees with Mr. Banks as to large hernia, the mortality here being 
 40 per cent. The mortality at Bale after simple herniotomy for strangulated hernia 
 seems to have been decidedly high— viz., 24.3 per cent., 28 per cent, for femoral, and 
 S.8 per cent, for inguinal cases. 
 
 ^ Several other conclusions of Prof. Socin will well bear quoting here : (1) Perma- 
 nent cure is possible ; it is the rule in recent hernise ; in older ones it is the exception. 
 (2) Permanent cure is more prominent in those who have not completed their growth, 
 other things being equal. (3) Prognosis as to permanency of cure is unfavorably 
 influenced by the existence of another hernia in the patient, as well as by a family 
 history of hernia. (4) Habitual bodily labor appears to favor a permanent cure; 
 coughing, on the contrary, tends to cause relapse, (o) Probability of recurrence con- 
 stantly decreases from the time of operation, being very slight indeed after the lapse 
 of two years. (6) The most favorable method of performing the radical cure is to 
 ligate the sac doubly or repeatedly at as high a point as possible, and to excise if. 
 Whether the ligature of the sac in inguinal hernia; is best done after withdrawing the 
 sac out of the inguinal canal, or after incising the canal, cannot as yet be finally 
 decided. Suture of the constricting ring is not advisable. 
 
580 OPERATIONS ON THE ABDOMEN. 
 
 flammatory thickening resulting from the operation, most surgeons 
 will prefer that their patients should, for some years at least, wear a 
 light hut well-fitting support, especially in cases where the hernia 
 and rings have alike been large, where the work involves sudden 
 strains, or where the patient is flabby or develops an habitual cough. 
 
 Indications.— The following are given only as types of appropriate 
 cases. Many others will suggest themselves : 
 
 i. Children of poor and ignorant parents, with large herniae, where 
 proper attention to the use of a truss cannot be secured. It will 
 probably be justifiable to go further than this, and to operate for radi- 
 cal cure in most cases of hernias in the children of the poor in which 
 the hernia is still distinct at four years of age.* By this time the 
 parts are larger and more easily kept sweet. The sac is more easily 
 dealt with now than later. 
 
 ii. Herniae, especially inguinal, in men under thirty-five, interfering 
 with the activity of life, profitable employment, etc. Subjects of 
 inguinal hernife with adherent omentum are never really safe, espe- 
 cially if of active life. 
 
 iii. Small femoral herniae containing irreducible omentum. These 
 hernise are difficult to fit with trusses, and the omentum keeps the 
 ring open, and thus paves the way for the'descent of bowel on any 
 sudden exertion. 
 
 iv. Large hernise, even colossal, where the patients, unfitted for 
 work of any kind, are a burden to themselves and others,t and per- 
 haps willing to run great risks ; for it cannot be denied that these are 
 very grave cases : " The operation usually difficult and prolonged, 
 and the dangers to be met and overcome both numerous and various" 
 (Banks). The best proof of this is given by Mr. Banks' series of 16 
 very large and enormous hernia? ; of these he lost 4, 2 from septicjemia. 
 In another, even his hands failed to complete the operation. 
 
 V. I consider ten to twentj'-five years of age as the most favorable 
 time, as combining parts easy to handle, the possibility of keeping 
 the wound aseptic, probable absence of any difficult adhesions, and 
 good vitality and health. 
 
 Choice of Operation. — The following have been brought promi- 
 nently before the profession — viz. : 
 
 * This age is mentioned above as giving time for trials with a truss. Before deciding 
 that a well-made truss will not keep up a difBcult case — e.g., a double inguinal hernia 
 — the hernia should be completely reduced with the aid of an ansesthetic. 
 
 t As in three cases given by Mr. Banks: one, a laborer unfitted for work, had 
 become an inmate of a workhouse ; the second was a wine-merchant, who had been 
 obliged to give up his business, rarely venturing out, and then obliged to conceal his 
 deformity under a large overcoat; the third, a glass-blower, reduced to perfect help- 
 lessness, had to depend on his wife for his support. 
 
RADICAL CURE OF HERNIA. 581 
 
 i. Operation by Open Method with Strict Aseptic Pre- 
 cautions. 
 
 ii. Subcutaneous Methods— c.(/., Prof. Wood's and Mr. 
 Spanton's.. 
 
 iii. Injection of Astringents— (^.(7., Oak Bark. 
 
 Of these, the operation by open method will be described first and 
 fully, as it is the one of all others which is generally chosen, owing to 
 the excellent. results which it has given, the precision with which the 
 structures concerned can be avoided or manipulated, and its safety 
 when aseptic precautions are strictly observed. There is no doubt 
 that special methods, such as those of Prof. Wood and Mr. Spanton, 
 give excellent results in the experienced hands of those who have in- 
 troduced them, but it is equally certain that they have not been gen- 
 erally adopted. This is still more true of the injection method, in 
 this country at least. 
 
 i. The Operation by Open Method with Strict Aseptic 
 Precautions.* — The patient having been kept iii bed for some time 
 before, according to the size of the hernia, any cough attended to, 
 only liquid diet is given for the few days preceding the operation, and 
 the bowels are duly attended to. 
 
 The parts being shaved if needful, and cleansed,t the thigh being a 
 little flexed, an incision is made with its centre over the external 
 abdominal ring, J the sac itself is reached and made certain of. 
 
 The sac being defined just below the external abdominal ring, the 
 surgeon must make up his mind how he is going to deal with it. At 
 least the four following courses are open, and all are well deserving 
 of trial : 
 
 A. The sac being freed from its connections, and its contents 
 reduced, it is ligatured close to the internal ring, and the fundus cut 
 away. Two or three silver sutures are then inserted in the pillars of 
 the ring and left in sitv, the object of the sutures being merely to hold 
 the parts together temporarily during healing (Banks). 
 
 B. The sac, separated not only from the inguinal canal, but also 
 from the inner surface of the internal ring, is reduced into the abdo- 
 men so as, bulwark-like, to protect the ring.§ While this is the 
 
 * The following remarks apply to inguinal hernia. 
 
 t Dr. Macewen {loe. infra cit ) recommends scr&bbing with a nail-brush and soap 
 and water; after drying, turpentine, to remove any grease, and then a little methylated 
 spirit to clear away the turpentine, the parts being then covered with lint soaked in 
 some aseptic solution. 
 
 X Mr. Kendall Franks advises that when the incision above is made parallel to the 
 canal, the skin should be drawn down. Thus the skin-wound does not correspond to 
 the sutures buried beneath, and is further removed from sources of sepsis. 
 
 I Hee p. 583. 
 
582 OPERATIOXS ON THE ABDOMEN. 
 
 primary point, the canal and external ring are most carefully closed 
 with sutures (Mac.ewen). 
 
 C. The neck only of the sac being freed (the fundus being left 
 'in situ), this is tied and divided. The stump is then pushed up into 
 the abdomen while the rings and canal are closed (Barker). 
 
 D. The sac, being freed quite up to and around the internal ring, is 
 twisted, and, the fundus being cut away, the twisted stump is secured 
 in situ by sutures passed through the external abdominal ring (Ball). 
 
 A. Method of Banhs'-^ — ^The sac, having been made certain of, is 
 separated from the cord with a finger or steel director, the vas deferens 
 being taken as a guide. This defining of the sac, and its separation, 
 are often matters of difficulty — in children, owing to the delicacy of 
 the parts and the minute size of the constituents of the cord, and in 
 adults from the closeness of the adhesions. The surgeon may easily 
 think he has reached the sac long before he really has. In this way 
 the parts may be needlessly interfered with and stripped off, and, 
 owing to oozing into opened-up areolar spaces, landmarks are lost, and 
 suppuration and even sloughing may occur. 
 
 Care must be taken not to drag the testicle out of its bed. In con- 
 genital cases, to avoid needless disturbance, the sac, when separated, 
 should be cut through above the testis, and this part sutured to form 
 a tunica vaginalis.! The cord is next separated, through the external 
 ring, up into the canal as high as the internal ring, the finger keeping 
 note, all the time, of the position of the cord. If the sac is clearly 
 empty, its neck is now ligatured with stout chromic gut or carbolized 
 silk as high up as to leave no neck, orifice, or dirajDle at the internal 
 ring. The fundus is then cut away about 2 inch below the neck. 
 
 If there are any doubts about the sac being empty, a small opening 
 is made and the little finger introduced to make sure of this point. 
 
 If it be needful, owing to adhesions of intestine or presence of 
 altered omentum, the sac must be freely opened, adhesions separated, 
 and the omentum tied | and cut away as directed at p. 562, and 
 returned. 
 
 While the omentum is being examined and dealt with, an assistant 
 
 * See footnote, p. 578. 
 
 f A running suture of cliromic gut should be used here. I employed this in two 
 cases in 1887 in a child of 6ve and a man of twenty-two, and on account of the possi- 
 bility of hydrocele, watched these artificial tunicae vagiuales with much interest for 
 some months. 
 
 X If the surgeon is in doubt about returning any stumps of omentum, he should 
 retain these in the canal by his sutures passed through this and the pillars. It will 
 render the fitting an ordinary truss more difficult, but not one with a horseshoe pad, 
 and will ultimately shrink and blend with other tissues. Even if this is delated, it 
 would be preferable to setting up peritonitis by returning any doubtful omentum. 
 
RADICAL CURE OF INGUINAL HERNIA. 583 
 
 must keep a finger carefully on the canal above, to prevent any slip- 
 ping upwards before all is ligatured, otherwise grave haemorrhage may 
 occur* 
 
 The next step is the suturing of the rings and canal. While, no 
 doubt, securely ligaturing the neck of the sac as high up as possible 
 is the first point, when this is effected, the above structures should be 
 as carefully sutured as possible, if time and the condition of the 
 patient, etc., admit of it. As might be expected, the materials used 
 are various — viz., wire, carbolized silk, chromic gut, and kangaroo 
 tendon. Mr. Banks uses silver wire f so thick that a single knot on 
 it will suffice to make it hold without any second knot and without 
 any twisting. The wire should be cut very close to the knot, so as to 
 leave no projecting sharp ends. 
 
 Chromic gut is a little uncertain, in some cases soon softening, in 
 others coming away but little changed, with points of suppuration. J 
 Carbolized silk is, on the whole, the most generally applicable, the 
 twisted, not the plaited, kind being made use of.§ 
 
 The surgeon's chief object in passing the sutures should be to bring 
 the conjoined tendon as close to Poupart's ligament as possible, at a 
 point as near the internal ring as may be, so as to make the canal 
 again a mere chink or valve instead of a short, wide tunnel. 
 
 With a curved needle on a handle (Fig. 100) or one in a holder, the 
 finger-nail being insinuated under the edge of the conjoined tendon 
 on the outer side of the rectus abdominis the needle should be passed 
 so as to take up the tendon and the external oblique aponeurosis 
 overlying it, the cord being then felt for, found, and pushed upwards 
 and inwards, the needle is then passed through Poupart's ligament as 
 near the centre as possible. In passing this highest and most im- 
 portant suture care must be taken to avoid the deep epigastric, the 
 cord, and the iliac vessels. Other sutures || are then passed (1) 
 through the conjoined tendon and external pillar; (2) through the 
 pillars of the external ring. Before any sutures are tied the cord 
 should be examined and found free. 
 
 Drainage is now provided with a bundle of horsehair, and the skin 
 wound closed with silk sutures. The dressings, iodoform and sal 
 alembroth gauze, are applied as at p. 564. 
 
 * This precaution will also meet any vomiting and re-descent of the intestine. 
 
 t " Its hold is certain and enduring beyond that of any other suture, while it is as 
 harmless as any" (Banks, Pamphlet, pp. 13, 14). 
 
 X If this is used it should be taken from a sample which the surgeon has tested in 
 operations, and the final soaking should be under his eye, 
 
 ? Note, p. 404. 
 
 II Three, at least, if possible, in a large hernia, 
 
584 OPERATIONS ON THE ABDOMEN. 
 
 B. Macewen's* (Pig. 100). 
 
 The object of this is twofold : (1) so to separate the sac as to allow of 
 its being completely reduced into the abdominal cavity, there to rest 
 on the inner surface of the circumference of the ring, and as a bul- 
 wark-like pad to " shed the intestinal waves away " from it.f (2) By a 
 particular mode of inserting sutures to l)ring the conjoined tendon in 
 close connection with that part of Poupart's ligament which is on a 
 level with the lowest part of the internal ring. 
 
 The first object is thus insured. The external ring being exposed 
 (after the preliminaries, footnote, p. 581), the internal ring and site of 
 the deep epigastric are examined, and the sac next freed and raised. 
 When this is done it is kept pulled down, while the index finger 
 sejjarates the sac from the cord, the canal, and finally for i inch 
 around the abdominal aspect of the internal ring.J The sac is now 
 folded on itself (Fig. 100) by means of a stitch which is firmly fixed 
 in the distal end of the sac. The free end, threaded on a needle, is 
 introduced through the canal to the abdominal aspect of the fascia 
 transversalis, and there penetrates the abdominal wall about 1 inch 
 above the internal ring. The wound in the skin is pulled upwards so 
 as to allow the point of the needle to project through the muscles 
 without penetrating the skin. The needle being withdrawn and un- 
 threaded by traction on the thread, the folded sac is drawn still 
 further backwards and upwards. Traction having been kept upon 
 the thread while the sutures are introduced, it is finally secured by 
 passing it several times through the external oblique muscle. 
 
 The second part of the operation, closure of the inguinal canal 
 (Fig. 100), is now undertaken. The finger passed into the canal and 
 lying between the inner and lower border of the internal ring in front 
 of and above the cord, makes out the position of the deep epigastric 
 artery so as to avoid it. 
 
 The hernia-needle, carrying chromic gut, then, guided bj^the index, 
 is made to penetrate the conjoined tendon in two places, first from 
 without inwards (a) near the lower border of the conjoined tendon, 
 and secondly from within outwards, as high up as possible, in the 
 inner aspect of the canal (6), this double penetration of the conjoined 
 tendon being accomplished by a single screw-like turn of the instru- 
 ment. One end of the suture is then withdrawn, and then the needle, 
 
 * Ann. of Sury., August, ISSti ; Brit. Med. Jotirn , December 10, 1887, with nine 
 woodcuts. 
 
 t Dr. Miicewen thinks that, however carefully and high up the sac is tied, there 
 remains a fimnel-shaped puckering, the apex of which presents in the internal ring, 
 and tliat this pouch gradually becomes a wedge, tending to open up the canal. 
 
 t All this is done through tlie original small incision, "sufficient to expose the 
 external abdominal ring." 
 
RADICAL CURE OF INGUINAL HERNIA. 
 
 585 
 
 with the other end is removed. Tims, a loop is left at the abdominal 
 as]ieet of the conjoined tendon. 
 
 Secondly the other hernia-needle, threaded with that part of the 
 suture which conies from the lower part of the conjoined tendon 
 
 Fig. 100. 
 
 On the left is one of Dr. Macewen's needles. They are made of one piece of steel. In the 
 middle is the folded sac. The right-hand figure (modified from those of Dr. Macewen) is 
 intended to show his mode of suturing the internal ring. The index linger in front of the 
 folded sac is separating the peritoneum round tlie internal ring. The suture a, 6, has pene- 
 trated the conjoined tendon at two places, first from "without inwards near its lower border, 
 and secondly from within outwards, as high up as possible, a loop being thus left on the abdo- 
 minal aspect of the conjoined tendon. At o' and b' the two ends of the above suture have been 
 passed, separately threaded on needles, from within outwards, through Poupart's ligament 
 below, and through the transversalis and obliques above. 
 
 {n'), guided by the index in the inguinal canal is passed from within 
 outwards, through Poupart's ligament, which it penetrates at a point 
 on a level with the lower suture in the conjoined tendon. The needle 
 is then completely freed from the suture and withdrawn. 
 
 Thirdly, the needle now threaded with that part of the catgut 
 which protrudes from the upper border of the conjoined tendon {!/), 
 is passed from within outwards through the transversalis and internal 
 oblique muscles and the ai^oneurosis of the external oblique at a 
 point on a level with the upper stitch in the conjoined tendon. It is 
 then quite freed from the suture and withdrawn. There are now two 
 free ends in the outer surface of the external oblique, continuous 
 with the loop of the abdominal surface of the conjoined tendon. 
 
586 OPERATIONS ON THE ABDOMEN. 
 
 The two free ends being drawn together tightly, and tied as a reef- 
 knot, the internal ring is firmly united. The same stitch may be re- 
 peated lower down in the canal, especially in adults with wide gaps. 
 The pillars of the external ring may likewise be brought together. In 
 the great majority of cases the first or uppermost stitch is all that is 
 required. The cord should lie behind and below the sutures and be 
 freely movable in the canal. It is advisable to introduce all the 
 sutures before tightening any of them. They may then be experi- 
 mentally drawn tight while a finger is introduced into the canal to 
 learn the result. During the operation the skin is drawn from side to 
 side to bring the parts into view. The skin falling into position, the 
 wound is opposite to the external ring, the operation being partly 
 subcutaneous. 
 
 C. Barker's* — This operation is similar to the above in that the sac 
 is fixed by a suture to the internal ring, but differs from it and all 
 others in the fact that the scrotal portion of the sac is left in situ. 
 The rings and the canal are carefully closed with sutures. 
 
 The neck of the sac being exposed f and cleared with all due care 
 of the cord, two stout silk threads are now passed round this close to 
 the external ring, precautions being taken not to include the cord, or 
 any intestine or omentum. The threads being tied, the sac cut across 
 between them, and the scrotal portion left in situ tied and with its 
 ligature cut short, one of the upper threads on the neck of the sac 
 threaded in a Lister's needle is passed up the inguinal canal, in front 
 of the vas, and guided by the left index, which pushes the sac before 
 it and feels for the inner aspect of the abdominal ring. Here the 
 needle is passed through one border of the ring and out through the 
 external oblique. It is again unthreaded and withdrawn, and carry- 
 ing the other thread is passed up the canal and then through the 
 opposite side of the ring and the external oblique. \Yhen these 
 threads are knotted securely the stump is withdrawn within the ab- 
 domen, and the internal ring is also closed. Three or four more 
 sutures are then passed thus. The needle, again carrying silk, is 
 passed up the canal and pushed from within outwards through one 
 of the walls high up, the cord being protected as before by the left 
 index. It is then withdrawn, still threaded, but leaving one end of 
 the silk through the tendon, and is then made to puncture the other 
 wall at a corresponding point, where it is unthreaded and withdrawn. 
 All sutures pass in front of the cord, and the lowest should not close 
 the ring too tightly upon it. 
 
 * Brit. Med. Journ., December 3, 1887; Man. of Oper. Surg., p. 334, Fig 51. 
 t The incision is represented as exposing botii rings and the canal. 
 
RADICAL CITRE OF IXGUIN^AL HERNIA. 587 
 
 D. Ball's* — Here the sac is twisted, the fundus cut away, and the 
 stump stitched in the ring. 
 
 1. The sac being completely isolated right up to the internal ring, 
 and ascertained to be empty, is gradually twisted up by a broad-catch 
 forceps grasping its neck, while the left fore-finger frees the upper part 
 of the neck. In ordinary cases, four to five complete revolutions are 
 sufficient, but this must depend on the thickness of the sac, the torsion 
 being continued till it is felt to be quite tight and likely to rupture. 
 An assistant, now holding the torsion forceps, maintains the twist, 
 while a stout catgut ligature is tied tightly round the twisted neck and 
 cut short. Two sutures of stout aseptic silk are now passed through 
 the skin about i- inch from the edge of the wound, through the outer 
 pillar of the ring, through the twisted sac in front of the catgut suture, 
 and then through the inner pillar and skin. As the sac now cannot 
 untwist it is cut off in front of these sutures, which are tied over 
 leaden plates, which lie at right angles to the wound. 
 
 2. Subcutaneous Methods— e.g*., those of Mr. Wood and 
 Mr. Spanton. — Successful as these have been in the hands of their 
 authors they have never been largely adopted by surgeons. Important, 
 no doubt, as is the subcutaneous principle in surgery, there is a wide 
 difference between it when applied to division of tendons, and to the 
 taking up with wire or corkscrew enough of important parts to ensure 
 a good result, while at the same time other most important structures 
 — e.g., peritoneum, vessels and cord — must be left untouched. The 
 difficulty of making sure of enough inflammation, adhesion and con- 
 solidation, the feeling that a certain amount of suppuration is needful 
 to ensure loosening and removal of the wire or corkscrew, and that 
 this suppuration may lead to serious results, while the having to remove 
 a foreign bodj' may break down much of the good done, are, it seems 
 to me, powerful objections. 
 
 Wood's Method.f — The rupture being completely reduced, an oblique 
 incision, 1 inch long, is made over the fundus of the sac. The skin is 
 separated, with the handle of the knife, from the deep coverings of the 
 sac for about 1 inch all round. The fore-finger is then passed into the 
 wound, and the detached fascia and fundus invaginated into the canal. 
 The finger then feels for the lower border of the internal oblique, lifting 
 it forwards to the surface. By this means the outer edge of the con- 
 joined tendon is felt to the inner side of the finger. The needle 
 (stout, semicircular, in a strong handle) is then carried carefully up 
 to the point of the finger along its inner side and made to transfix the 
 conjoined tendon, and also the inner pillar of the superficial ring. 
 
 * Brit. Med. Journ., December 10, 1887. 
 
 * Intern. Encyd. of Sure/., vol. v. p. 1040. 
 
588 OPERATIONS ON THE ABDOMEN. 
 
 When the laoint is seen to raise the skin, the latter is drawn over to the 
 middle line, and the needle made to pierce it as far out as possible. 
 The wire (stout, silvered copper about 2 feet long) is then hooked into 
 the eye of the needle, drawn back with it into the scrotum and then 
 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 pos- 
 sible frcm the deeper structures. The needle is then passed along the 
 outer side of the finger, and pushed through Poupart's ligament a 
 little below the deep hernial opening. The point is then directed 
 through the same skin puncture before made, the other end of the wire 
 hooked on to it, drawn back into the scrotal puncture as before, and 
 then detached. There is now a wire-loop at the groin, and two hook- 
 ends at the scrotal puncture. Opposite the latter the sac is then pinched 
 up Ijy the finger and thumb, in the same way that a varicocele is sepa- 
 rated from the spermatic duct when submitted to operation. An 
 assistant seizes it with finger and thumb, also in the same way, at 
 about 2 inches distance, both assistant and operator recognizing the 
 situation of the spermatic duct. The needle is then passed at one 
 corner of the scrotal puncture, across the sac in front of the duct, and out 
 at the other end of the scrotal puncture. The skin here is so elastic that 
 it stretches so as to allow this easily to be done. The inner end of the 
 wire — viz., that traversing the conjoined tendon — is next hooked into 
 the needle and drawn across behind the sac. Care must be taken by 
 dealing with the wire roundly, not to make an acute bend or kink 
 which would put a needless difficulty in the way of its subsequent 
 withdrawal. The two scrotal wires are now twisted twice or three 
 times together, the operator observing the direction of the twist, so as 
 to be able readily to untwist the wire when it has to be withdrawn. 
 The loop above is now drawn firmly upwards so as to invaginate the 
 scrotal fascia into the canal up to the internal ring, and is then twisted 
 down with the same precautions as the lower, and the two loops are 
 bent down and secured over a pad of lint, a little carbolized tow serving 
 to catch any discharge. The wire should be left in eight to twelve days 
 according to the amount of reaction. The wire is then untwisted and 
 withdrawn by cutting off the lower ends and pulling on the upper. 
 One of Mr. Wood's horseshoe trusses is then worn for a few months. 
 
 Spantoiv's Method.'^ — This is based on Mr. Wood's, but is believed to 
 have the advantage of drawing the pillars of the ring more securely 
 together. The instruments required are, a large tenotomy knife and a 
 screw instrument, shaped lilce a corkscrew, but with the screw rather 
 broader at the point. 
 
 The hernia being carefully reduced and kept up, an incision is made 
 in the scrotal skin over the fundus, generally about 2 inches below the 
 
 * Brit. Med. Jom-n., December 11, 1880. 
 
RADICAL CURE OF FEMORAL flERMA. 589 
 
 pubic spine, large enough to admit the tinger easily, and the skin sepa- 
 rated from the parts beneath with the handle of a scalpel, to an extent 
 determined by the size of the hernia and that of the canal. In order 
 to choose an instrument of proper size a careful examination is now 
 made of the rings, length of the canal, surrounding vessels, etc., with 
 the left forefinger, which is passed ujj to the deep ring invaginating the 
 fascia and hernial sac. The finger here is retained in the canal, pro- 
 tecting the cord, and at the same time closing the deep ring. The screw 
 dipped in carbolic oil is thrust through the skin of the groin so as to 
 transfix the aponeurosis of the external oblique, at a point somewhat 
 above that at which it is intended to pass through the conjoined tendon. 
 Having given the instrument one half turn to the right, if a right 
 inguinal hernia, and a whole turn if it be a left one, it is next made 
 to pierce subcutaneously the conjoined tendon as high up as can safely 
 be reached, the left forefinger carefully guarding the point from in- 
 juring vessels or peritoneum. This part of the operation must be 
 done continuously and deliberately. It will then be found that as 
 soon as a hold has been secured by the instrument the ring is practi- 
 cally closed. Another turn is now given to the screw, causing it to pass 
 through the invaginated tissue — whether fascia or sac, or both — and 
 it is again passed through the outer pillar, and then across the inner 
 pillar of the external ring, and another turn given, if possible, so as 
 to bring the point out at the wound in the scrotum. The handle should 
 then lie flatwise on the abdomen, and the point be protected by some 
 carbolized gauze. The amount of induration excited will be the guide 
 as to the removal of the instrument, but a week has usually been 
 found sufficient. The removal is easy, by keeping the instrument well 
 oiled, and by the loosening result of suppuration. Mr. Spanton ad- 
 vises the temporary use of a truss. 
 
 iii. Injection of Astringents.— I am unable to find space for an 
 account of this method. The full account given of the open method 
 will, I believe, meet all cases. That by injection has found no favor 
 amongst English surgeons. 
 
 RADICAL CURE OF FEMORAL HERNIA. 
 
 There is very much less necessity for this, women, in whom it is so 
 much more frequent, finding a truss more efficient and less irksome, 
 owing to their less active life and mode of dress. Omental femoral hernia 
 (p. 580j should be operated on when there is the least difficulty in fit- 
 ting, or unwillingness to wear, a truss, the sac being always ligatured 
 and taken away. The same course should be followed in all cases of 
 strangulated femoral hernia, when the condition of the patient admits 
 of it, care being always taken to make the smallest nick possible in 
 
590 OPERATIOXS OX THE ABDOMEX. 
 
 Gimbernat"? ligament, so as to minimize the risk of recurrence. The 
 steps have been fully given at p. 561. 
 
 Mr. Wood has introduced a subcutaneous wire operation for reducible 
 femoral hernia analogous to that already given for the invagination of 
 the sac in inguinal hernia.* 
 
 RADICAL CURE OF UMBILICAL HERNIA. 
 
 This operation is very rarely called for, as in children the tendencv 
 to a natural cure is so marked, and in adults the condition both of 
 the jjatient and the rupture is usually so unfavorable (pp. .574, o'ii'^. 
 
 In those rare cases in children where the operation is justifiable 
 from the large size of the ring, and the want of improvement under 
 the surgeon's own eye. the ring should be closed, with strict aseptic 
 precautions. To such eases an operation of Mr. Keetley's+is well 
 adapted. The sac being sei'arated and twisted, as in Mr. Ball's 
 method (p. •3~^7\ a stout catgut suture is jiassed throtigh it, and the 
 pieritoneum being very carefully separated from the linea alba above 
 the ring, a needle is passed up into the space thus made, carrying the 
 catgut, threaded, through the sac, and brought out througli the linea 
 alba. Then, on pulling the catgut tight, the twisted sac is drawn into 
 the space between the peritoneum and the linea alba. The edges of 
 the hernial aperture, now freed, are pared and brought together with 
 pins and twisted suture, 
 
 ;Mr. Wood has also described a subcutaneous wire opieration for the 
 cure of these cases. | 
 
 In the account of the operation for strangulated umbilical hernia 
 (p. 575), the steps for taking away the sac and the redundant skin, 
 and suturing the riuir, are uiven. 
 
 CHAPTER III, 
 COLaTOMY. 
 
 • 
 
 Under this term are included the operation of opening the ascend- 
 ing or descending colon in the loin, or lumbar colotomy — an operation 
 with which the name of Amussat^ is justly associated — and also the 
 anterior colotomy of Littre, in which the sigmoid colon is opened in 
 the left iliac rcuion. 
 
 * Intern. Encycl. of Sunj., vol. v. p. 1160, Fijjs. 1147, lliS. 
 t Annals of Sill ijnu, September, 1SS7. 
 J Loc. stipra cit., p 1169, Figs. ll'>0-1154. 
 
 i Stiulents are often perple.xed ns to the difference between Amussat's and Callisen'a 
 operations. Callisen (1790) was the first to suggest such an operation as colotomv, 
 
LUMBAR COLOTOMY. 591 
 
 LUMBAR, OR POSTERIOR, COLOTOMY (Figs. 101, 102). 
 Indications. 
 
 (1) Malignant disease of rectum not admitting of dilatation. 
 
 (2) Venereal, syphilitic stricture of rectum, in whicli previous 
 treatment, including dilatation, has failed, and in which proctotomy* 
 is not available. 
 
 In either of the above, extensive ulceration, much pain,t loss of 
 sphincter power, jirofuse blood stained or fa='co-purulent discharge 
 from the bowel or multiple fistulie, abundantly justify the operation. 
 
 It is in such cases as those where the symptoms are not yet very 
 urgent that the surgeon will find most difficulty in deciding when to 
 advise colotomy. When intestinal obstruction is actually impending, 
 the patient will be anxious to submit, owing to the amount of pain 
 and distress actually present, and the surgeon will be ready to per- 
 form an operation, even if the duration of life may be but brief. But 
 to return to less urgent cases, the patient or the friends, especially if 
 in a better rank of life, will frequently expect a decided answer as to 
 the amount of I'elief, and also the amount of annoyance which will 
 follow on an artificial anus. Before attempting to give any data on 
 which an answer may be founded, I would say that I think the more 
 frequently a surgeon performs this operation the more will he admit 
 that there are cases, occasional no doubt, in which this operation, 
 though well performed, fails to give the expected amount of relief. 
 
 Putting aside cases where the operation is performed too late, and 
 where the local mischief has been allowed to become too advanced, 
 those where secondary deposits exist, cases where the opening has 
 been too free, or where, with a proper opening, a constant cough, aided 
 by a relaxed condition of tissues, tends to bring about a worrying 
 
 and planned to open the descending colon by a vertical incision. This proposal was 
 condemned by contemporary surgeons. Amussat revived the retro-peritoneal opera- 
 tion, if he was not the first to perform it, but modified it by extending it to the ascend- 
 ing and descending colon alike, and by niaRing use of the transverse incision. Long 
 before Amussat's time, Littrfe (1710) had opened the sigmoid flexure through the peri- 
 toneum, and in 1776 Pillor^ had opened the escum. 
 
 t Linear division of a non-malignant stricture posteriori)'. If a finger cannot be 
 passed through the stricture, this is first divided with a probe-pointed bistoury to 
 admit the finger. Then a curved, sharp-pointed bistoury, passed through the stricture, 
 is made to transfix the bowel beyond the stricture, and the point is brought out close 
 to the tip of the coccyx. The parts are then cleanly divided by cutting out towards 
 the anus in the middle line. In about ten days the use of bougies is commenced. For 
 a good account of this excellent operation, see Mr. Cripps's Dis. of the Rectum and Anus, 
 p. 239. 
 
 t In a few and exceptional cases cancer of the large intestine may run its course, 
 set up visceral deposits, and kill the patient with very little pain. 
 
592 OPERATIONS ON THE ABDOMEK. 
 
 prolapsus, putting aside cases in which the opening was perhaps 
 originally too small, or in which the patient does not take the trouble 
 to keep the opening dilated as directed, I am of opinion that occasion- 
 ally causes of failure to give complete relief are met with after an 
 operation quite proi^erly carried out. While I cannot give, and have 
 failed to meet with, an explanation for every case, I think the follow- 
 ing are bona fide causes, and without detracting seriously from the 
 value of this excellent oi^eration, because only occasional, I feel that 
 they have been somewhat unduly overlooked, and that there is too 
 great a tendency amongst writers on colotomy to teach that, if it is 
 done sufficiently early, and if its immediate risks are survived, the 
 relief is always decided and the patient's condition always a most 
 satisfactory one. 
 
 Some of these instances of incomplete relief — viz., persistent passage 
 of motions over the malignant disease, and teasing diarrhoea from 
 the artificial and natural anus, have seemed to me to be due : (1) To 
 the lower communication with the bowel being too patent, sometimes 
 no doubt accounted for by the fact that the colon at the spot where 
 it has been drawn into the wound, owing to the shallowness of the 
 loin or the length of the meso-colon, is scarcely kinked or bent at all ; 
 this leads to escape of faeces over the malignant growth and much 
 pain and teasing diarrhoea. (2) To persistence of the growth in the 
 bowel below, causing a profuse sanious discharge. (3) To the growth 
 extending upwards towards the wound, or to the bowel having been 
 opened only just above the growth. 
 
 As a rule, the more complete the failure of previous treatment, the 
 more painful, difficult, frequent, and unsatisfactory the action of the 
 bowels, the greater the tendency of distension of the sigmoid or lower 
 intestines generally, the more frequent the attacks of gripings and 
 partial obstructions, which herald in the tormina of a complete 
 miserere; the younger the patient, and thus the longer the natural 
 prospect of active life, the more plain are the indications for colotomy. 
 On the one hand, certain special evils * call loudly for the relief which 
 the operation may give — viz., a patulous or invaded sphincter allow- 
 ing of involuntary escape of flatus and fa?ces, multiple fistulse giving 
 rise to foul sanious discharge, keeping the patient (perhaps a woman 
 of scrupulous cleanliness) in a constantly filthy condition, and lead- 
 ing to a brawny, painful condition of the buttocks, which thus readily 
 become the seat of cellulitis and its allies ; projection of the growth 
 
 * To quote only two special w retell edn esses — e.g., when a lady cannot rise from )ier 
 easy-chair wiiliont an escape of flatus or faeces taking place from a powerless sphincter 
 or when a man is threatened with agonies of pain from the carcinoma eating back- 
 wards and involving the sacral nerves, and causing caries of tlie sacrum, with fistnlse 
 and foul discharge. 
 
LUMBAR COLOTOMY. 593 
 
 downwards through the anus, leading not only to a patulous sphincter 
 and its consequent wretchedness, hut also to irksome or painful sitting. 
 On the other hand, certain condition's contraindicate the operation 
 —viz., exhaustion of strength, evidence of secondary deposits in the 
 peritoneal cavity, liver, lungs, or pleura , absence of much pain or 
 obstruction from first to last. 
 
 (3) Annular stricture of the sigmoid colon. 
 
 (4) Malignant disease of the large intestine higher up— viz., in the 
 splenic or hepatic flexures. 
 
 (5) Pelvic tumors pressing on the rectum. 
 
 (6) Results of pelvic cellulitis narrowing the rectum. 
 
 (7) Chronic intestinal obstruction due to any of the above causes. 
 
 (8) Vesico-intestinal fistula. 
 
 Lumbar colotomy is performed in cases of communication between 
 the large intestine, especially the rectum, and the bladder, to prevent 
 the passage of faeces into the bladder, with its results of cystitis, ago- 
 nizing obstruction of urine, and passage of flatus from the urethra 
 without notice and beyond control. 
 
 Such a fistula is much more frequentlj^ met with between the sig- 
 moid or rectum and the bladder ; if between the latter and the rectum 
 the communication may be found by the finger, or by passing a duck- 
 bill speculum and injecting colored fluids.* Too frequently malignant 
 in character, it is occasionally of a simjDler nature— e.g*., dysenteric, 
 etc., and so, perhaps, curable. Thus, in Mr. Holmes's case (3Ied. Chir. 
 Trans., vols. xlix. arid 1.) the ulceration between the sigmoid and the 
 bladder was not malignant, colotomy for fifteen months was most 
 successful, but a permanent cure was prevented by similar ulceration 
 taking place between the cacum and bladder which caused death. 
 Whether the cause is malignant disease or no, the life which lies before 
 the patient is scarcely tolerable. 
 
 The opening is far more frequently valvular in nature — i.e., while it 
 admits of the passage of faeces into the bladder, urine very rarely passes 
 per anum. 
 
 Site of the Proposed Colotomy.— In some cases, especially 
 where intestinal obstruction is threatening from malignant disease, the 
 surgeon may be in doubt as to the site of the disease, and therefore on 
 which side to, operate. It is quite impossible to make fixed rules for 
 advice, but the following will help in doubtful cases : 
 
 (1) The proportionate frequency of stricture in different parts of the large 
 
 * The following plan, based upon one made use of by Mr. Lnnd (Hunt. Led. 188-5, 
 p. 91), wonld very likely be nseful— viz., to pass into the rectum a bougie round which 
 is wound a strip of lint well soaked in starch and water and dried, and then to inject into 
 the bladder some diluted iodine solution. A btain of starch iodide on the bougie would 
 show the position of the fistula. 
 
 38 
 
594 OPERATIONS ON THE ABDOMEN. 
 
 intestine. The frequency of disease in the rectum and sigmoid flexure, 
 as compared with any other part of the large intestine, and, generally 
 speaking, the frequency of disease in the left side of the arch formed 
 by the large intestine, as compared with such disease in the right side, 
 are well known.* 
 
 (2) The Use of Large Injections. — Dr. Fagge {he. supra cit., p. 318), 
 thus writes on this subject : " Several writers, and especially the late 
 Dr. Brinton, have laid stress on the value of large injections as an aid 
 to diagnosis. The observer I have named has even laid down definite 
 rules for our guidance in this respect. ' It is quite singular,' he says, 
 ' how trustworthy I have found the conclusions thus arrived at. For 
 example, with a maximum injection of a pint of warm, bland liquid, 
 the obstruction in an ordinary male adult may be referred to a point 
 not lower than the upper third of the rectum. A pint and a half, two 
 pints, three pints, belong to corresponding segments of the sigmoid 
 flexure. The descending and transverse colon accept a larger, but more 
 irregular, quantity. In one case, in which it was evident that the 
 stricture occupied the upper part of the ascending colon, nine pints of 
 injection were always found to be the maximum.'" Dr. Fagge points 
 out that the correct determination of this point requires much care, as 
 («) some of the fluid measured may escape in the injection; and (6) 
 a stricture may be pervious to fluid injected from below, though the 
 intestinal contents may be unable to pass through it from above. 
 Thus, in a case in which there was a mass of disease in the sigmoid 
 flexure, just above the pelvis, 4 pints of water were injected per rectum ; 
 of this a small portion only returned, the greater part passing through 
 the stricture and adding to the accumulations above it. I would add 
 one more caution with regard to these injections. Patients, in much 
 misery, and having submitted to one or two rectal examinations, will 
 sometimes ask for an ana;sthetic. Such an aid must be used with great 
 caution if there is already abdominal distension. There is not only a 
 danger of adding seriously to the distension, and thus further weak- 
 ening or rupturing parts which may be already near the point at which 
 they give way — e.g., a cfficum with " distension ulcers " — but an anffis- 
 thetic, especially chloroform, has additional dangers in such cases as 
 these, where, in a patient probably no longer young, the action of the 
 heart and lungs are interfered with by the upward pressure against 
 the diaphragm. 
 
 (3) Tin; distance to lohiclt n long bougie or rectal tube passes is of very 
 little value, and needs only the briefest mention here, because the sur- 
 
 * Dr. Fagge, in drawing attention to tliis fact (Guy's Hasp. Reports, 1868, p. 314), 
 quoted the following statistics from Dr. Brinton : "Of 100 cases, 4 are in tlie Cfecum 
 10 in the ascending colon, 11 in the transverse colon, 14 in the descending colon 30 
 in the sigmoid flexure, and 30 in the rectum." The statistics of Dr. Fagge and M. 
 Duchaussoy confirm the above. 
 
LUMBAR COLOTOMY. 695 
 
 geon is still called to cases in which he is assured that the obstruction 
 cannot be in the rectum or low down in the sigmoid flexure, as a long 
 bougie has been easily passed its full length. This fallacy, which is 
 due to the bougie bending on itself, is more frequent than the other 
 one, in which the arrest of a bougie by one of Houston's folds misleads 
 into the belief that a stricture exists low down. 
 
 (4) The form of the abdomen may give valuable conclusions. Thus 
 Dr. Fagge {loc. mpra cit., p. 319), gives a case of cancer of the hepatic 
 flexure, in which it was observed during life that the cajcum and 
 ascending colon were distended, and not the descending colon. Again, 
 he observes that when the rectum or the sigmoid flexure is the seat of 
 obstruction, the lumbar regions and the epigastrium are no doubt 
 generally prominent, and the course of the colon is more or less 
 plainly marked out. That these conclusions are only valuable if not 
 too implicitly relied upon, is shown by the fact that cancer of the 
 rectum may be present, with vomiting, peristalsis, and borborygmus, 
 and yet there may be no general distension of the abdomen, no filling 
 out at all of its sides : on the other hand, a prominent epigastrium 
 and the appearance of a large horizontal coil of intestine here ma}' lead 
 to the conclusion that the transverse colon is distended, the disease 
 being, nevertheless, in the ilium, a distended coil of which has rivalled 
 the colon itself 
 
 (5) A symptom of some value, if verified by the medical man 
 himself, is the fact that for some time the motions have been narroio, 
 tape-like, brokenup, abnormal in bulk, shape, and length. Certain fallacies 
 diminish, however, the value of the above — e.g., that in cases of 
 stricture high up, as in the upper part of the sigmoid flexure, there is 
 probably room for the fseces, after they have got through the stricture, 
 to collect, till their characteristic form is given them, though we do not 
 know how far irritation of the intestine and formation of mucus at the 
 seat of the growth may interfere with this. 
 
 (6) A few other points — e.g., constant arrest of borhorygmi at one spot, 
 Jixedpain at oneplace, as in the right hypochondrium— may give useful 
 indications, while others, such as a,rectal examination, are so obvious as 
 scarcely to deserve mention. 
 
 If, after weighing the above, the surgeon is still in doubt as to the exact 
 sits of the disease of the large intestine, he should not hesitate to per- 
 form right-sided lumbar colotomy. He should not be deterred from 
 this by the anatomical difficulties* supposed to exist on this side. 
 Especially where the colon is at all thickened or distended, the opera- 
 tion on one side is no more difficult than on the other. 
 
 * Eg , a more complete peritoneal coat. 
 
596 OPERATIONS OX THE ABDOMEN. 
 
 Some Points in the Surgical Anatomy of Oolotomy, and 
 Landmarks Useful in the Operation.— The parts cut through, 
 and the means of recognizing the colon, are fully given below. Atten- 
 tion will here be drawn to the connection of the peritoneum with the 
 colon, and on this point we have nothing more accurate than the ob- 
 servations of Braune.* This anatomist writes : " It is usually stated 
 that the descending colon lies along the outer border of the quadratus. 
 . . '. . This is not always correct. At the level of the symphysis be- 
 tween the third and fourth vertebra, and at the fourth below the 
 kidney — and therefore exactly in the field of operation — the quadratus 
 lumborum covers in the colon posteriorly, and must be cut in order 
 to reach it. It is only when much distended, a condition which is not 
 so constant as one would expect in operations,t that the intestine in- 
 creases in breadth forwards and inwards, or overlaps the outer border 
 of the muscle." Professor Braune goes on to say that, from the im- 
 possibility of recognizing the peritoneum from its posterior aspect, 
 success can only be safely calculated on by measuring the distance of 
 the point of reflection of the peritoneum, and how far from the colon 
 this position is constant. " As regards the descending colon, which I 
 here particularly refer to after measurements of frozen bodies of full- 
 grown men, I find that this distance, in a straight line (therefore not 
 corresponding with the curvature of the wall of the intestine), is from 
 four-fifths of an inch to an inch, supposing the intestine empty and 
 contracted (at a level between the third and fourth lumbar vertebrae) ; 
 further, that the free side of the intestine does not look posteriorly, 
 but somewhat inwards, exactly towards the angle which the psoas and 
 quadratus make with each other. If, on the other hand, the small 
 intestines are much distended, .... the colon, bj' means of the 
 traction of the parietal peritoneum, would be rotated on its axis, so 
 that its free surface would be directed more outwards. 
 
 " Should the colon itself be distended, its surface, free of peri- 
 toneum, becomes considerably larger, and may assume a breadth of 
 from '2 to 2.5 inches." 
 
 It is beyond doubt that the surface free from peritoneum is less 
 extensive on the right than on the left side, and that a meso-colon is 
 more frequently met with in the case of the ascending than in that of 
 the descending colon. The former fact will not cause trouble when 
 the colon is distended ; the layers of the meso-colon, if identified 
 might be parted from each other, but the safest way of meeting these 
 complications is to perform the operation, whenever possible in two 
 
 * Atlas of Tojiiii/riiphical Anatomy (translated by Ml'. Bellamy), p. 133. 
 
 t Tlius in Fig. 2 (Firogolf), p. 131, of Prof. Braune's book, where the intestines are 
 shown mucli inflated with air, the ascending colon is well distended, the descending 
 somewiiat collapsed. 
 
LUMBAR COLOTOMY. 597 
 
 stages, and on all occasions to adopt the most stringent antiseptic 
 precautions possible. 
 Landmarks (Fig. 101). 
 
 1. The lower border and tip of the last rib. 
 
 2. A point 2 inch behind the centre of the crest of the ilium, this 
 point being found by accurate measurement along the crest between 
 the anterior and posterior superior spines (Allingham). 
 
 _3. A line drawn vertically up from the last-mentioned point to the 
 last rib. This gives, Avith sufficient correctness, the line of the outer 
 edge of the quadratus, and the position of a normal colon. 
 
 Owing to the varying length of the last rib, the upper end of this 
 line may meet this bone at its tip, or at a spot a varying distance in 
 front of or behind this point. It is well to dot the ends of this ver- 
 tical line with an aniline pencil. The dent of a finger-nail, made 
 when the patient has been brought under the anaesthetic, will mark 
 these points sufficiently to begin with, but a little later, in a difficult 
 case, the surgeon may be glad of having taken every possible pre- 
 caution. 
 Incisions. 
 
 1. Vertical, of Callisen. This at first sight is the best, as it follows 
 the above line, and thus corresponds anatomically to the colon, but it 
 has the disadvantage of giving but limited space, especially in a fat 
 or deep-chested patient ; and if prolonged upwards, so as to give all 
 the space possible, it divides the intercostal vessels running with the 
 last dorsal nerve, and gives rise to troublesome ha3morrhage. 
 
 2. Transverse, of Amussat. 
 
 3. Oblique, of Bryant, modified from the above. One of the two 
 latter is usually employed ; they have the great advantage of being 
 readily prolonged when more room is required, and the oblique 
 incision corresponds better with the course of the nerves and vessels.* 
 
 It is the one given below. 
 
 Operation (Figs. 101, 102). 
 
 The patient being turned on to his side (most usually the right) 
 with a firm pillow under the loin, the parts cleansed, the tip of the 
 last rib and the point on the crest of the ilium, as given above, being 
 dotted with an aniline pencil, an incision is made, beginning 22- or 3 
 inches from the spine, according to the size of the erector spine, a 
 little below the last rib, and running downwards and forwards for 
 
 * Mr. Greig Smith (Abdom. Surg., p. 396) thinks that this incision helps to prevent 
 prolapse of the bowel by lying almost transverse to its axis. He gives also the follow- 
 ing practical hint: "In thin patients, and particularly in women, whose iliac crests 
 are more prominent than in men, there is a tendency for the upper lip of the wound 
 to fall inwards, while the lower lip protrudes. This may be obviated by careful appo- 
 sition, and by not bringing the line of the incision too close to the ilium. "^ 
 
598 
 
 OPERATIONS ON THE ABDOMEN. 
 
 8i to 4 inches towards the anterior superior spine. The centre of this 
 incision should bisect the line given at p. 597 as the line of the colon. 
 The first cut should expose the muscles, the skin in the posterior 
 half being thick, and the subcutaneous fat often abundant. • The 
 next may go well into the muscles, the remainder of which should 
 be then carefully divided with the knife, or torn through with a 
 steel director, so as to expose the fascia lumborum ; any bleeding 
 vessels being now secured, this fascia is pinched up, nicked and slit 
 upon a director. Two retractors being placed on the lips of the 
 wound, the fat which lies around the kidney and behind the fascia 
 lumborum is next torn through with two pairs of dissecting forceps. 
 If the bowel is distended it will bulge up into the wound, pushing 
 before it the transversalis fascia, and the operation can be readily 
 completed. If, on the other hand, the bowel is empty, the real dififi- 
 
 FiG. ]01. 
 
 culties of the operation only begin at this stage. The wound being 
 well opened, the kidney, if it come down below the rib (as it occa- 
 sionally does, especially in a patient breathing heavily under the 
 influence of an anffisthetic), being kept out of the way by the finger 
 of an assistant, the intestine is sought for by scratching with a di- 
 rector, or two pairs of forceps, through the transversalis fascia (Fig. 
 101) exactly in the line to which attention has been already drawn. 
 Several layers of cellular tissue may be met with here, and it is now 
 that most of the difficulty is usually met with, owing to the operator 
 being afraid of the peritoneum, and to his not opening the trans- 
 versalis fascia with suflicient decision. 
 
 When this has been done, scybala in the colon will in many cases 
 be felt, but if the large intestine is empty much trouble may be met 
 
LUMBAR COLOTOMY. 599 
 
 with in detecting it and getting it up into the wound, especially if, 
 
 close by, the peritoneum is bulging up. 
 At this stage the following points niay be usefully remembered : 
 (a) The exact position of the line of the colon (pp. 696, 597). 
 (&) The lower end of the kidney, and its relation to the colon. 
 
 (c) The outer edge of the quadratus lumborum (p. 596). 
 
 (d) The sensation of thickness as given to the fingers in pinching 
 up the colon, thus distinguishing large from small intestine. 
 
 (e) The feel of scybala if present. 
 
 (/) Seeing one of the three longitudinal muscular bands which dis- 
 tinguish the colon.* 
 
 ig) Inflation with air or injection of fluid.f 
 
 (h) Mr. Bryant has advised rolling the patient over on to his face 
 at this stage, so that the colon may be felt to fall on the finger inserted 
 deep into the wound. 
 
 The bowel having been found, its posterior surface is to be drawn 
 well up into the wound, and if the case is not an urgent one, retained 
 
 Fig. 102. 
 
 Colotomy in two stages. The bowel is shown secured with pins at the close of the first stage. 
 
 there by passing long hare-lip pins through it. There is no need to 
 pass the pins through the edges of the wound ; they simply lie across 
 
 * Mr. H. Allingham (Brit. Med. Journ., April 28, 1888) seems to consider it very- 
 difficult to ensure finding one of these bands without opening the peritoneal cavity. 
 While I should be the last to make light of the difficulties which may beset this 
 operation, I feel sure that few surgeons, who have had a large experience of colotomy, 
 will agree that the above step is needful, especially if the line given by Mr. Allinghara's 
 father be strictly followed. 
 
 t Air is most readily made use of. It may be pumped in by a Higgenson's syringe, 
 a Lister's hand-spray, but, best of all, by the special apparatus described by Mr. Lund 
 {Lancet, 1883, vol. i. p. 588), which, by means of an elastic ring, secures air-tight 
 contact with the anus while air is being pumped in, either as an aid in colotomy, or 
 as a means of reducing an intussusception. In some cases of cancerous disease of the 
 rectum it will be very difficult to introduce any nozzle for inflation beyond the disease. 
 In the summer of 1885, when performing colotomy at Guy's Hospital in a patient, 
 the lower part of whose rectum had been unsuccessfully excised at another hospital, I 
 found it impossible to introduce any nozzle when desirous of inflating an empty colon. 
 
600 OPERATIONS ON THE ABDOMEN. 
 
 these, resting on the margins of the wound at either side, a few strips 
 of iodoform gauze being placed under them, or little slips of cork on 
 their ends. The pins should be passed through the bowel at a dis- 
 tance of at least f inch from each other, so as to render easy the 
 opening of the bowel in a few days' time, and they should not, if it 
 can be managed, penetrate all the coats of the intestine. The pins 
 are so fine* that any puncture of the canal itself Avill probably give 
 rise only to a little flatus, readily met with iodoform. The margins 
 of the wound are then carefully closed with silver wire or carbolized 
 silk sutures, and a few fine ones may be passed between the bowel 
 itself and the margins of the wound. Dry gauze dressings are then 
 applied, iodoform being dusted over the bowel and wound. These 
 dressings will probably not need changing till the fourth day, when 
 the operation is completed by opening the bowel with a tenotomy 
 knife between the pins; this opening may be a small crucial one, 
 very little but flatus will pass at the time, but a director will show the 
 presence of faeces, and mild aperients may be given as soon as the 
 parts are firmly healed. The above method of performing colo- 
 tomy by two stages was introduced at Guy's by some of ray 
 senior colleagues, Mr. Bryant, Mr. Howse, and Mr. Davies-Colley, 
 being based on that most important modification of gastrostomy 
 which Mr. Howse was the first to make use of in this country. Mr. 
 Davies-Colley brought before the Clinical Society {Trans., vol. xviii. 
 1885, p. 204) a paper on " Three Cases of Colotomy with Delayed 
 Opening'of the Intestine." It was from him I learnt the use of the 
 pins t given above. Some operators — viz., Mr. Bryant and Mr. 
 Howse — have had good results after simply drawing out the knuckle 
 and leaving it protruding in the wound without any sutures to secure 
 it, or fixed with torsion forceps, the blades covered with drainage- 
 tube, applied with just sufficient force to hold up the intestine without 
 causing sloughing. To apply the right degree of pressure is a matter 
 of some difficulty, and with regard to the method of leaving a knuckle 
 without sutures, I agree with ]Mr. Davies-Colley (loc. supra cit., p. 209) 
 that serious difficulties may arise from the bowel slipping back into 
 the wound. J This is especially likely to occur in a restless patient, 
 
 * A good form of jiin is mentioned in footnote following. 
 
 f In six cases of colotomy which I performed in 1887, I used some pins made for 
 me by Messrs. Downs. Their steel is sufficiently tempered to be slightly flexile, 
 thus yielding a little, a point of mnch importance when the knuckle of the colon has 
 to be dragged up to the surface of u, very fat loin, and thus exerts much tension on 
 the pins. The flat heads rest comfortably on the skin margins of the wound, without 
 causing any ulceration. 
 
 X In one case which was under my care two years ago, in which, after drawing out 
 a knuckle of sufficient size, I had been content to fix it with numerous very fine silk 
 
LUMBAR COLOTOMY. 601 
 
 in cases where the wound is very deep, and where, owing to the pa- 
 tient's weakly condition or from suppuration taldng place, the intes- 
 tine does not early become firmly fixed. The great advantage of this 
 two-stage method is that it defers the opening of the bowel till this 
 is sufficiently adherent. (2) By this delayed escape of intestinal 
 contents the gravity of any injury to the peritoneum at the time of 
 the operation is very much diminished. (3) The second great trouble 
 after colotomy, that of burrowing suppuration up and down the 
 planes of cellular tissue, which have, of necessity, been freely opened, 
 is done away with. The opening of the intestine being delayed, pri- 
 mary union to a very large extent can be secured, especially with the 
 aid of deeply passed sutures, or of chromic gut ones cut short and 
 dropped in, and dry dressings. 
 
 If it is necessary to complete the operation at one stage the bowel 
 should be drawn up into the wound as much as is possible, and a few 
 silk stitches inserted so as to shut off the surrounding cellular tissue 
 planes from the escaping fteces. The bowel may then be opened by 
 an incision J. inch long, and these cut edges also stitched to the mar- 
 gins of the wound. The rest of the wound is then closed as accurately 
 as possible, the parts around the wound freely smeared with euca- 
 lyptus and vaseline, the wound dressed with this or carbolic oil, and 
 a pad of carbolized tow, and the dressings kept in position by a many- 
 tailed bandage, by which means they are readily and painlessly 
 renewed. 
 
 If the bowel is too tense to allow of its being stitched in situ before 
 it is opened, it maj' be secured by passing a ligature first through one 
 lip of the wound, then across the bowel and through the opposite lijj, 
 and another in the same way about i inch from the first, an incision 
 4 inch long is then made into the gut, over these sutures, their centre 
 hooked up into the wound, and the four halves tied on either side, 
 a few other sutures being put in between the cut bowel and the wound. 
 If the bowel is much distended there is always some risk of faecal 
 matter being forced into the different planes of cellular tissue, unless 
 every precaution is taken to keep the knuckle well up, and to close 
 the wound thoroughly around it. 
 
 If the bowel is full of hard scybala no attempt should be made to 
 remove them ; they may be left for a day or two till aperients can be 
 given. At times the bowel seems so empty as to suggest a failed 
 operation ; there is no occasion to be troubled at this ; the contents 
 will pass shortly. 
 
 sutures, the bowel was found, on the third day, when the wonnd was dressed, to have 
 slipped deeply back, owing to the above fine sutures cutting through, and very great 
 difficulty was met with in completing the operation. The wound had here united 
 without suppuration, but the patient was most restless. 
 
602 OPERATIONS ON THE ABDOMEN. 
 
 Difficulties in Oolotomy. 
 
 1. An empty bowel* This has been already alluded to (p. 599). 
 
 2. Mistaking bulging peritoneum for colon and opening it. This 
 may be due to the surgeon forgetting the line of the bowel, and work- 
 ing deeply, too far forwards ; or it may take place from no fault of the 
 surgeon, being due to the presence of a meso-colon, or to the ex- 
 tremely contracted condition of the colon.f It by no means always 
 causes peritonitis. When this accident has happened, as shown by 
 the escape of a little serous fluid, the appearance of a coil of small 
 intestine or of omentum, the opening should be at once taken up with 
 dissecting-forceps and tied round with carbolized silk or chromic gut, 
 and a little iodoform dusted round the opening. 
 
 3. A very fat loin. This is not a very uncommon source of diffi- 
 culty in elderly people who require colotomy. It must be met by a 
 very free incision in which all the tissues are cut equally throughout 
 (i.e., not making a conical wound deep only in its very centre). It 
 not only adds to the difficulty of finding the bowel, but also of retain- 
 ing it in situ afterwards. To meet the additional tension and tendency 
 of the gut to drag away in these cases, it must be more carefully 
 secured by close stitching, especially if it is necessary to do the oper- 
 ation in one stage, every care being taken to prevent extravasation of 
 faeces into the surrounding cellular tissue. ;{; In fat people the surgeon 
 
 * It is noteworthy that the intestine may be found empty, even in obstructions of 
 long continuance. Thus, Mr. Curling {Diseases of the Rectum, p. 182) writes : " In a 
 case of carcinomatous stricture of the rectum, in which I performed colotomy, after a 
 month's obstruction, in a woman aged forty, not only was the colon contracted, but it 
 was actually compressed against the spine, and put out of the way by the distended 
 small intestine, so that it was impossible to reach the bowel without opening the peri- 
 toneum. No inflammation or unfavorable symptoms resulted." It would have been 
 interesting to know whether more than one obstruction did not exist in the large 
 intestine in this case. 
 
 t In a case in which, owing to the e.xtreme pain during defecation, the patient had 
 dreaded any action of the bowels, and had eaten very little, the colon was much con- 
 tracted and lay far back. In trying to find it, I opened the peritoneum, and omentum 
 pi'Otruded. A carbolized sponge was kept over the opening while the colon was found, 
 the opening then tied up with chromic gut, and the colon not opened for four days. 
 No ill result followed. As in supra-pubic lithotomy, the peritoneum may give way 
 during vomiting. Thus Dr. Walters (Brit. Med. Journ., 1879, vol. i. p. 212) was 
 stitching the colon to the wound when "the patient retched violently, causing the peri- 
 toneum to give way and a coil of intestine to protrude from the anterior part of the 
 wound. This was immediately covered with warm sponges, cleansed from the feculent 
 matter it had acquired by contact with the open colon, and returned." When, five 
 weeks later, the patient sank from e.xhaustion, no trace of peritonitis was found at the 
 post-mortem examination. 
 
 J As much of the wound as is possible should be closed before tlie intestine is 
 opened. 
 
LUMBAR COLOTOMY. 603 
 
 must be prepared, not only for much subcutaneous but for abundant 
 extra-peritoneal fat also, coarse, and difficult to dissect in. If, in 
 such a case, the colon is contracted, there are few more difficult 
 operations. 
 
 4. Presence of a meso-colon. This may be a cause of much difficulty 
 and doubt, and render opening of the peritoneum necessary. Where 
 this is the case, the surgeon should always defer opening the colon if 
 possible. Mr. Jessop {Brit. Med. Journ., 1879, ii. 614) mentions cases 
 in which, owing to the presence of the above, he was obliged to open 
 the peritoneal cavity and incise the gut through its peritoneal coat. 
 The cut edges of the bowel, brought through the opening in the peri- 
 toneum, were stitched to the skin as in the ordinary operation. No 
 bad effect followed. Mr. Bennet May (Brit. Med. Journ., 1882, i. 940), 
 operating on the right side, found an empty colon, " and it was only 
 by keeping strictly in Allingham's line, and patiently searching there 
 between the layers of a great length of meso-colon, that the intestine 
 was reached, collapsed and empty." 
 
 5. Abnormality of colon. Every surgeon must remember cases in 
 which the descending colon, though present, was displaced, and came 
 down in the middle line. Occasionally part of the large intestine is 
 actually absent. Mr. Lockwood {St. Barthol. Hosp. Reports, xix. 256) 
 mentions three cases in which the colon could not be found at opera- 
 tions ; in two its absence was verified post mortem, both on the right 
 side. One of these cases is reported fully. The following are the 
 main points : Owing to obstruction of the large intestine, the site of 
 which was doubtful, it was decided to cut down on the right colon. 
 No colon could be found, and, relief being imperatively demanded, 
 the peritoneum was opened and a looped small intestine drawn out- 
 side the wound. Death occurred four hours after the operation, and 
 at the autopsy the right colon was quite absent,* the caecum being 
 found behind the liver in the right hypochondrium, the large intes- 
 tine extending from this to the splenic flexure in the usual manner. 
 
 If the colon cannot be found, three courses are open to the surgeon 
 — (a) To open the small intestine through the peritoneum from the 
 colotomy incision. The objections to this step are that it is very fatal, 
 and that there is no telling what part of the small intestine is ojsened. 
 (/?) To perform colotomy on the opposite side, and if the colon is here 
 distended, to open it, by two stages when practicable. This is the 
 course that should always be followed if possible, (y) If no colon can 
 
 * Mr. Lockwood (Brit. Med. Journ., 1882, vol. ii. p. 574) explains the abnormalities 
 of the large intestine by the fact that, during its development, it is very mobile, the 
 caecum occupying first the umbilical, then the left, next the right hypochondrium, 
 and, finally, the right iliac region, abnormalities following its arrest at any part of its 
 course. 
 
604 OPERATIONS ON THE ABDOMEN. 
 
 be found, or if the part found is below the obstruction, the linea alba 
 should be opened to admit two fingers to explore for the displaced colon, 
 and, if no colon can be found, to draw up and attach a loop of small 
 intestine, chosen as near the cfficum as possible. Or Nfelaton's opera- 
 tion may be performed, this being the wiser step if the patient is ex- 
 hausted by a previous prolonged operation. 
 
 6. Malignant disease at the site of colotomy. This is best met by 
 performing colectomy in appropriate cases, or by performing coloto- 
 my on the opposite side. 
 
 Troubles which may be met with after Colotomy. 
 
 1. Too large an opening in the bowel. This may lead to prolapse 
 of the mucous membrane. If this take place to a large extent it is a 
 great nuisance to the patient, owing to the moist, excoriated, bleeding 
 surface which results, difficult to keep up by any apparatus. Even 
 where the opening has been small, a good deal of prolapse may take 
 place if there is much cough and a flaccid condition of the side. 
 
 2. Too small an opening in the bowel. This is of much less moment, 
 as it can be readily dilated by tents.* Of these, laminaria are much 
 the most efficient'; two should be inserted at a time to effect rapid 
 dilatation. Then the opening is easily kept i)atent by the occasional 
 insertion of the little finger, and by the wearing of a proper plug. 
 
 3. Teasing descent of scybala into the bowel below the artificial 
 anus. This, which often renders a colotomy disappointing, is best 
 met by bringing the colon sufficiently into the wound at first by mak- 
 ing and keeping patent an adequate opening. If scybala still find 
 their way down, the colon may be washed out from the anus or the 
 wound. If these fail, the only course, and one by no means devoid 
 of risk, is to open up the wound, to divide the bowel, and attach the 
 upper end in the wound, and then to ligature the lower end and drop 
 it in. 
 
 Causes of Death after Colotomy. 
 
 1. Peritonitis. This may be due to the operation directlj^, or more 
 indirectly from fiecal or jjurulent retro-peritoneal extravasation, or 
 from septicaemia. Often it is not due to the operation, but to the want 
 of it at an earlier stage. Thus, the distended bowel may have given 
 way just above the obstruction ; often it is that weak spot, the caecum, 
 which is found perforated after the stress of distension. f 
 
 * Tliese should, of course, be secured when in situ. If, however, the surgeon finds 
 that a tent has accidentally slipped into the colon, he need not fear any disaster. This 
 accident happened in two of my cases, owing to the dressers not having taken efficient 
 steps to prevent it. One was passed ; the other was never heard of in the year and 
 nine months during which life lasted after the operation. 
 
 f Tlie following reasons have been given in explanation of this well-known fact — 
 viz., the proneness of the coecum to give way under the stress of distension, and even 
 
INGUINAL COLOTOMY. 605 
 
 2. Extravasation of feces and burrowing suppuration. This is 
 especially liable to happen in very fat patients, in whom there is 
 difficulty in getting the colon well up into the wound, especially if the 
 bowel must be opened at once. As the fasces pump out under high 
 pressure,* a free opening should in these cases be made in the bowel 
 after this has been secured as carefully as possible. 
 
 3. Exhaustion. Especially if the operation has been deferred too 
 long. 
 
 4. Vomiting. This has been noticed in a few cases to occur obsti- 
 nately and fatally after colotomy. Mr. Couper {Brit. Med. Journ., 
 1869, ii. 557) thinks that it is not an unfrequent cause of death, and 
 suspects that traction on the bowel, its proximity to the stomach, and 
 the fact that both receive nerves from the solar plexus, will account 
 for this. 
 
 5. Septic cellulitis, erysipelas, etc. 
 
 6. Broncho-pneumonia ; pleuritic effusion, especially if the wound 
 has become septic in an exhausted patient. 
 
 INGUINAL OR ANTERIOR COLOTOMY. 
 
 This, when performed on the left side for opening the sigmoid 
 flexure, is known as Littrfe's operation. 
 Indications. 
 
 1. Inguinal colotomy is usually performed on the left side in cases 
 of malformation of the rectum, when this part of the intestine cannot 
 be found by a dissection in the perineum. It has been disputed in 
 these cases whether, after an unsuccessful exploration in the perineum, 
 an inguinal or a lumbar colotomy should be jjerformed. The great 
 majority of surgeons have preferred the former operation, following 
 here Mr. Curling. f This surgeon pointed out that the lumbar opera- 
 tion was contraindicated on the following grounds : (o) the death-rate 
 is relatively greater ; (/3) the kidney, varying in size at this time of 
 life, may, when large, overlap the colon ; (y) the colon, instead of being 
 distended with meconium, as might be expected, is sometimes con- 
 when at some distance from the obstruction. Dr. Coupland and Mr. Morris {Brit, Med. 
 Journ., 1878) attribute it to the cul-de-sac nature of tliis part of the intestine ; its fixity ; 
 dependent position ; its being the place where two currents meet — viz, from the ileum 
 and, in case of regurgitation, from the colon ; and the pressure to which it is subjected 
 between the iliacus and the abdominal muscles. Mr. Lockwood (St. Barthoh Hasp.. 
 Reports, vol. xix. p. 26) thinks that tlie explanation lies rather in the peculiarity of 
 structure of the csecum, as it contains a very large amount of lymphoid tissue, and as its. 
 walls are not strengthened equally with other parts of the large intestine by encircling 
 bands. 
 
 * The danger of this may perhaps be diminished by the use of a trocar (p. 609). 
 
 f Diseases of the Rectum, p. 228. 
 
606 OPERATIONS ON THE ABDOMEN. 
 
 tracted and very hard to find ; (5) in addition to the irregularities in 
 the position of the colon which have already been mentioned, a meso- 
 colon is frequently present* 
 
 Mr. Morrant Baker,t as far as I know, is the only surgeon who has 
 of late years advocated the lumbar operation in cases of imperforate 
 rectum. His reasons appear to be that he thinks that Amussat's opera- 
 tion gives these cases " a good chance of an unwounded peritoneum," 
 and that those who think Littre's operation the better one do so 
 on insufficient grounds. It is noteworthy that Mr. Baker's case, though 
 most successful and ahve when last heard of, nearly three years after 
 the operation, was not sent to him till the nineteenth day after birth, 
 when " the abdomen was enormously distended, and the vomiting fre- 
 quent, and the child much exhausted." No doubt if we could always 
 thus defer operating in these cases, lumbar colotomy would be rendered 
 much safer, but the peril of the children would be much increased. 
 But from my experience at Guy's and the Children's Hospital with 
 which I am connected, the surgeon is called upon to interfere long 
 before this. The question was raised by M. HuguierJ whether, when 
 the inguinal operation was going to be performed, the right loin should 
 not be chosen, as he considered that on this side the surgeon was more 
 certain to reach some part of the large intestine. M. Giraldes, § on the 
 other hand, has shown that all the inquiries undertaken to elucidate 
 this subject tend to show clearly that the surgeon may rely on finding 
 the sigmoid in the left groin. " Numerous anatomical investigations, 
 together with the records of those of Curling and Bourcart, have shown 
 me that in the great majority of cases in the fretus and newly born 
 child the sigmoid flexure is placed on the left and not on the right. 
 In 134 autopsies below the age of a fortnight I found the sigmoid 
 flexure on the left side in 114; in 50 cases of Littre's operation which 
 I have collected the operator always met with the sigmoid flexure on 
 the left side; in 30 post-mortem examinations of infants operated on 
 for imperforation the intestine was always found on the left; in 100 
 examinations of new-born children Curling found the sigmoid flexure 
 
 * Mr. Curling {loc. supra cit.) gives the results of twenty dissections on the bodies 
 of infants, both operations having been first performed. In eighteen out of the twenty, 
 Littre's operation was found easy, whether the bowel was distended or no. In two, 
 this operation failed, as the colon crossed the spine to run down, on the right side, into 
 the pelvis. In eight out of the twenty subjects, lumliar colotomy was easily performed, 
 without opening the peritoneum. In six, the operation was " more or less difficult," 
 and, as Mr. Curling remarks, the diflSculties would have been increased in the living. 
 In six, lurnbar colotomy was impossible owing to the distinctness and looseness of the 
 meso-colon. 
 
 t Clin. Snc. Trans., vol. xii. p. 240. 
 
 J Bull, de I' Acad, de Sled., torn. xxiv. p. 445. 
 
 'i Lcr^. Cliniq., p. 121. Quoted by Mr. Holmes {Dis. of Children, p. 179), 
 
INGUINAL COLOTOMY. 607 
 
 on tlie left side 85 times ; and Bourcart, who made prolonged researcheB 
 in order to elucidate this question, found the sigmoid flexure in its 
 normal position 117 times out of 150." 
 
 2. It has been proposed by some surgeons^e.gr., Mr. Reeves and Mr. 
 H. Allingham* — to perform inguinal instead of lumbar colotomy 
 in those cases of malignant ulceration which are by the majority of 
 surgeons considered to call for the latter operation. The following 
 are the reasons given by the latter surgeon : (a) The position for the 
 administration of ansesthetics is better if the abdomen be distended. 
 To this I should reply that the cases are comparatively few in which 
 colotomy is performed with much distension present, and that, with 
 increasing carefulness in diagnosis, it should always be easy in these 
 cases of chronic obstruction to prepare the patient for submitting to 
 this operation before much distension is present, and at a time when 
 the operation by two stages can be performed. (/?) The sigmoid does 
 not tend to fall away from the wound. This is no doubt sometimes 
 troublesome in lumbar colotomy, in spite of an assistant making firm 
 pressure on the abdomen, (y) Mr. Allingham thinks that the diffi- 
 culties of a lumbar colotomy are so great as frequently to end in the 
 peritoneum being opened. Having seen one case in which it was 
 found needful to open the peritoneum and insert the hand to discover 
 the ascending colon, and in which the patient did well, he goes on to 
 say, " Since that case, when performing lumbar colotomj'", after a fair 
 trial has been made to find the gut which fails, I always purposely 
 make a small opening in the peritoneum, introduce my finger, and 
 feel for the gut; if this does not succeed, I enlarge the opening and 
 introduce my hand into the belly ; by one of these means one cannot 
 fail to find the large intestine." Without disputing the truth of this 
 last remark, it would be interesting to know the results if it were need- 
 ful to perform colotomy in this way on a large scale. (5) Mr. AUingham 
 does not think much of the objection to inguinal colotomy in these 
 cases, that it is too near the disease, as he has found from experiments 
 on the dead body that, as a rule, only 4 inches intervene between the 
 inguinal and lumbar operations, and as cancer of the sigmoid flexure 
 is so rarely met with. With regard to the first of these points I would 
 suggest that an artificial anus placed 4 inches away from the disease 
 may be a very different thing as regards the comfort of the patient to 
 one placed close to it. As to the rareness of disease in the sigmoid 
 flexure, the remark of Mr. Arlington does not coincide with the expe- 
 rience of Dr. Brunton and Dr. Fagge (p. 594). 
 
 It will be seen that I do not agree with the reasons brought forward 
 by Mr. Allingham for preferring the inguinal operation. One point I 
 
 * Brit. Med. Journ., 1887, vol. ii. p. 874. 
 
608 OPERATIONS ON THE ABDOMEN. 
 
 think has not had sufficient prominence given it, and will, for some 
 time at least, prevent the inguinal operation displacing the lumbar, 
 and that is, the fact that the peritoneum must be opened in the 
 former, while in the latter it is only exceptional to do so. I cannot 
 agree with Mr. Allingham in his words, " Now that surgery, through 
 perfect cleanliness, has made such gigantic strides, and the peritoneum 
 is no longer held in awe as in former days, the opening of that serous 
 cavity, if due care be taken, does not to any great extent increase the 
 dangers of the operation, and is certainly not more harmful to the 
 patient than the disturbance of cellular tissue and parts around, so 
 frequently incurred when there is difficulty in finding the bowel in 
 lumbar colotomy." Even if a larger number of cases of inguinal 
 colotomy show the operation to be as safe as it was in Mr. Allingham 's 
 hands in five cases, I cannot think this operation so generally suited 
 to all cases, and to all operators, as the lumbar one. Difficult 
 as this undoubtedly is sometimes, and I have not made light of this 
 matter (p. 601), I think that the difficulties are not likely to produce 
 such serious results as a general adoption of inguinal colotomy, with 
 its needful opening of the peritoneum. 
 
 I have no space here to discuss the question as to whether an anus 
 in the loin is superior to one in the groin. While I am aware that 
 French surgeons* have published several cases in which patients with 
 Littrfe's operation have grown up, gone into society, and m'arried, I 
 should have thought that one in the groin would have been, for obvi- 
 ous reasons, more repulsive in the relations of adult life. 
 
 Operation. — The parts being duly cleansed, an incision li to 3 
 inches long, according to the age and fatness of the patient, is made 
 parallel with the outer third of Pou])art's ligament and about i inch 
 above it. The structures are divided partly with the knife, and more 
 deeply with the point of a steel director, the muscular branch of the 
 circumflex iliac given off near the anterior superior spine being thus 
 torn through in a child, and secured in an adult. The transversalis 
 fascia being reached, it is slit up, and all ha3morrhage most carefully 
 arrested before the i^eritoneum is opened. This is then incised for 
 about 1 inch, and in an adult especially should be united to the cut 
 muscle and skin with a few points of suture, one or two sponges 
 attached to silk being first inserted to prevent any blood entering the 
 peritoneal cavity. The surgeon then examines the piece of intestine 
 which has first presented into the wound. If there be any doubt about 
 this, it should be gently pulled upon ; if the coil comes out readily 
 
 * See the quotations from M. Kochard's paper in Mr. Holmes' Surg. Dis. of Children, 
 p, 173. M. Rochard lived in Brest, where malformation of the rectum is said to be 
 extremely common. 
 
INGUINAL COLOTOMY. 609 
 
 with a well-defined mesentery, it is of course small intestine. Lar,L;:e 
 intestine, on the other hand, is more fixed, its mesentery is attached 
 to the left side,* while it shows, in an adult, longitudinal bands and 
 appendices epiploicffi. 
 
 The intestine is now stitched with fine carbolized-silk sutures to the 
 surrounding edges of the wound, the stitches not taking up if possilile 
 the mucous coat. The peritoneal surface of the intestine is thus 
 closely opposed to the parietal peritoneum stitched around the wound. 
 During all these steps the greatest care should be taken to prevent any 
 fluids or gas reaching the peritoneal cavity, and any sponges introduced 
 are withdrawn one by one as the surgeon unites the circumference of 
 the intestine and the wound, paying particular attention to the parts 
 around the spot where he intends to open the intestine, and also to 
 the angles of the wound. 
 
 If opening the bowel may bo deferred, a little iodoform being 
 dusted on, dry dressings are applied and left undisturbed, if possible, 
 to the third day.f 
 
 If 'it is needful to open the intestine at once, or soon after the 
 operation, this should be done, as Mr. Barker J advises, with a trocar- 
 puncture. In an infant, and adults with distension, there will be 
 meconium or jDrobably sufficient fluid fa?ces to run off in this way 
 and give. relief, thus avoiding risk of contamination to the jDeritoneal 
 cavity. 
 
 Mr. H. Allingham, in order to secure the formation of a good spur, 
 and thus to prevent the passage of fasces below the opening and over 
 the growth, recommends the following way of treating the bowel:; 
 " When the gut is found and brought to the surface, I look for a piece 
 with a sufficient mesentery ; of course this can only be done if the 
 disease is in the rectum or lower part of the sigmoid, for only the part 
 
 of the sigmoid first picked up has quite sufficient mesentery A 
 
 needle threaded with carbolized silk is passed through the mesentery 
 close to the intestine on both sides, then through the abdominal walls 
 on both sides nearer the lower than the upper angle of the wound, 
 and these are tied up tight. If there is little or no meso-colon, I am 
 obliged to pass the suture through the muscular and serous coats of 
 the gut at its posterior part. Leaving a piece of loose gut outside the 
 wound, I next sew it all round the skin, passing the thriE-ad only 
 through the muscular and serous coats of the gut at its posterior 
 part To open the gut I use scissors, cutting the intestine from 
 
 * Cripps, Diseases of Recimn and Anus, p. 46. 
 
 t As stated in the account of coiotomy and gastrostomy by two stages, the exposed 
 surface of the viseus is so altered with lymph, etc., that a guiding stitch should always 
 be made use of in adults. 
 
 J Man. of Surg. Oper., p. 309. 
 
 39 
 
610 OPERATIONS ON THE ABDOMEN. 
 
 above downwards to the extent of about 1} inch ; through the incision 
 can be seen two orifices separated by a well-formed spur, the upper 
 opening being the lar-er, the lower the smaller." The lower of these 
 is only required to clear out the rectum and to allow any retained 
 ffEces,' etc., to come up. Mr. Allingham points out that it is import- 
 ant to fasten the gut well outside of the wound, for it is only by so 
 doing that a good spur and its results are obtained. 
 
 CHAPTER IV. 
 
 OPERATIONS ON THE KIDNEY. 
 
 NEPHROTOMY — NEPHRO-LITHOTOMY — NEPHREC- 
 TOMY— NEPHRORRAPHY. 
 
 NEPHROTOMY. 
 
 As this operation is performed by the same steps which form the 
 preliminaries of more important operations * and as the conditions 
 which call for it are dealt with a little later,t it will be only briefly 
 considered here. 
 
 Indications. — Partly as an exploratory and partly as a curative 
 step. (1) In hydro-nephrosis resisting tapping. (2) In pyonephrosis, 
 the pelvis and ureter being carefully explored. (3) In tubercular 
 kidney, and in suppression of urine, probably calculous. 
 
 Operation. — The kidney, being exposed by the incision given 
 fully below, is punctured with a fine trocar, and the puncture con- 
 verted into a small incision, which is plugged with the finger, and 
 dilated with this and dressing-forceps. An assistant steadies the 
 organ by firm pressure from the front. When the fluid has been 
 evacuated, very free drainage must be provided, by the largest sized 
 drainage-tube, any cj'st opened being stitched to the margins of the 
 wound, and the same precaution being adopted in the case of a sup- 
 purating kidney which drops down much, and will probably allow of 
 septic leakage into the cut jilanes of cellular tissue. 
 
 Hffimorrhagc is not unfrequently met witli in the form of trouble- 
 some oozing from a suppurating kidney. In a delicate tubercular 
 patient this must be promptly arrested bj'- plugging the wound in the 
 kidney itself by strips of aseptic gauze carefully packed around the 
 drainage-tube, and bandaging with firm, even pressure. 
 
 * See tlie full account oTnephro-litliotomy, p. 613. 
 
 f E.g., tubercular kidney, at p. 623 ; hydro-nephrosis, at p. 624. 
 
KEPHUO-LITHOTOMV. 611 
 
 NEPHRO-LITHOTOMY. 
 
 Indications. — Before deciding to perform the above operation, 
 safe as it usually is, the surgeon should carefully consider the follow- 
 ing points : 
 
 A. Evidence of Existence of a Renal Calculus. — Some of the following 
 will usually be present, though the way in which renal calculi, even 
 of large size, are sometimes tolerated without any symptoms what- 
 ever, is remarkable and well known (pp. 613, 620). 
 
 i. Pain. This is usually twofold, (o) Constant, dull, aching, fixed 
 just below the last rib and outside the quadraliis lumborum. {^Ij) Ra- 
 diating along the branches of the lumbar plexus — e.g., into the lower 
 part of abdomen, hip, thigh, and testicle.* These pains are made 
 worse after exercise, any rough walking or jolting, repeated flexion of 
 the thigh,f or lateral twisting of the body. It is often felt severely at 
 night, a fact which may be explained in two ways. Thus, Mr. Morris 
 thinks it is due to the passage of flatus in the colon over the kidney 
 and calculus. It may also be exjdained by the probable concen- 
 tration of the urine at this time. 
 
 The pain of renal calculus has occasional exacerbations of two 
 different kinds — (1) Those due to the passage of a renal calculus 
 well known, and needing no further mention here. (2) Others, often 
 repeated and periodic, without any passage of stone; these are 
 probably due to additional deposit on the surface of the calculus, or 
 to temporary interference with the exit of the urine from the kidney. 
 
 ii. Tenderness in the loin, and, perhaps, rigidity of the muscles. 
 
 iii. Heematuria. This is almost always present at some time or 
 another, at least to microscopic examination, especially if the calculus 
 is in the kidney tissue, or a calyx, not in the pelvis. It is most pro- 
 fuse after exercise. This, on the whole the most valuable sign (vide 
 infra), was entirely absent in the case of the patient from whom I 
 removed the smaller stone figured on p. 622. No amount of running 
 up and down stairs, practicing twisting movements of the spine, or 
 fj-equent flexing the thigh on the abdomen ever produced hematuria. 
 I often thought that if it had been justifiable' to persuade him to 
 
 * In a case of Mr. BiUlin's (Clin. Soc. Trans., vol. xv. p. 113) the patient sought 
 relief from severe neuralgia of the right testis, which was generally retracted and 
 extremely tender. Later on it was noticed that these neuralgic attacks were associated 
 with some lumbar pain and tenderness. Complete recovery followed after the removal 
 of a small, prickly, calcium oxalate calculus from the pelvis of the right kidney. 
 
 t As in going upstairs, probably from the pressure on the kidney by the contracting 
 psoas. But the relation (if the pain to movement, and the kind of movement which 
 most induces pain, vary greatly. Thus Mr. Butlin's patient is said to have suffered 
 greatest pain when driving, least when riding. Prolonged walking seems tlie most 
 frequent cause. 
 
612 OPERATIONS ON THE A3DOMEN. 
 
 " stand a back " in leap-frog the above decisive symptom might have 
 been obtained. 
 
 iv. Examination of the urine. By this information may be ob- 
 tained as to the presence of uric-acid or lime-oxalate crystals, or blood 
 discs, the information being important according to their frequency. 
 
 V, History of the patient, as bearing on his liability to oxaluria or 
 lithiasis. Of these, the former, formed in the kidney itself, is brought 
 about by imperfect oxidation and metamorphosis both of tissues and 
 foods — e.g., by (1) abuse both of nitrogenous and non-nitrogenous 
 foods, viz., starch and sugar ; (2) insuificient oxidation and deficiency 
 of red-blood corpuscles ; (3) sedentary habits ; (4) a jaded nervous 
 system going with over-much head-work, over-fatigue, sexual hypo- 
 chondriasis. Lithiasis, on the other hand, is due to hepatic derange- 
 ment, leading to the production of insoluble lithic acid and lithates 
 instead of soluble urea. Thus the importance of a history of generous 
 living and little exercise, habitual surfeiting from dining out, etc. 
 
 B. Failure of Preiious Treatment to give Relief. 
 
 C. Inability to Work from Inevitable Attacks of Pain. 
 
 D. Absence of Symptoms refei-able to the other Kidney. 
 
 E. The Urine. — This should be as nearly normal as possible, both 
 in amount and as to the proportion of solids, especially urea. The 
 percentage of this, with ordinary diet, should be aboiat 2. The re- 
 action of the urine should be distinctly acid, and its daily amount 
 about 2 pints. The temperature of the patient, the state of his skin, 
 and his power to assimilate food should also be carefully noted. 
 
 Preparatory Treatment before Operation. — The diet should 
 be very simple, mainly fluids — e.g., thin soups, a little white fish, game 
 or poultry, poached eggs, light puddings, flavored, not sweetened, 
 jellies. Sufficient water to sluice out the kidneys, and prevent con- 
 centration and formation of crystals — e.g., soda-water, ApoUinaris, 
 Salutaris, well-diluted whisky, or Marsala. Attention should also be 
 paid to the bowels and skin. All chills should be scrupulously 
 avoided. 
 
 Conditions simulating Renal Calculus.— Some attention will 
 here be given to this point. For while the operative treatment has 
 been placed on a firm basis, the diagnosis is still, not unfrequently, at 
 fault. 
 
 Putting aside lithiasis as giving rise to the passage of acid urine, 
 crystals, and thus pain ; movable kidney as, while painful, causing 
 very different pain, not producing hix?raaturia, and as being associated 
 with certain other well-known evidence, there remain a few other con- 
 ditions which very closely simulate renal calculus. These are, first 
 and foremost, a tubercular kidney, before it is advanced, with its pain, 
 a certain amount of htematuria, and frequent micturition. Probably, 
 
NEPHRO-LITHOTOMY. 613 
 
 however, the pus being m excess here will give a hint as to tlic nature 
 of the disease. Bacilli detected in the urine will be decisive.* My 
 old friend George Wright,t of Manchester, lays stress upon the fact 
 (previously mentioned by- Mr. Bennet May J) that in some cases spinal 
 caries may very closely simulate renal calculus. The following are his 
 words : If " we remember the great number of symptoms wliich may 
 be present in renal calculus, and, on the other hand, bear in mind that 
 no two of them necessarily co-exist in cases where a stone is present, 
 we shall see that there is occasionally much difficulty. Thus, where 
 a local patch of caries of a vertebral body exists, and especially where 
 deep suppuration occurs and presses upon the kidney, as in a case of 
 my own and one or two others that I have seen, nearly all the symp- 
 toms of calculus have been present. In my own case, without any 
 deformity or tenderness of the spine, there was unilateral rigidity, 
 testicular pain, intermissions of symptoms, increased frequency of 
 micturition, nausea during attacks, and oxaluria, with local pain and 
 tenderness ; subsequently an abscess developed, and, on exploration, 
 a small patch of caries was found, and the kidney was felt exposed in 
 the anterior wall of the abscess cavity." 
 
 Quite a diilerent condition, in a case of my own, so closely imitated 
 renal calculus that it deserves mention. A man, born and having 
 passed his early boyhood in Norfolk, was in childhood cut for stone 
 in the bladder, by Mr. Birkett, in Guy's Hospital. As he grew up he 
 followed the sedentary occupation of a tailor, and passed gravel at 
 times. He came under my care for pain in the right loin, fixed just 
 below the last rib and outside the quadratus lumborum,but also radi- 
 ating into the thigh, buttock, and abdomen ; hematuria and frequent 
 micturition were present in addition. Careful examination of the 
 bladder§ giving negative results, the right kidney was explored, but 
 thorough manipulation, aided by frequent acupuncture, revealed 
 nothing. Five days later the patient died very suddenly. A small 
 mass of carcinoma involved the n'^/Ai twelfth dorsal nerve just outside 
 
 * An exaininalion of the viscera, including testis, cord, prostate, and vesicidse semi- 
 nales, will, of conrse, help in doubtful cases. 
 
 t J\fcd. Chron., vol. v. No. 6, p. 462. The- following are the concluding words of this 
 interesting paper : "My own conclusion is that renal hfematuria is the only single 
 symptom iif anything like cardinal injportance, and that this, if the trouble is of more 
 than a year's standing, and there is no evidence of nephriti'^, and there is no tumor to 
 be felt, makes the diagnosis of calculus fairly certain." 
 
 X Birmmciham Med. Review, January, 1887. 
 
 I The htematnria, frequent micturition, and acid urine led me to discuss the proba- 
 bility of growth in the bladder. The urine was repeatedly examined for cells, and the 
 bladder was soimded under chloroform in the hope of detaching some growth. This 
 was, however, nullified by the position which the primary growth occupied, and by its 
 small size. 
 
614 OPERATIONS ON THE ABDOMEN. 
 
 its exit from the spinal column. This was secondary to a patch, very 
 thin in depth and slight in extent, of soft carcinoma, affecting the 
 mucous membrane of the bladder, at the apex only. The left^' kidney 
 was occupied by a large branching calculus, its cortex being in the last 
 stage of atrophy. The suddenness of the death seemed due to embolic 
 masses of the secondary growth, where it involved the pelvic glands, 
 eroding and entering the external iliac vein. 
 
 Operation. — The patient being in much the same position as that 
 for lumbar colotomy, on the sound side, with a firm pillow under the 
 opposite flank, the surgeon defines, carefully, the lower border and 
 length of the last rib. That this is not an unimportant detail in renal 
 operations 'is proved by the fact that Prof. Dumreicher,t of Vienna, 
 accidentally opened the pleural cavity during an attempt to remove a 
 pyo-nephrotic, calculous kidney. Post mortem it was found that the 
 last rib was rudimentary, that the pleura projected a good deal below 
 the lower edge of the eleventh rib, and that thus, when the incision 
 was carried upwards, the accident had become unavoidable. Dr. Lange, 
 of New York, has called aitention to the investigations of Dr. Holl,t 
 of Vienna, on the frequency of rudimentary development of the last 
 rib, and the importance, therefore, of counting the ribs before intended 
 operations on the kidney. Dr. Lange§ himself shows that, in some 
 cases, which are, however, exceptional, even normal development of 
 the twelfth rib may demand extreme caution, as the pleura may pro- 
 ject considerably below it.|| 
 
 The surgeon, having defined the length and position of the lowest 
 rib, makes an incision,^ 4 inches long, I inch below it, and beginning 
 about 2i inches from the spine. The skin and fasciae being divided, 
 the muscles — viz., anterior fibres of the latissimus dorsi, the external 
 and internal oblique — are cut through, either on a director, or simply 
 by light sweeps of the knife. As soon as the )'ellowish-white lumbar 
 fascia is reached, any bleeding vessels which have been temporarily 
 
 * No history of pain had been given here, the patient's attention having been drawn 
 to the right side, where so terrible a cause of siifTering existed. As bearing on the 
 latency of the calculus liere, I would refer my readers to p. 620. 
 
 t Quoted by Dr. Lange, loc. infra fit. 
 
 X Dr. HoU found that in quite a considerable percentage the last rib is so abnorma>lly 
 short that it does not reach as far as the outer border of the sacro-lumbalis, or so rudi- 
 mentary that 'in some cases it more resembles a transverse process ; that in these cases 
 the lower edge of the pleura passes from the lower boundary of the last dorsal vertebra, 
 almost horizontally, towards the lower edge of the eleventh rib. 
 
 ^ Annals of Siirgerg. vol. ii. -October, 1885, p. 286. 
 
 II In other cases the re\>erse condition may be present; though the last rib be rudi- 
 mentary, the pleura may pass from the lower edge of the eleventh dorsal vertebra 
 horizontally towards the eleventh rib, and thus be altogether out of danger. 
 1[ The parts being previously cleansed with mercury-perchloride solution (1 in 1000). 
 
NEPHEO-LITHOTOMY. 615 
 
 secured with Spencer Wells' forceps are tied or twisted. If the last 
 dorsal nerve cross the incision, it, together with its accompanying- 
 vessels, should be drawn aside and left untouched if possible. The 
 lumbar fascia is next slit up on a director. The peri-renal fat which 
 next bulges into the wound is then torn through with two pairs of 
 dissecting-forceps. With two large retractors opening up the wound, 
 the surgeon continues to tear through the above fat* till he can see or 
 easily feel the posterior surface of the kidney. During this first stage 
 of the operation the surgeon will find sometimes that the muscles are 
 much thickened by reflex irritation from the presence of the stone, 
 and, if the stone has been combined with suppuration and peri-renal 
 inflammation, the tissues will be more or less densely blended and 
 matted together. 
 
 An assistant now makes powerful pressure on the opposite side of 
 the abdomen so as to keep the kidney up into the wound, this being 
 widely opened by full-sized retractors, aided, if needful, by an assistant 
 pulling up the lower ribs with a hand previously made aseptic. Thus 
 the surgeon is enabled to examine the organ, which is done systemati- 
 cally; the finger is first directed to the jjelvis, then the posterior sur- 
 face; next, by passing the finger round the outer border, the anterior 
 surface, which, as Mr. Howse has pointed out,t can be done effectually 
 by pressing the kidney back against the firm unyielding psoas. The 
 sensation given by a stone has been compared to that of an uncut end 
 of a pencil,;}: or the last joint of a finger.§ 
 
 If no stone can be felt by the exploring finger, a needle should be 
 thrust into the different parts of the organ, exploring it bj^ successive 
 punctures made at short distances ; twelve or more such punctures 
 may be made. Some surgeons have advised a needle mounted in a 
 handle, or one held in torsion or Spencer ^^^ells' forceps ; a long hare- 
 lip pin answers all the purposes, and is devoid of the vibrations which 
 are liable to accompany a needle held in forceps. || 
 
 If the above means, aided by exploring the kidney between the finger 
 and thumb, fail, it has been advised to incise the kidney itself I am 
 strongly of opinion that this, if done freely, is a hazardous step, though 
 not so much from the immediate bleeding. The hemorrhage which 
 may occur after scraping away the kidney and pelvic tissue over a 
 stone of long standing (Fig. 103), and over which the kidney substance 
 
 * If tliis fat is very abundant, some of it should be ligatured with chromic gut 
 and removed ; poorly vitalized, it is prone to suppurate tediously and to delay healing, 
 t Clin. Soc. Trans., vol. xvi. p. 93. 
 t Morris. 
 
 I flowse, he. supra cit. 
 
 II If the kidney is at all enlarged, a fine aspirator-needle would be preferable in 
 case any pyo- or hydro-nephrosis is present as a result of the stone. 
 
616 OPERATIOXS ON THE ABDOMEX. 
 
 is atrophied, may be very free. Such hfemorrhage is very likely to 
 need plugging. If a free incision be made into a kidney healthy in 
 size and structure in search of a small stone, it is almost certain to be 
 followed by profuse hajmorrhage. Plugging may arrest this, but the 
 hfemorrhage may reeur, and repeated plugging is very likely to lead 
 to fatal cellulitis and retro-peritoneal suppuration.* Another, and I 
 think a preferable, method of exploring in doubtful cases, is to open 
 the pelvis, or the thinner kidney tissue close by, and to pass a finger 
 up into the organ, so as to explore the calyces, and then down into the 
 ureter, in the hope of tracing a stone.f If additional room is required, 
 the outer edge of the quadratus lumborum may be divided; if there 
 is still too little space for exploring, the incision should be converted 
 into a T-shaped one, by cutting downwards towards the crest of the 
 ilium with a probe-pointed bistoury from within outwards, and at once 
 securing any cut vessels. When the stone is easily detected, the pelvis 
 or the Iddney tissue is lacerated by the finger-nail,|: a curette, or sharp 
 spoon, and the stone turned out or removed with dressing or small 
 lithotomj' forceps. 
 
 If the stone is irregularly branched§ it may avoid some laceration 
 of the kidney tissue if it is broken up and removed in two or more 
 fragments. II In this case the bed in w'hicli the stone has been lying 
 
 * Such a. case occurred at Birmingham, and ended fatally. It is possible that 
 other operators may not have been so candid. 
 
 f In the following case under the care of Mr. T. Jones, of Manchester {3Ied. Chron., 
 June, 1887, p. 212), this step of opening the pelvis alone sufficed to find the stone, after 
 systematic exploration of the kidney had failed: "The forefinger was passed to the 
 anterior surface, and the organ grasped between tlie finger and the thumb; nothing 
 however, could be felt. The kidney was then carefully explored by systematic punc- 
 ture with a long needle, also passed towards the pelvis, but no calculus could be found. 
 An incision, snfHciently large to admit the tip of the index-finger, was then made 
 through the kidney substance into the pelvis by means of a fine bistoury. On intro- 
 ducing the forefinger, a small stone was discovered firmly lodged in one of thcsuperior 
 calyces. Small, straight lithotomy forceps were introduced, and the stone thus I'e- 
 moved." Very free haemorrhage attended the above incision, but it yielded to pressure 
 made with carbolized sponges and kept up for five minutes. The patient made a good 
 recovery. The calculus, consisting of lime oxalate, weighed twenty grains. Tliis plan 
 of opening the pelvis might be thought to cause a risk of leaving a urinary fistula, but 
 the numerous cases in which calculi have been removed from the renal pelvis with 
 entire success do not support this view. 
 
 X Mr. Morris [Dis. of the Kidney, p. 528) advises the use of the finger, as it will 
 sufficiently lacerate the kidney-tissue, while, at the same time, it plugs the wound. 
 
 ^ The question of nephrectomy, which may arise here, is considered below, p. 620. 
 
 II Mr. Kendall Franks [Lancet, 1880, vol. ii. p. 1223) thus removed, piecemeal, a 
 friable stone weighing 171 grains, and composed of lime carbonate and phosphates. 
 In this case the urine had been fetid, though acid. The wound healed by first inten- 
 tion. In cases of piecemeal-removal of calculi, especially when friable, a certain 
 ntnount of doubt will often remain as to the entire removal. 
 
NEPHRO-LITHOTOMY. 617 
 
 should be freely washed out with very dilute carbolic acid or satu- 
 rated boracic-acid lotion. 
 
 If the stone is situated on the anterior aspect near the centre of the 
 kidney where the large vessels he, the posterior aspect of the kidney 
 or its pelvis had better be incised and the stone pushed through, l.y 
 making pressure on the front, the vessels here thus running no risk 
 of damage. 
 
 If the kidney be enlarged, with its calyces expanded into cysts, on 
 scratching through the pelvis over a stone, the gush of fluid and col- 
 lapse of the expanded kidney may cause the stone to disappear, and 
 thus lead to much trouble in its removal (Symonds, Clin. Soc Trans., 
 vol. xviii. p. 181). 
 
 When the stone has been all removed, if blood continues to ooze 
 freely, and there is nothing to tie, it must be stopped by sponge 
 pressure, either by pressing sponges on sponge-holders for a few 
 minutes, or by packing the wound witJi sponges thoroughly car- 
 bolized and dusted slightly with iodoform, these sponges having silk 
 attached to admit of their ready withdrawal. If the oozing cannot 
 be arrest(^ by such pressure, any wound in the kidney must be 
 plugged with strips of iodoform gauze, which can probably be re- 
 moved in twenty-four hours.* 
 
 A full-sized drainage-tube should be introduced to the very bottom 
 of the wound, lying in close apposition to the wound in the kidney 
 or pelvis (or actually in it if this wound is large)t the rest of the 
 wound closed, and aseptic dressings applied. I have generally used 
 dry iodoform or sal alembroth gauze with boracic lint outside, kept 
 in situ with a many-tailed bandage. Salicylic wool or wood wool are 
 efficient substitutes. Whatever dressing is used will liave to be 
 changed twice daily, for, in all probability, three or four days, owing 
 to the soakage of urine. To reduce the irritation of this to a mini- 
 mum, the parts around the wound should be well smeared with 
 eucalyptus and vaseline. By means of pillows against the shoulders 
 and pelvis, the patient should be kept off the wound, otherwise dis- 
 charges will quickly soak out of the dressings, and the drainage-tube 
 will irritate the wound. 
 
 After-treatment. 
 
 The chief points here are : 
 
 1. The meeting of shock after a prolonged operation. 
 
 * If such plugging has to be made use of, it should be carried out efTectively and 
 once for all, otherwise recurrent bleeding and repeated plugging is very likely to 
 lead to cellulitis, which may end futally, to say nothing of the painfulness and shoclc 
 caused by tlie repetition of the plugging, unless an aiiiesthetic is given. 
 
 f If the kidney has contained pus or other fluid the tube must be carried well into 
 the cavity of the organ. 
 
618 OPERATIONS OS THE ABDOMEX. 
 
 2. Changing of the dressing at sufficiently frequent intervals at first, 
 according to the amount of urine and blood which soak through. 
 
 3. Gradual shortening of the drainage-tube instead of entire re- 
 moval, especially where there has been much interference with the 
 surrounding parts, or where pus, etc., have been present in the 
 kidney. 
 
 4. Avoidance of all chills. 
 
 5. Appropriate food, mainly the blandest fluids in regulated 
 amounts, especially where the condition of the other kidney is 
 doubtful. 
 
 Lastly, it may be pointed out that the after-histories of these cases 
 should be followed up most carefully, to see how far the cure remains 
 a complete one; to aid this, the patient should jsay life-long attention 
 to his diet, habits, exercise, etc. 
 
 Difficulties in Nephro-Lithotomy. 
 
 1. An insufficient incision. 
 
 2. Abundant fat — e.g., in the subcutaneous tissues, around the 
 kidney, and extra-peritoneal, rendering the wound very deep. 
 
 3. Rigidity, and perhaps thickening of the muscles, i^ue to the 
 irritation of the stone. This condition was present in a very marked 
 degree in a patient from whom I removed the smaller calcium-oxalate 
 calculus (Fig. 103). No amount of anaesthetic seemed to have any 
 effect on this condition. Fortunately the loin was a thin one, and 
 the stone very obvious on reaching the pelvis. 
 
 3. Matting of the parts around the kidney, rendering it difficult to 
 explore this organ, its different parts and relations exactly. 
 
 4. An indurated condition of the kidne}' itself from the irritation 
 of a stone. 
 
 5. A stone present but very difficult to detect. This may be due to 
 (a) The small size of the stone,* especially if it is in a calyx or com- 
 bined with a very indurated kidney. How exceedingly difficult, in 
 fact, at times, impossible, it is to detect a stone, even of fair size, is 
 shown by a case published by Mr. Morris, f in which this authority, 
 with all his experience, after thoroughly exploring the kidney, 
 compressing it all over witli the finger and thumb, and also aft6r 
 puncturing it, failed to detect a stone which lay in a hollowed-out 
 calyx. Though the calculus was the size of a small marble, it was so 
 
 * Mr. Haward {Lancet, lSS(i, vol. i. p. 1112) briefly records a case in which he ex- 
 plored the kidney in a patient witli " well-marked symptoms of renal calcnhis wanting, 
 however, in the presence of hsematnria." Nothing was fonnd, bnt the patient was 
 believed to have passed a stone abont three months later, after one of the old attacks 
 of pain. iSince this he had remained well up to the time of the report. 
 
 t Med.-Chir. Trans., vol. xlviii. p. G9. The woodcut (p. 73) shows well the relation 
 of the stone to the surrounding kidney. 
 
NEPHRO-LITHOTOMY. 619 
 
 thickly surrounded by kidney-tissue, that, even after the removal of 
 the kidney, the position of the stone could not be detected by press- 
 ing on the kidney with the fingers as it lay on a table. The patient 
 made a good recovery. 
 
 (b) A sacculated kidney, into one of which sacculi a small stone, 
 may fall and be hard to find (p. 617). 
 
 6. A stone on the anterior surface of the kidney, especially if near 
 the entrance of the vessels (p. 617). 
 
 7. A very large or a branching stone. Mere size does not neces- 
 sarily create difficulties in extraction, though, owing to the changes 
 entailed in the kidneys, the general health, etc., by the long duration 
 of a calculus, the prognosis is rendered very much less favorable. Thus, 
 in the calculus (Pig. 103) weighing 473 grains, or very nearly an ounce, 
 the very bulk of the stone rendered its detection easy ; it was readily 
 loosened from the much-dilated pelvis with lithotomy-forceps. A 
 branched calculus presents, of course, much greater difficulties. Mr. 
 Bennet May* has published an excellent instance of this kind in 
 which he successfully removed a very large somewhat S-shaped 
 caculus from a man aged thirty-four, with symptoms of sixteen years' 
 duration. Though the stone weighed 473 grains, and was three 
 inches long, manipulation failed to make it out distinctly, but acu- 
 puncture detected it a.t once. In such a case the kidney tissue must 
 be incised over the stone and the wound plugged and then enlarged 
 with the finger-nail. If the surgeon finds that he cannot dislodge the 
 first end of the stone which he exposes, he should either divide the 
 stone with a small pair of cutting-bone forceps, or expose the other 
 end, which may be smaller. 
 
 8. A stone which breaks up readily. Another condition allied in 
 difficulty is where a calculous deposit rather than a distinct calculus 
 is present. This is especially grave, as the deposit here will usually 
 be phosphatic, and point to co-existing pyo-nephrosis. These two 
 conditions are best met by a sufficient opening into the kidney, re- 
 moving with fine forceps, or scoops, every particle of stone, and then 
 thoroughly washing out the cavity with boracic acid solution or 
 Thompson's fluid.f 
 
 9. Multiple calculi, as in the case at p. 620. 
 
 10. A very mobile kidney. The importance of having an assistant 
 to push the kidney well up into the wound has already been insisted 
 on. It is essential to have this well done both for detection of the 
 
 * OUn. Soc. Trans., vol. xvi. p. 90. The calculus is well figured on pi. iv. 
 
 t Water, 4 oz. ; glycerine, 4 oz. ; borax, 2 oz. To be diluted with water to ] in 10, 
 or 1 in 4, according to the condition of the part syringed. SoliKions of carbolic acid 
 or mercury perchloride should be avoided in such cases, for fear of irritation or 
 absorption. 
 
620 OPERATIONS ON THE ABDOMEN. 
 
 stone and for its removal, in order to avoid needless disturbance of 
 the surrounding parts. 
 
 Mr. May {loc. supm cit.) explains the remarkable fact that his large 
 stone was not felt when the kidney was thoroughly exposed by the 
 tendency of this organ to fall forwards, and thus embarrassingly 
 increase the depth of the Avound. 
 
 Question of Nephrectomy during a Nephro-lithotomy.— 
 In several of the above conditions the question of the advisability of 
 removal of the kidney will arise, e.g., where the kidney has been much 
 handled and repeatedly incised, where the stone is large and branched 
 and difficult of removal, where many stones are present, or where one 
 is present and very friable, where the kidney is much altered l_\y pyo- 
 or hydro-nephrosis, and finally where the surgeon is certain a stone 
 exists but cannot find it, as in Mr. Morris's case already alluded to at 
 p. 618. 
 
 In such cases the surgeon will be guided by the age of the patient; 
 the knowledge he possesses as to the condition of the other kidney 
 (the amount of urine, the percentage of urea, etc.) ; the degree to 
 wdiich the kidney he is operating on has Ijeen disturbed from its rela- 
 tions, and its structure interfered with ; the amount of disease, e.g., 
 numljer of sacculi, condition of pus contained in them, the thinning 
 of the cortex, etc. When the surgeon is certain from the history and 
 failure of previous treatment that a stone exists which cannot be 
 found, he must be chiefly guided by the degree to which life has been 
 made miserable. Finally, the length of time that the operation of 
 nephro'-lithotomy has already lasted, and the condition of the patient 
 must be taken into account. Where the patient is young, where the 
 other kidney is healthy, where the kidney operated on is much dam- 
 aged either by previous disease or by manipulation added to disease, 
 where several stones are present, nephrectomy either now, or a little 
 later, is indicated ; of these immediate removal of the kidney is pref- 
 erable if the patient's condition admits of it.* 
 
 * A case wliich has recently been under my care illustrates well many of the above 
 difficulties — viz., multiple and large calculi, a mobile kidney, the question of nephrec- 
 tomy arising during nephro-lithotomy, and the formation of multiple calculi in one 
 kidney without symptoms. In February, 1888, I was asked by Dr. Good hart to see a 
 case of probable renal calculus. Tlie boy, aged fifteen, had been admitted with ab- 
 dominal pain and grating of an indistinct and delicate nature in the left renal region. 
 This kidney was slightly enlarged. When asked to localize his pain, the patient 
 pointed to the region of the left kidney and the left loin. This kidney being explored 
 was I'ound to be occupied by irregular nodulated masses. A hare-lip pin at once came 
 on and between calculi. The kidney being incised, host of calculi, comparable only 
 to a gravel-pit, ucre found in the calyces and pelvis, the chief nests being at the upper 
 and lowe?- extremities. The former of these, lying as they did high U|i under the ribs, 
 gave njuch trouble. To get at them the kidney-tissue was again scraped tliroiigh 
 
NEPHRO-LITHOTOMY. 621 
 
 Causes of Death after Nephro-lithotomy.— Vory few unsuc- 
 cessful cases have been published ; the following appear to be most 
 probable causes of after-trouble : 
 
 1. Ha?niorrhage. If it has been thought needful to incise the kid- 
 neys freely, and the bleeding has been arrested with difficulty after 
 imperfect and repeated plugging, it may readily bring on 
 
 2. Cellulitis. Other causes of this will be found in much disturb- 
 ance of the wound or fingering by many hands. Sepsis. 
 
 3. Uraemia, if the other kidney is the site of calculous disease or 
 disorganized. This was chiefly the cause of death in the case in which 
 I removed the large stone (Fig. 103). The patient was a solicitor, aged 
 fifty-eight, of sedentary life, and gouty history, who had suffered from 
 attacks of right renal colic oif and on for upwards of thirty years, these 
 attacks becoming increasingly fierce for the previous six months. 
 Occasionally he had had slight pain on the left side, and on the 
 morning fixed for the operation he passed two small fawn-colored 
 calculi of lithic acid and lithates. These were quite insuflRcient to 
 account for all his suffering, and as prolonged and careful treatment 
 had entirely failed, and as his " life was not worth having at the price," 
 the operation was proceeded with, and the huge renal calculus figured 
 below removed. This was affected with the utmost ease, as the stone, 
 from its size and hai'dness, was readily detected occupying the dis- 
 tended pelvis of the kidney. A profuse jet of venous blood followed 
 its removal with lithotomy forceps, after it had been loosened by a 
 scooping movement of the finger. The hemorrhage was at once 
 arrested by sponge-pressure kept up for a few minutes. All went well 
 
 directly over them, and many of them thus reached. The chief diiBculty of the opera, 
 tion, in addition to the number of stones, was the great mobility of the kidney, though 
 this organ was well pushed up from the front. The condition was perha[is due to the 
 almost entire absence of surrounding fat. When I realized the condition of the kidney, 
 I expressed myself in favor of nephrectomy, as the organ was almost useless, as the 
 stones were so numerous, and as a prolonged attempt at removal would produce more 
 shock in bo weakly a subject. One or two less important pointsin favor of nephrectomy 
 were the mobility of the kidney and entire absence of adhesions. Dr. Goodhart's 
 counsel was, however, against this step, owing to the small percentage of urea — tliis 
 had never been above 1.2 per cent,, and often less. I accordingly continued; when 
 forty-six calculi had been removed, and the operation had lasted three-quarters of an 
 hour, the pulse failed so ominously that I was obliged lo desist. Very little blood 
 escaped as long as the opening was plugged with the finger, but considerable oozing 
 followed as the finger brought out the stones. The patient never rallied well, and died 
 three hours and a half after the operation. Post-mortem ; There was a little ecchymosis 
 around the left kidney; it still contained calculi at its upper and lower parts. The 
 rightkidney, of which the boy had never complained, also contained a large number of 
 stones. Its substance, though much wasted, still contained a fair amount of secreting 
 substance. The condition of the opposite kidney thus abundantly justified my old 
 friend's opinion. 
 
622 
 
 OPERATIONS OX THE ABDOMEN, 
 
 for the first week, save for persistent oxaluria, wliicii no treatment 
 could remove. The patient was able to sit up and read ; appetite re- 
 turned, and the wound was healing well. On the sixth day a change 
 for the worse set in, iirst much flatulence and nausea, then constant 
 restlessness, followed by coma, ending in death on the morning of the 
 eighth day. I cannot doubt that the opposite kidney was here also 
 the seat of stone, and its tissue too much impaired to admit of recov- 
 
 FiG.103. 
 
 The larger calculus is the one mentioned here in the text. It weighed 473 grs., and consisted 
 of lithlc acid and lithates. The main mass lay in the dilated pelvis, the processes fitted into the 
 calyces. The smaller calculus, composed chiefly of oxalates, was successfully removed from a 
 patient aged twenty-four. It weighed 42 grs. The two are good instances of what nephro-lithot- 
 omy can, and what it cannot, do without grave risks. 
 
 ery, though I was unable to obtain a post-mortem examination to 
 verify this. I should add that the urine in this patient before the 
 operation was acid, of sp. gr. lOlS, and without sugar or albumen. 
 The quantity passed was natural, and the urea sometimes normal, 
 sometimes slightly deficient. 
 
 Dr. A\'hipham and Mr. Haward * have recorded a case in a patient 
 about the same age as my own — viz., fifty-six — who had for " several 
 years " been troubled with " gravel." The symptoms here were chiefly 
 indicative of calculous mischief in the left kidney, but there was some 
 tenderness on the right side as well. The urine here was 1006 sp. gr., 
 alkaline, and containing pus. The left kidney was explored, and 
 found in a state of pyo-nephrosis, no calculus was found, but a copi- 
 ous discharge of pus took place soon afterwards, giving great relief. 
 The patient a little later again lost ground, and the wound was thor- 
 oughly explored a second time, but the patient sank a few hours after 
 this, a month after the first operation. The left kidney pelvis was 
 much dilated in its upi>er part, and communicated with a large peri- 
 
 * Clin. Soc. Trans., vol. xv., p. 123, 
 
NEPHRECTOMY, 623 
 
 nephritic abscess. The right kidney contained a large branching 
 calculus. 
 
 Both this case and my second one point urgently to the importance 
 of surgeons being permitted to explore earlier in such cases. 
 
 4. Septiciemia. This condition may be induced by the wound 
 becoming foul, a complication which can always be prevented after 
 removal of small stones from healthy kidneys. But where ])yo- 
 nephrosis exists, it may be impossible to keep the wound sweet from 
 the first. And it is to be noted that septicemia may occur after a 
 nephro-lithotomy, successful as far as the removal of the stone goes, 
 after a considerable interval, where pyo-nephrosis coexists. This is 
 an additional reason for carefully considering the advisability of per- 
 forming nephrectomy in such cases. 
 
 Dr. Shepherd, of Montreal, has published* a very interesting 
 instance of this kind. Nephro-lithotomy was performed in a patient 
 aged twenty-six, who had suffered from sj^mptoms of stone for seven 
 years, with no tumor, and pus in the urine varying from a small trace 
 to 25 per cent. An enormous, unbreakable stone of triple phosphate 
 was removed with much difficulty from the left kidney. It weighed 
 4 ozs. and 7 drs., and measured Si inches in length and 9 inches in 
 circumference. The tissue of the lower part of the kidney exposed 
 seemed healthy, and no pus being evacuated it was thought best not 
 to remove the organ. The wound continued to discharge pus, and 
 the temperature varied correspondingly for three months and a half 
 after the operation, when septicffimia set in and proved fatal. The 
 autopsy showed that the upper part of the kidney, which was not ex- 
 posed, consisted of large communicating sacs, containing over 10 ozs. 
 of fcetid pus, and a number of irregular branched calculi. Dr. )Shep- 
 herd points out that the fatal septicaemia was undoubtedly due to 
 these abscesses, showing the need of thorough exploration in all cases 
 where a large stone has set up grave changes, and of extirpation in 
 most of them. 
 
 NEPHRECTOMY. 
 Indications. 
 
 i. Cases of strumous pyelitis or pyo-nephrosis explored previously 
 and drained by nephrotomy, but in which a sinus and discharge per- 
 sists. Here the kidney should be removed when the following con- 
 ditions are favorable — viz., the age and strength of the patient, the 
 absence of visceral infection, tubercular or lardaceous, and, if possible, 
 a date not too long deferred, for the additional reason that the kidney 
 will be increasingly matted down and difficult of removal, while its 
 fellpw may have become involved in the disease. 
 
 * New York Med. iVews, April 23, 1887 ; Annals of Surgery, vol vi., August, 1S87, p. 
 185. Tlie condition of the opposite kidney is not mentioned. 
 
624 OPERATIONS ON THE ABDOMEN. 
 
 ii. Calculous pyelitis or pyo-nephrosis, where the kidney is destroyed 
 by long formation of calculi and consequent suppuration, where the 
 numerous calculi exist with sacculation of the kidney, or where a large 
 and branching calculus is so imbedded as to resist removal. These 
 indications for nephrectomy have been already considered under the 
 heading Nephro-lithotomy (p. 620), as it is during the performance of 
 this operation that the question of removing the kidney for the above 
 conditions will arise.* 
 
 iii. A kidney the site of hydro-nephrosis, and resisting repeated 
 lumbar aspirations, and later on nephrotomy and suture of the cyst- 
 margins to the edges of the wound, and aseptic drainage. Occasion- 
 ally repeated aspirations are sufficient, as in Mr. Croft'sf case, in which 
 eight aspirations (through the lumbar region) within four months, be- 
 tween three and four pints being withdrawn each time, sufficed to 
 cure a hydro-nephrosis in a boy aged twelve. It is noteworthy that 
 the case was distinctly traumatic in origin and that the last fluid with- 
 drawn contained a very large amount of albumen. 
 
 In deciding here between nephrotomy followed Ijy drainage, after 
 suturing the sac to the wound-edges, and nephrectomy, the surgeon 
 will be guided mainly by the time that the case has lasted, the age and 
 health of the patient, and the condition of the other kidney. On the 
 one hand, Mr. MorrisJ writes thus of drainage : " This practice has 
 been very successful, and ought certainly to be adopted when aspira- 
 tion fails and before nephrectomy is dreamt of Of seventeen cases 
 collected by Staples,§ all recovered, though, in more than half of them, 
 it is stated that a fistula in the loin was formed. In a few cases a com- 
 plete cure will be effected, and the wound will quite close. In most 
 cases, however, a fistula must be expected; but the fistula gives little 
 inconvenience to a person of ordinary intelligence and patience." Mr. 
 Morris gives three eases in support of this opinion, two of whom were 
 certainly leading very active and useful lives. 
 
 On the other hand, some authorities — e.g., Mr. Barker|| — thinks 
 much less highly of drainage. " Free drainage of hydro-nephrosis is 
 
 * The above conditions are put first, as it is tlieir frequency and the slow, but in- 
 evitable destruction of the kidneys which they bring about that make them the most 
 frequent indications for nephrectomy. In fact, it is probable that further experience 
 will show that extirpation of the kidney is chiefly called for in such inflammatory or 
 suppurating conditions and for new growths in their early stage. 
 
 t Clin. Soc. Tninu., vol. xiv. p. 107. 
 
 J Surg. Dis. of the Kiihinj, p. 323. Dr. 'Weir, of New York [Annals of Surga-y, 
 April, 1885), implies that Billroth (" Ueber Nierenexstirpation," Wien. Med. Woch., 
 Nos. 24, 2o, 2t), 188-1) ie in favor of drainage in these cases in preference to nephrec- 
 tomy. 
 
 § Journ. Amer. Med. Assoc, April, 1884. 
 
 II Diet, of Sure/., vol, i. p. 761. 
 
NEPHRECTOMY. 625 
 
 not much more successful than aspircation, and is not devoid of risks. 
 Of course a large sac will be in a better position to contract if freely 
 and continuously drained than if only occasionally emptied. But the 
 time consumed in the process is usually very great, and the patient 
 often suffers great distress from the process of drainage, and the 
 necessity, lasting for months, for constantly changing the wet dress- 
 ings. Again, there is always the risk of suppuration in the sac, with 
 consequent septic infection." Mr. Barker is, therefore, inclined towards 
 nephrectomy at once, or, at all events, after a sufficiently free but short 
 drainage. 
 
 From observation of two cases in which incision and drainage had 
 been made use of, I should quite agree with Mr. Birker, especially 
 when the patient is young and the case is at a standstill after about 
 two months of drainage. Mr. Morris evidently considers that the 
 troubles of a renal fistula can be met Ijy the permanent wearing of a 
 lumbar urinal.* I would submit that in hospital patients, certainly, 
 this will meet the case very imperfectly. It will too often be neglected 
 and laid aside, especially by young patients, leading to an eczematous 
 raw area round the sinus, which itself, in one case I saw, contained 
 foul phosphatic material. Where, therefore, the patients are young, 
 with every prospect of a long and active life before them, where about 
 two months' drainage have failed to bring about any considerable 
 alteration in the amount escaping, and where the fluid thus coming 
 away contains but a small amount of urine, and where there is evi- 
 dence that the other kidney is competent, I think an attempt should 
 be made to extirpate from the loin the cyst and remaining kidney 
 tissue, before it has become more firmly matted to the surrounding 
 parts.f 
 
 iv. Certain cases of malignant disease. These fall into two groups, 
 which must be looked at separately from an operative point of view. 
 One group, the sarcomata, occur in children before ten, usually much 
 earlier, before five. In such cases, the risks of immediate death from 
 shock, aided often by peritonitis, of early recurrence, or of death from 
 secondary deposits elsewhere, should be put clearly before the parents, 
 together with the certainty of an early death if the growth is left. 
 
 The other group, the carcinomata, occurs usually in patients past 
 middle age. Here the surgeon will be aided by the power of the pa- 
 
 * As made by Maw & Thompson. 
 
 t The very liigh mortality met with previously in nephrectomy for hydro-nephrosis 
 — Dr. Staples (loc. supra cil ) gives twenty-one cases, of which seventeen were treated 
 by laparotomy with eleven deaths, and three by the Inmbar incision with one death — is 
 mainly dne to extraction of large kidneys without previous drainage, and perhaps in 
 some measure to the errors in diagnosis, by which, in several instances, this condition 
 was taken to be an ovarian cyst. 
 
 40 
 
626 OPERATIONS ON THE ABDOMEN. 
 
 tients themselves to come to a decision after the risks have been fully 
 explained to them. 
 
 In either case, an operation should only be performed in an early 
 stage, while the growth is still internal to the capsule, and while the 
 strength, health, and condition of the viscera are satisfactory. On the 
 other hand, where the history makes it probable that the growth has 
 got beyond the earlier stage, when there is any extension to the 
 lumbar glands or other viscera, when there is nausea, emaciation, or a 
 temperature inclined to fall, the time for operation has gone liy. So, 
 too, any ascites or cedema of the lower limb are absolute contra-indi- 
 cations. With regard to the frequency of secondary deposits, it is 
 very noteworthy that Dr. Dickinson* found these to be present in no 
 fewer than 15 out of 19 cases of malignant disease of the kidney in 
 which post-mortem examinations were made.* This seems at first 
 sight a most serious objection to nephrectomy in malignant disease 
 of the kidney, but it only strengthens, very decisively, the argument 
 in favor of early operations, while these growths are small, at which 
 time, moreover, they can be successfully attacked through a lumbar 
 incision sufficiently enlarged by the steps given at p. 631, or by one 
 made anteriorly, as in the case quoted at p. 638. 
 
 A recent writer on the subject of malignant diseasef thus speaks on 
 the question of operation in these cases : 
 
 " The death-rate on the total number of cases is enormously large, 
 more than 60 per cent., for carcinoma more than 71 pier cent. Nor do 
 I think that a study of the causes of death, whether made from the 
 paper of Gross or from the reports of the individual cases, will lead 
 to the opinion that there is a reasonable prospect of largely dimin- 
 ishing it, unless the diagnosis of the disease can be made at a much 
 earlier period than it has been hitherto. 
 
 " The successful cases are, I am sorry to say, much more easily dis- 
 posed of ;|; .... For the operations for sarcoma (from wdiich fourteen 
 survived) .... we may count two complete cures in the total num- 
 ber of cases. It is interesting to observe that not one instance of cure, 
 or even of long relief, is recorded in the cases of children. 
 
 * Dis. of the Kidney, and Urinary Deranganents. 
 
 t Butlin, Oper. Surg, of Malig. Dis., p. 2.54. 
 
 X Mr. Butlin, quoting in detail from Prof. Gross (Amer. Journ. Med. Sci., July, 
 188.5), thus specifies the results in the cases of the fourteen survivors; "One died of an 
 unknown cause; one was living with recurrence at the end of four months; and five 
 died of the disease in from five to eighteen months of the ojieration ; two were lost sight 
 of; and five were alive and well at the end of seventeen, twenty-two, twenty-three, 
 thirty-five months, and five years. The thirty-five months may fairly be stretched to 
 three years, so that we can count two complete cures in the total number of cases.'' 
 
NEPHRECTOMY. 627 
 
 " The results of the operations for carcinoma are even worse than 
 those for sarcoma* .... 
 
 " Of the eighteen persons, therefore, who recovered from the opera- 
 tion, only two can be regarded as cured ; for only two, both of whom 
 had suffered from sarcoma, were alive and well at the end of three 
 years after the operation." 
 
 The following conclusions are thus drawn by Mr. Butlin : 
 
 " Nephrectomy for the removal of carcinoma has been so fatal and 
 so thoroughly unsuccessful that the results do not appear to justify a 
 continued trial of the operation. 
 
 "Nephrectomy for the removal of sarcomatous kidney in children 
 has not been so fatal as for carcinoma in adults; but not one thor- 
 oughly successful result can be claimed, and it is probable that the 
 operation will fall into disrepute. 
 
 " Nephrectomy for sarcoma of the kidney in adults has hitherto 
 afforded the best results, but the successful cases are so few, and the 
 mortality is so large, that the operation is not likely to find favor in 
 the eyes of either surgeons or their patients." 
 
 The main point with regard to future treatment here appears to me 
 to be this, that when a case shows signs of renal malignant disease — 
 viz., a steadily growing swelling in the position of the kidney, with 
 perhaps haemorrhage and pain — the doubt should be early cleared up 
 by an exploratory lumbar incision, to be converted, if need be, into 
 one for nephrectomy by the additional incisions given at p. 631. For 
 such cases alone, in their early stage, will the wise surgeon be at all 
 inclined to urge an operation. 
 
 Where the growth is already larger, and the patient or his friends 
 are left, as they should lie, to decide the matter after this has been 
 explained in all its bearings, the surgeon may be asked as to what resi- 
 due of life may be expected if no operation is performed. In answer 
 to this question, it will be useful to remember that Dr. Roberts gives 
 2J years as the average duration of life, without operation, in adults. 
 Dr. Fagge, speaking of carcinoma in adults, states that the average 
 duration of life is " probably from- 6 months to 2 years after the first 
 appearance of symptoms." 
 
 V. Certain cases of injury. These are very rare, and fall into the 
 following groups : 
 
 (a) Where an injured kidney protrudes from a wound of the ab- 
 domen, usually the loin. 
 
 (b) In some cases of non-penetrating wound of the kidney, as when 
 it is ruptured from a fall or blow.. 
 
 * ''Four patients recovered from the operation,, of whom two died of secondary 
 growths within two months of their recovery ; one was alive and well at the end of 
 two months, the other at the end of thirteen months." 
 
628 OPERATIONS ON THE ABDOMEN. 
 
 (1) Where there is hasmaturia which does not yield to treatment,* 
 the bleeding being well marked, or latent and insidious, giving evi- 
 dence indirectly of its existence, by the increasing pallor, the failing 
 pulse, impending syncope, and perhaps swelling in the loin. 
 
 (2) Later on, when the injured kidney is setting up serious suppu- 
 ration, which does not yield to nephrotomy and drainage, or where, 
 during an exploratory nephrotomy, the injury to the kidney is found 
 to be very severe, e.g., a transverse rent. 
 
 (3) For ruptured ureter. Mr. Barker has recordedf a most suc- 
 cessful case, in which, after other treatment had failed, he removed a 
 kidney three months after the rupture. The child, aged three and 
 a half, had been run over, but beyond some bruising and one small 
 clot passed there was nothing to point to injury of the urinary tract. 
 Having left the hospital in a fortnight, apparently convalescent, he 
 was, a few days later, admitted with a fluctuating swelling in the right 
 loin. This increasing, was aspirated, the fluid yielding J per cent, of 
 urea. The swelling was subsequently drained, and the drainage-tube 
 becoming blocked with phosphatic deposits, and thus causing a good 
 deal of constitutional disturbance, the kidney was removed. It 
 proved to be healthy, the ureter being torn across just below it. 
 
 (c) Penetrating wounds. 
 
 Very rarely indeed nephrotomy may be called for here when 
 haemorrhage does not yield to treatment aided by exploration and 
 plugging. 
 
 When a urinary fistula persists after such a wound in certain 
 cases — e.g., when the other kidney is healthy. 
 
 {d) Gunshot wounds. 
 
 Owing to the increase of revolver-injuries and recent advances in 
 abdominal surgery, this matter has lately received much attention. J 
 
 Whether in civil or military practice, gunshot wounds of the 
 kidney are only too likely to be complicated with injuries of the intes- 
 
 * In Mr. Rawdon's case (loc. infra cit.) nephrectomy was performed for haemorrhage 
 after an injury, but at rather a later date— c.ijr , on the seventeenth day after the fall — 
 to prevent blood from entering the bladder and increasing the acute cystitis present. 
 Here the hsen;aturia had diminished at first, and then subsequently increased. 
 
 t Lancet, January 17, 1S85. 
 
 i As might be expected, American surgeons have not been slow to avail themselves 
 of their opportunites. Prof. Nancrede (Annah of Surgery, June, 1887, p. 480) suggests 
 that where the renal or splenic artery is cut by a bullet, the viscus should be removed, 
 as gangrene is inevitable. He further states that Dr. Keen has removed a kidney for 
 uncontrollable htemorrhage following gunshot injury. Dr. Parkes {loc. supra cit, 
 November, 1887, p. 379), in a case of bullet-wound of the abdomen, having sewn up 
 five perforations of the intestine, found that the left kidney was perforated. The 
 hemorrhage was very slight at this time. After doing well for twenty-four hours, 
 the patient began suddenly to fail, and died collapsed from haemorrhage from the 
 kidney. Dr Parkes regretted that he had not performed nephrectomy. 
 
NEPHRECTOMY. 629 
 
 tines, liver, and spine. When in the course of an exploratory opera- 
 tion in the case of a gunshot wound of the abdomen, the kidney is 
 found to be the seat of haemorrhage, uncontrollable by other means, 
 nephrectomy should be performed. 
 
 (e) In a few cases of nephrorraphy. 
 
 Where, after nephrorraphy, the mobility of the kidney is not much 
 diminished, still less abolished ; where there is much real pain, 
 nausea, inability to carry out the duties of life, nephrectomy may be 
 resorted to if the condition of the opposite kidney admits of it. In a 
 small class of cases nephrorraphy will be found to fail, owing to the 
 intervention of organic disease, as in the instance given at p. 644. 
 
 Operations. 
 
 Three will be described here. 
 
 A. Through the Lumbar Region. 
 
 B. Through the Abdominal Wall and the Peritoneum as 
 well. 
 
 («) By an incision at the outer edge of the rectus. 
 (b) By one in the linea alba. 
 
 C. Through the Abdominal Wall, without opening the 
 Peritoneum. 
 
 These methods are compared at p. 639. 
 
 A. Lumbar Nephrectomy. 
 Operation. 
 
 The position * of the patient and the earlier steps are much as those 
 already given in the account of Nephro-lithotomj^, p. 614. 
 
 When the lumbar fascia has been slit up and the fat around the 
 kidney torn through, this organ should be well thrust up by an 
 assistant making careful, steady pressure with his fist against the 
 abdominal wall : the wound being now wideh' dilated with re- 
 tractors, the surgeon examines the kidney, and has next to decide on 
 three points : 
 
 (1) Is removal required?! 
 
 (2) "Will more room be wanted ? If so, the incision already made 
 slightly oblique and about i inch below the twelfth rib, should be 
 
 * Additional care should be taken to open out the space between the last rib and 
 the crest of the ilium by the arrangement of pillows underneath the loin, and pre- 
 cautions must be taken here to avoid shock — e.g., bandaging the limbs in cotton-wool, 
 having only the site of the wound exposed, keeping the head low, having injections 
 of brandy or whisky ready, and giving ether instead of chloroform. If the condition 
 of the patient is low, the spray had better be dispensed with, and an assistant told off 
 to occasionally irrigate the wound with a solution of mercury perchloride, glycerine, 
 and water (1 in 1000). 
 
 t This question has already been alluded to in the case of a strumous kidney in- 
 cised and drained (p. 623); in that of a kidney nuich damaged by one or more 
 calculi, under the subject of Nephro-lithotomy (p. 620) ; and in the case of hydro, 
 nephrosis p. 624). 
 
630 OPERATIONS ON THE ABDOMEN. 
 
 converted into a T-shaped one by another made downwards from its 
 centre, or at its posterior extremity, along the outer edge of the 
 quadratus lumborum. Additional room may also be gained by an 
 assistant slipping his hand under the lower ribs and drawing them 
 forcibly upwards. 
 
 (3) Is the kidney firmly matted down or no? If there has been no 
 surrounding inflammation, the extra-peritoneal fat, the peritoneum, 
 and colon will be readily separated by the finger working close to 
 the kidney until the pelvis and vessels are reached. But if inflam- 
 mation has caused firm adhesion and matting down of the kidney to 
 adjacent parts, the altered fat and thickened and adherent capsule 
 must be divided down to the kidney itself, and this gradually enu- 
 cleated (partly with the finger, partly with a probe-pointed bistoury) 
 from out of its cajasule which is left behind. 
 
 The only guide in such a case is the tissue of the kidney itself, 
 close to which the finger and knife must be kept. 
 
 A case of Mr. H. Marsh's well shows this difficult3'. On exploring 
 a kidney, the site of pyelitis, probably tubercular, and stripping off 
 the capsule from the part of the organ which presented, the kidney 
 was incised, giving vent to much foetid pus. The organ was now 
 found to be so extensively diseased as to require removal. Its enu- 
 cleation could not, however, be effected, owing to the size of the 
 kidney and the firmness with which it was embedded in the sur- 
 rounding, condensed areolar tissue.* That part of the kidney which 
 had been exposed was accordingly transfixed with a strong, double 
 ligature, and cut away. Complete suppression of urine t followed 
 the operation, and the patient died in about thirty hours. 
 
 At the post-mortem examination the remaining part of the right kid- 
 ney and its ureter were so firmly embedded in dense cicatricial material 
 that they were dissected out only with difficulty. The kidney itself 
 was converted into numerous sacculi, in the walls of which, however, 
 some remains of renal structure could still be traced. The opposite 
 kidney weighed 6 ozs. Its capsule was adherent, and there were two 
 .or three small cysts on its surface. On section, its structure looked 
 
 * Mr. Marsh, in his remarks on tliis case (Clin. Soc. Tranji., vol. xv. p. 142), points 
 out that the stale of the kidney liere proved to be murli worse than there had seemed 
 reason to anticipate. Although it had been impossible to feel it in a very careful 
 examination under ether, it was dilated to a very large size. Mr. Marsh further 
 thinks " it very doubtful whether it will not ultimately be found that the safest way 
 of removing the kidney is by abdominal section through an incision just external to 
 the rectus," as "the lumbar incision <loes not aftbrd sufficient space for the removal of 
 a kidney of large size, or of one that is firmly bound down by adhesions." It is not, 
 however, stated whether the lumbar incision made use of by Mr. Marsh, "an oblique 
 incision in tlie loin,'' was prolonged forwards freely (p. 631), and still further room 
 given by converting it into a T incision. 
 
 t The urine had been horribly foetid, and the sp. gr. never above 1015. 
 
NEPHRECTOMY. 631 
 
 somewhat confused and cloudy, but its condition was not such as to 
 indicate advanced disease. 
 
 Mr. Greig Smith draws attention* to the fact that, in cases of old- 
 standing suppuration with great enlargement, the vena cava and the 
 aorta may be intimately adherent to the capsule. " One such case 
 was recently met with in the post- mortem room of the Bristol Infirm- 
 ary ; here it was simply impossible, after death, to dissect apart the 
 venous wall and the renal capsule. In another case, for similar 
 reasons, the organ could not have been removed by any proceeding • 
 claiming to-be recognized as surgical." 
 
 If further room is still required, this may be easily and effectually 
 gained by making use of additional incisions as recommended by 
 Prof. K6nig,t of Gottingen. This surgeon, having found great diffi- 
 culty in getting free access to the kidney by the ordinary lumbar 
 incision, cuts through the soft parts vertically downwards along the 
 border of the rector spina3 to just above the iliac crest. He then 
 curves round anteriorly towards the navel, and ends at about the 
 outer border of the rectus, if necessary going through this muscle to 
 the umbilicus. It may be often advisable to make the perpendicular 
 cut oblique, running in a flat curve into the umbilical part. All the 
 muscles are incised quite down to the peritoneum. This method gives 
 a surprisingly free entrance, Ijut it can be much improved by intro- 
 ducing the hand through the perpendicular part of the cut, separating 
 the peritoneum in front and pushing it forwards. Prof Konig pro- 
 poses to call this the retro-peritoneal lumbo-abdominal incision. If 
 sufficient space is not thus afforded, or if for diagnostic tir operative 
 purposes it is desirable to approach the tumor from the abdominal 
 cavity, the peritoneum can be divided in the transverse cut. If in- 
 fectious material is to be removed, this peritoneal opening must be 
 carefully looked after. Two recent cases are given illustrating the 
 second method. (1) Old pyelo-nephrosis, with a colossal calculus in 
 the pelvis. The removal of the stone was only possible by the 
 additional peritoneal opening. (2) Vesical catarrh with stinking 
 pyelitis. Cure took place in both cases, excepting slight remaining 
 fistulfe. 
 
 The danger of ventral hernia is guarded against by using deep 
 sutures, by allowing only gentle movements after the patient gets up, 
 and by the use of a support. In this way hernise do not result. J 
 
 * Abdom. Surg., p. 508. 
 
 t Centf. Cldr., 188C, No. 35; Annals of Surgery, November, 1886, p. 445. 
 
 J It is noteworthy that Prof. Bergmann, of Berlin, whose name is well known in 
 connection with the surgery of the urinary organs, advocates the lumbar operation 
 for the removal of malignant growths of the kidney (Annals of Surgery, September, 
 1886, p. 256). 
 
632 OPERATIONS OX THE ABDOMEN. 
 
 ^Vhen the kidney has heen sufficiently enucleated either out of its 
 capsule, or, together with this, out of the peri-renal fat, the vessels 
 and ureter must be di^alt with. The latter should be taken first, as 
 this step, especially if the ureter be enlarged, will facilitate dealing 
 with the vessels. 
 
 If the ureter is dilated, and contains foul pus or tubercular matter, 
 the stump should be carefully cleaned out with a sharp spoon and 
 dusted with iodoform, or brought up into the wound with, and 
 retained there by, a suture, for fear of its infecting the wound. 
 
 The vessels are then tied in at least two bundles with sufficiently 
 stout carbolized silk.* This is passed, with an aneurism-needle ot 
 sufficient length and suitable curve, through the centre of the bundle, 
 each half of which is tied separately, and finally one of the ligatures 
 is thrown round the two halves together. In passing the ligatures, 
 they should be pushed well in towards the spine, so as to leave suffi- 
 cient room between them and the kidney to prevent all risk of their 
 slipping. If the kidney can be raised out of the wound, passing the 
 ligature is much simplified. If this is impossible, the surgeon may 
 find heljj by having the lower limbs well pulled up by an assistant, 
 while another keeps the kidney well up l:iy pressure against the ab- 
 dominal walls, light being also thrown in, in case of need, by a laryn- 
 geal mirror. While the ligatures are being tied, or in dividing the 
 pedicle, no tension should be put upon them. 
 
 As soon as the ligatures are securely in position, the pedicle is 
 snipped through at a safe distance from them with blunt-pointed 
 scissors. If the pelvis of the kidney contains foul or tubercular pus, 
 and if there is room, a large pair of Spencer Wells' forceps should be 
 put on the pelvis, and the pedicle cut through l>ctween this and the 
 ligatures, so as to prevent escape of septic material. These last are 
 then cut short. If any hemorrhage now takes place, it is probably 
 due to some vesself not being included, or an artery having slipped 
 through the knot owing to the parts being stretched at the moment of 
 ligature. In the event of attempts to arrest such haemorrhage by 
 
 * See foot-note, p. 404 
 
 t Mr. Greig Smith (loc. svpra rit.) gives the following practical hints as to the 
 vessels : The vein.s are a good deal larger tiian the arteries, and overlap them. At 
 the hilum the veins branch (juite as mnch as the arteries — i.e., four or five times — 
 and the subdivision extends farther towards the middle line. It is very frequent for 
 two or more trnnks to represent the renal vein, and sometime surround the artery. 
 The want of uniformity in the renal vessels is against the possibility of ligaturing the 
 artery and vein separately. In many cases this will be found impossible; in none 
 is it necessary. Indeed, the walls of the veins, by acting as a sort of padding, may 
 add to the safety of ligatures, preventing the thread from slipping. Mr. Greig Smith 
 further stales that tiie only deaths as yet recorded from secondary hsemorrhage were 
 in two cases where the vessels were separately tied. 
 
NEPHEECrOMY. 633 
 
 ligature failing, it must be stopped by applying Spencer Wells's for- 
 ceps and leaving them in situ, or by firm plugging with aseptic gauze 
 dusted with iodoform. 
 
 When a pedicle presents especial difficulties from its shortness, 
 th'ickness, and the way in which it is ov'erlapi)ed by the kidney, a 
 preliminary ligature should be applied and the kidney cut away well 
 in front of it,* a step which will give access to the vessels and ureter ; 
 a double ligature is then applied behind the temporary ligature, which 
 is now removed. 
 
 A modification of the above method of leaving a portion of the 
 kidney to form the pedicle may be made use of in eases of kidneys of 
 large size which cannot be brought through the wound. In such 
 cases, the vessels being secured by a temporary ligature or by a 
 Spencer ^^'ells' forceps, the kidney should be cut away in separate 
 portions, thus doing away with the struggle required in bringing out 
 a large kidney and the risks of producing serious shock by pulling on 
 the vessels. t 
 
 By the above methods the risk of wounding the cava or aorta is 
 avoided. If the amount of kidney left is small, it will no doubt 
 atrophy and give no further trouble, but, if large, some sloughing will 
 probably take place ; in such a case iodoform should be dusted on to 
 the stump and free drainage provided. 
 
 Another difficulty which may be present now is caused by the 
 kidney having contracted adhesions to the peritoneum and some of 
 its contents. Thus in a case in which Mr. Adams removed a carci- 
 nomatous kidne}^ by lumbar nephrectomy, in separating the adhesions 
 the peritoneal cavity was opened and the thin free edge of the liver 
 
 * Dr. Lange (New York Surg. Soc, November 22, 1886 ; Annals of Surgery, April, 
 1887) has shown tliat in a case in which lie ado[)ted this course no sloughing took 
 place, as the thick, fetiy part of the pedicle beyond the ligatures was gradually ab- 
 sorbed by the healthy granulations of the wound, which remained aseptic Dr. Leopold 
 (Arch.fiir Gyniik., xix. 1), in a case of nephrectomy, tied the pedicle in three, and left 
 a triangular portion of the kidney parenchyma, in order to prevent haemorrhage. The 
 patient made a good recovery. 
 
 t The question of how far serious shock may be induced by tightening ligatures on 
 parts in such intimate relation with the abdominal sympathetic centres is one of great 
 importance, and needs further investigation. According to Mr. Barker {Did. of Surg., 
 vol. ii. p. 49), who lias taken the trouble to have the pulse watched carefully at this 
 stage of the operation, it is not much affected to the touch, but a sphygmographic 
 tracing taken in one case showed some irregularity during the necessary handling of 
 the kidney, and increased arterial tension when the pedicle was ligatured. But 
 ■whether or no these observations are confirmed in the future, it is certain that all 
 manipulations of an organ like the kidney cannot be too carefully carried on, especially 
 towards the close of a difficult nephrectomy. 
 
634 OPERATIONS ON THE ABDOMEN. 
 
 exposed * The wound in the peritoneum was closed with fine catgut 
 sutures, and, in spite of a very troublesome cough, the patient made 
 a good recovery from the operation, dying forty-four days later from 
 malignant deposits in the chest-wall, opposite kidney, and lumbar 
 glands (Clin. Soc. Trans., vol. xv.). 
 
 If before or after ligature of the pedicle there is still much difficulty 
 in getting a large kidney through the wound (though if the aids already 
 given are followed — viz., making the first incision into a T, dragging 
 up the ribs, prolonging the horizontal or oblique incision well forward, 
 and separating the peritoneum forwards also — a great increase of space 
 will be given), the surgeon may follow the example of Mr. Barwell.f 
 who, in a case of nephrectomy calling urgently for completion owing 
 to the hfemorrhage, obtained the necessary room for reaching the 
 pedicle by partially breaking up the gland, and next, having tied the 
 pedicle, cut the gland in two towards the ligature, and then, verifying 
 bloodlessness, .severed each half from the pedicle and removed them 
 separately. 
 
 The pedicle being secured and cut through at a safe distance from 
 the ligatures with blunt-pointed scissors, the surgeon should examine 
 for any bleeding point,! ^o which the ligatures already in place will 
 act as a guide. When all bleeding is stopped,§ a large drainage-tube 
 
 * In a case of attempted nephrectomy (Amer. Journ. Med.Sci., 1882, vol. ii. p. 116) 
 the removal of the organ was rendered impossible, not only by its adhesions to the 
 tissues aroundj but also, as was proved postmortem, to the colon and pancreas as well, 
 
 f Trans. Intern. Med C'ongr., vol. ii. p. 276. 
 
 X This may be due to the renal vessels breaking np into a larger number of branches 
 than usual, or to some abnormal vessel. Dr. Lange, of New York (Annals of Surgery, 
 October, 1885, p. 297), in several bodies found a rather thick venous branch coming 
 from below, behind the pelvis and ureter, and entering into a branch of the renal vein, 
 which took origin abnormally from the renal substance on a level behind the pelvis. 
 Dr. Lange suggests that this vessel may have been a spermatic vein, but was unable 
 to verify this point. 
 
 § The question may arise as to what is to be done if hicmorrhage still persist after 
 the kidney is got out, and its pedicle tied. Very few cases will occur in which liga- 
 tures cannot be applied to each bleeding point if the wound be well opened up, care- 
 fully dried, and light thrown down to the bottom. But if bleeding still goes on, either 
 Spencer Wells' forceps must be applied to the bleeding jioint and left in situ for two or 
 three days, during which they will also help to drain the wound, or careful plugging 
 must be resorted to, strips of iodoform or sal-alembroth gauze or carbolized sponges 
 (the deepest attached to silk) being systematically packed into the bottom of the wound 
 around a large drainage-tube till the wound is thoroughly filled ; an external gauze 
 dressing is then applied, and over this a firm but elastic padding of .sal-alembroth 
 wool, which is kept in si/w by firm bandaging. Mr. Clement Lucas (Trans. Intern. 
 Med. Coiiyr., vol. ii. p. 271) nearly lost, from secondary haemorrhage, a case in which 
 nephrectomy had been successfully performed for suppurating strumous pyelitis. This 
 was brought on about the fifteenth day, probably from the ligauires which had been left 
 long being dragged upon. The hsemorrhage again occurred on the sixteenth day, when 
 
NEPHRECTOMY. 635 
 
 should be inserted, with one end carried down to the very bottom of 
 the wound and the other cut almost flush with the surface. The wound 
 is then accurately closed with silver-wire and carl)ulized-silk sutures, 
 some iodoform dusted on, and aseptic dressings ai)plied. 
 
 Dr. Weir, of New York (Ann. of Surg., April, 1885, ]). 311), during 
 a case of nephrectomy in a young woman the subject of ])yo-nephrr>sis, 
 met with very severe hajmorrhage after ligature of the pedicle. This 
 had apparently been effected with a single ligature. After removing 
 the kidney, a gush of venous blood ensued, which was only partly 
 arrested after repeated seizures with long forci-pressure forceps, but 
 was finally controlled by stuffing the wouna full of sponges and turn- 
 ing the patient on her back. The shock was profound, and all the 
 measures to produce reaction were resorted to, such as heat, stimulants, 
 the application of Esmarch's bandages to the limbs, and saline trans- 
 fusion. The latter, repeated twice to a total amount of 22 oz., gave 
 rise at first to great improvement in consciousness, pulse, and warmth 
 of body ; for a while the patient appeared to rally, but she died ten 
 hours after the operation. The autopsy showed that the ha:'morrhage 
 came from a vein of considerable size, 1.5 centimeter above those se- 
 cured by the ligature and forceps. 
 
 B. Nephrectomy by Abdominal Incision through the 
 Peritoneum. 
 
 (I. By Langenbeck's Incision at the Outer Edge of the 
 Rectus. 
 
 b. By an Incision in the Linea Alba. 
 
 These two methods may be taken together. The former is the one 
 most usually employed, as it has the following great advantages : 
 
 1. The incision is nearer the vessels and ureter. 
 
 2. There is much less general exposure of the peritoneal cavity.* 
 
 3. The kidney is reached through the outer or posterior layer of the 
 meso-colon, a step which avoids (a) hicmorrhage and (6) the risk of 
 sloughing of the colon, as it is the inner or anterior layer — that between 
 the colon and the middle line — which contains most of the vessels to 
 the colon, this layer being especially rich in veins. It is this laj'er 
 which is divided in the incision through the linea alba. 
 
 4. The operation can be rendered largely extra-peritoneal by having 
 
 an attempt was made, after opening up the wound, to slip a ligature along the old ones, 
 and thus to re-tie the pedicle. Haemorrhage again occnrring on the seventeenth day, and 
 the patient being in a most precarious state, the wound was tightly and forcibly plugged 
 with two large sponges steeped in perchloride of iron, and the abdomen bound firmly 
 round with a flannel bandage. Morphia was given subcntaneously. About a week 
 later the removal of the sponges, by cutting away the protruding part, was commenced, 
 and this was completed by the end of another week. Ko bleeding recurred after the 
 plugging, and the patient made a good recovery. 
 * Knowsley Thornton. 
 
636 OPERATIONS OX THE ABDOMEN. 
 
 the inner edge of the cut meso-colon and that of the parietal peritoneum 
 held in ai)position or sutured with catgut. 
 
 Both operations give good room for necessary manipulations, both 
 afford an opportunity for examining with the hand the condition of 
 the opposite kidney * After both the wound can be drained, poste- 
 riorly, from the loin, but more easily after Langenbeck's incision. 
 
 a. Langenbeck's Incision.— The abdominal wall being cleansed, 
 an incision is made, at least 4 inches long to commence with, in the 
 line of the linea semilunaris on the side of the disease, the centre of 
 the incision being usually opposite to the umbilicus. The structures, 
 skin, subcutaneous tissue, and the aponeurosis at the outer edge of the 
 rectus being divided down to the transversalis fascia, all hasmorrhagef 
 being carefully arrested, the transversalis fascia and peritoneum are 
 pinched up together, punctured, and slit up on a finger used as a di- 
 rector, the hand is introduced, and the size of the growth and the 
 condition of the opposite kidney investigated. In the case of a large 
 growth, the incision will now be enlarged, and any further haemor- 
 rhage arrested. The growth, if large, is usually now seen in part. Any 
 presenting intestine is turned over to the opposite side, and kept out 
 of the way with a soft flat sponge. The outer or posterior layer of the 
 meso-colon will now probably present itself pushed forward by the 
 growth, which is often bluish-white in appearance, and covered by large 
 veins. The above-mentioned layer of the meso-colon is next torn 
 through, either in a vertical or transverse direction as will best avoid 
 the vessels exposed. Any bleeding should be at once arrested by 
 Spencer Wells' forceps and ligatures of chromic gut or fine carbolized 
 silk. 
 
 A sufficient opening being made in the meso-colon, the fingers are 
 introduced to examine into and further separate the connections of 
 the kidney. 
 
 During all the necessary manipulations in the case of a growth, the 
 greatest possible gentleness must be used so as not to rupture the cap- 
 sule. In rapidly growing sarcomata, especially in children, the con- 
 sistency may be jelly- or glue-like, and thus, if the capsule is opened, 
 
 * I cannot bnt think tli.it this advantage of the incisions throngh the peritoneum 
 has been made too much of. In Mr. Barker's words (Diet, of Surg., vol. ii. p. 48), 
 "though the hand may reach the kidney opposite to the one it is proposed to excise, 
 its soundness or the reverse cannot be ascertained by mere palpation. Great enlarge- 
 ment, or, (in the other hand, great reduction, in size, or complete absence, might he 
 delected; but the organ might be tubercular, or fibroid, or contain a, moderate-sized 
 calculus, and yet the hand be unable to delect the condition " 
 
 t The amount of this, as will be familiar to all surgeons who have opened the peri- 
 toneal cavity by this incision for intestinal obstruction, intussusception, etc., varies a 
 good deal. 
 
NEPHRECTOMY. 637 
 
 portions of the growth may easily be left behind. Again, hamiorrhage 
 may easily follow this accident, and prove most embarrassing.* 
 
 The same precautions as to not damaging the capsule should be 
 taken in the case of a kidney full of fluid. Where there is any risk of 
 such fluid or of soft growth being spilt into the peritoneal cavity, 
 sponges (duly counted) should be carefully packed around, or the cut 
 edges of the meso-colon and the parietal peritoneum united (p. 636). 
 
 The kidney being sufficiently isolated, the ureter is first tied and 
 divided ; the vessels are then found, and divided with the precautions 
 already given (p. 632). All dragging on the pedicle should be most 
 scrupulously avoided. 
 
 The kidney being removed, the site of the operation is most care- 
 fully cleansed and dried. If troublesome oozing has occurred and is 
 at all likely to persist, a large drainage-tube had best be passed out 
 through the loin by pushing a short pair of dressing-forceps from the 
 site of the kidney so that it bulges in the loin, where it is cut down 
 on, and drags through, the tulje. If the patient's condition admits of 
 it, the divided edges of the meso-colon, if not already dealt with, may 
 be united with a few points of catgut suture, but this precaution does 
 not seem to be absolutely needful, as they usuallj' fall readily into 
 apposition. 
 
 Mr. K. Thornton's suggestion to bring the ureter, where this is in a 
 septic condition, as in pyonephrosis, up into and to fix it in the 
 wound seems not unlikely to risk the occurrence of future intestinal 
 obstruction, by raising up a band between the pelvis and the abdominal 
 wall. It would seem far preferable to bring it out, if the stump cannot 
 be disinfected after ligature, through the loin by a counter-puncture 
 here. 
 
 b. Nephrectomy by an Incision in the Linea Alba. — For 
 reasons already given, p. 635, this method is not recommended, that 
 of Langenbeck, already fully described, being preferred. 
 
 The incision in the linea alba will not materially differ from that 
 for ovariotomy or abdominal exploration, pp. 654, and the same pre- 
 cautions are called for in removing a kidney by this method as in 
 that through the linea semilunaris, of which the chief only need be 
 recapitulated here — viz. : 
 
 * Thus it has happened to Prof. Czerny, whose experience in nephrectomy is almost 
 unrivalled, to be driven to tie the abdominal aorta. The profuse haemorrhage met 
 with in removing a large growth of the left kidney could only be stopped by pressure 
 on the abdominal aorta. This vessel was accordingly tied. Death took place ten hours 
 later. It was found that the renal artery had been torn through at its entrance into 
 the tumor. Tiie ligatnre on the aorta had been so placed that, while the blood-supply 
 through the left was cut off, the right vessel was pervious. 
 
638 OPEEATIOyS ON THE ABDOMEN, 
 
 1. Keeping the intestines well over to the opposite side by carefully 
 applied sponges. 
 
 2. By the same menns keeping the general peritoneal cavity shut 
 off as much as possible ; as pointed out already, this method has the 
 grave objection of more readily causing infection of the peritoneum. 
 
 o. Avoiding all large vessels which are met with over the kidney, 
 and securing these carefully with chromic-gut or fine carbolized-silk 
 ligatures before dividing them. 
 
 4. Securing as full access as possible to the kidney pedicle. 
 
 5. Dealing as gently as possible with the kidney when distended 
 with fluid, and still more when it is the seat of a soft vascular growth. 
 
 6. Separating adhesions, especially any situated posteriority, with 
 the utmost carefulness. 
 
 7. Avoiding all tension on the pedicle. 
 
 8. Scrupulously cleansing the site of the wound. 
 
 9. If fluids or portions of the growth have escaped into the general 
 peritoneal cavity, ensuring cleansing of this with sponges, or, perhaps 
 better, by irrigation with a warm 2 per cent, solution of boracic acid. 
 
 10. Taking care that the cut edges of the peritoneum over the 
 kidney are in exact apposition, either by natural adaptation or by 
 the aid of catgut sutures. 
 
 11. Providing sufficient drainage (p. 637) if the operation has been 
 a difficult one and the parts much disturbed, and, always, if septic 
 fluids have escaped into the peritoneal cavity. 
 
 12. Conducting the different steps of the operation, especially the 
 earlier ones, with as much expedition as possible, and, in addition, 
 providing against shock by taking those precautions recommended 
 for this purpose in any grave operation, as at p. 630. 
 
 C. Nephrectomy through the Abdominal Wall, but 
 without opening the Peritoneum.— Having made use of this 
 
 method in one case five years ago, and being much struck by the 
 room afforded, I may make brief mention of it. The patient was a 
 woman, aged fifty-four, the subject of a movable kidney on the right 
 side, the kidney being also the seat of malignant disease. As the 
 abdominal walls were thin, and as the kidney could easily be made 
 to project in the anterior part of the right lumbar region, I made a 
 longitudinal incision from the anterior superior spine up to the eighth 
 rib. The different layers were cut through, very little haemorrhage 
 being met with ; when the peritoneum was reached this was then 
 stripped up out of the iliac fossa, upwards and inwards, then upwards, 
 off' the anterior surface of the kidney until its vessels came in view. 
 N(i difficulty was experienced in dealing with the pedicle — first the 
 ureter, and then the vessels. The vena cava was seen for about IJ 
 inch receiving pulsation from the aorta. The patient never rallied 
 
NEPHRECTOMY. 639 
 
 thoroughly from the operation * and sank about twenty-four hours 
 after. Post mortem the ligatures were found firmly tied ; one of 
 those on the renal vein had slightly puckered in the inner surface of 
 the vena cava. A clot the size of the little finger constituted all the 
 bleeding that had taken place. The kidney was, save for one small 
 patch at the lower part, entirely converted into encephaloid carci- 
 noma. Two or three of the aortic glands were enlarged; there were 
 no other secondary deposits. 
 
 Choice between Lumbar and Abdominal Nephrectomy.— 
 While it is certain that all kidneys of small or moderately enlarged 
 size can be easily removed by a lumbar incision sufficiently enlarged 
 (p. 630), time alone will show whether I am right in my belief that 
 large kidneys can be best attacked by surgeons through an extra- 
 peritoneal abdominal incision {vide sirpra), or by the method of 
 Konig's (p. 631). And this leads up to the question of chief impor- 
 tance : How far is the danger reallj' increased by going through the 
 peritoneum to get at the kidney ? I am strongly of opinion that, in 
 spite of all the recent improvements in abdominal surgery and their 
 success in preventing 'peritonitis, interference with the peritoneum, 
 save in the shortest and simplest instances, remains, on the score of 
 shock, as grave a thing as ever it was. I am quite aware that, in the 
 hands of a few operators, such as Sir S. Wells, Mr. K. Thornton, and 
 Mr. Tait, removal of kidneys, even in difficult cases, through an 
 abdominal wound involving the peritoneum has given excellent 
 results — results perhaps as good as, or better than, those by the 
 lumbar method. But while allowing this, it cannot, I think, be lost 
 sight of that the kidney is an extra-peritoneal organ, not one, like the 
 uterus and ovary, within the peritonea] cavitj'. It will assuredly 
 never be brought about that reiuoval of the kidney will pass, like 
 oophorectomy and removal of the uterus or its ajjpendages, into the 
 hands of a few operators especially skilled in abdominal surgery. 
 This being so, and the organ in question being one behind and out- 
 side the peritoneum, while each man will decide for himself according 
 to his special experience and line of work, the majority of surgeons 
 will, I think, prefer to make their attacks from behind. 
 
 Lumbar Nephrectomy — Advantages : 
 
 1. The peritoneum, save in case of exceptional difficulty, is not 
 opened or contaminated. 
 
 2. Efficient drainage is easily provided. 
 
 3. The structures interfered with are much less important. 
 
 * I think that the thinness of the abdominal walls prolonged the operation, owing 
 to ray anxiety not to wonnd the peritonenra. As has been said above, the haemor- 
 rhage was very slight, and I was careful not to pull upon the pedicle. 
 
640 OPERATIONS ON THE ABDOMEN. 
 
 4. As pointed out by Mr. Greig Smith, "in the case of its being 
 unwise, as in abscess, or in tumor infecting the surrounding tissues, 
 to proceed to removal, it is less serious to the patient." 
 
 6. If the kidney is firmly matted down, as in the condition given 
 at p. 630, such dense posterior adhesions are most readily dealt with 
 by the lumbar method. 
 
 6. The lumbar incision, if converted into a T-shaped one, or pro- 
 longed forward by KiJnig's method, will give sufficient roona for 
 meeting most of the conditions which call for nephrectomy. Thus 
 modified, it will suffice for new growths in their early stages. If these 
 are operated on later, one of the abdominal methods will have to be 
 made use of. 
 
 Lumbar Nephrectomy — Disadvantages : 
 
 1. It is usually thought that too little room is given by this method 
 for the removal of large kidneys. It has already been shown (p. 631) 
 how extensively this incision can be enlarged. It is doubtful, there- 
 fore, if the above objection holds good for any cases, even those of 
 unusually long-chested patients, or those with spinal deformity. 
 
 2. In a fat subject the organ may be difficult to reach, even when 
 well pushed up from the front. 
 
 3. The pedicle is less easily reached,* and thus, in cases of diffi- 
 culty, bleeding at a very important stage of the operation is less 
 easilj' dealt with. 
 
 4. If the kidney be very adherent, important structures — e.g., the 
 peritoneum (p. 633) and colon — may be opened into, unless great 
 care is taken. 
 
 5. The condition of the opposite kidney cannot be examined into.f 
 Nephrectomy t.y Abdominal Incisions in the Linea Alba, or at 
 
 THE Edge of the Rectus, the Peritoneal Cavity' being opened — 
 Advantages : 
 
 1. Additional room in case of large kidneys. 
 
 2. More easy access to the pedicle. 
 
 3. The possibility of examining the condition of the other kidney. 
 It has already been pointed out (p. C>3()) that this advantage is 
 probably overrated. 
 
 Mr. Greig SmithJ thus states the question with regard to the 
 operation in the llnea semilunaris : " Langenbeck's operation is, in 
 its way, a i)erfect surgical procedure, securing its aims by a minimum 
 of injury to surrounding tissues. In the linea semilunaris, the ad- 
 vantages of avoiding large muscular masses are secured ; and, by 
 
 * This objection ami (lie next can be met by very freely enlarging the wound. 
 t Possible fallacie.s here have been pointed out, p. 636. 
 X Abdmn. Surg., p. 513. 
 
NEPHRECTOMY. 641 
 
 tearing through the peritoneum in front of the colon, the vitality of 
 the bowel is not endangered. It gives plenty of room for removal of 
 the kidney. Lastly, it secures the all-important advantage of giving 
 information as to the condition of the alternate kidney." 
 
 Nephrectomy by Abdominal Incisions through the Peri- 
 toneum — Disadvantages : 
 
 1. The peritoneal cavity is opened. 
 
 2. The peritoneal cavity may be seriously contaminated if a 
 kidney containing septic matter, or one largely converted into soft 
 growth, is ruptured during the needful manipulations. 
 
 3. The intestines may be difficult to deal with, and may, by 
 crowding into the field of operation and the incision in the abdominal 
 wall, prove most embarrassing. 
 
 4. The vitality of the colon may, by interference with its blood- 
 supply, be endangered. 
 
 5. It is more difficult, by this method, to deal with any dense adhe- 
 sions which may exist behind the kidney. 
 
 6. Efficient drainage is less easily provided in cases of any contami- 
 nation of the peritoneal cavity, or of oozing after the kidney is got 
 out. 
 
 7. The after-complication of a ventral hernials much more probable 
 by this method, though it must be allowed that the free lumbar incision 
 already alluded to may be followed by the same objection. 
 
 Causes of Death after Nephrectomy. 
 
 1. Shock. — This may be induced by haemorrhage, much traction on 
 the pedicle, and thus, ]3robably, interference with the solar jjlexus, 
 injury to the colon, or, where the peritoneal cavity is opened, by much 
 disturbance of its contents. 
 
 2. Hsemorrhage. — This is especially to be dreaded where the pedicle 
 is deep and difficult to command ; where there are aberrant renal ves- 
 sels; where these vessels are enlarged and perha^js softened; where, 
 owing to too much tension on the pedicle, a vessel retracts from within 
 its loop of ligature ; where the kidney capsule and tissue are broken 
 into. In the intra-peritoneal method there is the additional danger 
 of enlarged veins within the meso-colon. 
 
 Secondary hsemorrhage has been alluded to above, p. 634. 
 
 3. Urtemia and Anuria.— These are only likely to occur when it has 
 been impossible to form a correct estimate of the condition of the 
 opposite kidney, or where, to give a patient a chance, the surgeon 
 operates in what he knows to be a doubtful case. Where there is 
 reason to believe that the suppression of urine may be due to a calculus 
 in the opposite kidney, this should at once be cut down upon in the 
 hope of finding a calculus that can be removed. A brilliant example 
 of what nephrolithotomy may do in such peril setting in at a later 
 
 41 
 
642 OPERATIONS ON THE ABDOMEN. 
 
 date is given by a case of Mr. Lucas's,* in which, four months after a 
 successful removal of one kidney, a calculus was successfully removed 
 from the remaining one on the onset of total suppression. 
 
 4. Peritonitis. — This may be simple (i.e., traumatic) or septic. While 
 it is certainly more likely to follow the intra-peritoneal operation, it 
 may occur after that through the loin, especially when much difficulty 
 is met with here, owing to numerous adhesions, or to working in a 
 wound of insufficient size.f 
 
 5. Septic Trouble — Cellulitis — Erysipelas— Pyaemia. — These are 
 especially likely when the kidney contains septic matter, when the 
 soft parts are much bruised, or when many fingers enter the wound. 
 
 Other, rarer, causes of death are — 
 
 6. Pulmonary embolism. 
 
 7. Empyema. — This may be brought about by an extension of septic 
 cellulitis, or by removing during the operation a portion of rib in order 
 to get more room — a step the danger of which cannot be too strongly 
 enforced, p. 614. An anatomical predisposition favoring the passage 
 of inflammation from the kidney to the pleura has been pointed out 
 by Dr. Lange, of New York. This authority on renal surgery found, 
 in one subject, in the diaphragm an enormous gap, the muscle fibres 
 being absent from the ligamentum arcuatum internum as far as the 
 outermost part of the eleventh rib. Between these two points the 
 fibres of the diaphragm communicated in a high arch, bounding an 
 area in which the fatty tissue about the kidney was in direct contact 
 with the pleura. 
 
 NEPHRORRAPHY. 
 Indications. — Where the surgeon is able to satisfy himself that a 
 persevering trial of a well-fitting belt has failed ; that the pain, whether 
 constant or paroxysmal, is bondjidc ; X and that it really cripples and 
 spoils the patient's life. Constipation and dyspepsia will of course 
 have been treated, tight lacing given up, and a trial of massage com- 
 bined with the use of a belt. 
 
 Operations for Movable Kidney.— These are : 
 
 A. Nephrorraphy. 
 
 B. Nephrectomy. 
 
 It is the first of these that will be considered here. Nephrectomy 
 
 * Brit. Meil. Journ., March 8, 1884. 
 
 f That injury to the peritoneum is not always fatal here is shown by a case men- 
 tioned (without reference) by Mr. Morris {loc. supra cit., p. 535), in which the pus of 
 ■a, scrofulous pyelitis had contaminated the inner surface of the peritoneum. The patient 
 here rapidly recovered, the operation, wliich lasted two hours and a half, having been 
 throughout all but bloodless. 
 
 J As when it is accompanied by undoubted vomiting. Another condition of movable 
 kidney which calls for operation is when, in stooping, the viscus comes down so far as 
 to be jammed between the ribs and the crista ilii. 
 
NEPHROREAPHY. 643 
 
 for movable kidney has been alluded to at p. 629, and will be briefly 
 considered at p. 645. 
 
 A. Operation of Nephrorraphy.— The kidney is first exposed 
 by the incision * and the steps already fully given (p. 614). The 
 lumbar fascia being opened, the wound is widely dilated by the use 
 of retractors, which gather up the whole thickness of the wound down 
 to the renal capsule, and by an assistant pulling up the ribs if need 
 be. During the rest of the operation another assistant with steady 
 pressure on the right spot forces the kidney into the wound and keeps 
 it there. 
 
 The surgeon now examines the kidney, as to whether it is sound, 
 enlarged, etc. If the viscus be quite healthy, the surgeon next, in the 
 words of Mr. Greig Smith, seeks " to diagnose the exact nature of the 
 conditions associated with the mobility. If it is clear that the fatty 
 tunic is closely adherent to the fibrous capsule, the former need not 
 be opened. But if the kidney has space for movement inside its fatty 
 capsule, then this ought to be freely opened, and the finger, inserted 
 through this opening, moved freely over the renal surface, so as to 
 excite jjlastic inflammation." f 
 
 Several questions now arise as to the sutures. (1) What is the best 
 material? (2) What tissues are to be taken up? (3) Are they to be 
 dropped in? — (1) The sutures should be of both carbolized silk and 
 chromic gut if they are going to be dropped in ; of carbolized silk only 
 if they are left for subsequent removal. (2 ) With regard to the tissues 
 taken up, the sutures should certainly' include kidney tissue itself. In 
 other words, passing them, however numerously, into the peri-renal 
 fat or kidney capsule will not be sufficient. This was well seen in the 
 case of nephrorraphy mentioned at p. 644, in which, after numerous 
 sutures had been thus placed, the kidney still dropped away out of 
 sight as before. 
 
 The third question, whether the sutures are to be dropped in or not, 
 is still an open one. Most surgeons, I believe, do so, and this was the 
 method I adopted in two cases of nephrorraphy. The kidney being 
 thoroughly exposed, pushed well up, and its structure, the amount of 
 surrounding fat, and the looseness of capsule having been examined, 
 the surgeon passes from four to six sutures — some of carbolized silk, 
 some of gut — through adjacent parts of the kidney itself and the 
 deeper of the soft parts. The material used is of medium size, so as 
 not to cut out too readily, and the needles are curved and used with 
 a holder. The sutures should be inserted one or two at the lower end, 
 
 * In a fat patient a T-shaped incision will be needed. 
 
 t If this be carefully done with an aseptic finger, there is no fear of exciting dan- 
 gerous cellulitis. With this operation carried out with strict precautions, there is fear 
 of too little rather than of too much inflammation. 
 
644 OPERATIONS ON THE ABDOMEN. 
 
 two or three at the outer and one or two at the inner border. They 
 should dip well into the kidney tissue on the one hand, and pass 
 through the lumbar fascia and muscles on the other. When sufficient 
 are inserted and knotted so that the kidney no longer falls away when 
 the supporting hand of an assistant is removed, a little iodoform is 
 dusted in, the sutures are cut short, and the wound over them closed 
 with silk and wire sutures. 
 
 Very little bleeding follows the simple punctures of the kidney- 
 substance implied in the above method. 
 
 The objection to this plan is that if only chromic-gut sutures are 
 made use of, they may soften and come away too soon.* If silk are used, 
 even when care has been taken with the preparation, they may come 
 away with vexatious repetitions through a long persistent sinus (p. 404). 
 Another method is one used by Mr. ^Iorris,t and' consists in passing 
 sutures of silk and chromic gut through the entire thickness of one lip 
 of the wound, then through the capsule and cortex of the kidney, and 
 finally through the other lip of the wound. When these sutures are 
 tied, the wound is closed and the kidm-y fixed at the same time. 
 Some buried sutures passing between the kidney and the deep part 
 of the incision might be made use of as well. In one of Mr. Morris's 
 cases a single stout catgut suture passed as above seems to have been 
 successful in fixing the kidney. In the other case, where silk and 
 catgut sutures were thus passed, the former was not removed till the 
 thirteenth day. 
 
 Two cases of nephrorraphy have been lately under my care. In 
 the first the kidney proved to be not only movable but the seat of 
 pyelitis as well. The woman, aged forty-four, was a patient of Dr. 
 F. Taylor's ; other treatment, including a well-fitting belt, having 
 failed to give relief, I was asked to perform nephrorraphy. The loin 
 being a thin one, and the kidney easily brought up to the surface, the 
 operation was very easy. I began by putting in eight or ten gut 
 sutures between the peri-renal tissues and the edges of the wound. 
 These had no effect whatever, as when my dresser, Mr. A. E. Poolman, 
 removed the very efficient support which he was applying through 
 the abdominal walls, the kidney receded completely out of sight. 
 Three carbolized silk sutures passed between the kidney itself (the 
 needle being dipped well into its substance) and the edges of the in- 
 cision, and cut short, kept the kidney, without any other support, 
 (j^uite up in the wound ; in fact, the patient being thin, the organ now 
 lay almost subcutaneous. The wound was so completely closed by 
 
 * Dr. Newman {Glasg. Med, Jouin., 1883) has observed, as might be expected, that 
 the part of the catgut sutures which lies in the vascular kidney-tissue itself softens 
 with especial quickness. 
 
 t Annals of Surgery, April, 1887. 
 
ACUTE INTESTINAL OBSTRUCTION. 645 
 
 the viscus that no drainage-tube could be inserted. Primary union 
 took place throughout, and the wound was healed in ten days. About 
 two months later, the pain being re-established, further examination 
 proved that the urine, which had before lieen found normal, n^jw 
 contained pus. Three months after the nephrorraphy I explored tlie 
 wound. This was rendered a Httle difficult by the incision jmssing 
 through scar tissue. The silk sutures fixing the kidney were found 
 ill situ. The kidney itself now showed two cystic expansions, both 
 small — one about the size of a hen's egg, the other that of a walnut — 
 one at the upper and one at its lower extremity. Fine trocar punct- 
 ures removed pus. After consultation with my colleague, Mr. Howse, 
 I removed the kidney. Not being much enlarged it came out easilj- 
 through the ordinary lumbar incision, and the patient made a good 
 recovery.* 
 
 B. Nephrectomy for Movable Kidney. — This operation will 
 be very rarely required. It should be reserved for cases where (i) 
 the kidney is not only movable, but diseased, as at pp. 639, 644. (ii) 
 Where nephrorraphy has failed, (iii) Where a misplaced, movable 
 kidney cannot be pushed back into the loin.f 
 
 CHAPTER V. 
 
 OPERATIONS ON THE INTESTINES. 
 
 AOUTEJ INTESTINAL OBSTRUCTION.— ENTEROTOMY. 
 —FORMATION OP ARTIFICIAL ANUS IN INTESTI- 
 NAL OBSTRUCTION.- SUPPURATIVE PERITONITIS. 
 —CLOSURE OF ARTIFICIAL ANUS AND RESECTION 
 OF INTESTINE.-COLECTOMy. 
 
 ACUTE INTESTINAL OBSTRUCTION. 
 
 The following practical, though very brief, remarks on the chief 
 varieties may be helpful at the time of operation ; 
 
 * Tlioiigh the kidney had been earelully inspected at tlie previous operation by Dr. 
 Taylor and myself, though I had had opportunities of handling it, and though the 
 needle-punctures gave vent only to blood, I think the suppuration must have been 
 present at the time of tlie nephrorraphy. Thin case and that recorded at p. 638 show 
 that movable kidneys do sometimes have a basis of organic disea.se. 
 
 I would allude to another case of nephrorraphy to emphasize the remarks made in 
 the foot-note at p. 404. Here, in inserting sis sutures of carbolized silk between the 
 lower extremity and borders of the kidney and the edges of the cut lumbar fascia, I 
 made use of the closely plaited silk known as Turner's. This can so resist all cell 
 changes, etc., that for eleven months the sinuses persisted, discharging these silk sutures 
 absolutely unchanged. I finally had to open up the sinus and remove the last stitch. 
 It was absolutely unaltered. t Morris, Sarg. Dis. of the Kidney, p. 42. 
 
 J Chronic intestinal obstruction has been alluded to under the head of Colotomy, p.593. 
 
646 OPERATIONS ON THE ABDOMEN. 
 
 A. Strangulation by Bands and through Apertures* 
 
 1. Adventitious peritoneal bands. Perhaps there has been a history 
 of peritonitis, starting possibly from the cfficum, the uterus, and 
 appendages, or a mesenteric gland. These bands are usually attached 
 by one end to the mesentery. 
 
 2. Omental bands. Here some part of the lower end of the omen- 
 tum has become adherent to the brim of the pelvis, a hernial sac, the 
 uterine appendages, or the ca?cum. 
 
 3. Meckel's diverticulum. This is visually met with in young sub- 
 jects. Tubular or cord-like, it will be found attached at one end to 
 the ileum, within 3 feet of the caecum, at the other near the umbilicus, 
 or to the mesentery or intestine. Under this arch small intestine is 
 very liable to slip. In other cases one end is free, and ensnares or 
 knots up a loop of intestine. 
 
 4. Some normal structure abnormally attached. Such are a Fallo- 
 pian tube or the vermiform appendix. 
 
 •5. Some aperture or slit. This may be congenital or traumatic, and 
 situated in the omentum, mesenterj-, etc. 
 
 In all the above, the lower part of the ileum is the portion usually 
 strangulated. 
 
 B. Vohndus. — The intestine here is usually either twisted on its 
 mesenteric axis, or bent at an angle. The former is the more acute 
 condition, owing to the strangulation of vessels. It i& much most 
 common in the sigmoid flexure, when this has a long meso-colon, 
 especially in adults who have been subject to constipation (Treves). 
 
 The distension may be enormovis, this part of the intestine appear- 
 ing to occupy all the abdominal cavity. Ulceration leading to fatal 
 peritonitis may set in either in this intestine, or in the colon or caecum 
 (p. 604). 
 
 C. Strictures. — These have been considered, with chronic obstruction, 
 under the head of colotomy (p. 593). 
 
 I>. Foreign Bodies (e.g.. Gallstones) becoming Impacted. — The patients 
 here are usually over forty-five : often stout women of sedentary 
 habits, with history of past colic, etc. The stone is usually a large 
 one which has ulcerated into the duodenum. The urgency of the 
 symptoms will vary, of course, with the size of the stone,t the com- 
 
 * Mr. Treves {Intest. Obstruct., p. 13 ; Did. of Surg., vol. ii. p. 802) groups these 
 together from the similiirity of tlieir obstruction and their close resemblance to strangu- 
 lated hernia. The above classification is borrowed from Mr. Treves. 
 
 t Sometimes no such history is obtainable. Thus, in a very interesting case of Mr. 
 Bryant's {Clin. Soc. Tnms., vol. xii. p. lOG), in which he removed a gall-stone from 
 the ileum which had caused complete obstruction for three days, the patient is stated 
 to have been perfectly healthy up to llie time of the attack, save for occasional indi- 
 gestion. At the post-mortem examination an old communication was found between 
 the gall-bladder an.d the duodenum.. 
 
INTUSSUSCEPTION. 647 
 
 pleteness of the impaction, and the site. This is usually in the lower 
 ileum. 
 
 E. Xntiissusceptimi.— From its frequency, especially in young life, 
 its fatality in infants, the fact that its treatment is more satisfactory 
 because its diagnosis is easier than other forms of obstruction, this 
 form of intestinal obstruction deserves careful notice. Of the varieties 
 —the enteric, the colic, the ileo colic, and the ileo-ca3cal— the fre- 
 quency of the last is well known. It is to this variety, especially in 
 children, that the following remarks mainly apply. 
 
 The frequency with which intussusception is still left undiagnosed 
 must receive mention, a fact which appears to be due to a failure to 
 examine the rectum, or to a misinterpretation of what is found there 
 in acute cases (an intussusception being called a prolapsus), and, in 
 less acute cases, to their sometimes presenting very few symptoms at 
 all. 
 
 With regard to treatment, it cannot be too strongly insisted upon 
 that, in this form of obstruction, there is no excuse for delaying 
 active treatment. If intussusception is suspected, the trial of bella- 
 donna or opium, warmth aided by friction, should be a brief one ; 
 and if a tumor is to be felt, especially if per rectum as well as through 
 the abdomen, it should be briefer still. No delay should be lost in 
 trying inflation or injection. I prefer to begin with the former. A little 
 ether being given, the lower limbs being somewhat raised, the nozzle 
 of a Lund's inflator, or a full-sized catheter, or a rectal tube, attached 
 by tubing to a bellows and well coated with vaseline, is carefully 
 passed into the bowel. The nates being securely pressed round the 
 tube, air is steadily pumped into the colon, while the surgeon keeps 
 one hand on the abdomen, not only to j)revent over-distension, but 
 also to watch for any receding of the tumor towards the cffical region. 
 
 With regard to the force used, Dr. Goodhart Hoc. supra cit., p. 125) 
 remarks: " Replacement of the bowel can usually only be effected by 
 considerable distension of the whole colon, and distension of the 
 colon sometimes requires a good deal of rather forcible pumjaing to 
 complete it." This is especially the case with regard to the last few 
 ounces of air sent in. Probably the advice of Dr. Taylor* on this 
 point will minimize the risk of rupture of the bowel. " The risk can 
 be reduced to a minimum by injecting, carefully and slowly, succes- 
 
 * Clin. Soc. Trans , vol. xvi. p. 71. Dr. Taylor thinks that two kinds of cases are 
 unsuited for inflation : One, in which the intussusception actually projects from the 
 anus, as this form shows enormous forcing power on the part of the intestine, while, 
 after replacement by the fingers, the amount of air that can be brought to bear is 
 necessarily small. Dr. Taylor's other group unsuited for inflation is where no tumor 
 can be felt and the diagnosis depends solely on symptoms. He points out that here 
 it ia impossible to judge of the effects of inflation. 
 
648 OPERATIONS ON THE ABDOMEN. 
 
 sive small quantities, and by gently kneading the abdomen so as to 
 facilitate the passage of air upwards, and thus prevent the sudden 
 over-distension of short lengths of the colon." * 
 
 Inflation failing, if the condition of the patient admits of it, more 
 powerful means may be made use of by connecting the rectal tube 
 with an improvised water-cistern, placed high above the bed, a more 
 equable and forcible distension being thus obtained. f 
 
 These methods failing, while the child is still under an anassthetic, 
 preparations should be made for operation. Before describing this, it 
 may be useful to point out, as far as this is possible, in what cases 
 this is likely to be called for and how often it is likely to be suc- 
 cessful. The following will help towards an answer to the above 
 questions : 
 
 a The duration of the case. In the majority of cases, especially in 
 children, the tendency of the condition is to strangulation, and not 
 incarceration, and while the rapidity of the strangulation varies a 
 good deal, the chances of inflation or injection are small, unless in 
 recent cases. 
 
 /? If the above is correct, it is obviously of much importance to 
 decide whether the bowel is strangulated or incarcerated. Mr. 
 Hutchinson {Med. Chir. Trans., vol. Ivii. p. 31) points out that the 
 severity of the symptoms will be helpful here — viz., the urgency of 
 the vomiting, the degree of the constipation, the character of any 
 stools passed,! ^tc, any indications of collapse, and, above all, as 
 utterly incompatible with gangrene, advance of the tumor further on 
 in the large intestine. § 
 
 * Tlie value of this was shown decisively in the case of an infant recently inflated 
 by Dr. Perry and myself. Pumping in of air had at first little effect ; while it was 
 continued, and my colleague manipulated the parts, first, one gently snapping sound, 
 and a little later a louder one, as of unfolding intestine, were heard, and the swelling 
 was found to have disappeared. Though the infant passed a natural motion, the 
 intussusception recurred. 
 
 + Goodhart {he. supra cit.). It is pointed out that this method entails a greater 
 risk of rupture of the bowel, but that the end justifies the means (considering the 
 great danger of these cases), provided that the requisite distension cannot be pro- 
 cured without. 
 
 i Dr. Fagge and Mr. Howse {MIed. Chir. Trans., vol. lix. p. 90) point out that 
 blood in the stools of these cases does not necessarily mean strangulation and threat- 
 ening gangrene. Thus it may be present in chronic cases, from the first, as in Mr. 
 Hutchinson's, where blood-stained mucus was passed for a month, at the end of which 
 time Mr. Hutchinson was still able to reduce the intussusception by a successful 
 operation. In other chronic cases no blood may be passed for a long time ; it may 
 then appear with other symptoms and rapidly destroy life, though no gangrene is 
 present. Lastly, in some of the cases in which tho bowel has sloughed away, no blood 
 has been, at any time, passed. 
 
 § Dr. Goodhart (he. supra cit., p. 122) points out that while this symptom means 
 that no sloughing and no firm adhesions are present, it cannot be inferred, owing to 
 
IKTUSSDSCEPTIOJT. 649 
 
 y The condition of the patient as to collapse, etc. 
 
 ^. Age. In infants under a year, unless reduction is early tried and 
 is quickly successful, the prognosis is very desperate whether an 
 operation is performed or no. Mr. Hutchinson thinks that this fact 
 may be held to justify very early resort to operation. 
 
 The same surgeon thinks that, while, on the one hand, the cases 
 best suited for operation are those which have persisted for some 
 considerable time, and in which the intestine is only incarcerated, 
 on the other hand, " cases in which the symptoms are very severe, or 
 the stage greatly advanced, it may be wiser to decline the operation 
 and to trust to opiates." 
 
 Operation. — The child being still under the influence of the ether 
 which lias been given for the attempted reduction, the parts being 
 cleansed and any urine drawn off, an incision is made, usually in the 
 middle line,* sufficient to admit of the easy introduction of two or 
 three fingers. Before opening the peritoneal cavity the bleeding 
 should be entirely arrested. The intussuscepted mass is now found, 
 and, if possible, hooked out into the wound. If this be feasible, 
 careful persevering attempts are made at reduction by a continued 
 action of gently squeezing the lower end of the mass so as to push 
 out the ensheathed mass, while at the same time the ensheathing 
 layer is drawn off. 
 
 If the parts are not sufficiently mobile to allow of thus bringing 
 up the intussusception, the wound must be enlarged sufficiently to 
 introduce two fingers of each hand. The following remarks of Mr. 
 Hutchinsonf show how great may be the difficulties and the best 
 means of meeting them. Having failed to hook up the mass or to 
 reduce it in situ, he was " obliged to enlarge the wound freely above 
 the umbilicus, and to allow the intestines, much distended with gas, 
 to escape. It was only when the abdomen was almost empty that I 
 could bring the neck into view in the wound, and then made repeated 
 attempts to draw the bowel out, but without success. That there 
 were no adhesions was proved by the fact that an inch or two could 
 be easily drawn out, the impediment was clearly due to the ensheath- 
 ing bowel being thrown into folds by traction, and thus constituting 
 a series of strictures which gripped its contents. In this dilemma, 
 and when almost in despair as to whether I should accomplish the 
 reduction, it occurred to me to seek the lower end of the invaginated 
 part, and try to hold the ensheathing part to prevent its being drawn 
 
 the oedema and inflammation which are already present, tliat because the tumor thus 
 alters its position, therefore it can be reduced. 
 
 * Or in one linea semilunaris, usually the left. 
 
 t Med. Chir. Trans., vol lix. p. 100. The patient in this, Mr. Hutchinson's second 
 case, was only six months old, and died of peritonitis. 
 
650 OPERATIONS ON THE ABDOMEN. 
 
 into folds The attempt to hold the ensheathing layer straight 
 
 at once revealed the true mode of reduction, for by pulling this 
 downAvards instead of trying to pull the involved part upwards, I 
 accomplished the replacement with the greatest ease."* Mr. Hutch- 
 inson thinks that, in future, the lower ends should be always first 
 caught, and that reduction by squeezing this or pulling the sheath 
 down rather than dragging the contained tube out might be accom- 
 plished without bringing the parts into view. If this failed it would 
 be more easy, in intussusception into the descending colon, to bring 
 the lower part into the wound than the upper one. This opinion of 
 Mr. Hutchinson's has been confiraied by the following cases — e.g., Mr. 
 Howse's, a successful operation on an adult {Med. Chir. Trnns., vol. 
 lix. p. 88} ; Mr. H. Marsh's case, also successful (■ibid., p. 81), in an 
 infant seven months old ; and in another case of the same surgeon's 
 (St. Earth. Iio8f. Report% vol. xii. p. 98). Here, as by no justifiable 
 force could any part be drawn out, the contained bowel was pushed 
 or backed out by gentle squeezing movements between the finger and 
 thumb, these being shifted gradually upwards along the gut till the 
 Cfficum appeared. 
 
 Whichever method is found to answer best must be persevered 
 with till every atom of the mass is reduced, this being often known 
 by the appearance of the vermiform appendix. 
 
 Sometimes the success may be only partial, the last inches of an 
 intussusception resisting every attempt at reduction. Thus, in Dr. 
 Fagge's and Mr. Howse's paper (loc. supra cit.) a case is given of a 
 child aged five months who had suffered for a month from ileo-csecal 
 intussusception. At the operation a large part was reduced without 
 difficulty, but the last 4 inches were so adherent and softened that 
 even gentle traction caused two rents, from which ffeces escaped. The 
 remaining intussusception was therefore cut away, and the ends 
 sutured. The child only survived a few hours. 
 
 In a child aged seven months, to which I was called by Dr. 
 Warner, of Woodford, though symptoms had only lasted about thirty- 
 eight hours, I was unable to completely reduce an intussusception 
 which had reached half-way down the descending colon. The lower 
 end could only just be brought into view; by a continued traction 
 and upward squeezing a few inches were reduced, and then there was 
 an absolute block. Further attempts caused a tear in the peritoneal 
 coat at cTiie spot, and as the child was much collapsed, the sjnuptoms, 
 in spite of the verj^ short duration, having been very acute from the 
 
 * To meet tlie difBciilty of red\icing the small intestines, Mr. Hutchinson punctured 
 tliem at two or three spots to let onl flatus. Unfortunately, faeces escaped from one, 
 which required closing. 
 
OPERATION IN ACUTE INTESTINAL OBSTRUCTION. 651 
 
 first (they appear to have been started by the father dancing the child 
 up and down), and having resisted repeated attempts at inl^ation, I 
 felt compelled to close the abdomen. Death followed a few hours 
 later. 
 
 Every care should be taken throughout the operation to prevent 
 chilling, both of the child's body and Hmbs, and especially of any 
 intestine which may have to be withdrawn, p. 655. For these reasons 
 I do not advise the use of the spray in a child, preferring to irrigate 
 the wound in the abdominal w^all, and to adopt the other precautions 
 given a little later, as to instruments, irrigation of peritoneal cavity if 
 needful, and closure of the wound. 
 
 As in all abdominal sections, this operation should be concluded 
 as speedily as may be. 
 
 The chief points in the after-treatment consist in a wise use of 
 warmth, milk and brandy, and laudanum. 
 
 EXPLORATION OF ABDOMEN IN ACUTE INTESTINAL 
 
 OBSTRUCTION. 
 
 Question of Operation in these Cases. 
 
 While it is impossible, owing to the obscurity of the diagnosis, to 
 lay down any definite rules, I trust that the following remarks may 
 be found of some help : 
 
 1. Difficulty of Diagnosis. — This is a matter of twofold importance. 
 (a) Is the case one of acute obstruction at all, or is it one of peri- 
 tonitis, or peri-typhilitis? (/J) If the symptoms are due to some 
 mechanical cause brought about by acute obstruction in the form of a 
 band, internal hernia, or volvulus, which of these is it; and is it one 
 admitting of remedial interference? 
 
 It seems to me that this is one of those instances in which the 
 advances made in operative surgery have outstripijed those of diag- 
 nosis. From the necessarily hidden nature of the lesion this must be 
 so, but as long as the diagnosis of these cases remains so obscure, so 
 long shall we be uncertain and hesitating in our treatment. 
 
 2. IJ^iat is the Proportion of Natural Recoveries without Operation in 
 Cases of Acute Intestinal Obstruction f — On this point there are two 
 quite different camps of opinion, and neither, it seems to me, can 
 really point to any better success than the other. On the one hand, 
 Mr. Hutchinson, a man of vast experience and one of the acutest 
 observers the profession has ever known, submitted this proposition 
 to the Bath* Meeting of the Association : " In the present state of 
 surgical knowledge, exploratory operations for the relief of abdominal 
 obstruction, the cause of which cannot be diagnosed, are not warrant- 
 
 * Brit. Med. Joum., 1878, vol. ii. p. 305. 
 
652 OPERATIONS ON THE ABDOMEN. 
 
 able." Mr. Hutchinson based this opinion on the fact that instances 
 of spontaneous recovery in acute intestinal obstruction are " very 
 numerous, and that they prove conclusively that no one can tell 
 when an abdominal obstruction case of uncertain diagnosis is hope- 
 less, and that unless it be practically so, the dangerous expedient of 
 opening the abdominal cavity is not justifiable." 
 
 On the other hand, we have surgeons— e.g'., Mr. Treves and Mr. 
 Greig Smith*— condemning expectant treatment, and strongly urging 
 an early resort to abdominal section. 
 
 I am compelled to say that Mr. Hutchinson's reasoning does not 
 carry conviction to my mind. Though he stated that he knew that 
 cases of spontaneous recovery in acute obstruction are very numerous, 
 he only alluded to three, and that briefly. Now two of these were 
 not cases of acute obstruction. One was " a woman of middle age " 
 who " had suffered from obstruction during a long period." Another, 
 " a woman aged forty, had experienced obstruction for twenty-five 
 days." The third is extremely briefly mentioned, and nothing is 
 said about its duration. 
 
 But while I differ toto calo from Mr. Hutchinson as to the frequency 
 of spontaneous recovery, while I agree with those surgeons who hold 
 that such recovery is quite exceptional, I cannot think that they have 
 proved their case that the indication is clear for early operation. 
 Every one who has even a limited acquaintance with surgical litera- 
 ture must have noticed the number of operations that have been 
 performed for acute obstruction in late years. Yet how few have 
 been successful. And can any one doubt that the published cases 
 bear a small proportion of the whole number submitted in late years 
 to operation ? I am aware that the answer is that the surgeon is not 
 called in till too late. Not being without experience in this matter, I 
 fear that this answer will not cover all the cases. It is at least a 
 striking fact that those who are rightly considered authorities on this 
 subject, men who have had the opportunities of urging early opera- 
 tions, have not been able to publish cases which should make us hope 
 at least that the tide is on the turn. And this leads me up to my 
 next point. 
 
 3. A certain Proportion of these cases, probably a large one, are hopeless, 
 if notfrohi the first, so early in the case as to render any operation futile. — 
 I say this not as holding pessimist views on this question, but from a 
 deep conviction from numerous cases that I have seen, and several 
 
 * The following are Mr. Greig Smith's words: "To cases of acute obstruction there 
 
 is practically but one termination— death Certainly 95 per cent, of all such 
 
 cases die. Here, then, the indication is clear enough — as clear as the indication to 
 tie a bleeding carotid — operation." 
 
OPERATION IN ACUTE INTESTINAL OBSTRUCTION. 653 
 
 that I have operated upon. I refer not of course to cases of intussus- 
 ception, or simple bands * but to those of volvuli with severity of 
 twist, complicated snaring or knitting up by bands, and matting of 
 coils by old inflammation started in mesenteric glands. To name 
 one more condition, how often has the surgeon in operating found 
 the obstruction, set free some imprisoned loop, and then found all 
 his trouble made of nought, this first loop being only lately drawn 
 under the constriction, by another coil which he finds deep in the 
 pelvis, evidently the source of the trouble, and for some time past 
 recovery ? 
 
 In writing this I would not dissuade from early operations, but I 
 cannot agree with the tendency which has set in at the present time 
 to write and say that the only reason these operations are not suc- 
 cessful is because they are performed too late. Even if it is possible 
 to operate always early a considerable proportion will, unless I am 
 mistaken, continue to baffle us. 
 
 4. The comparisons which have been made between an operation in 
 these cases of acute obstruction and those for herniae, between abdominal sec- 
 tion here and in ovariotomy, is most misleading and dangerous. Thus, 
 a surgeon for whom I have the highest respect, Mr. Teale, writes 
 thus : " As to the impunity with whicli the peritoneal cavity may be 
 opened, I need hardly remind you how constantly this is proved in 
 operations for hernia. We think nothing of pulling out and handling 
 coils of intestine, and we rarely look for danger unless the bowels 
 have been damaged by too long continued strangulation." I am 
 afraid the two cases are not comparable. A carefully conducted 
 herniotomy, even in a huge inguinal hernia with omentum, small 
 intestine, and C£ecum down, can be made, with care, a practically 
 extra-peritoneal operation. It would be easy, moreover, to show 
 that in the shock, in the time taken, in the condition of the structures 
 met with, the two operations are scarcely comparable. 
 
 So too with the comparison with ovariotomy, the same surgeon 
 writes : " Again, in ovariotomy, what are the dangers there ? Mainly 
 from the fluids poured out from adhesions and divided vessels, dan- 
 gers which, as a rule, are absent in gastrotomy." I cannot think, 
 save in a few cases, these operations will ever run on parallel lines. 
 Ovariotomy is an operation in which diagnosis has much more kept 
 pace with operative treatment. In ovarian tumors it is the difflcult 
 cases, the delayed operation, which will more and more become the 
 
 * So, too, cases of Meckel's diverticulum will always be amongst the most favorable 
 ones for operation, from the greater simplicity of the lesion, and the usually young 
 and healthy patient. 
 
654 OPEKATIONS ON THE ABDOMEN. 
 
 exception, in acute intestinal obstruction I fear the conditions are 
 such that the above will remain the rule.* 
 
 5. The Failure of Prcnious Treatment. — From the very first the treat- 
 ment should be limited to warmth, enemata, ice to suck, and only 
 sufficient morphia to secure sleep enough to support the strength and 
 to allay pain, not to mask important symptoms, and give a fallacious 
 appearance of improvement. How long should this treatment be 
 persisted in ? Each case must be decided by itself, but in the great 
 majority of cases of acute olistruction, the operation, to be successful, 
 must be performed within forty-eight hours. 
 
 6. The Condition of the Patinit.—li an operation is to be performed 
 the pulse should at least be fair, the temperature not falling, the ab- 
 domen not much distended, and with sufficient evidence of peris- 
 talsis to make it probable that there is but little or no peritonitis. On 
 the other hand, when the patient has been for many days treated by 
 drug§, the operation should not be performed, as it too often is, on 
 the mere chance of relief I may quote here from a previous paper 
 of mine :t " Those who wait, as I venture to say too many have 
 waited, till the abdomen is generally and enormously tympanitic, till 
 the temperature is filling before the inevitable end, till the pulse is 
 runnino- down and the patient in a condition of irrecoverable collapse, 
 those who wait till all or any of these things are present had far best 
 not operate at all. It is only too easy to foretell the operation that 
 folio W9. The abdominal cavity is opened readily enough, and then 
 the difficulties begin ; coils of enormously distended intestine at once 
 crowd up at the mouth of the incision, the operator has the greatest 
 difficulty in finding a contracted portion, and so of tracing out the 
 point of obstruction ; perhaps, during his endeavor to do so, a faecal 
 odor becomes apparent, showing that the intestine has already given 
 way; or, granting that the seat of mischief is found, and the cause 
 removed in spite of all his endeavors the surgeon finds himself with 
 several coils outside the abdomen, and at his wit's end to get them in 
 again, perhaps he punctures them, but owing to the paralysis of the 
 muscular and the infiltration of the serous coat, which has by this 
 time taken jalace, the puncture in the mucous coat is not closed, or 
 does not slip away from directly l)eneath the opening in the serous; 
 as the intestine is returned liquid fieces are seen escaping at two or 
 three points, any attempt to close these with sutures only makes 
 
 * It would not be difficult to show that the condition of the patient before ovari- 
 otomy is very different from one submitted to abdominal section for obstruction. And 
 with regard to the operation itself, in the one case the surgeon knows what to expect; 
 in the other he is too often utterly in the dark. 
 
 f Brit. Med. Juurii., Seiitemlier '27, 1879 : " Case of Acute Intestinal Obstruction by 
 Bands; Operation; Death Ten Days after." 
 
OPERATION IN ACUTE INTESTINAL OBSTRUCTION. 655 
 
 matters worse, and the patient sinks quickly after his removal from 
 the table." 
 
 Operation. — Before preceding to this the surgeon should see that 
 the following are in readiness — scalpels, probe-pointed bistoury, Key's 
 and ordinary steel directors, six pairs of Spencer Wells' forceps, liga- 
 tures, and fine sutures of carbolized silk and chromic gut, absolutely 
 reliable sponges, known to be clean beforehand, and soaking for two 
 hours in carbolic acid (1 in 60), two of these should be flat, two or 
 three quarts of a 2 per cent, solution of boracic acirl, kept warm, for 
 irrigation of the peritoneal cavity if needful, some new towels cut in 
 half and soaked in warm carbolic solution (1 in 60) very fine needles, 
 a large drainage-tube, and iodoform. 
 
 The bladder is first emptied, and the abdominal wall shaved and 
 cleansed (p. 649). The parts being relaxed, and ether given, the sur- 
 geon begins with a central incision below the umbilicus, going quickly 
 down to the peritoneum, but arrests all hsemorrhage before this is 
 opened. If the linea alba is not hit off exactly, and is not quickly 
 found, any muscular fibres are torn straight through with a steel 
 director, and the transversalis fascia and peritoneum thus quickly 
 reached. 
 
 The peritoneum should always be well lifted up before it is opened, 
 especially if there is distended bowel beneath. The opening is 
 then enlarged for about 2 inches with a blunt-pointed bistoury or 
 scissors, two fingers with the palmar aspect turned upwards serving 
 now as the best director. Up to this time either irrigation* or the 
 spray has been made use of, but are now stopped. 
 
 Mr. Greig Smith advises, where the peritoneum is thin, to pinch it 
 up between the finger and thumb, and roll it about to see that no 
 bowel is included.! 
 
 The surgeon should now decide which mode of exploration he will 
 make use of. The following is as useful as any. If the parts are not 
 much distended, these possible sites of strangulation should be first 
 looked to. The cascum, which will give twofold evidence, first, its 
 distension or emptiness telling whether the obstruction is above or 
 below it; and secondly, the state of its appendix, whether normal or 
 free, whether empty or containing some concretion. Next, the in- 
 ternal inguinal, the femoral, and obturator rings are explored, to 
 make sure that no tiny hernia exists imperceptible from the outside. 
 The fingers are next swept upwards towards the umbilicus, in the 
 hope of finding one of the diverticular bands mentioned at p. 646. 
 If, up to this, the search has been fruitless, the brim of the pelvis is 
 
 * With mercury perchloride, glycerin, and water (1 in 1000). 
 
 f If much fluid is present, it now often shows itself throu^'h the peritoneum. 
 
656 OPERATIONS OK THE ABDOMEN, 
 
 next examined, as bands of omenta are often fixed hereabouts, and 
 also because, in women, local peritonitis, originating in the uterus or 
 its appendages, is, not unfrequently, the source of the obstruction. 
 
 If the above search with two or three fingers fail, and it often will 
 when distension is present, embarrassing the fingers in their move- 
 ments, and obscuring the relation of parts, one or two of the loops 
 which lie nearest to the wound should be carefully scrutinized.* 
 These should be followed in the direction of increasing congestion 
 and distension, thus leading to the stricture. If it be needful for 
 getting in sufficient fingers to examine the coils, the incision must 
 be enlarged. 
 
 If this second method fail, there is nothing for it but to draw out the 
 most distended part of the intestinef under a new piece of towelling, 
 just wrung out of carbolic acid (1 in 60), or boracic acid (2 per cent.), 
 both of these being kept warm. When there is not much distension, 
 the plan adopted by Mr. Cripps I is the simplest — i.e., to draw out some 
 inches of intestine at a time, bit by bit, from the upper part of the 
 wound, passing it in again into the belly through the lower part, in such 
 a way that at no time are more than 5 or 6 inches of intestine exposed. 
 After drawing out and replacing some feet of intestine in this way, it 
 is probable that, owing to the increasing congestion or resistance, the 
 surgeon will reach the obstruction. § It now remains to take the dif- 
 ferent causes separately. In any case the medium of strangulation 
 must somehow be got into view. If it cannot be brought up into the 
 wound, the intestine should be pressed out of the way, to one 
 side, and kept there, if possible, by a flat sponge, while the mischief 
 is dealt with. 
 
 Bands\\ and AperturRa'^ (p. 646). — In [most cases these are not diffi- 
 
 * Mr. Greig Smith says that as the most distended coils will rise nearest the surface, 
 and the greater amount of bowel is within three inches of the umbilicus, there is a 
 probability that the most dilated coils will be in sight. 
 
 f i.e., that part of it which is most inclined to protrude at the wound. 
 
 % Clin. Soc. Trans., vol. xi. p. 22o. 
 
 I If he find that the bowel is getting healthier and emptier, the surgeon must re- 
 verse the direction of his search. Mr. Cripps, finding that, as at first the intestine was 
 drawn more and more from the leftside, he was approaching the duodenum, and believing 
 that the obstruction was low down in the small intestine, reversed his process of exposure. 
 
 II As stated at p. 653, some of these, notably Meckel's diverticula, may be expected 
 to give a large percentage of successes. 
 
 If An excellent instance of this form of obstruction has been recently published by 
 Mr. II. Marsh {Brit. Med. Joarn., June 2, 1SS8). Here a loop, probably in the middle 
 of the jejunum, had slipped through a hole in the mesentery. The mesentery at this 
 spot seemed of normal thickness and pliability, and the edge of the opening was so 
 yielding that Mr. Marsh could readily stretch it with his finger-nail siiflSciently to 
 allow the loop to be drawn out. The patient made a good recovery, though in much 
 danger, for a while, from the paralyzed condition of the damaged intestine. 
 
OPERATION IN ACUTE INTESTINAL OBSTRUCTION. 657 
 
 cult to deal with. If bands do not give way to the finger as attempts 
 are made to hook them uij, they should be divided between two liga- 
 tures of chromic gut. Occasionally transfixion is required. Intricate 
 kinking of loops may be most baffling. When one band has been dis- 
 covered, the possibility of a second, attached to the pelvic brim, must 
 always be remembered (p. 653). 
 
 Volvulus (p. 646). — If, as will probably be the case, attempts at re- 
 ducing this fail, it should either be opened, emptied, and, the aperture 
 being closed with a Lembert's suture, fresh attempts at untwisting 
 made, or a left or right colotomy performed, though it is very doubtful 
 if this opening the bowel above will be sufficient, unless the volvulus 
 itself is emptied. 
 
 Intusmsceptioa.— This has been already fully dealt with (p. 647). 
 
 Gallstones. — If one of these were discovered blocking the intestine, 
 and resisting all attempts to pass it into the large bowel, the looj) being 
 drawn outside, and the stone extracted, the opening must be most care- 
 fully closed.* 
 
 The cause being removed, it remains to replace any loops of intestine, 
 which if left outside have been kept warm by an assistant, to clean the 
 peritoneal cavity, and close the abdominal wound. A very important 
 point raised by Mr. Greig Smith (loc. supra cit, p. 378) now claims 
 attention. To quote his own words : " It is not always proper to return 
 distended intestine into the abdominal cavity. I hold, on the contrary, 
 that no operation for intestinal obstruction is properly completed if 
 the patient leaves the table with a greatly distended abdomen. The 
 effects of distension are doubly deleterious, on the system generally, 
 and on the bowels themselves. That dyspnoea, palpitation, and what 
 may be called abdominal shock, follow great distension of the abdo- 
 minal cavity is well enough known. That paralysis may, and does, 
 follow over-distension of a viscus such as intestine .... is also known. 
 But it is not generally recognized that the mere presence of an excess 
 of fluid or gas in the intestine is in itself an efficient cause of obstruc- 
 tion. When the intestine, confined by mesentery in the limits of the 
 abdominal cavity, is fully distended, it does not form gentle curves but 
 acute flexures. At these flexures the intestinal walls on the mesenteric 
 side encroach on the lumen, so as to form valves which obstruct the 
 passage of contents The disappointing results of simple tap- 
 ping of the bowels is thus explained ; the gut is emptied down to the 
 second or third flexure and no further To open the bowel, it is 
 
 *^ In one case {Brit. Med. Journ., May 31, 1879), after the removal of a concretion 
 from the jejunum, the bowel was so thinned that, "although it was well stitched with 
 carbolized catgut," it would not hold together. The patient died in four hours. 
 
 42 
 
658 OPERATIOXS ox THE ABDOMEN. 
 
 best to make an incision by a scalpel transversely to its axis at the point 
 most distant from the mesentery. A trocar and cannula, large enough 
 to admit outflow with sufficient rapidity, would make a ragged, bruised 
 wound, not so suitable for being dealt with and not so likely to heal 
 kindly as a simple incision. The bowel, perfectly protected, is pulled 
 a few inches away from the wound, and held over a receiver, while an 
 assistant gently kneads the sides of the abdomen to force the fluids up 
 to the opening. The first flow of gas and liquid rushes out with con- 
 siderable force, and a notable diminution in the size of the abdomen will 
 at once be apparent ; artificial pressure, however, is wanted to empty 
 the rest of the bowels. Of course the bowel that had been constricted 
 will have been carefully examined to see that there is no chance of its 
 being ruptured in the manipulation." The opening is closed with a 
 Lembert's suture of carbolized silk. 
 
 The peritoneal cavity must be next cleansed of any spray* fluid, and 
 above all of any discharges, either by sponges introduced on large 
 Spencer Wells' forceps down into the pelvis and along the costo-ver- 
 tebral furrows, or by irrigation with a warm solution of boracic acid 
 (2 per cent.) in boiled water. 
 
 The opening in the abdominal walls is then closed with sutures of 
 wire, and silk or fishing-gut, care being taken to include the parietal 
 peritoneum, and, as the sutures are inserted, to prevent, by a flat 
 sponge, any blood entering the cavity of the peritoneum. 
 
 The advisability of forming an artificial anus is alluded to below. 
 
 ENTEROTOMY: FORMATION OP ARTIFICIAL ANUS 
 IN ACUTE INTESTINAL OBSTRUCTION. 
 
 This is done, under two chief conditions, when the surgeon cannot find 
 the site of stricture, or finds that he cannot deal with this and makes 
 an artificial anus on the middle line, or when he decides not to per- 
 form abdominal section, but to relieve the distension, etc., by opening 
 the bowel above the stricture, usually making use of Nflaton's opera- 
 tion. Neither is more than palliative, and neither should be made use 
 of save when everj^thing else fails, and when the surgeon feels sure 
 that the obstruction is low down in the small intestine. f 
 
 * This will not have been used if there has been much collapse or a prolonged oper- 
 ation. As little of the body snrface as possible should be exposed to it, and it should 
 never be allowed to plug in the viscera. Any exposure of these should be prevented, 
 as far as possible, by keeping the edges of the wound together, and by carbolized flat 
 sponges, and towels (p. 6-55). 
 
 f If the artificial anus be high up in the small intestine, death from inanition is 
 certain. 
 
ENTEEOTOMY: FORMATldN OP ARTIFICIAL ANUS. 659 
 
 Nelaton's* Operation— Right Iliac or Inguinal Enter- 
 otomy. 
 
 Operation. — The small intestine may be opened low down by 
 drawing a line from the umbilicus to the right anterior superior spine, 
 taking a point a little below the centre of this line as the middle of a 
 vertical incision about 2 inches long. Another method is in use, by 
 much the same incision as in Littre's operation— viz., one parallel with, 
 and about 1 inch above, Poupart's ligament, beginning just outside the 
 site of the internal ring and carried upwards and outwards towards the 
 anterior superior spine. 
 
 In either case the structures are divided down to the peritoneum, and 
 all haemorrhage carefully stopped. In a weakly patient, it may be well 
 to tear through the muscles with a steel director. The opening into 
 the peritoneum should not be more than 1 or 1} inch long. The first 
 piece of intestine which presents in the wound, or the one which seems 
 to be the most distended, is drawn into the wound and sutured most 
 carefully, two stitches, if possible, being introduced at either end, and 
 three on each side. The sutures should be of silk, or fishing-gut and 
 horsehair. If there is time, peritoneal apposition should be ensured 
 by stitching the parietal peritoneum first to the margins of the wound 
 by a few points of chromic gut. If jDossible, some hours should be 
 allowed to elapse before opening the intestine. If it is absolutely 
 necessary to open it at once, this should be effected with a small and 
 very sharp trocar, the cannula left in and plugged. Another means of 
 preventing contamination of the peritoneal cavity would be to insert 
 a drainage-tube through the cannula and thus lead liquid fa?ces quite 
 away from the opening. Every care should be taken to keep the parts 
 sweet as in colotomy, pp. 600, 601. If needful later, the wound must 
 be dilated by sponge-tents. Especial care must be taken to ensure the 
 regular wearing of a plug, and to prevent any accumulation above by 
 regular attention to the bowels and by injections. 
 
 Formation of an Artificial Anus in tlie Middle Line.— This 
 will probably be more frequently made use of in cases where the 
 obstruction cannot be relieved. A loop, as near as possible to the 
 
 * M. N^laton, introducing this operation in 1840, believed that some obstructions 
 would relieve themselves in time if a temporary outlet emptied the accumulation 
 above; in other cases, where the obstruction vviis malignant, the relief thus given 
 would be sufBcient for the remainder of the patient's life if the small intestine was 
 only opened low down, while this simple operation involved much less shock and 
 disturbance of the abdominal contents. While the above are true, this operation, 
 which is, after all, only palliative, usually fails, from what I have seen, by leaving 
 irrecoverable mischief behind in those very cases to which it is best suited — viz., acute 
 obstruction where the lesion cannot be found or where it is beyond recovery. Another 
 disadvantage is the large amount of intestine above the opening which may remain 
 distended and partly paralyzed. 
 
660 OPERATIOXS ON THE ABDOMEN. 
 
 disease, being drawn out, the wound is accurately closed around this, 
 and the bowel is then stitched in situ with the precautions already- 
 given. 
 
 OPERATIVE TREATMENT OF SUPPURATIVE PERI- 
 TONITIS. 
 
 Indications. — When a case of peritonitis has resisted other treat- 
 ment, especially if it show dulness, fluctuation more or less obscure, 
 perhaps oedema of the skin, when the vomiting is so constant that 
 the patient's condition is becoming critical, the peritoneal cavity 
 should be opened and the collection drained. 
 
 This may be either diffuse or localized,* and the treatment will 
 vary accordingly. The peritoneal cavity being opened by an in- 
 cision,t either over any localized dulness, oedema, etc., or in the 
 middle line, at' first about 2 inches long, when the collection is 
 reached, pus will come out freely, often foul and of varying consis- 
 tency. It must all be removed, if possible, by varying the patient's 
 position, irrigation with a 2 per cent, solution of boracic acid in 
 boiled water,! till all runs out clear, and by introducing sponges on 
 holders or in clamp-forceps. Every gentleness must be used, as the 
 peritoneum is soft and altered, and bleeds readily. The question will 
 next arise, if the pus is here and there dammed up in pools by coils 
 of adherent intestine, how far it will be wise to break these down and 
 drain all the fluid away once for all. This must chiefly depend upon 
 these points — (a) The age and condition of the laatient ; (6) the strength 
 of the adhesions ; (c) the character of the pus as to foulness, etc. 
 
 In doubtful cases it will be wiser to follow the advice of Mr. Greig 
 Smith (loc. supra cit., p. 441): " It is possible, as I can from experi- 
 ence testify, to do too much at first in these cases. The shock of 
 cl'^ansing the abdomen and breaking down adhesions may at once 
 kill the patient, where waiting a day or two, while the advantage of 
 evacuating jjus is having its beneficial effect, may give the patient an 
 opportunity of rallying a little. AMien a little improvement shows 
 itself, abdominal irrigation may be instituted, and if there is a 
 removable cause, this may be treated later on. I am convinced that, 
 in the most severe cases of purulent peritonitis, the safest proceeding 
 is to treat by stages, and not at one operation." 
 
 If the collection is an encysted one, it may not be found at once 
 
 * It is of importance for the surgeon to remember the chief causes — e.g., some per- 
 foration of a hollow viscus, mischief starting in the appendix, or uterus, or ovaries, 
 or following an exanthem, injury, or chill. 
 
 t The urine should be first drawn off, and the best anesthetic will be ether. 
 
 J With the condition of peritoneum met with this will probably be preferable to 
 carbolic-acid or niercnry-perchloride solutions, for fear of absorption. 
 
CLOSUEE OF ARTIFICIAL ANUS. 661 
 
 especially if the median incision is made use of. When the collectiou 
 is found by the finger, it should, if possible, be opened in situ, and 
 the median wound closed, so as to keep the general peritoneal cavity 
 sweet.* 
 
 If any cause of the peritonitis, such as ulcer of the intestine or 
 perforated appendix cseci, is found, it must be treated. The ulcer 
 should be closed by tying up, or by Lembert's suture (p. (J65) after 
 paring. 
 
 The appendix, if ulcerated, sliould be removed, and the end liga- 
 tured, the serous coat being drawn over the others, and sutured 
 separately if feasible.! 
 
 After the removal of the pus, a large drainage-tube should be 
 inserted, and the wound closed, and every attempt made to support 
 the patient's strength by judicious feeding and opiates. 
 
 CLOSURE OF ARTIFICIAL ANUS. 
 Indications. — Cases where the opening dates to injury, hernia, 
 etc., and admits of being safely closed ; when, owing to its site being 
 high up in the intestine, serious marasmus is threatened, and when 
 sufficient time has elapsed and enough troublej has been taken to 
 make it certain that there is no hope of spontaneous closure. The 
 patient's condition and strength must be satisfactory. 
 
 * This course was successfully adopted by Mr. G-odlee {Clin. Soc. Trans, vol. xix. 
 p. 90). As no cause for the peritonitis was found beneath the opening, the finger v/tis 
 passed down to the caecum where mischief was expected, finding slightly adherent 
 coils and giving vent to foul pus The abdominal wall over the right iliac fossa being 
 projected by the finger passed here from the wound, an inuision, 1 inch long, was 
 made. It was now foimd, on exploring, that the pus came from the neighborhood of 
 the appendix, which, though thickened, was not ulcerated, and contained no concre- 
 tion. The patient made a good recovery. 
 
 t The case will not be forgotten in which Mr. Symonds, at the suggestion of our 
 colleague, Mahomed, successfully removed a concretion from the vermiform appen- 
 dix, the cause of recurrent typhlitis. The operation was extra-peritoneal [Clin. Soc. 
 Trans., vol. xviii. p. 2S5). 
 
 X When both openings are easily found, trial should be made of a simple and 
 ingenious method of Mr. B;inks (Clin Notes, p. 94). In an artificial anus in the groin, 
 after a femoral hernia, he introduced a thick piece of india-rubber tubing into the 
 opening, and pushed one end up the ascending bowel and the other down the de- 
 scending. It was fastened by silk hanging out of the opening. It was calculated 
 that the pressure of the tubing against the projecting spur would press it back, and 
 allow the faeces to pass round the corner without flowing out of the artificial anus. At 
 the end of seven weeks nearly all the fjeces passed by the rectum instead of by the arti- 
 ficial anus, this being reduced to a sinus, giving vent to a few drops of yellowish fluid. 
 At the end of three months this completely closed. According to Mr. Makins {loc. 
 infra cit.), the average duration of Dupuytren's method varies from four and a half to 
 twelve months. Mr. Barker has suggested the use of Spencer Wells' forceps to 
 destroy the spur. 
 
662 OPERATIONS ON THE ABDOMEN. 
 
 Operation. — I know of no clearer account than that of Mr. 
 Making.* The skill with which this operation was carried out was 
 only equalled by the thoughtfulness M'ith which it was planned. 
 
 The patient was aged twenty-one. The artificial anus, dating to a 
 herniotomy, was high up in the small intestine, and opened about } 
 inch above the centre of Poupart's ligament. Here, at the bottom of 
 a small pit, the mucous membrane of the intestine was slightly pro- 
 lapsed. The gut was firmly attached ; the finger only i^assed into the 
 upper opening ; the lower could not be found. First, the usual 
 exzematous condition was very much improved by the use of a small 
 shield, and mopping away of discharge with absorbent wool. No 
 food was given by the mouth after the evening of the second day 
 before the operation, nutrient enemata being given every four hours. 
 During the day before, the upjjer end of the bowel was washed out 
 with injections of salicylic lotion. As bile-stained fluid was escaping 
 from the fistula an hour before the operation, this washing out was 
 repeated. Before beginning the operation a bit of carbolized sponge 
 attached to string was passed for 2 inches into the upper end of the 
 bowel. A vertical incision of 2J inches being made through the 
 abdominal wall, the upper end of the intestine, normal in size, was 
 dissected free from its adhesions ; the lower end lying just below it 
 was contracted to the size of a pencil, with an opening only large 
 enough to admit a director. f 
 
 The two ends of the gut being now provisionally clamped with 
 forceps (Fig. 104), sheathed in tubing, they were drawn out, and a 
 
 Fig. 104. 
 
 Mr. Making' clamp-forceps^ for use in resection of intestine.^ 
 
 number of sponges attached to string packed round them. The 
 sponge was then drawn from the upper end of the intestine, and 
 about 1 inch removed from the upper end and 2J from the lower one, 
 together with a wedge of mesentery 4 inches long by f inch wide. 
 The cut surfaces then nearly corresponded. The bleeding points 
 having been tied in the mesentery, this was united with six silk 
 
 * Si. Thomas's Hosp. Reports, vol xiii. p. 18. 
 
 t Over two months had ehipsed since the formation of the fistula, and one month 
 since the la«t proper action of the bowels. 
 
 X Mr. Makins prefers these clamps as less cnmhrons than any others. If fingers 
 are used, tlie compression varies a good deal, and dries and damages the intestine. If 
 a temporary ligature of catgut is made use of, and passed through the mesentery, it 
 puckers the bowel and prevents even stitching^ 
 
EKTEKOTOMY — COLLECTOMY. 663 
 
 sutures, and the gut then sutured as follows : A first row of twenty- 
 five very fine China-twist stitches were passed with a small curved 
 needle through the whole thickness of the gut ahout -^ inch from its 
 free margin, commencing at the mesenteric border. These were tied 
 in batches of five at a time. Then a second row of Lembert's sutures 
 (Figs. 106, 107) were passed and tied in the same manner. During 
 the stitching, which took about three-quarters of an hour, the gut was 
 kept moist with warm salicylic lotion. After the bowel was closed 
 and returned, it was found impossible to close the whole wound. As 
 this could only be brought together above and below, the granulations 
 were shaved away and the intestine left at the bottom of a deep pit. 
 Iodoform gauze and pine-wood dressing were applied. The patient 
 made a good recovery. Two days later the intestine could be seen at 
 the bottom of the wound covered with lymph and showing vermicular 
 movements. The bowels acted naturally two days after the operation. 
 No fieces came by the wound, but twelve sutures were thus discharged. 
 
 ENTEREOTOMY— COLECTOMY. 
 
 Indications. — Manj^ of these must be considered unsettled. While 
 for artificial anus in such a case as that of Mr. Makins, where such 
 conditions are present as those of increasing marasmus in an other- 
 wise healthy patient, or in cases of limited injury to the gut, the 
 operation may be unhesitatingly entertained ; it is otherwise, I think, 
 in many of the other cases in which it has been performed — viz., gan- 
 grenous intestine and malignant disease. These are, it seems to me, 
 instances of the way in which modern surgery has planned and 
 carried out operations which have got far in advance of the strength 
 of our patients. Where gangrenous intestine, as after hernia or intes- 
 tinal obstruction, is met with, owing to the critical condition of the 
 patient, and the unsatisfactory condition of the intestine in the 
 vicinity of the resection, no more should be attempted than the 
 formation of an artificial anus, the two ends of the gut being brought 
 outside, and their union left to another date. 
 
 Again, in malignant disease, do the published cases show that it is 
 worth the patient's while, save in a few most exceptional cases, to 
 undergo the great risk of resection, while the probability is so great 
 that glandular enlargement or other deposits are present, and while 
 there is abundant and certain evidence that colotomy, if performed 
 in time, gives such distinct prolongation of life and such marked 
 relief? It must not be forgotten that in many of these cases of resec- 
 tion of the intestine for malignant disease the surgeon will, partly from 
 the extent he has been obliged to remove, partly from the condition 
 of his patient, be obliged to complete his operation in two stages, with 
 a prolonged interval between them, and that, if secondary deposits 
 
664 OPERATIONS ON THE ABDOMEN. 
 
 are present, the time for the completion of the operation may never 
 come, and thus the patient, having run a greatly increased risk, will 
 be in no better condition than if he had only been submitted to colot- 
 omy. 
 
 I propose first to describe the operation as suited to any of the 
 above conditions, and then to give the difficulties and contra-indica- 
 tions. 
 
 Operation. — This will include: 
 
 1. The Incision. — The site of this must vary, as it is impossible to 
 lay down a definite rule here. Thus, (a) Mr. Bryant* successfully 
 performed colectomy through a colotomy incision, and where the 
 disease, in this position, is so limited, this is no doubt the right course 
 to pursue. Time alone will show how many cases of malignant disease 
 are, both in position and limitation, suitable cases ; I fear but few. 
 (6) The incision in the linea alba: this has the advantage of affording 
 an opportunity to explore in doubtful cases, of giving room by allow- 
 ing of extensive enlargement, and of thus, perhaps, reaching secon- 
 dary deposits in the glands, (c) An incision over the growth, as in 
 the right or left inguinal regions, or, as suggested \)y Mr. Whitehead,! 
 as a convenient compromise between these and that in the linea alba, 
 an incision along the outer border of the rectus. 
 
 2. Isolation of the Groivth. — By whatever incision the growth is 
 exposed, the surgeon will next have to decide whether isolation is 
 feasible. He may find a growth isolated and apparently free from 
 secondary deposits, and thus suitable for resection, but so fixed as to 
 make it impossible to bring it up into the wound by any amount of 
 traction that can be called safe. In such a case the operation had 
 best be abandoned, and colotomy substituted in the case of tlie large 
 bowel. Other indications for abandoning resection will be glandular 
 enlargement, if at all extensive, and adhesions of the afi^ected intestine 
 to neighboring parts. 
 
 3. Resection of the Intestine. — If it be found possible to bring up the 
 intestine into the wound,| and feasible to resect it, sponges are care- 
 fully packed all around so as to shut off the peritoneal cavit}', and the 
 bowel is occluded just above the intended sites of section, either by 
 the fingers of an assistant or bj^ clamps. Of these, Mr. Makins' (Fig. 
 104) seem as simple and efficient as any. The diseased portion is then 
 cut away with a triangular wedge of mesentery, the base correspond- 
 ing exactly to the part of bowel removed. Anv vigorously bleeding 
 points are now tied with fine catgut, and the edges of the mesentery 
 
 * Med. Cldr. Trans, vol. Ixv. p. 131. 
 f Brit. Med. Journ., January 24, 1885. 
 
 X The softened condition of the bowel at the site of disease, the varying length of 
 the meso-colon, etc., must be borne in mind. 
 
SUTURE OF THE INTESTINE. 
 
 665 
 
 brought together with continuous or separate points of suture of the 
 same material. 
 
 4. Suture of the Intestine. — After resection of the intestine and mesen- 
 tery, the ends of the cut bowel are carefully emptied, cleansed, and 
 
 Fig. 105. 
 
 This shows the appearance of a completely resected bowel with its edges much everted prior 
 to the introduction of sutures. Four stitches have been inserted in the mesentery to join its 
 two cut edges. (MacCormac.) 
 
 M 
 
 brought into apposition, a point of some difficulty owing to the ever- 
 sion of the mucous membrane (Fig. 105). Of the numerous forms of 
 sutures, most have become obsolete. 
 
 Two modes only will be described here. In one a double row are 
 inserted ; the first, being tied within, take up the mucous membrane 
 
 ^^■ 
 
 Fig. 106. 
 
 Five sutures introduced by Lembert's 
 method. (MacCormac.) 
 
 Fig. 107. 
 
 V - 
 
 Lembert's suture, as used by Sir 
 W. MacCormac in two successful 
 cases of intra-peritoneal rupture of 
 the bladder. 
 
 only. Fig. 107 shows their mode of introduction. An external line 
 of sutures is then applied after Lembert's method. Each of these 
 
666 OPERATIOXi OS THE ABDOMEy. 
 
 should be iiuerted not l^ss than i inch from the cut edze. run along 
 in the muscular or between the muscular and serous coats . it is then 
 made to emciee just wide of one cut ed.-e. re-inserted just beyond the 
 oppc'site edL'e. then at once made to travel between the coats and to 
 emerj^ as before. This method has the aJvantaire of turning in and 
 keepiniT in cuntact the peritoneal membrane which hounds the edges 
 on either side. 
 
 In the other mode of suturing', the above suture of Lemben's is 
 alone tru^:ed to. with'Uit any internal row in the n.ucous membrane. 
 Sir W. MacCormac thinks that the siugic- row is enough, as long as a 
 sufficient width of surface is taken up. 
 
 Fine Chinese twist silk. thL'rC'Uirlily carbolized. is the l^est material, 
 and a sufficiency of fine round needles so that the aperture i; at once 
 pluiTired by the thread shouM be at hand. Flat nrTules. however, if 
 onlv fine enough, will serve the purpose well. Difl^erent curv-i-s should 
 be provided, and two or three nee'lle-ho'lders. and the operator must 
 be kept well supplied. 
 
 One or two points require special atteiuion. The sutures should be 
 inserted about > inch from each other, and from twentv-uve to lortv 
 will be required in the two rows xoz'^il'i':^:. each "oeinir inserted as far as 
 possible at an interval between two others. The chief attention is 
 needed at the attachment of the mesentery, the outer sutures being 
 dipped here well into the muscular coat, so as to bring the serous 
 surface firmly in contact, and thus avoid any extravasation into the 
 triangular interval which here exists at the Separation of the perito- 
 neum into two layers. 
 
 "\Mien all the intestine is chised, it is cleansed, and gentle pressure 
 is made, after removal of the upper clamp, to see if the contents pass 
 beyond the line of -uture safely. If all is water-tight, the parts are 
 again thorouLthly cleansed, all sutures of uneven lenirth trimmed, the 
 protecting sponges removed, the neighborhood made clean, and the 
 intestine and mesentery returned, having finally had a little iodoform 
 dusted on and rubbed over it. The wound is then closed in the 
 usual wav. 
 
 CHAPTER YI. 
 
 OPERATIVE INTERFERENCE IN GUNSHOT AND 
 OTHER INJURIES OF THE ABDOMEN. 
 
 My space docs not allow me to consider separately those other 
 cau-e- of al>dominal injury which may call for exploration — viz., 
 ruptured intestine from a horse-kick, or a wheel going over the ab- 
 
GUNSHOT INJURIES OP THE ABDOMEN. 667 
 
 domen. The following remarks will be found to appljr to these 
 injuries also. 
 
 We owe the great advances lately made in this subject, in the first 
 place, to modern antiseptic surgery, and, in the second, to the zeal 
 with which American* surgeons have taken up the matter and made 
 known their results, unsuccessful as well as successful. 
 
 1. Examination of the Wound, with Begard to Penetratimi.—The edges 
 of the wound. Blackening of this and the clothes with powder sug- 
 gests a close shot and probable penetration. Edges clean cut and 
 equally stained show that the bullet has struck perpendicularly; un- 
 equal staining and raggedness suggest obliquity of impact, and the 
 less perpendicular this is, the less the probability of penetration. 
 If there exists a continuous track of tenderness, especially if accom- 
 panied with slight redness, from the wound for some distance over 
 the abdominal surface, it is' fair to infer that the missile has wormed 
 itself between the layers, without penetration (Parkes). 
 
 2. Si/mptoms indicating Penetration. 
 
 (a) Circumscribed dulness and bulging near the wound, fluctua- 
 tion in the peritoneal cavity, or either of the last two felt per rectum 
 or vaginam, indicate wound of a large vessel and accumulation of 
 blood, and penetration, with visceral injury, probably; but, to be 
 diagnostic, it must come on within a couple of hours. 
 
 (/3) Rapidlyt forming tympanitis indicates penetration and escape 
 of gas from the intestine. 
 
 (y) Escape of faeces, bile, or urine from the wound is, of course, 
 diagnostic of penetration, but rare. 
 
 {S) Repeated hfematemesis indicates penetration and injury to 
 the stomach or small intestine high up. It may, however, be due to 
 contusion. 
 
 (e) Profuse haemorrhage per anum points to penetration and injury 
 of intestine, but is seldom seen sufficiently early to be of value. 
 
 (0 Hsematuria indicates injury of some part of the urinary tract. 
 
 Q?) Escape of blood from the wound, if too profuse to be accounted 
 for by a wound of a vessel in the abdominal wall, points to penetra- 
 tion and visceral injury. 
 
 (0) Paralysis of any part below the level of the wound is a most 
 grave complication, indicating, as it does, injury to cord or nerves, as 
 well as, probably, to viscera. 
 
 (i) Sliock. This does not go for much unless hjemorrhage is 
 
 * In addition to the American writers I have quoted from below, I have had the 
 advantage of readings very careful study of this subject by my old dresser, Dr. J. H. 
 Barnard, now of Paris, Des Plates de I'Intestin par Armes-i-feu (These pourle Dootorat 
 en Medecine. Paris. 1887). 
 
 f If delayed, the tympanitis may be due to paralysis of the intestines from shock. 
 
668 OPERATIONS ON THE ABDOMEN. 
 
 clearly present also, owing to the great difference in individual 
 peculiarities. 
 
 Other points will be, the size of the bullet and amount of fulrai- 
 native or powder, the distance and direction in which the firearm 
 w^as held. A single opening gives, per se, a faint hope that there is no 
 penetration. 
 
 In cases of doubt as to penetration, the wound will be first ex- 
 plored,* then enlarged, and the line of damage to the tissues care- 
 fully followed up, any exploring instruments being kept strictly 
 aseptic. 
 
 3. Probable Amount of Damage. — Dr. Parkesf gives the following 
 suggestions : " An antero-posterior shot below the level of the um- 
 bilicus and well towards the lateral surfaces of the body will be very 
 likely to miss the small intestines entirely, and expend its damage 
 on the large bowel. The same kind of wound high in the lateral sur- 
 faces may pass into or through the liver without injuring the intes- 
 tines, or the spleen alone if the entrance is on the left side. 
 
 " If the wound is so situated that the bullet enters the abdomen 
 through the diaphragm, adding injury of abdominal viscera to that of 
 the contents of the chest, the surgeon's help will probably be of little 
 use. A wound of entrance and exit, or an entrance wound alone, 
 showing passage of the ball from side to side through the abdomen, 
 means the worst of injuries, and suggests the need of the greatest 
 care in stajdng of hajmorrhage, repair of intestines, and toilet of the 
 contents. 
 
 " Antero-posterior perforation, if complete, can only fail to wound 
 the small intestines when situated well on the outskirts of the sur- 
 face of the abdomen ; seemingly there can be no exception to this 
 proposition, save in those extremely rare instances in which the per- 
 forating body traverses the cavity without injuring the contents. 
 
 " Penetration through the posterior walls of the cavity, if complete, 
 with likelihood of laceration of important fixed organs, argues an in- 
 jury of the most severe character, one in which the surgeon's aid will 
 be of no avail in the majority of cases. The exceptions in which the 
 severity will not prove insurmountable will be, transit through the 
 space between the lower end of the kidney and the crest of the ilium, 
 and in wounds occupying the outskirts of the entire posterior sur- 
 face Many instances are recorded of recovery from posterior 
 
 penetration of the large and fixed viscera of the abdomen without 
 any surgical operation whatever." 
 
 * Any probe used should not be too fine or sharp pointed. A clean bougie will 
 usually be preferable. The old advice not to probe or explore these injuries must, 
 nowadays, be considered exploded. 
 
 f Ann. of Surg., November, 1887. 
 
GUNSHOT INJURIES OF THE ABDOMEN. 669 
 
 Question of the Advisability of Operative Interference.— 
 
 While some cases of penetrating wounds with very severe injury {e.g., 
 perforation of intestine and wound of solid viscera) have occasion- 
 ally recovered, the proportion here is extremely small— Prof. Nan- 
 crede gives 8 per cent. ; death from septic peritonitis or haemorrhage is 
 so common as to justify our urging, in most cases, as early an opera- 
 tion as is possible. The exceptions would appear to be, cases where 
 sufficient time has elapsed to allow of much extravasation and the 
 onset of a peritonitis which is certain to be fatal whatever is done, 
 cases of injury to the spinal cord, severe wounds of the solid viscera, 
 and those where such grave shock is present as to make it certain 
 that the needful interference with the contents of the abdomen will 
 be necessarily fatal.* 
 
 Prof. Nancrede (loc. supra cit., p. 474) thus states the advantages of 
 an operation : " We can either forestall septic peritonitis or reduce 
 its dangers to a minimum; we can prevent saprcemia — a common 
 
 cause of death, as I believe Should peritonitis have set in, we 
 
 can afford sufficient drainage, for the effusions, which may in them- 
 selves be already poisonous, or, as we have shown, will assuredly be- 
 come the chief cause of danger ; we can substitute for adhesion of 
 doubtful permanency certain methods which secure the escape of the 
 injured portions of gut into the lumen of the bowel ; we can prevent 
 the fatal results which must follow the casting off of a decomposing 
 slough of a wounded portion of omentum or mesentery into the 
 general peritoneal cavity ; we can arrest hsemorrhage, which from its 
 amount will prove fatal, or from decomposition will equally produce 
 lethal result ; we can restore the continuitj^ of the gut, if it be nearly or 
 completely severed, the former condition being not uncommon ; we 
 can avoid the risk of ffecal fistula .... and we can remove a hope- 
 lessly damaged kidney or spleen, and repair a wounded pancreas or 
 liver." 
 
 Operation. — An excellent account of this will be found in the 
 very helpful article of Prof. Nancrede to which reference has been 
 already made. 
 
 With the utmost care the preliminary details of preparation are 
 entered into first — viz., the cleaning and shaving of the skin, the pro- 
 viding of abundance of water recently sterilized by boiling, or solu- 
 tion 1 in 10,000 of mercury bichloride, or 1 in 500 of carbolic acid, 
 also boiled. Most scrupulous cleansing of instruments. Plenty of 
 
 * Dr Barnard {Inc. svpra cit.. p. 58) quotes Dr. Hamilton, of New York, as of opinion 
 that operative interference is contra-indicated if forty-eiglit hours liave elapsed since 
 the accident. 
 
670 OPERATIONS ON THE ABDOMEN. 
 
 soft old linen, lying in the hot sterilized water, to cover the intestines 
 with. Abundance of ligatures of gut and silk of different sizes* 
 
 " Now as to technique. The patient's limbs and trunk must be 
 carefully wrapped in blankets, with towels, wrung out of the aseptic 
 or antiseptic solution tucked under and folded over them around the 
 abdomen to prevent any accidental contamination of the peritoneal 
 cavity. If not previously done, the urine should now be drawn 
 off. ... . Ether should be most cautiously administered. The in- 
 cision should always he median, as otherwise it is almost impossible 
 to gain a proper view of the parts, and should usually extend from a 
 short distance above the umbilicus to about 2 inches above the pubes. 
 The abdomen having l)een opened, any clots or blood which obscure 
 the operating field may be removed, but otherwise, unless it is mani- 
 fest that severe hremorrhage is going on, the small intestines,! which 
 usually first present, should be carefully gone over, inch by inch, from 
 the stomach to the ileo-ctucal valve, keeping them constantly envel- 
 oped in towels wrung out of hot water (sterilized) ; afterwards the 
 stomach, spleen, liver, pancreas, large bowel, kidneys, bladder, omen- 
 tum, mesentery, and abdominal vessels must be examined. I do not 
 mean that, if various wounds are discovered, say in the small intestine, 
 and the place of exit of the ball from the abdominal cavity, all in such 
 relations as would absolutely exclude injury of the stomach, liver, 
 kidneys, spleen, or bladder, such a detailed examination should be 
 made — far from it, for every unnecessar_y manipulation is injurious; 
 but I do advise that, rather than overlook a wound, much manipula- 
 tion which the result proves to have been unnecessary had better be 
 made. Of course the source of a severe hfemorrhage must be at once 
 sought for, and any wounds of the hollow viscera ignored for the time 
 being, care, however, being taken that the general peritoneal cavity is 
 protected from faK-al extravasation l)y removing the intestines outside 
 the abdomen, keeping them wrapped in warm, moist cloths ; such 
 haemorrhage is, however, most unusual. "Whichever plan is pursued, 
 let everything be done methodically, and each injury repaired as it is 
 detected, as this saves much time and renders any oversight almost 
 impossible. All wounds of the bowel, however trivial, should be 
 minutely cleansed, coaptated by the Lembert suture of fine silk intro- 
 duced with an ordinary sewing-net'dle, and the suture line rubbed 
 over with a little iodoform. When necessary from the size or number 
 of the wounds, a portion or whole calibre of the gut must be exsected. 
 Wounds of the liver, if situated at the free border of the organ, should, 
 
 * Tlie temperature of the operating-room will have been attended to 
 
 f Dr. Barnaril {loc. supra cil.) points out that wonnds of the diiodemim are very 
 
 rarel.v met with, and that wounds of the upper aspect of the transverse colon and of the 
 
 omentum at this level are amongst the most difhoilt to discover. 
 
GUNSHOT INJURIES OF THE ABDOMEN. 671 
 
 if possible, be coaptated with dry aseptic gut, which will soon swell 
 and fill the track made by the needles. If this cannot be done, the 
 hajmorrhage may perhaps be arrested by the judicious use of the ther- 
 mo-cautery. Unless the bleeding be free, the wound should be plugj^ed 
 with an iodoform-gauze tampon, which is to remain permanently, 
 or may, perhaps, be carefully removed at the close of the operation, 
 when, if the bleeding be almost entirely checked, the cautery may then 
 be used as a further precaution ; if the flow be free, the tampon must 
 be replaced and allowed to remain permanently. 
 
 " Wounds of the pancreas, spleen, or kidneys (p. 628) must be treated 
 in a similar manner, or, if these measures fail, either spleen or kidney 
 must be excised. Since a wounded splenic artery would lead to gan- 
 grene of the organ, it must be removed. The same advice holds good 
 for wound of a renal artery, but in these cases death from ha'morrhage 
 will usually result before art can intervene ; still, such possible com- 
 plications must be provided for. Wounds of the bladder had best be 
 sewn with dry chromic and sulphurous acid gut, which, by its swell- 
 ing, will fill the track of the little wounds ; and the needle should be 
 a round one, as small as can be made to carry the thread. Contused 
 bowel will almost certainly slough, so that the injured portion had 
 better be excised and the healthy peritoneal surfaces united by suture. 
 Wounded or contused omentum or mesentery must also be excised, 
 and the edges carefully united by interrupted sutures. The experience 
 of at least one case has shown that since an omental slough cannot be 
 ehminated into the lumen of the bowel, as occurs in wounds of the 
 intestine, a fatal generalized peritonitis will result from the local gan- 
 grene. All bleeding must be checked, even from the smallest vessels, 
 for quite extensive oozing will occur from most insignificant vascular 
 orifices, because they are situated in a closed cavity, and, although 
 the amount lost may not be dangerous yer se, it will prove so as a 
 source of septicaimia or peritonitis. 
 
 " If a segment of bowel is to be excised, the cuts should be made at 
 such points as correspond to the distribution of a large mesenteric 
 branch, in order to secure a due blood-supply to the edges of the in- 
 cisions, and the parts to be removed should be laid upon a large flat 
 sponge, or folded napkins, to prevent f:ecal extravasation into the 
 abdominal cavity. To obviate kinking of the bowel, a V-shaped piece 
 of the mesentery must be removed, the branches of the V not corre- 
 sponding to the cut edges of the bowel, but presenting a free margin 
 of i inch, lest want of vascularity cause failure of union at this the 
 most doubtful point. After arresting htemorrhage, the mesenteric 
 wound must be carefully coaptated by numerous points of interrupted 
 
 suture. 
 
 " Should the pulse fail at any time during the operation owing to 
 
672 OPEEATIONS ON THE ABDOMEN, 
 
 irritation and paresis of the abdominal sympathetic, flushing the 
 intestines and peritoneal cavity with hot water will often at once 
 remove the unfavorable condition. The most scrupulous care must 
 be exercised in the peritoneal toilet, which can be most quickly and 
 effectively made by thorough irrigation of the cavity with warm steri- 
 lized water and subsequent careful removal of all fluid in the ordinary 
 manner by sponges, especial attention being paid to the case of the 
 pelvis and the renal regions. 
 
 " When possible, the peritoneum should be united over the 
 orifices of entrance and exit of the ball, and a little iodoform rubbed 
 in 
 
 " When incipient peritonitis exists at the time of operation, with the 
 probable formation of large quantities of acrid septicasmia or saprfemia 
 
 inducing serum, drainage should in all cases be instituted 
 
 The tube, preferably of glass, should have its end kept well down 
 between the bladder and rectum in the male, or in Douglas's cul-de- 
 sac in the female, with the external orifice plugged with iodoform 
 cotton." 
 
 Prof Nancrede's remarks on the chief points in the after-treatment 
 will well repay perusal. Rectal feeding for forty-eight hours.* Peri- 
 odic emptying of the drainage-tube with a syringe, or even irrigation 
 through it. Morphia injections, combined with atropia (about -iwgv.) 
 rather than opium. Cold to abdomen by means of ice coil. These 
 and many others are well discussed. 
 
 The following details are the outcome of experiments by Dr. Parkes.f 
 They have already laid foundations for much good work. " There 
 was no reason to suppose that the extent of the incision added much, 
 if at all, to the gravity of the operation. After opening the abdomen, 
 the intestines were all turned out, critically examined for perforation 
 or contusion, the situation of these fixed, and the haemorrhage there- 
 from controlled by means of the snap-forceps, after which wounds of 
 special organs were sought for. If the substance of the spleen or the 
 kidney was found perforated, the organ was immediately removed 
 after ligating its bloodvessels, the stump being returned. If slight 
 lacerations only at some point on the surface had been produced, 
 these were closed by bringing the peritoneal surfaces of the organ over 
 the wound by the continued suture. The peritoneal sac was then 
 carefully and thoroughl}' cleared of blood, etc., by repeated sponging 
 or irrigation. The intestines, which, during this process, had been 
 protected by being enveloijed in towels wrung out of warm water, 
 were now cleanly sponged, while all unwounded portions were 
 
 * The passage of a long tube ui;iy bring about the escape of flatus, and so give great 
 relief. 
 
 f Gunshot Wounds of tha Small Intestines. Chicago: 1884. Dogs were the patients. 
 
GUNSHOT INJURIES OF THE ABDOMEN. 
 
 673 
 
 returned into the abdomen Where several wounds occurred 
 
 rather close together, and were enough to destroy a considerable por- 
 tion of the integrity of the bowel, one resection 'was made to include 
 all of them, even when the length removed measured 10 inches or 
 more. Where the points of injury were widely separated from each 
 
 Fig. 108. 
 
 Fig. 109. 
 
 Multiple b\illet wounds (ten complete per- 
 foratious) In IS inches of ileum. A good instance 
 of a class of cases most diiRcult to manage and 
 fatal in their results. (Parkes.) 
 
 To the left a bullet wound is shown pared, 
 with six Lembert's sutures in position 
 ready for tying. To the right the entire cir- 
 cumference of the bowel is shown, so man- 
 gled as to require resection. (Parkes.) 
 
 other, and extensive damage done at each point, several resections of 
 a length of the tube just sufficient to include the injured portions were 
 made.* In the former case, in which several inches of the tulie were 
 taken away, the mesentery was ligated as close as practicable to the 
 intestine (Fig. Ill) in sections corresponding to the number of vessels 
 going to the resected portions. The mesentery was then divided close 
 to the intestine, and a V-shaped portion of it removed. After this the 
 tube itself was divided and the wounded portion removed. One 
 artery always needing ligation was found in the divided ends at the 
 point of junction of the mesentery with the intestine. Before the final 
 division of the intestine, its contents were pushed back out of the way, 
 compression exercised on its walls by forceps or temporary ligature. 
 .... The safest compressionf can be made by an assistant's fingers 
 (p. 662, Fig. 105). 
 
 "Results soon demonstrated the paramount necessity of carefully 
 selecting the place for final division of the intestine, in order to avoid 
 
 * It seems probable tliat tbe greatest succe.ss will follow a .single resection, even if 
 that include a niinilier of perforations, and involve 8 or 10 inches of the gut, in com- 
 parison with those cases wliere several excisions are made of wounded parts widely 
 separated. 
 
 t The constriction mark made by the forceps or ligatur*' was to be plainly seen 
 several days after the operation. 
 
 43 
 
674 OPERATIONS ON THE ABDOMEN. 
 
 sloughing of the edges, the results being beat in those cases where the 
 division was made close to the point at whi.ch any given mesenteric 
 artery approached nearest to the intestine, as compared with those 
 where the cut was made in the intervals between any two branches, 
 and this was seemingly dependent on the better supply of blood. 
 Immediately after division of the intestine, there followed a regular 
 and considerable contraction of the calibre of the tube close up to the 
 divided edge, caused by the contraction of the circular muscular fibre. 
 This persisted for a time, but was soon followed by an aversion of the 
 mucous membrane, which rolled out and over the constricted portion 
 in a remarkable manner (Figs. 108, 110, 111). This protrusion forms 
 a serious obstacle to easy and close approximation of the ends of the 
 bowel; and when turned into the 1x)wel, diminishes its calibre con- 
 siderably, although it was not demonstrated that the obstruction was 
 ever sufficient to prevent the jjassage of the intestinal contents. Sev- 
 eral attempts were made to get rid of it, but all these were finally 
 abandoned.^ 
 
 " In all instances where a perforation was severe enough to require 
 a resection of the wounded part, it was found advantageous to leave, 
 if possible, a strip of the bowel near the mesenteric junction (Fig. 110), 
 taking out the wounded portion by a V-shaped incision. The j^art left 
 acted as a support to the wound, avoided division of the bloodvessels, 
 opposed the action of the longitudinal fibres, and in no instance in 
 which this plan was adopted Avas there any appearance of separation 
 ofthewound.f .... Perforations through the mesenteric surface of 
 the intestine were the most difficult to treat, and, even if slight, seemed 
 always to require a complete excision. A partial excision of this sur- 
 face of the bowel resulted in an acute-angled elbow which never did 
 well. The point of attachment of the mesentery with the bowel will 
 usually be found the most troublesome to manage in applying the 
 
 sutures in restoring a complete division The difficulty arises 
 
 apparently from the manner in which the folds of peritoneum separate 
 from each other before passing on to invest the bowel, leaving a little 
 triangular interval filled with loose connective tissue, fat, and vessels. 
 
 * Thus " it waa pared away with scissors ; it was dissected np from the other coats for i 
 incli from tlie edges; but the conclusion w.as finaHy rearhed that, instead of being a 
 harm, its jiresuuce was useful in giving support, protection, and, perliaps, vascularity 
 to the freslily sutured edges ; at least, in all instances where it was removed the stitches 
 were found torn out and union defeated; in no instance where it was left entire did 
 there fail to be union in some part, and no sutures gave way when properly applied." 
 
 t Dr. Parkes found thai, in small perforations of the stomach and intestine, the case 
 did well after drawing the peritoneal surfaces some distance from the edges thereof 
 over it by a continued suture, thus converting it into a linear wound. He thinks this 
 plan may safely take the place of excision in not a few cases of quite severe injury. 
 
GUNSHOT INJURIES OF THE ABDOMEN. 
 
 675 
 
 Now, if the suture fails to include the muscular coat as well as the 
 peritoneum at this point, the junction will surely give way. To make 
 this point secure, the greatest care must be taken in placing at least 
 three sutures, this number being usually quite enough to include the 
 troublesome area, and these should always be the first sutures applied. 
 In completing the junction, it assists materially, and especially avoids 
 trouble from the everted mucous membrane, to apply one at the most 
 convex surface, and then one half-way down on each lateral surface. . . . 
 
 Fig. 110. 
 
 Fig. 111. 
 
 A shows the strip of bowel left at the mes- 
 enteric border (p, 674) ; B, the triangrular inter- 
 val where the mesentery encloses the gut. a spot 
 veiy hard to close. (Parkes.) 
 
 (Parkes.) 
 
 The greatest number of mishaps followed draAving the sutures too 
 tightly, which, if done, leads to death of the applied edges and of 
 course to failure. They mu&t be drawn only sufficiently close to bring 
 the surfaces fairly in contact ; the subsequent swelling from obstructed 
 circulation will hold the surfaces firmly together untilglued to each other 
 by the rapidly forming adhesive material."* With regard to the best 
 way of disposing of the divided mesentery after removal of some length 
 of intestine. Dr. Parkes does- not seem to be decided. It would seem 
 from his account, which is not clear on this point, that, after tying the 
 mesenteric vessels (Fig. Ill) and suturing the divided ends of the in- 
 testine, the cut mesentery should be united to the now joined intestine, 
 making as nearly as possible a continuous surface of mesentery. 
 
 I quote the following as instances of what injuries the surgeon may 
 expect to have to deal with. Bullet wound near umbilicus; seven 
 openings in alimentary canal — viz., three openings close together in 
 
 * The sutures were of No. 1 catgut or No. 2 silk ; fully curved round needles are 
 recommended, or, preferably, ordinary straight sewing -needles. The method used was 
 the continuous or Lembert's (Figs. 106, 107). Great stress is laid on not allowing the 
 needle to enter the cavity o-f the intestine, a point of which the importance has been 
 shown by Mr. Howse in gastrostomy. 
 
676 OPERATIONS ON THE ABDOMEN. 
 
 the sraall intestine (31 feet below the duodenum), two openings in the 
 descending colon, and two in the rectum ; no great extravasation ; also 
 a large vein wound in the mesentery; death from peritonitis; bullet 
 found near ischial spine (Aiinandale, Lancet, April 15, 1885). Pistol 
 wound near navel ; seventeen hours later, operation ; two pints of 
 bloody serum let out, with small clots, but no faeces ; seven penetrating 
 wounds of intestine, six in the small, one in the sigmoid containing 
 the bullet; all the openings plugged with ragged, everted mucous 
 membrane ; no fecal escape till edges were separated ; careful suturing 
 and toilet; recovery after a very critical condition for a week (Bull. 
 New York Mc'il. CVvm., February 14, 1885; Ann. nf Surrj., ^lay, 1885). 
 Bullet wound (five other superficial ones in hands, etc.), in right iliac 
 fossa; no injury to intestine by bullet, which had lodged near spine; 
 while it is clear that the peritoneal cavity was entered, the exact 
 nature of the abdominal injury is not very clear; the case, however, 
 reflects the greatest credit on the operator, who had to meet it almost 
 single-handed, and without preparation i Skelly, Ann. of Snrij., Juh-, 
 1887). Bullet entered through border of cartilages of ribs to left of 
 umbilicus, passing out at the back at a point nearly opposite ; opera- 
 tion fifteen hours later ; much bloody serum sponged out, but no clots, 
 and nothing like contents of stomach or intestine; left lobe of liver 
 just incised; no wound found in stomach, which was slightly distended; 
 six days later all abdominal symptoms had subsided (Andrews, Journ. 
 Amer. Med Assoc, August 15, 1885; An.n. of Surg., November, 1885). 
 Bullet entrance close to navel; operation two hours later; abdominal 
 cavity full of blood; spirting artery in mesentery; eleven wounds 
 requiring suture in small intestine, and two in ascending colon ; no 
 fecal extravasation, but a melon-seed body found and removed ; on the 
 thirteenth day great rectal tenesmus led to discovery of blood effusion 
 in pelvis; three pints let out by incision about 2 inches within anus ; 
 recovery ; bullet passed per anuni ( Hamilton, Journ. Amcr. Mril. Assoc, 
 August 'z'2, 1885: Ann. of S'inj., November, iSSji. Bullet entrance 3J 
 inches al)ove uml>ilicus, and just to left of middle line; operation 
 within twenty-four hours; rent in omentum close to great curvature 
 of stomach, and two linear rents in tins viscus found with much diffi- 
 culty; operation had to l>e concluded quickly from patient's critical 
 condition; death within a i'esx hours with acute .peritonitis; four 
 wounds found in upper jiart of jejunum, all witliin a distance of 3 
 inches (Briddon, New York .Surg. Soe., December 8, 188C) ; Ann. (f Surg., 
 April, 1.SS7), Bullet wound 2 inches al)ove and 2 inches inside right 
 anterior superior s])ine; operation in nine hours ; wound found in 
 ascending colon jiouring out fa'ces; another wound in colon also 
 pouring out llrees; both sutured; recovery (McGraw, CJiintgo Med. 
 Journ. and E.nim., July, 1887; Ann. of Surg., December, 1887). Bullet 
 
GASTROSTOMY. 677 
 
 wound above right anterior superior spine; operation bix hours after; 
 large loop of ileum protruding, with several openings from which fajces 
 were oozing ; resection ; wound enlarged, and several small shot and 
 some wadding removed ; wound not closed ; three drainage-tul>es ; ftecal 
 fistula; ultimate complete recovery (Freyer, Deiita. Med. ]l'()(:h., No. 28, 
 July 15, 1886; Ann. of Sur;/., October, 1886). Bullet wound at level of 
 top of ensiform cartilage to right side of middle line, over border of 
 costal cartilage ; opieration three hours and a half after ; bruise of liver 
 and slight tearing of omentum ; clots of blood, bullet, and wads re- 
 moved from latter ; recovery. Two bullet wounds, the one of entrance 
 31 inches internal to right anterior superior spine, the one of exit 3 
 inches behind this point; double perforation of ileum, 3 feet above 
 cfficum ; much blood, no fteces, gas in abdomen ; resection of intestine ; 
 death on sixth day witli moderate peritonitis and pneumonia (Barker, 
 Brit. Mai Jouni., March 17, 1888). A helpful table will be found in 
 this paper, and one by .Sir W. MacCormac, ibid., May 11, 1887. 
 
 CHAPTER VII. 
 OPERATIONS ON THE STOMACH. 
 
 GASTROSTOMY.— GASTROTOMY. —DIGITAL DILATA- 
 TION OF PYLORUS.— EXCISION OF PYLORUS.— 
 CURETTING CANCER OF STOMACH.— GASTROEN- 
 TEROSTOMY. — DUODENOSTOMY. — JEJUNOSTOMY. 
 
 GASTROSTOMY. 
 
 This is one of those operations which, after being called into 
 temporarily marked vitality, are just now allowed to languish. 
 Indications. 
 
 1. Cancerous stricture. This also includes invasion of the oesopha- 
 gus, secondarily, from primary cancer of the mediastinal glands, etc. 
 
 2. Cicatricial stricture, whether traumatic or syphilitic. 
 8. Cancerous disease of the pharj'nx. 
 
 The first of these, from its frequency, requires separate notice. 
 
 1. Cancerous Stricture. — Here several points call for attention. 
 Amongst the chief are— the question of the treatment of oesophageal 
 cancer by passage of tubes or gastrostomy ; the mortality of the latter 
 operation ; the best date for performing it. 
 
 Between treatment by gastrostomy and that by tubes no fair 
 comparison can be made, because the former operation has, in such 
 a large number of cases, been performed under most unfavorable 
 
678 OPERATIONS OS THE ABDOMEN. 
 
 conditions. Much too often it has been put off till the patient, 
 scarcely able to swallow liquids, is just kept alive by enemata. Such 
 patients, worn out by the miseries of slow starvation, often with sec- 
 ondary disease and luns and pleural trouble, are not in a condition to 
 be submitted to abdominal section, and are not likely to respond to 
 the call made upon their vitality to unite two serous surfaces firmly 
 together, on which depends the success of the operation. I do not 
 think that I exafrgerate if I say that, in a distinct proportion of the 
 cases in which the surgeon is asked to perform gastrostomy, the hand 
 of death is already on the patient, and something next door to the 
 decomjiosition of the grave has already set in. 
 
 In advising gastrostomy each case must be decided on its merits; 
 the patients here are not only adults, but well on in life, and, when 
 assured that the end is certain, the surgeon may, in most cases, 
 having put all the risks before the patient, leave it to him to decide. 
 But I think that if the patient, having previously declined it, only 
 asks for operation when it is clearly too late, the surgeon should 
 be firm enough to decline to operate where, on every ground, his 
 interference will be hopeless. 
 
 The following points help in a decision between gastrostomj- and 
 tubage : 
 
 i. Food taken. — As long as pulpy, semi-solid, or even a proportion 
 of solid food is taken, tubage should be persevered with. But when 
 the time comes that the patient is becoming restricted to liquids, the 
 hour for a successful gastrostomy is slipping by. When the patient 
 is fed by enemata only, and merely takes ice by the mouth, it is too 
 late to operate. 
 
 ii. Amount of pain felt with and difficulty in passing bougies or 
 tubes. — This will vary a good deal with different cases. "When, from 
 the increased expectoration, cl_vs]in<T?a, paroxysmal cough, fcetor of 
 sputum or bougie, it is evident that the passage of instruments causes 
 increased ulceration and sloughing, when this is increasingly accom- 
 panied with pain and evidence of laryngeal irritation, gastrostomy 
 should be proposed. 
 
 iii. Site of stricture. — The lower down this is, the more difficulty 
 will there usually l)e in dealing with it by dilatation, and the nearer 
 are important parts. 
 
 iv. Condition of patient. — Here the rate of emaciation must be 
 watched — anytliing like a loss of 1 to 2 lbs. a week is very ominous. 
 How far is the strength preserved ? how far does the patient tend to 
 give up his life-habits ? liow far is he bedridden? Where the pulse 
 is thready, the extremities cold, the temperature never up to normal, 
 the case has gone too far. 
 
 V. Condition of viscera. — Evidence of implication of trachea or 
 
G A STROSTOM Y, 679 
 
 bronchi, of pleuritic effusion, and of broncho-pneumonia must be 
 sought for. 
 
 I would thus sum up this question of gastrostomy or treatment by 
 tubes : As long as a patient can swallow solids or semi-solids, treat- 
 ment by tubes and bougies should be persevered with, ^^'henever 
 they can be introduced, the tubes ingeniously devised by xMr. Sy- 
 monds* will be preferred. These have a funnel-shaped extremity 
 resting on the upper end of the stricture, are introduced by a conical 
 bougie, and are kept in situ by a loop of silk, which comes out of the 
 mouth and is looped round the ear. They are not unsightly, have 
 the great advantage of allowing the patient to swallow his saliva and 
 food, and thus retain the pleasures of taste. 
 
 If a larger pattern of bougie is needed, none is more suitable than 
 the flattened bulbous one, ending in a conical point, of ]Mr. Durham.f 
 
 Any surgeon treating cancerous stricture here liy dilatation must 
 remember that treatment of cancer in this way is contrary to what is 
 generally practiced, and is only justifiable here on special grounds — e.g., 
 the fatality of the disease and the risks of gastrostomy ; that these risks 
 have been enormously increased by the way in which this operation 
 has been deferred ; that there comes a time in these cases when tubes, 
 both short and long, can no longer be made use of; and that if gas- 
 trostomy has been deferred till now it had better not be performed at 
 all. In other words, the patient should understand that if he shuns 
 the risks of an early operation he renders himself liable to other but 
 as serious risks by deferring it till an hour when he can only ask for 
 it, and the surgeon only attempt it, as an almost utterly forlorn hope. 
 
 The question of which gives the greatest comfort cannot be an- 
 swered dogmatically. But no one who has seen many cases of 
 gastrostomj', and met with a fair proportion of success, will hesitate 
 to prefer the result of this, if performed earlj', with its gain of weighty 
 and freedom from pain and irritation, to the passage of tubes neces- 
 sarih' more and more frequent and difficult as the case progresses, 
 with the not infreqtient distress and choking when thev are intro- 
 duced, the blockage of the hollow one by septum or food, and the 
 withdrawal and re-introduction, easily effected, no doubt, for some 
 time, but ever irritating and fretting the growth. 
 
 * Clin toe. Trans., vol. xviii. p. 155. It is clear from this case that patients can be 
 kept alive as long by tnbage as by ga,«trostomy, and that in some cases even a malig- 
 nant strictnre can be dilated. On the other hand, the pa.ssage of tubes, where there 
 is considerable narrowing, clearly requires some f(irce, and thus needs skilled and 
 very careful hands. Furthermore, the blocking of the tubes in the later stages will 
 necessitate frequent changing. The tubes are made by Messrs. Downs. 
 
 t Syst. of Surg., vol. i. p. 798. The bougies are made by Krohne and Hawksley. 
 
 t Mr. Symonds' case (loc. supra cit.) gained at first 1 St. 9 lbs., and could, with the 
 tube in, drink a pint of milk at a draught. 
 
680 OPERATIONS ON THE ABDOMEN. 
 
 I have performed gastrostomy seven times, in each case for cancer 
 of the rrsophagus : in three patients the operation was aslied for too 
 late ; in one, my seventh case, the patient died from an accident, for 
 Avhich I am responsible ; the other three recovered well. One, a young 
 married woman, had had symptoms six months ; she was in the fourth 
 month of pregnancy when operated on ; she lived in comfort for six 
 months, and died, a month after giving liirth to a child at the full time, 
 of extension to the lung. Another patient lived between three and four 
 months, and would have survived longer if it had not been for his care- 
 lessness as to exposure. A third was alive and progressing satisfac- 
 torily when last heard of four months after the operation. 
 
 Operation (Fig. 112).— Method of Howse* by Two Stages. 
 
 Fird >S'if(//c.— Those precautions being taken against shock, such as 
 warm wraps, hot bottles, ether as an anresthetic if the condition of the 
 lungs admits of it, and if it is quietlj^ taken without troublesome, 
 heaving breathing, the surgeon will usually find it most convenient to 
 stand on the right side and to have his patient drawn over to this side 
 of the tabk'. The outline of the stomach should be percussed out first, 
 and the shoulders somewhat raised and the hips slightly flexed, to 
 relax as much as possible the tension of the soft parts, which often 
 here fall with harassing sharpness over the epigastric angle from the 
 IDrominent ribs down to the wasted, retracted umbilical region. 
 
 Mr. Howse (Diet. Pract. Surf/., p. 590) recommends the following 
 incision : (1) An oblique one, about 2i inches long, parallel with and 
 about 1 inch below the lower margin of the left costal cartilages. This 
 incision should start about 1 J inch from the middle line, and its length 
 must depend on the varying development of the rectus muscle. It 
 should not go higher than the above point, as it will not leave enough 
 free skin and muscle between the cartilages and the incision to fasten 
 the sutures to. This first incision is only to be carried tlirough the 
 skin and fascia. When made, the sheath of the rectus will be seen at 
 the inner end, and at its outer end a portion of the linea semilunaris 
 and of the external oblique. The usual plan of continuing the opera- 
 tion is to have the muscles and fasciae of the abdomen incised in the 
 same way as the superficial parts. Mr. Howse prefers to continue the 
 operation as follows : (2) The lips of the wound being separated 
 towards the inner part as widely as possible by retractors, a vertical 
 incision is made in tlie sheath of the rectus a little from its outer 
 margin. The vertical fibres of this muscle will then be seen, and these 
 
 * Mr. Greiff Smith {Abduvi. Surg., p. 302) states that the plan of operating in two 
 stages was originallv suggested by Egebert, a Norwegian surgeon (1841), and also 
 advised by Nfelaton. It is to Mr. Howse's practice, however, that we owe our knowl- 
 edge tliat this operation is safe if performed in two stages, with strict antiseptic pre- 
 cautions, and when not too long deferred. 
 
GASTROSTOMY, 
 
 681 
 
 BhouM be separated, not cut, with the handle of the scalpel and the 
 posterior part of the sheath exposed. This may then be incised ver- 
 tically. 
 
 From ray experience of seven cases I prefer, as simpler, a single 
 veitical incision (Fig. 112) beginning opposite to the end of tlie eighth 
 inte?costal space and passing down for 3 inches over the rectus— i e 
 about 2 inches from the linea alba. The fibres of the rectus, being 
 exposed, are torn straight through with a steel director, and the 
 posterior, somewhat concave layer of its sheath exposed. This is 
 carefully divided for the full length of the incision, and the extra- 
 peritoneal fat (if present) and the 
 
 peritoneum picked up and opened Fig. 112. 
 
 together. A finger is now intro- 
 duced (Fig. 112) to feel for the 
 stomach,* and I think it well now 
 to cover the wound over with car- 
 bolized lint and to stop the spray, 
 as this avoids chilling the patient 
 and also prevents any spray run- 
 ning into the peritoneal c.ivity. 
 
 As a rule, the contracted stomach 
 lies high up under the left lobe of 
 
 the liver, and requires to be hooked The finger searching for Uie stomach 
 
 , , through a vertical incision. 
 
 downwards and forwards into the 
 
 wound. Not unfrequently the great omentum presents first, and it is 
 easy, by seeking too low down, to draw up the colon. In case of 
 difficulty the best plan is to find the anterior border of the liver, trace 
 up the under surface to the portal fissure, and thence along the lesser 
 omentum to the stomach. This is told by its thicker, more substantial 
 feel and pink-red color. 
 
 The stomach being drawn up, a part is chosen on its anterior sur- 
 face, free from vessels, and as near as possible to the cardiac end. 
 
 The stomach is next fixed to the edges of the wound with sutures 
 of carbolized silk and wire. Mr. Howse thus ties his chief sutures 
 over bits of bougie : " Drawing the stomach well over to one side, a 
 needle (in handle) carrying the silk should be passed through the 
 serous and muscular coats of the stomach only, and should then 
 transfix the abdominal parietes about 1 inch from the wound. The 
 needle is now withdrawn, leaving one end of the silk on the surface, 
 and, without unthreading the other end, the abdominal parietes are 
 again punctured alone. The needle is now unthreaded and withdrawn. 
 The two ends of silk will thus be left projecting from two distinct 
 
 * While the finger feels for the stomach, it also examines for any enlarged glands. 
 
682 OPERATIOXS ox THE ABDOMEN. 
 
 wonnJ? on the skin, clu?o bv one another, and holding np a hit of thf 
 serous and muscular coats of the stomach. Before tying any one 
 suture it is best to introduce the othi-rs. drawing the stomacli well 
 over from the side toward- which it is wishL-d to introduce the suture. 
 Six or eight sutures introduced in this fashion are usually used. The 
 result is to fix the gastric peritoneum in a circle about 1 inch round 
 the wound- The part of tlie stomach exposed in the wound should 
 then be tixed to the lips of the inci^iull by small wire sutures, intro- 
 duced bv a small curved needle held in a needle-holder, tluso again 
 onlv takiiii; up the SLrt>us and muscular coats of the stomach " 
 
 Other surgeons have Ji^pcnsid with the above, using sutu^cS in the 
 ordinary way. By some, hare-lip pins have been ustd. Others, to 
 ensure apposition of the peritoneal suifaet-s, have first satured the 
 parietal peritoneum to the edux - of the wound. 
 
 The additional time spent in careful stitching will well repay the 
 operator. However the sutures are inserted, the following points, on 
 which Mr. Howse in introducing his oj^eration laid much strtss, should 
 be carefully attended to: {a) To make the needle travel for a sufli- 
 cient distance in the muscular coat in taking up the stomach. (,j > 
 Not to include or puncture the mucus coat, for fear of causing septic 
 fistulip. ^;) To bring the needle through the parietes quite an inch 
 from the edges of the wound. y3) In doing so. to include the parietal 
 peritoneum, i^^) To bring up a circle of stomach a full inch in 
 diameter. 
 
 AVhen the stomach is secured — and the sooner it is to be opened, the 
 more carefully must the stitching be carried out — a suggestion, I 
 believe, of Mr. Bryant s should be followed, and one or two fine 
 sutures of silk or catgut introduced in the centre to guide tlie surgeon, 
 in a few days, to a safe site of puncture {ride infrti). The upper and 
 lower angles of the wound are next closed, if gaping. 
 
 Free as the wound has seemed before, it is now markedly puckered 
 up. A little iodoform is dusted on, a piece of protective smeared with 
 carbolic oil applied, and then dry gauze dressings and salicylic wool, 
 with a many-tailed bandage. 
 
 When in bed the iiosition of the patient must be such as to relax the 
 parts. A little morphia should be given sulK'Utaneously, whenever 
 not contra-indicated ; great attention paid to keeping the patient 
 warm, and nutrient enemata, followed by one of Burrotighs and 
 Wellcome's nutrient supjiositories, given every three, four, or six 
 hours.* 
 
 SxiiiiJ StiKjc. — This in all cases admitting of delay should be deferred 
 till the third, fourth, or fifthf day, so as to give time for firm adhesions 
 
 * Tliirst may be relieved bv glycerine and iced water a.'; a mouth and throat wash. 
 t Mr. Howso has usually adopted this date. 
 
GASTROSTOMY. (583 
 
 to form between the two snvtaees. nnd tluis to si^nndly slun off the 
 sioneral peritoneal eavity. No previo\is cliange of .h-essiiio- will proba- 
 bly have been required. The woniul is now found still more puekered. 
 Its edges inverted somewhat, and almost in ajtposition save for the 
 strips of li-auze whieh have bt-eii inserted. Tlie stomach surface is no 
 longer recognizable as sneh. being coated with lymph, this sliowing 
 the importance of the guiding sutures. Between these, or close to a. 
 loop if single, the stomach wall is iiunetured by a quick stab -svith a 
 very sharp tenotomy knife, the wall being raised and steadied by the 
 loop. .\ piece of No. 7 gum-elastic catheter is then slipped in as the 
 knife is withdrawn.* To the end of the catlieter a bit of tubing and 
 a small funnel having been attached, a few drachms of milk and 
 brandy are thus quickly given. The tube i* then tied with silk or 
 plugged, and left projecting amongst some strips of drv aauze which 
 cover the wound. The sinn v i> used for the first few dressiuL^s. and a 
 little iodoform dusted on after each. .\ larger tube is socmi introduced, 
 and an india-rubber tracheotomy tube is sometimes found convenient 
 till the fistula is soundly formed. 
 
 For the first few days milk and brandy, just warmed, and peptonized 
 if preferred, should be the chief food given with the yolks of one or two 
 eggs. A little later beef-tea. soups, well-pulped vegetables, with plenty 
 of fluid, should be given. In Jlr. HowseV words. " \A'hen the larger 
 sizes of tubes have been introduced, solid food may be poured into the 
 stomach by the aid of a large wide-mouthed syringe. This food should 
 be minced meat, with a certain projiortion of vegetables, all finely 
 ground in the mincing machine." 
 
 Patients are often very ingenious in feeding thiTuselves. Some, to 
 enjoy the taste of food, have masticated solids and then passed them 
 through the fistula.f 
 
 If the operation has been deferred till too late, and it is absolutely 
 needful to feed the patient at once, the safest method will probably be 
 to introduce, every few hours, a small amount of liquid through one 
 
 * This *onniis simple ennngli, Imt it is bv no means always ea<y to leel certain that 
 the stomach ha.s lieen opened, lliis is due to the piukcini ooniraction ol'the wound 
 and .ilteration of ils ~n;i'm'. the ^IhiikkIi cixil l>eing lleis no longer roioenizable. to it? 
 lying much deei^er than wonKi be expected, making " the operator sometimes leai that 
 he has punctured the leaser bas^dl'ilie peritoneum" (How.-eK In oneca^e. my seven ;li, 
 though I thought I had punctured the ^lonia^h directly and sutiiciently, it was not so. 
 The patient dMiK tu.i day~ ai'ier. peritoniiis and tluid foixl in the abdominal c;ivity 
 were found. The puncture and catheter liad Inith rnn obliquely through the stomach 
 wall, and communicated with the cavity ol" this vi>cns and that of tlie peritoneinu a^ 
 well. 
 
 t Thu.s, Mr. "Dnrhani .<■ .-f of S.rg., vol. i. p. SO;',: L.,!. .Vf ,'. E\- . March, ls>' 
 mentions a patient of Trendelenburg who, after inasiicaiiiii: hi> food, spat it into a 
 funnel, and then foroed it on through a tube into his sioii:.uh. 
 
684 OPERATIONS ON THE ABDOMEN. 
 
 of the large hypodermic syringes made for exploration, and holding 
 a drachm or two. The puncture must be repeated at each occasion of 
 feeding. In these cases especial care must be taken to the suturing the 
 stomach, and, if this is opened at once and a tube introduced, every 
 precaution must be taken to go through the mucous membrane, and 
 not to detach this or to loosen the sutures. If a catheter or tube is 
 introduced at once, it must be a fine one, otherwise escape of secretions 
 will render the wound aseptic, and the result a fatal one. 
 
 DiflBculties in and after G-astrostomy. 
 
 i. The very prominent angle formed between the ribs and the sunken 
 umbilical region (p. 680). 
 
 ii. Hemorrhage. This will be almost nil if the rectus fibres are 
 separated with aj director, and the veins on the stomach carefully 
 avoided. 
 
 iii. Finding the ston/ach. 
 
 iv. Dra-iving this up into the wound if itself affected by disease, as 
 when the primary disease is situated very low down in the oesophagus, 
 or if it is adherent by reason of secondary deposits. 
 
 v. Completing the second stage of the operation. 
 
 vi. Intense pain on introducing food into the stomach. In a patient 
 of ]\Ir. Butlin's {Brit. Med. Joarn^ April 14, 1883) this was found to be 
 the case, the patient dying nearly a month after the operation. Mr. 
 Butlin attributes this pain to his opening having been close to the 
 pylorus.* If it is thought that the opening is made too near either 
 extremity of the stomach, it would be well after feeding to keep the 
 patient turned on to the opposite side. 
 
 vii. Leakage of gastric juice and regurgitation of food. This is an 
 extremely troublesome complication, leading, as it does, to most rebel- 
 lious eczema and erysipelas. It is best prevented by making as small 
 a wound as possible in the abdominal walls, going through the rectus 
 muscle, and opening the stomach by a mere puncture. If, in spite of 
 these precautions, leakage still takes place, leaving out the tube for a 
 few hours at a time ^\\\\ allow of some recontraction. The patient 
 should also be kept as flat as possible after feeding. Regurgitation of 
 food is often due to the stomach being opened too near to the pylorus. 
 
 In some cases of gastrostomy for non-malignant stricture the fistula 
 has l>een subsequently closed. I did this in 1877, at Mr. Howes's 
 request, in a most successful case of gastrostomy of his for oesophageal 
 stenosis after swallowing a corrosive poison. Mr. Davies-Colley has 
 published another equally favorable ending in a case in which the 
 
 * Thus eniising constant dragging on a fixeJ jiart. The middle, or cardiac end of 
 the stomach shonld be opened, as being more movable and less likely to lead to rapid 
 escape of the food. 
 
GASTROTOMY. g85 
 
 (Esophageal mischief had been syphilitic (Gm/s Hnq). Beports, 1884, 
 vol. xxvii. p. 367). 
 Causes of Death after Gastrostomy. 
 
 1. Inanition and exhaustion, the operation being performed too late. 
 
 2. Peritonitis. 
 
 3. Extension of the disease to surrounding parts— <?.</,, trachea, 
 bronchi, etc. 
 
 4. Lung affections. 
 
 5. Hasmorrhage. 
 
 6. Acute gastritis. 
 
 GASTROTOMY.* 
 
 Indications. — These are very few, the majority of bodies swallowed 
 passing through the pylorus. Of the few which will call for operations, 
 forks, as in MM. Labbe's and Pean's cases, and masses of hair, as in 
 Mr. K. Thornton'sf patient, are good instances. Increasing pain, 
 vomiting, emaciation, and sufficient time having elapsed to allow of 
 the body passing will he the chief justifications of an operation. 
 
 Operation.— Such cuses as Mr. Thornton's show that this oper- 
 ation can be safely performed at one stage.J 
 
 The parts being cleansed and the abdomen relaxed, one of the fol- 
 lowing incisions is made : (1) Over the body itself, when this can be 
 felt. (2) In the case of a large body, in the middle line, from the 
 xiphoid cartilage down to or below the umbilicus. (3) One of the in- 
 cisions given for gastrostomy— c.^r/,, one parallel with the left costal 
 margin and about an inch below it, reaching from a point near the 
 xiphoid cartilage obliquely downwards and outwards to a point opj^o- 
 site to the ninth rib. One of the first two will probably be the best. 
 The abdominal wall being divided, and the peritoneum opened as in 
 gastrostomy (p. 681), the exact site of the foreign bod\' is made out. 
 If this be pointed, great care must be taken not to let it damage the 
 stomach during the needful manipulations. In such cases the exter- 
 nal opening must be free, that the -surgeon may see what he is about. 
 In the case of such a body as a fork the blunt end must first be found. 
 
 * B_v this term is meant Rn incision into the stomach for the removal of foreign 
 hodies, the opening being immediately afterwards closed, as opposed to "gastrostumy," 
 the making of a more or less permanent fistulous opening. 
 
 f Lancet, January 9, 1 886. 
 
 J It has been proposed by some to facilitate finding the stomach by distending this 
 with effervescing media, but, as Mr. Greig Smith points out, the disadvantages are se- 
 rious — viz , trouble to the patient, liability of the distending medium to escape into the 
 peritoneal cavity, and, lastly, the increased difficulty of finding the body in a distended 
 stomach. In Mr. Thornton's case, the hair, weighing 2 lbs., greatly distended the 
 stomach. It would probably be well, in the case of a smaller body, to wash out the 
 stomach beforehand with a dilute solution of boracic or salicylic acid. 
 
686 OPERATIONS OS THE ABDOMEN. 
 
 When the surgeon has decided where to open the stomach, he brings 
 this part out of the wound and carefully packs sponges all around it, 
 so as to steady it, and also to shut off the peritoneal cavity. 
 
 The stomach is now opened )jy an incision transverse to its long 
 axis, and of length adapted to the case. As far as possible any vessels 
 must be avoided,* but any that spring will at once be commanded by 
 Spencer AVells' forcoiis. The body is next extracted with suitable for- 
 ceps or a scoop, care being now taken not to damage the stomach, 
 especially if the foreign, body basset up inflammation or ulceration, 
 and to allow no blood or mucus to escape into the peritoneal cavity .f 
 
 Before introducing the sutures, ]Mr. Thornton placed a carbolized 
 sponge " to keep the edges in apposition for suture, and to prevent 
 accumulation of blood in the organ. Fifteen sutures gf fine carbolized 
 silk were then introduced through all the coats, the needle being 
 slanted through the wall so as to come out just at the inner edge of the 
 mucous membrane, which was much inclined to curl. The interrupted 
 sutures were passed so as to control the cut vessels, and no ligatures 
 were used. Another row of similar sutures was then passed between 
 each of the deep sutures, but only through the peritoneum. The deep 
 sutures entered the peritoneal coat about 1 inch from the edge of the 
 incision, and were i inch apart ;. the superficial sutures were entered 
 about the same distance from the edge, and ran along just under the 
 peritoneum. When these were all in place the sponge was removed 
 from the stomach, and they were tied, the deep first. These two rows 
 caused some inversion of the peritoneum, and the two outer and upper 
 edges of the peritoneal edges of the depression thus formed were 
 brought together by a continuous suture of very fine carbolized silk. 
 
 . . . The closed wound measured exactly 3 inches." 
 
 Stomach feeding was only commenced forty-eight hours after the 
 operation, a teaspoonful of iced water and milk being given every half- 
 hour, the quantity being increased till the afternoon of the next day, 
 when 2 oz. were given every hour. On the sixth day 3 oz. were given 
 every two hours. (!)n the fourteenth day corn-flour was added to the 
 diet, on the fifteenth some crmnbled bread, and gradually an ordinary 
 light diet. During the first week 3 oz. of beef-tea were injected into the 
 Ijowel every three hours, with 2(J drops of laudanum every six hours. 
 The patient made an excellent recovery, though Mr. Thornton had to 
 remove a sponge from the abdomen the day after the operation. 
 
 ■* Blunt-pointed scissors will probalily be most convenient here. 
 
 f Mr. < treig Sinitli (loc snpra cit.) writes : " When the foreign boiiy has been reraoveH, 
 it may be wise, if there is mnch mncoid, purulent, or bloody materia] in the stomach, 
 to cleanse it by means of small sponges on holders. The less the stomach is irritated 
 the better, however." 
 
DILATATION OP THE PYLORUS. 687 
 
 DIGITAL DILATATION OP THE ORIFICES OP THE 
 
 STOMACH. 
 
 We owe this operation to Prof. Loreta * of Bologna, wliose two first 
 cases Mr. Holmes was, I believe, the first to bring prominently under 
 the notice of English surgeons. 
 
 DILATATION OP THE PYLORUS. 
 
 Indications.f — In deciding as to the justifiability of the operation, 
 we must consider— (1) the diagnosis; (2) the failure of previous 
 treatment. 
 
 (1) The Diagnosis.— Cancer and idiopathic gastritis are the chief 
 conditions which must be distinguished from simple fibrous stricture 
 of the pylorus. 
 
 (n) Cancer.— This may be excluded by the long course of the symp- 
 toms, the delay in the onset of cachexia and exhaustion, and by the 
 age| of the patients. 
 
 ((S) Dilatation due to Idiopathic Gastritis.— Prof. Loreta points out 
 that here the diagnosis will be aided by attention to the following : 
 If the matters rejected or extracted from the stomach in the two dis- 
 eases are allowed to settle, and then examined, the deepest layer of 
 the sediment in cases of obstruction from fibrous stricture will be found 
 to consist of acid chyme well digested, and that the patients here have 
 appetite or even hunger after vomiting ; that, on the contrary, in idio- 
 pathic gastritis the deep layer of the vomit contains much undigested 
 detritus and but little chyme, and that after vomiting there is indiffer- 
 ence to or loathing of food. Prof Loreta explains these differences 
 by the fact that in the mechanical obstruction the coats of the stomach 
 are more likely to be uninjured, and that thus gastric digestion still 
 goes on and the peptones are still absorbed. § 
 
 * Prof. Loreta's first case is reported in the Lancet, August 18, 18^3. The ninth 
 operation, one of dilatation of the cardiac orifice, is briefly given in the same journal, 
 April 26, 1884. Mr. Holmes's summary, a very full one, of two papers by Prof Loreta 
 will be found in the Brit. Med. Journ., February 21, 1885. Any surgeon about to per- 
 form these operations should refer to this. Mr. Haggard's case — the first successful 
 one performed by an English surgeon — was published in the Brit. Med. .Town., Feb- 
 ruary 19, 1887. In the same journal for March 17, 1888, is a note that the patient 
 continues perfectly well. 
 
 t These must include those for both operations. 
 
 X Thus in six of the cases mentioned in Mr. Holmes's paper the ages were eighteen, 
 twenty-four, twenty-six, twenty-one, thirty-four, and "a young woman." 
 
 § These points and several others are fully put forward in Mr. Holmes's paper. Prof. 
 Loreta moreover points out that, if the mechanical obstruction has lasted sufficiently 
 long, disease of the coats will ultimately take place, thus rendering examination of the 
 vomit alone fallacious. 
 
688 OPERATIONS ON THE ABDOMEN. 
 
 (2) Failure of Previous Treatment.— If this, carefully persevered 
 with, and including washing out the viscus, has failed to prevent 
 emaciation and exhaustion ; if the vomiting is so constant as to make 
 it certain that rectal nourishment will shortly have to be resorted to, 
 the time for operative measures has come. 
 
 Operation.— The stomach should be well washed out* a few days 
 before, and also on the morning of the operation, with dilute solutions 
 of boracic or salicylic acids, and the time fixed should be as early as 
 possible in the day. The previous meals should be fluids, small in 
 amount and readily digested. The skin being cleansed, an anffisthetic 
 given, and the parts relaxed, an incision about 5 inches long is made 
 on the right side of the middle line, from a point about 1 inch below 
 a'nd outside the xiphoid cartilage to one just below the cartilage of the 
 ninth rib. Hemorrhage is arrested before the peritoneum is opened, 
 and one or two fingers introduced to feel for and examine the pylorus. 
 No definite tumor will probably be felt, but distinct hardness of the 
 pylorus. If the omentum is adherent to the stomach, it must be sep- 
 arated after both this and the pylorus are drawn out of the wound. 
 Sponges are now most carefully packed around the pjdorus, and the 
 stomach is opened, with Idunt scissors, about the centre of its anterior 
 asf)ect, but rather nearer to its pyloric end.f Any bleeding points 
 are secured by Spencer Wells's forceps ; then the right index examines 
 the condition of the pjdoric orifice. While attempts are made to 
 dilate it, this end of the stomach is steadied by the left hand. Much 
 gentleiiess and patience must be used in applying the great force 
 which is often required for dilatation. Mr. Haggard, finding that he 
 could not introduce his finger, used a pair of dressing-forceps, and, 
 having thus started the dilatation, followed it up by the passage of a 
 female urethra dilator (probably having guarded the blades with 
 drainage-tube), and dilated gradually till he was able to get his " index 
 and next finger into the duodenum without feeling them at all tightly 
 packed." Prof. Loreta, in his first case.;}: having introduced his right 
 index, found that " no force that could be safely used succeeded in 
 dilating it till the left index was also introduced and employed to 
 steady the pylorus, ^^'llen this was done, the end of the right fore- 
 finger was gradually squeezed through the ai)erture. Then the finger 
 was used to hook down the pylorus towards the abdominal wound, a 
 manoeuvre which enabled the operator to get the left index also through 
 the pylorus. But it was still exceedingly difficult to eff'ect any sepa- 
 
 * Tliis miiy alsii bring almiit simie contraction of tlie viscns. 
 f Of ciinrse, any larije vessels will, as far as possible, be avoided. 
 X The patient was aged forty-seven, and symptoms of dyspepsia bad lasted twenty 
 years. 
 
DILATATION OP THE CAKDIAC ORIFICE. 689 
 
 ration of one finger from the other, so great was the resistance, not 
 only of the sphincter itself, but also of the coats of the stomach and 
 duodenum. The attempt at dilatation threw the muscular fibres 
 into spasmodic action, which quite overcame all the force that could 
 be exerted. Three such attempts were made in vain, but then the 
 pylorus began slowly to yield to the force employed, which was very 
 considerable. At length a sensation was experienced, 'showing that 
 the tissue was so far distended that it could not obev the dilating 
 finger further without being torn.' The fingers were now kept apart 
 for a short time, and the spectators noted that one finger was about 8 
 centimetres (more than 3 inches) from the other."* 
 
 The wound in the stomach is next closed with Lembert's suture, of 
 carbolized silk; or the method employed by Mr. Thornton, p. 686, 
 maybe made use of The suture should pass'through any points that 
 still bleed after forcipressure is stopped. If any ligatures are really 
 required, fine chromic gut should be used. Perhaps the introduction 
 of a sponge during the insertion of the sutures may focilitate this step 
 by everting the mucous membrane. When the stomach is soundly 
 closed, the sponges are removed from the peritoneal cavity,t the viscus 
 replaced, and the wound in the abdomen carefully closed. 
 
 The after-treatment will be much the same as for gastrotomy, p. 686. 
 Prof Loreta seems to feed his cases by the mouth very early — " on 
 the fourth day " (Haggard) ; according to his own paper, on the same 
 evening, in his first case, every half hour he gave teaspoonfuls of the 
 yolk of an egg beaten up with Marsala. Mr. Haggard allowed nothing 
 but ice to enter the mouth till the seventeenth day. The condition of 
 the patient, and the way in which enemata are retained, must decide 
 this. 
 
 It should be noted that in this case the hasmorrhage had been 
 troublesome. Thus " terrific bleeding followed the incision " into the 
 stomach, and was difficult to arrest completely during the suturing of 
 the stomach. Pure blood was vomited on the third day, and about 
 two teaspoonfuls on the sixth. 
 
 DILATATION OF THE OARDIAO ORIFICE. 
 
 This operation, introduced by Prof Loreta J for non-malignant 
 stricture of the oesophagus, and successfully performed bj' him in at 
 least four cases, seems to me to stand on quite a difierent footing to 
 
 * However the dilritation is effected, it should be kept up for a few minutes. 
 
 t If any cleansing of the peritoneum is required, this will be done now. To prevent 
 any chance of leakage, sutures should be placed at the very angles of the wound, or 
 even beyond them, as recommended by Sir W. MacCormac in suture of the bladder 
 (Fig. 107). 
 
 X In 1885, as mentioned by Mr. Holmes {loc supra cit.). 
 
 44 
 
690 OPEEATIONS ON THE ABDOMEN. 
 
 the other as to usefulness. In the first case the inventor thinks that 
 instrumental dilatation of the oesophagus through a wound in the 
 stomach is much preferable to gastrostomy, owing to the almost uni- 
 form fatality of the latter operation. In this he seems ignorant of the 
 results obtained in this country in favorable instances, and of cases 
 in which the rest given by gastrostomy has enabled surgeons to dilate 
 an innocent stricture previously imjjassable, and to close the gastric 
 fistula later on (p. 684). Furthermore, it remains to be proved how 
 far strictures of the oesophagus thus treated can be considered, as Prof. 
 Loreta claims for his operation, radically cured. For the surgeon is 
 here not able to get as directly at the disease as in dilatation of the 
 pylorus, and Prof. Loreta allows in another part of his paper that the 
 cure here may be only transitory and partial, as in the case of the 
 cardia the surgeon loses the peculiar sensation to his fingers of fibres 
 so far stretched as to have entirely lost their tonicity and power of 
 resilience. It will probably be well to keep up the dilatation of a 
 stricture thus commenced from the stomach by means of bougies 
 passed from the mouth. 
 
 Operation. — The following account is from that given in Mr. 
 Holmes's paper of the first case thus operated on by Prof. Loreta.* 
 The patient, aged twenty-four, had swallowed caustic alkali. At- 
 tempts to dilate the stricture by bougies were unsuccessfvrl, and at 
 last it became impossible to pass anj' instrument. The point at which 
 the sound was arrested seemed to correspond with the fourth dorsal 
 vertebra. The patient was entirely unable to swallow, and emaciation 
 had become extreme. Eleven months after the injury an incision 
 about 5 inches long was made from the xiphoid cartilage downwards 
 and to the left. Some difficulty was met with in finding the stomach, 
 owing to its contraction and the way in which the liver overlapped 
 it ; but at length the operator succeeded in drawing the greater part 
 of the stomach out of the wound, and a longitudinal incision was 
 made through its walls between the two curvatures, having its upper 
 end as near the cardia as possible. The next step was to find the 
 orifice of the cesophagus, in order to introduce the dilator; but this 
 involved considerable difficulty, and the search was interrupted by a 
 considerable quantity of bile, which regurgitated from the duodenum 
 into the stomach. At length, by searching with the left index be- 
 tween the under-surface of the liver and the small curvature of the 
 stomacli, the end of tlie oesophagus was found. Then the distended 
 stomach Avas kept drawn down by an assistant while the operator 
 introduced a dilator (sometliing like that of Dupuytren for lithotomy). 
 
 * Four cases in I'rof. Loieta's hands, and two under other Italian surgeons, all 
 recovered. 
 
EXCISION OF THE PYLORUS. 691 
 
 The wound was then sewn up and the stomach returned. The pa- 
 tient rallied well, and in six hours swallowed some soup, with the 
 yolk of an egg, to his great joy, as for twelve months he had been 
 unable to do more than swallow mouthfuls. Recovery was complete 
 in about eighteen days, but on the fourth day after the operation he 
 was seized with dyspnoea and abundant mucous expectoration from 
 the trachea and bronchi. This same disturbance took place in another 
 case. Prof Loreta is uncertain whether it was due to irritation or 
 paralysis of the sympathetic or vagus during the dilatation, or to in- 
 flammatory exudation. 
 
 EXCISION OF THE PYLORUS. 
 
 This operation, which we owe especially to German surgeons, Bill- 
 roth, Woelfler, Gussenbauer, and v. Winiwarter, cannot yet be said to 
 be definitely accepted in English surgery. To my mind, the very 
 high mortality and the rapidity of recurrence render it extremely 
 doubtful whether this- operation should ever be performed, even in 
 the most exceptional cases. But I ought to state that this is the out- 
 come of an examination of published cases, and not from any per- 
 sonal experience of the operation. 
 
 Indications. — Is the operation ever justifiable? and,if so, in what 
 cases ? What are the results and the mortality f Dr. Winslow {^Amer. 
 Journ. Med. Sci., 1885, N.8., vol.. Ixxxix. p> 345) has collected fifty-five 
 cases in which pylorectomj' was performed for cancer. Of these, 
 forty-one died from the effects of the oi^eration, giving a mortality of 
 about 76 per cent. Mr. Butlin {Opcr. Surg, of Mal.lg. Dis., p. 217) 
 quotes Bramer {Cent. J. C'hir., 1885, p. 548) as having collected seventy- 
 two cases of pylorectomy for cancer, of which fifty-five died from the 
 operation, a mortality again of about 76 per cent. 
 
 Duration of Cure. — Mr. Butlin (loc, supra cit.) shows that all the 
 cases which have been properly reported are either dead or suffering 
 from recurrence. All save one died in a period of from four to 
 eighteen months. The exception was one of ^\'oelfler's, which re- 
 mained well for a year, and then had a recurrence in the cicatrix 
 which was operated on. Later on the groin glands became affected, 
 and four years after the pylorectomy the patient was dying slowly of 
 cancerous recurrence. In Mr. Butlin's words, " There is not one, 
 therefore, of those who recovered from the operation who can be 
 
 claimed to have been really cured of the disease Yet the cases 
 
 in which recovery from the operation took place were, so far as could 
 be judged, singularly favorable for the operation. In the very large 
 majority of them the disease was very limited in extent, was not 
 complicated by adherence to the surrounding j^arts, while the glands, 
 as far as could be seen, were not affected by the cancer." 
 
692 OPEKATIOXS ON THE ABDOMEN. 
 
 Mr. Butlin goes further when he states his belief that, while no 
 patients have been cured by this operation, the relief it gives is not 
 likely to be abiding, as the recurrence in several has taken place 
 in situ, and that this causes as much suffering as the primary disease. 
 
 With regard to statistics, it should, I think, always be remem- 
 bered — (1) that a very large number of these cases have been treated 
 by hands especially practiced in this operation, and yet the mortality 
 is extremely high ; (2) that the statistics do not give the whole mor- 
 tality, as it is highly probable that a large number of operations 
 have been performed with unsuccessful results, and therefore not 
 published. 
 
 Time alone will show whether the above adverse opinion is un- 
 justifiable. Any surgeon deciding to operate will weigh carefully the 
 following in a case of undoubted malignant obstruction. 
 
 i. Is the mass localized to the pylorus ? — i.e., how far is it (a) with- 
 out any secondary deposits ? (/) free from adhesions ? It is probably 
 quite impossible to be certain as to these points. While in many 
 cases cancer of the pylorus may remain long limited to the pylorus 
 itself, it is very liable to infect the lymphatic glands around the head 
 of the pancreas, and to cause secondary growths in the liver and 
 other parts. Adhesions, too, are very frequently* met with between 
 the stomach and the colon, pancreas, and liver. The following cases 
 show how easily the surgeon may be mistaken in these points. In 
 Mr. Southam's patient (Brit Med. Jouni., July 29, 1SS2— an instructive 
 paper, from which I shall again quote later), aged forty-three, though 
 the hard nodular mass in the situation of the pylorus moved with 
 respiration, and shifted as the patient moved from side to side, though 
 the symptoms were only of four months' duration, and the disease 
 appeared to be limited to the pylorus, there was a mass of enlarged 
 glands surrounding the head of the pancreas, and some slight adhe- 
 sions of the stomach to these. Mr. Morrisf mentions a patient in 
 whom, though the growth could be easily moved in different direc- 
 tions, it was found so firmly adherent that the operation had to be 
 abandoned. 
 
 Mr. Morris gives also the following instructive case : " A man 
 under my care in the Middlesex Hospital, with a movable cancerous 
 mass in the pyloric region, consented to the operation of j)\^lorectomy ; 
 his strength and general, as well as local, condition seemed favorable, 
 and all the final preparations for the operation had been made, when 
 
 * The statistics of Giissenbauer and Winiwarter (Langenbeck's Arch., Bd. xix. 
 p. 372, 1876) show that, of 5-12 cases of cancer of the pylorus, adhesions were present 
 in 370. 
 
 t Intern. Eiicyd. Surg , vol. v. p. 1107. The case was under Prof. Lietherin (Brit. 
 Med. Journ., June 3, 18«2). 
 
EXCISION OF THE PYLOBUS. 693 
 
 some increased distinctness of the superficial veins of the abdomen, 
 and some slight tumidity in the lumbar regions, suggested the advisa- 
 bility of watching and waiting for a day or two. Within a week the 
 whole abdomen was distended with ascitic fluid, the surface veins 
 were greatly enlarged, and the lower limbs wdematous. The patient 
 lingered on several weeks, and died with abundant secondary cancer. 
 It is needless to speculate what might have been the result of the 
 operation had it been attempted in this case." 
 
 ii. The strength and age of the patient. The general condition, 
 power of repair, etc., must be sufficient to justify the patient being 
 submitted to an operation on very vital parts, which will certainly 
 take an hour and a half, and may take between two and three. 
 
 iii. The rate at which vomiting, pain, and emaciation are in- 
 creasing. 
 
 iv. The amount of dilatation of the stomach, and how far this 
 yields to washing out. 
 
 Operation. — For some days before the operation the stomach 
 should be washed out with tepid water, siphon-fashion, by an india- 
 rubber tube and funnel, till the contents come out clear, this being 
 done more frequently according to the degree of dilatation of the 
 viscus. Immediately before the operation* the stomach is again 
 washed out with some dilute aseptic solution, as salicylic acid. For 
 some time beforehand the patient must be fed with that food which is 
 found to cause least vomiting. In Mr. Southam's case this was found 
 to be peptonized milk and custard. f The bowels should be well 
 cleared out with enemata, and every precaution at the time of the 
 operation should be taken against shock — viz., wrapping up the pa- 
 tient well, hot bottles, bandaging the limbs in flannel, keeping the 
 head low, the administration of ether if possible for the greater part 
 of the operation, and subcutaneous injections of ether and brandy. 
 
 Various incisions have been made — viz. (1) A vertical one in the 
 linea alba, above the umbilicus. (2) A vertical one in the right linea 
 semilunaris, or through the rectus, tearing its fibres so as to avoid 
 haemorrhage (p. 680). (3) Obliquely from above downwards, and 
 from within outwards, between the umbilicus and right ribs. (4) 
 More transversely over the tumor.J Either of the last two gives more 
 room, and thus better access to the growth. But as both are accompa- 
 
 * In Mr. Southam's case tlie need of this final washing was proved by the fact that 
 a quantity of dark-colored griimoiis matter was brought away, which otherwise might 
 have escaped into the peritoneal cavity. 
 
 t Nothing should be taken by the mouth for twelve hours before the operation. 
 
 X If this has sunk very low, it ra ist first be raised, if possible. 
 
694 
 
 OPERATIONS ON THE ABDOMEN. 
 
 nied with more haemorrhage, and are more difficult to close* — a point 
 which may be of much importance at the close of such an operation— 
 a free oblique incision, 4 to 5 inches long, commencing a little to the 
 left of the middle line, but not completely dividing both recti, is to 
 be preferred. All hasraorrhage being first arrested, the transversalis 
 fascia and peritoneum are pinched up and opened so as to admit two 
 fingers, which examine the growth, the presence of adhesions, enlarged 
 glands, invasion of the liver, pancreas, or colon, or curvatures of the 
 stomach itself. If the disease is so localized as to allow the surgeon 
 to go on, the opening in the peritoneum is enlarged so as to get a 
 better view of the disease, and to enable the mass to be drawn for- 
 wards with vulsellum -forceps. This having been done as much as 
 possible, the stomach is packed around with towels soaked in carbolic 
 acid 1 in 20 for some days, and for an hour or two in 1 in 40, or 
 sponges, so as to prevent any escape of fluids into the peritoneal 
 cavity. The omenta are next separated with scissors, either between 
 double ligatures of carbolized silk or chromic gut previously passed 
 with an aneurism-needle, or between large pairs of omental clamp- 
 forceps, the tissues being cut piece by piece, and each bleeding point 
 taken up. 
 
 Excision of the Disensed Pylorus. — Previous to this, towels or sponges 
 should be still more carefully packed around the stomach, and the 
 
 Fig. 113.t 
 
 Oblique division of the stomach and duodenum in pylorectomy. Billroth in this case made 
 half the division of the stomach first, united this with " occlusion sutures," next severed the 
 rest of the stomach, then the duodenum, finally uniting this to the greater curvature. (Billroth.) 
 
 duodenum should be secured, either with a ligature of thick silk tied 
 round it well wide of the disease, or by a clamp, as in Fig. 104. The 
 ligature seems preferable, as it not only prevents escape of contents 
 
 * In Mr. Southam's case, the incision, 6 inches long, was made 2 inclies above the 
 umbilicus, and across both recti ; the contraction of these muscles led to much difB- 
 cnlty in adjusting the abdominal wound. 
 
 t This and the next four figures are taken from Prof. Billroth's Clinical Stirgery, pt. iii. 
 
EXCISION OF THE PYLORUS. 
 
 695 
 
 and controls hpemorrhage, but also gives a secure hold, preventing 
 the intestine slipping, and allowing it to be drawn over towards the 
 cardiac orifice. The duodenum is then cut through, as in Fig. 113, 
 
 FiQ. 114. 
 
 Duodenum united to the greater curvature ; ten occlusion sutures unite the upper part 
 of the cut stomach. (Billroth.) 
 
 with scissors, at least i inch from the disease. This incision, oblique, 
 so as to diminish as far as possible the difference in the openings be- 
 
 FiG. 115. 
 
 V 
 
 (Billroth.) 
 
 tween the stomach and duodenum, is made with a series of clean 
 careful snips, any bleeding points being secured at once with Spencer 
 Wells's forceps if few, and with fine chromic gut if numerous. 
 
 The section of the stomach has been made in different ways. The 
 most usual one is shown in Fig. 113. The section is made obliquely, 
 with the precautions already given in the case of the duodenum. As 
 the cut end of the stomach is so much larger than that of the duodenum, 
 the former must be reduced by suturing part of it before it is completely 
 divided. The surgeon will decide whether he will unite the duodenum 
 to the greater or lesser curvature, or to the part between the two.* In 
 
 * Prof. Billroth prefers uniting the duodenum to the greater curvature. 
 
696 
 
 OPERATIONS ON THE ABDOMEN. 
 
 the former case he cuts the stomach from above downwards, and from 
 left to right, and it will be well to unite that part of the stomach which 
 will be superfluous before the section is completed (Fig. 114). The 
 same course is followed if the duodenum is united to the lesser curva- 
 ture ; but here the section is made from below upwards, and from right 
 to left. Figs. 115, 116, show the mode of uniting the duodenum midway 
 between the two curvatures. 
 
 Fig. 116. 
 
 Fig. 117. 
 
 (Billroth.) 
 
 Closure of the Stomach, and Union of this and the Duo- 
 denum. — That part of the stomach which is superfluous is closed 
 M'ith carbolized-silk sutures, inserted by Lembert's method, the sutures 
 being left long and held in forceps, so as to steady and move the 
 stomach as may facilitate its union with the duodenum. The ligature 
 on this being removed, it is united either to the greater or lesser 
 curvature, or centre, as follows, beginning with sutures passed from 
 within (Fig. 117). These, of fine carbolized silk, are passed with a 
 
 needle in a holder, first at the cut 
 edge of the stomach between the 
 mucous and muscular coats, carried 
 on between the muscular and serous, 
 then through the same layers of the 
 duodenum, and finally brought out 
 between these layers and the mucous 
 membrane at the cut edge of the 
 duodenum. When the posterior 
 aspect of the two viscera is thus 
 soundly closed, the anterior one is 
 
 Insertion ofthe posterior ring sutures from ""'^^^d by Lembert's SUture. If the 
 
 witiiin. (Billroth.) cut mucous membranes do not come 
 
 accurately together, a few sutures 
 may be put in here separately from within. 
 
 Care must be taken in inserting the sutures to avoid the formation 
 
GASTRO-ENTEROSTOMY. 697 
 
 of any folds (Billroth). The same surgeon says it is well to put a few 
 additional superficial sutures at the point where the borders of the 
 duodenum join those of the stomach. If the stomach contains fluid 
 in spite of the washing out, it must be mopped dry with carbolized 
 sponges kept for this purpose alone, and it may be a help to introduce 
 sponges into the cut ends while the sutures are being inserted, with- 
 drawing them before the stitches are tightened. The sutures being 
 carefully looked over and cut short, a little iodoform is rubbed in, the 
 sponges or towels removed, and the stomach replaced. If any fluids 
 have escaped into the peritoneal cavity, this must be carefully cleansed. 
 The abdominal wound is then closed in the usual way and the dress- 
 ings applied. 
 
 After-treatment. — This will be conducted on much the same lines 
 as after gastrotomy, p. 686. Mr. Butlin (loc. mpra cit.) points out that 
 tliese patients, much let down and exhausted, will not last long on the 
 administration of ice and nutrient enemata only. After the first 
 thirty-six hours teaspoonfuls of milk should be given every half-hour 
 or hour, gradually increased up to a pint in twenty -four hours at the 
 end of a week. 
 
 GASTRO-ENTEROSTOMY. 
 
 The object of this operation is to make an opening between the 
 blocked stomach and the small intestine as high up in the latter as 
 possible, so that the food may still find its way into the intestine and 
 there meet with the other digestive fluids. Owing to the great fatality 
 of pylorectomy, this operation, or jejunostomy (p. 699) or that of 
 curetting the disease will probably take its place, and not only in 
 those cases in which excision of the pylorus cannot be performed 
 owing to the condition of the patient, the presence of adhesions or 
 secondary deposits, or by the growth involving the stomach itself as 
 well as the pylorus. 
 
 Operation. — The preliminaries are the same as those given for 
 pylorectomy (p. 693). The following account of the operation subse- 
 quent to exposure of the stomach is taken from a very successful case 
 of Mr. Barker's : * " After pushing the omentum, which was not volu- 
 minous, to the left, the first part of the jejunum was caught in the 
 fingers, and a loop drawn out of the incision. The middle of the 
 anterior surface of the stomach was also drawn out, and supported all 
 round by warm carbolized sponges. I now passed a piece of india- 
 rubber tubing through the mesentery at each end of the loop, and, 
 having emptied the portion of gut by gentle pressure, drew the ends 
 of the tubing tight enough to prevent access of the contents of the 
 
 * Brit. Med. Journ., February 13, 1886. 
 
698 OPERATIONS ON THE ABDOMEX. 
 
 bowel into the loop to be operated on, and fixed each piece of tubing 
 with catch-forceps. The empty loop of gut was now laid upon the 
 portion of stomach to be opened, and a longitudinal fold of the latter, 
 about IJ inch from the great curvature, was pinched up between the 
 finger and thumb of the left hand, together with the collapsed gut. 
 I now made an incision about U inch long in the fold of the stomach, 
 and another corresponding in the approximated fold of gut. These 
 incisions only penetrated through the serous and muscular tunics, 
 and left the mucous coat of both viscera intact for the present. Still 
 holding the parts, as before, between finger and thumb, I now united 
 the corresponding posterior edges of the wounds by a continuous 
 suture, the needle entering and emerging in each case between mucous 
 and muscular coats, and the threads crossing the cut edges of the mus- 
 cular and serous coats. In this way the serous surfaces were closely 
 united from end to end before either viscus was opened. This row of 
 stitches (which were about i inch apart) was carried about i inch 
 beyond each end of the incision in the coats of the bowel. The 
 moment had now come to open both the stomach and intestine com- 
 pletely, and this was done with a stroke of scissors through the 
 mucous coat in each case, special sponges being ready to receive any 
 fluid which might escape. A few drachms of s cms entericus flowed 
 from the bowel — little or nothing from the stomach opening. After 
 careful cleansing, the anterior borders of both openings were now 
 united by a row of interrupted fine-silk sutures, introduced according 
 to Czerny's method. When this was completed, the two openings 
 were securely closed, but, as an extra precaution, the intestine was 
 turned over, and the posterior suture wa? reinforced by a second row 
 of interrupted sutures, placed about i inch away from the first. The 
 anterior M'as then similarh' reinforced by a row of continuous sutures 
 taking up, as before, only the serous and muscular tunics. Lest there 
 should be any 'kinking' of the latter, as in one of Billroth 's cases, I 
 stitched its efferent portion to the stomach wall, about i inch from 
 the right extremity of the opening between the stomach and jejunum." 
 
 The rest of the operation and the after treatment will be much the 
 same as that already given (pp. 686, 697). 
 
 Mr. Barker's case soon began to vonjit turbid fluid, which became 
 very fetid — apparently pancreatic secretion mixed with bile. This 
 was checked by the use of creosote and placing the patient in the 
 semi-recumbent position, which, allowing the intestine to shp down, 
 caused its opening not to be exactly over that in the stomach. 
 
 DUODENOSTOMY. 
 
 This and the following operation have been proposed, in cases 
 unsuited for pylorectomy, as a means of getting nourishment into the 
 
JEJDXOSTOMY— TREATMENT OP GASTRIC CANCER. 699 
 
 alimentary canal below the disease, and thus giving rest to the diseased 
 parts. Time alone will show how fiir these are preferable to gastro- 
 enterostomy ; but it is certain that duodenostomy, which has received 
 but little favor, is destined to be dropped. It has the serious objec- 
 tions that it deals with a fixed portion of intestine, and one into which 
 important fluids are poured, and thus may readily escape from a fistula 
 made here. Furthermore, all the cases have, I believe, beea fatal, 
 
 JEJUNOSTOMY. 
 
 This operation has been performed in a few instances. One of these, 
 which I had the advantage of seeing, was brought by Mr. Golding Bird 
 before the Clinical Society {Tniii^., vol. xix. p. 70). The following 
 remarks are mainly taken from my colleague's paper. Mr. Golding 
 Bird was inclined to consider this operation as superior to gastro- 
 enterostomy as giving the cancer much more complete rest, as avoid- 
 ing the risk not only of extravasation of contents of bowel and stomach 
 contents, but also of that obstruction of the colon which mav be found 
 to be due to the necessary bringing up of the small intestine from below 
 it. Finally, by feeding both toward and from the duodenum, perfect 
 intestinal digestion can be carried on. This was proved ).iy the rapid 
 improvement in Mr. Golding Bird's case. 
 
 Operation. — The precautions as to feeding and washing out the 
 stomach have been already given (p. 693). A vertical incision being 
 made in the linea alba or right linea semilunaris, and the peritoneum 
 opened with the precautions already given, the transverse colon and 
 great omentum being drawn up, the omentum pushed over to the left, 
 the first piece of small intestine which presented itself is seized. To 
 bring this to the left, it is felt closelj^ attached to the spine just above 
 the aorta, and thus recognized as the commencement of the jejunum. 
 A portion of this is then drawn forward in the lower angle of the wound, 
 while the upper two-thirds of this are united. When this is done, the 
 bowel is stitched to the edges of the wound by interrupted sutures, very 
 much as in gastrostomy. The after-treatment of the two operations 
 would be much alike. 
 
 TREATMENT OF GASTRIC CANCER BY THE USE OP 
 
 THE CURETTE, 
 
 This new operation has been introduced by Prof. Bernays* with 
 two most successful cases. As it is not improbable that it will replace 
 other operations here, it will be briefly mentioned. Prof. Bernays, 
 believing that cancer of the stomach, by the time it comes under the 
 surgeon's hands, has ceased to be a local disease, and that therefore 
 
 * Annals of Surgery, December, 1887. 
 
700 OPERATIONS ON THE ABDOMEN. 
 
 radical extirpation is out of the question, recommends gastrostomy 
 followed by curetting * 
 
 Having opened the peritoneal cavity — an incision to the left of the 
 linea alba parallel with the ribs was used— the anterior wall of the 
 stomach was found, and punctured with a trocar so as to let off the 
 gas. The parietal peritoneum was then united to the edges of the 
 wound and the stomach (about the centre of its anterior surface), 
 stitched most carefully to the parietal peritoneum and muscles. The 
 wound was then irrigated with 1 in 20 carbolic acid, to prevent, by its 
 slightly caustic action, any infection from the contents of the stomach. 
 The stomach was then opened for 11 inch, very little bleeding follow- 
 ing, and the lips of the stomach wound and that in the skin united by 
 thirty-six silk sutures. The stomach was now well washed out with 
 warm water, and a soft growth felt nearly filling the pylorus, but 
 leaving the lesser curvature intact. With two fingers half this was 
 now removed. Most profuse bleeding followed, but ceased when the 
 hard base of the tumor was reached with a sharp sj)oon, and the 
 stomach was irrigated with cold carbolized water till this ran out clear. 
 Nine hours after the operation the patient was allowed to take glasses 
 of milk at intervals, but none came through the dressings, these not 
 being changed till the fifth day. The fistula should be kept open for 
 repetition of the curetting. In one case l-l ozs., in the other 14 drs., 
 of growth were removed. In the second case, great difficulty was met 
 with in dilating the pylorus, the carcinoma here being much harder 
 and circular. The history of the cases is not complete, but it is clear 
 that very great relief was given in the few months which had elapsed 
 since the operations, the patients gaining weight, ceasing to vomit, 
 and no longer needing morphia. 
 
 CHAPTER VIII. 
 
 EXCISION OF THE SPLEEN. 
 
 Indications. — All of these are rare, and many of them are still 
 doubtful. 
 
 1. Cystic spleen. When this is found unsuited for drainage. Mr. 
 K. Thornton's case of this kind was the first successful splenectomy 
 in England. 
 
 2. Injury. This has been already alluded to when gunshot injuries 
 of the abdomen were considered (p. 672). Other cases in which it 
 
 * The fact that cancer here grows towards the cavity of the organ, and tiie relief 
 given by repeateil curetting in uterine cancer first led him to attempt this. 
 
EXCISlOX OF THE SPLEEN. 701 
 
 may be called for are, prolapsus of a spleen, injured or not, through a 
 wound, rupture of the spleen, and stabs of this viscus. 
 
 3. Movable or wandering spleens. When this condition causes 
 troubles, analogous to those of movable kidney, not relieved by a belt. 
 
 The remaining conditions are much more doubtful. 
 
 4. Malignant disease. Primary sarcomatous or carcinomatous 
 disease of the spleen is extremely rare. The only case I can quote is 
 one removed for primary sarcoma by Prof. Billroth (Lancet, June 7, 
 1884). Mr. Butlin, referring to the same case, says that it was reported 
 shortly after that recurrence had proved fatal in a few months. 
 
 5. Hypertrophy of the spleen. The operation must here be limited 
 to those rare cases in which simple (non-leuka?mic) enlargement of the 
 spleen resists other treatment. In Mr. Thornton's table,* in fourteen 
 cases of splenectomy for '' Hypertrophy," four were successful, and 
 ten fatal. 
 
 6. Leukffimia.f This operation has been so invariably fatal that it 
 ought to be abandoned. 
 
 Operation. — The preliminary steps will be directed to ensure 
 asepsis and to diminish shock (pp. 655, 669). The incision has usually 
 been one in the linea alba. That in the linea semilunaris, or one fur- 
 ther out (Bryant), from the left anterior superior spine to the ribs, 
 would probably give better command over the pedicle. All haemor- 
 rhage being stopped, the peritoneum is opened freely and the hand 
 explores the tumor. Any adhesions, as of the overlying omentum, 
 are separated, being ligatured if needful. The spleen is now brought 
 out of the wound, the lower extremity first, and either carbolized 
 sponges or towels are carefully packed around it. This extraction of 
 the viscus must be carried on with the utmost caution and gentleness, 
 as its friability may easily lead to a tear and most profuse oozing, and 
 as dragging on the pedicle may easily induce collapse and is also 
 likely to lead to some small vessels retracting from the ligatures as 
 they are applied, and causing fatal haemorrhage. 
 
 The spleen being wholly outside the body, the most important part 
 of the operation, securing the pedicle, remains. This structure, if 
 present,J must be carefully examined. If the jjatient's condition is 
 good, the safest plan will be to secure the vessels as far as possible 
 separately, the pedicle being divided, as Mr. Greig Smith {loc. supra 
 
 * It seems to me that this distinction has not been snfEciently made. Several of the 
 cases operated on read like an eai'ly condition of leukaemia, and in those ending fatally 
 the rapid onset of death after the operation is often suggestive of the ending of leukae- 
 mic splenectomy. 
 
 t Mr. Greig Smith gives IS cases ; Mr. Thornton, 13 ; Mr. Collier, 16 — all fatal. 
 
 J In a case of Mr. L. Browne's {Lancet, vol. ii. 1877, p. 310) there was no pedicle as 
 such, four very large arteries being met with and secured with double ligatures. 
 
702 OPEEATIONS ON THE aBDOiMEX. 
 
 cit., p. 563) suggests, piecemeal between pressure-forceps; where there 
 is not time for this, it will be wiser to secure the vessels in tAVO or three 
 portions, transfixing in two places, and locking the ligatures (Thorn- 
 ton). Carbolized silk should be used, fairly stout, and not tied too 
 tightly so as to cut its way. However the pedicle is treated the fol- 
 lowing precautions should be followed: (1) To prevent any tension 
 being exerted on the pedicle (ride mipra). (2) To secure every vessel. 
 (3) To divide them, in a relaxed condition, at a sufficient distance 
 from the ligatures. (4) Not to include the tail of the pancreas. (5) 
 After all the ligatures have been applied, it may be well for safety to 
 throw one round the whole. (6) Not to twist the spleen round at all 
 in dealing with the pedicle.* 
 
 The abdominal cavity is next cleansed and the operation completed 
 as after ovariotomy. The after-treatment is also much the same. 
 
 Causes of Death. t — By far the most frequent is haemorrhage. 
 This may be from the omentum adherent over the spleen, from the 
 large vessels to this viscus-, from some small vessel which has retracted, 
 from the splenic vein, or from sponge-like adhesions. (Bryant.) 
 
 CHAPTER IX. 
 
 OPERATIONS ON THE LIVER AKD GALL- 
 BLADDER. 
 
 HYDATIDS.— HEPATIO ABSOESS.-TAPPING AND IN- 
 CISING THE GALL-BLADDER.-REMOVAL OF BIL- 
 IARY CALCULI.-EXTIRPATION OF THE GALL- 
 BLADDER. 
 
 OPERATIONS FOR HYDATIDS. 
 
 This will include different forms of puncture, free incision, and 
 electrolysis. While the milder measures of puncture and electrolysis 
 have proved successsful, we do not know for certain how the death of 
 the parasite is brought about by them in successful cases, and they 
 are largely uncertain. 
 
 A. Puncture. — While incision is the only certain and reliable 
 mode of cure, it is worth while to try the different forms of puncture, 
 especially in certain cnses. 
 
 .Sir S. Wells (Uleil. Times and Oaz., January 6, 186f), p. 4) draws attention to this. 
 Having done so in order to bring the vessels into a cord, the splenic vein was ruptured. 
 t Adeimann, to render splenectomy safer, has suggested its performance in two 
 stages. 
 
OPERATIONS FOE HYDATIDS. 703 
 
 There is no need to do more than to describe brieflj^ such an opera- 
 tion as this, and to tabulate the chief practical points. 
 
 The parts being cleansed and an aniosthetic* given if the patient is 
 very nervous, the surgeon chooses a spot for puncture at the most 
 prominent part of the tumor, satisfying himself afs to dulness.f If the 
 skin is thick he makes a minute puncture with a scalpel and sends in 
 a fine trocar or aspirator needle. The quantity withdrawn must vary 
 with the case, the size of the cyst, the timidity of the patient, etc. 
 From six to sixty ounces are instances of small and large quantities. 
 The aspirator should, on the whole, be preferred, as likely to remove 
 more fluid, and thus, probably, more likely to produce a cure, but as 
 the exhaustion is more likely to plug the cannula, a fine wire must be 
 in readiness. J Escape of bile, blood, or the setting up of a cough are 
 indications for stopping. "While the cannula is withdrawn the sur- 
 rounding parts should be pressed around it, and rather depressed, to 
 diminish the risk of leakage as the cannula leaves the cyst. The 
 puncture is then closed with ether and collodion, a small pad of dry 
 gauze, and salicylic wool comfortably secured with a many-tailed 
 bandage. A little opium or morphia should be given for the first 
 twenty-four hours. The instruments used should be scrupulously 
 clean, and in hospital practice and in towns, the additional trouble 
 entailed by the spray will not be thrown away. 
 
 Practical Points. 
 
 1. Puncture alone is more likely to be radically curative in the fol- 
 lowing cases : A small cyst, seen early. An acephalocj^st. The more 
 daughter-cysts, brood-capsules and scolices are present, the less likely 
 is it that puncture will suffice. 
 
 2. Puncture is often very useful as a means of diagnosis in these 
 obscure cases, in which hydatids of the liver simulate disease of the 
 pleura or lung. 
 
 3. Incision should be made use of where suppuration is present or 
 imminent, where tapping fails, where scolices instead of fluid form the 
 greater part of the contents of the cyst, and where chest complications 
 are set up by the hydatid, showing perhaps a risk of perforation. 
 
 * Jt is well to dispense with this, if possible, from the possibility of leakage taking 
 place after the subsequent vomiting. As an injection of cocaine will give almost as 
 much pain as the fine trocar, tlie part may be frozen with the ether spray if needful. 
 
 f If this is presenting against the right ribs another spot should, if possible, be 
 chosen (foot-note, p. 704). Hydatids of the liver should never be explored or attacked 
 through the ribs, if another site is obtainable. 
 
 X Dr. Fagge (Medicine, vol ii. p. 321) thought that the value of the aspirator must 
 depend entirely on the position of the hydatid. If a large part of the cyst is outside 
 the liver-substance, tlie aspirator may be used with advantage; but if the cyst be almost 
 entirely buried in liver substance, Dr. Fagge thought the possible suction on a cyst 
 surrounded by resistenl tissue must involve some risk of setting up inflammation. 
 
* 
 
 704 OPERATIONS ON THE ABDOMEN. 
 
 4. A few weeks after puncture secondary enlargement is often no- 
 ticed. This is not undesirable as long as it subsides, which it usually 
 will do gradually, being due to inflammation. On this account Dr. 
 Fagge advises that no second operation on a hydatid should be per- 
 formed within twelve months, unless suppuration is present. 
 
 5. Leakage after puncture may be shown by fluctuation, more or less 
 distinct, in the flanks. The result of this seems to have been variable. 
 In some cases it has been absolutely harmless, as in a case of elec- 
 trolysis of mine mentioned below. In others it has been as certainly 
 followed by fatal peritonitis. 
 
 6. Cases of hydatids treated by puncture should be watched for 
 some time to make certain that the cure is a sound one. 
 
 7. It must not be forgotten in operating on hydatids that the sur- 
 roundings are of truly vital importance, and that sudden death has 
 followed an operation more than once. Thus, in Mr. Bryant's case 
 in tapping a hydatid cyst, the portal vein which had been pushed 
 upwards and forwards by the projection of the cyst on the under sur- 
 face of the liver was transfixed. Death followed in five minutes, and 
 was thought by Dr. Fagge to be due to hydatid fluid being sucked 
 into the vein as the trocar was withdrawn. 
 
 A Russian case was published {Lond. Med. Record, 1885, p. 414) in 
 which the pulse suddenly stopped while the cyst, which had been ex- 
 posed by abdominal section, was being stitched to the incision. At 
 the post-mortem, a crumbled echinococcus had made its way into the 
 right auricle, and a fragment of one into the right division of the pul- 
 monary artery, by an opening between the thinned cyst and the 
 inferior vena cava.f 
 
 B. Incision. — The indications for this in preference to tapping have 
 been given above (p. 703). It may be performed in one or two stages. J 
 Surgeons owe their knowledge of the safety of the onc-strif/c method to Mr. 
 Lawson Tait. The operation is thus performed: The parts being 
 cleansed and the other preliminary steps taken, the surgeon makes an 
 incision about 4 inches long over tlie most prominent part of the swell- 
 ing § (previously carefully percussed), down to the peritoneum; all 
 
 ■" Clin Soc. Trans., vol. xi. p. 23(J. 
 
 t Mr. WiUett {Brit. Med. Journ., November 13, 1886) mentioned a casein wliicli he 
 had to aspirate a doubtful swelling of the liver. He used an ordinary-sized needle, 
 and within two minutes the patient was dead. It turned out to be a case of malignant 
 disease. No large vein had been pricked, and there was no hsemorrhage. The fatal, 
 sudden syncope seemed due to the impression made on the nervous system through the 
 solar plexus. 
 
 } The operation by one stage is called by some hepatotomy. 
 
 ? This incision should always be made in front. Even if a cyst or abscess shows its 
 greatest point of prominence through the ribs, it should not be opened here if possible, 
 as it is difficult to ensure adequate drainage, and the large drainage-tube needful 
 easily causes caries of the closely adjacent ribs. 
 
OPERATIONS FOR HYDATIDS. 705 
 
 hemorrhage is next arrested, and this layer carefully slit up. The liver 
 is now recognized, and carbolized sponges or towels (p. G56) are care- 
 fully packed in on either side so as to prevent any escape of fluid into 
 the peritoneal cavity. 
 
 The needle of an aspirator or a fine trocar is then thrust in, and the 
 existence of fluid beneath thus verified. Ae the needle is withdrawn 
 the liver is incised, and a finger quickly plugs, and then enlarges to IJ 
 inch, the opening made by the knife. Hainorrhage, if free, is easily 
 arrested thus, or by sponge-pressure. Escape of fluids into the peri- 
 toneal cavity is prevented by the use of the sponges already mentioned, 
 by an assistant keeping the edges of the wound carefully adjusted to 
 the liver, and, lastly, by the next step, which consists in hooking up 
 the opening in the liver with the finger or forceps, and in stitching the 
 edges of the wound in the liver to that in the abdomen with a contin- 
 uous suture of carbolized silk. In inserting this care must be taken to 
 unite peritoneum to peritoneum, and to take up a sufficiency of tissue 
 by inserting the needle well away from the edges of the wound. As 
 the suture is inserted the sponges must be gradually withdrawn, and 
 if the fluid escapes very freely it may be well to turn the patient over 
 on his side. Any scolices which are within reach are next removed, 
 and if the cyst is firmly stitched and the patient's condition good, the 
 contents of the hydatid may be cleared out with sponges on holders, 
 aided by scoops. All handling must be of the gentlest. A large drain- 
 age-tube is then inserted, and dry sal alembroth or iodoform gauze 
 dressings applied. 
 
 Operation by Tivo Stages. — This operation, based on the readiness with 
 which two peritoneal surfaces adhere, is a very satisfactory one, being 
 free from any risks of escape of blood or other fluids into the perito- 
 neal cavity. I thus performed it in two cases of hydatid of the right 
 lobe under the care of my colleagues Dr. Pye Smith and Dr. F. Taylor. 
 An incision, 4 inches long, was made through the abdominal wall, about 
 2 inches to the right of the middle line, from just below the ribs to the 
 level of the umbilicus. All bleeding being carefully stopped, the peri- 
 toneum was picked up and slit open. The liver, recognizable by its 
 characteristic color, was at once seen moving with respiration. To 
 make certain of the position of the fluid a fine trocar was now thrust 
 in, one or two carbolized sponges being first inserted. In one case, 
 which was crammed with scolices, very little fluid escaped, in the other, 
 an acephalocyst, the fluid spirted out under the high pressure not un- 
 frequently met with. After 8 ozs. had been withdrawn, any leaking was 
 stopped by sponge-pressure, the parietal peritoneum was stitched to 
 the edges of the wound by a few points of chromic gut suture, the 
 sponges removed, and dry gauze dressings firmly bandaged on with a 
 good deal of pressure so as to keep the abdominal wall as far as pos- 
 
 45 
 
706 OPERATIONS ON THE ABDOMEN. 
 
 sible in contact with the liver* On the third day the operation was 
 completed by incising the liver, now well adherent, and inserting a 
 large drainage-tube. Both cases did well, though very slowly. One, 
 a woman, three months pregnant at the time of the operation, went 
 her full time subsequently. 
 
 C. Electrolysis.— This mode of treatment was used by Dr. Fagge 
 and Mr. Durham in eight cases, and the results brought before the 
 Medico-Chirurgical Society. f The modm operandi here is uncertain, as 
 in puncture, but it seems probable that neither the electrolytic action 
 nor the leakage of fluid into the peritoneal cavity, but the puncture 
 alone of the needle is the essential element.^ This being so, and the 
 method requiring special instruments, it has, I believe, fallen into 
 abeyance. In one case, a patient of Dr. Moxon's, I made use of this 
 method after previous tapping had failed. The steps taken by Dr. 
 Fagge and Mr. Durham were carefully followed. Two electrolytic 
 needles were passed into the most prominent part of the swelling, 
 about 2 inches apart, and were then attached to wires both connected 
 with the negative pole of a galvanic battery of ten cells. A moistened 
 sponge connected with the positive pole was placed on the skin at a 
 little distance. The current was passed for half an hour. The punc- 
 tures were then closed with a pad of gauze. Indistinct fluctuation 
 could be made out in the flanks during the next forty-eight hours. 
 There was no constitutional disturbance, the tumor steadily diminished 
 in size, and a good recovery took place. 
 
 HEPATIC ABSCESS.— HEPATOTOMY.g 
 
 As tapping by a trocar, and draining the abscess by the cannula 
 left in, or a drainage-tube passed through the cannula, this being then 
 withdrawn, is unsatisfactory,] | and as the use of the aspirator here is 
 
 * One case bulged out the right lower ribs most markedly. For reasons already 
 given, I preferred to attack it in the front of the right hypochondrinm. On exposing the 
 liver, a hydrocele trocar passed through IJ inch of hepatic tissue before fluid was 
 reached. Very little hsemorrhage followed the completion of the second stage of the 
 operation. 
 
 f Trans,, vol. liv, p. 1. 
 
 X Thus, in a case of Dr. Playfair's, related in the appendix to Dr. Fagge's paper, 
 progressive diminution, almost identical to that noticed after electrolysis, followed 
 acupuncture only. 
 
 I This term is also applicable to incisions of the liver for hydatids. 
 
 I! Thus (1) the cannula and tube may slip out. (21 The drainage is inefficient. 
 (3) If the pus leaks into the peritoneal cavity, it does so unseen. (4) The trocar may 
 puncture important parts. Thus, in one case of Mr. K. Tiiornton's (Med. Times and 
 Oaz., 1883, vol i p. 89), the omentum, containing large veins, lay over the liver. (5) 
 Puncture and drainage would be quite insufficient in cases where more than one 
 abscess existed. 
 
HEPATIC ABSCESS. 707 
 
 mainly exploratory and palliative, it is to a free incision that we must 
 look for a permanent cure. This may be employed in three ways— 
 
 1. Direct incision and drainage, when tenderness, u'dema, and 
 redness make it probable that adhesions exist. This needs no further 
 comment. 
 
 2. Incision and drainage by abdominal section, in two sta.^cs. 
 
 3. Incision and drainage l)y abdominal section, at one sitting. 
 
 The methods of treating an hepatic abscess by abdominal section, 
 whether in one or two stages, have already been spoken of at p. 704, 
 under the heading of Hydatids. They have the following advantages 
 over other modes of treatment: («) The benefit of a free incision and 
 thorough drainage ; (6) the surgeon can see what structures he is deal- 
 ing with (see last foot-note on p. 706) ; (c) bleeding from the liver can 
 be seen and arrested ; (rf; if pus escapes into the peritoneal cavity this 
 can be cleansed. 
 
 Very little need be said here of the treatment by abdominal section 
 in addition to that already written at p. 704. In the two-stage method 
 the surgeon will open the peritoneal cavity, suture the parietal jaeri- 
 toneum to the edges of the wound, insert some gauze, and endeavor, 
 by well-adjusted bandaging, to keep the al>dominal parietes in contact 
 with the liver, opening the abscess on or after the third daj'. 
 
 In the method by direct incision, a free incision of 4 or 5 inches is 
 made, and the position of the pus being verified by a fine trocar or 
 aspirator-needle, some soft carbolized sponges (previously counted) 
 are carefully packed around. The abscess is then incised, and the 
 opening at once jjlugged, and freely dilated with the finger. Any 
 escape of pus into the peritoneal cavity is prevented (1) by the careful 
 sponge-packing ; ('2) l^_y the finger hooking up the liver against the 
 wound ; (3) by an assistant keeping steadilj- the parietes against the 
 liver ; (4) by seizing the edges of the liver with catch-forcejjs and so 
 keeping them against the parietes. Haamorrhage is prevented by the 
 above forceps or sponge-pressure. When the abscess is empty,* its 
 opening is plugged with a sponge, and the liver and the parietes being 
 still kept accurately together, the sponges first inserted are removed,! 
 and the edges of the liver wound stitched with carbolized silk passed 
 with curved needles on a holder, to the edges of the abdominal inci- 
 
 * Mr. Greig Smith (Abdom. Surg., p. 527) advises that, if the abscess does not 
 empty itself readily, a large tube lying in carbolic lotion may be pinched at the end, 
 and when placed at the bottom of the abscess will act as a siphon. He also draws 
 attention to the need of exploring the abscess cavity for signs of a second abscess, and, 
 if this be fonnd, opening it with the finger or dressing-fcjrceps. All manipulations 
 now must be of the gentlest for fear of haemorrhage. 
 
 f If any pus or blood has escaped into the peritoneal cavity this must be now 
 cleansed. 
 
708 OPERATIONS ON THE ABDOMEN, 
 
 sion, care being taken to keep peritoneal surfaces well in contact. If 
 the pus is fetid, the abscess cavity should be well irrigated with a 
 dilute antiseptic lotion. A considerable thickness of dry gauze dress- 
 ings will be needed at first, easily renewed by means of a many-tailed 
 bandage. 
 
 TAPPING AND INOISINO THE GALL-BLADDER.— OHO- 
 LEOYSTOTOMY.— REMOVAL OF BILIARY CALCULI. 
 
 Indications.— The justifiability of, and the indications for, the 
 above operations may be considered together, depending as they 
 usually do upon the presence and effects of biliary calculi. 
 
 1. Gall-stones.* When previous treatment has failed to relieve the 
 patient from repeated crippling attacks of biliary colic and jaundice 
 when the hepatic or common duct is blocked. 
 
 2. Dropsy and empyema of the gall-bladder.f This is usually due 
 to impaction of calculi, the bile gradually losing its coloring matter 
 and becoming more and more mucoid and watery, and the increased 
 tension gradually causing suppuration. 
 
 3. Obstruction in the common duct. The most likely cause of this 
 for the surgeon to deal with is a calculus. Very grave results, if this 
 block be unrelieved, are, jaundice and cholsemia (vide infra). 
 
 4. Certain cases of injury to the gall-bladder. Such are, wounds, 
 rupture, if any coexisting lesion is not going to be fatal, and bursting 
 of an empyema of the gall-bladder. 
 
 The following indications for operation are given by Mr. Greig 
 Smith 4 
 
 * Mr. Tail (Lancet, 1885, vol. ii. pp. 239, 424) divides, for practical purposes, gall- 
 stones into two classes — (1) the solitary; (2) the numerous. The former are seldom 
 more than two or thrge in number, and often of considerable size. They are liable to 
 be caught in the cystic duct, to give symptoms of bloclcing it, together with distension 
 of the gall-bladder, but no jaundice, as the bile, prevented from entering the gall- 
 bladder, flows constantly into the duodenum, The gall-bladder is easily opened, but 
 the removal of the calculus from the duct may be very difficult. In the second class 
 several hundreds of calculi may be present. As these from their size usually admit 
 of a flow of bile past them, jaundice is seldom seen, and the distension of the gall- 
 bladder is intermittent. The operation here differs considerably. As the gall-bladder 
 is not distended, the diagno.sis is more uncertain, and, wlien the abdomen is opened, 
 the gall-bladder is less easily found. Care must be taken that no stones are left 
 behind. 
 
 f As the diagnosis of gall-bladder swelling is not always easy, it will be well to 
 remember the direction in which the gall-bladder enlarges. According to Mr. Taylor 
 [Brit. Med. Journ , 188-5, vol. i. p. 737), this is in a line drawn from the tip of theright 
 tenth cartilage to the opposite side of the abdomen, crossing the middle line just below 
 the umbilicus. 
 
 J Abdominal Surgery, p. 541. 
 
OPERATIONS ON GALL-BLADDER AND BILE DUCTS. 709 
 
 " In every case of wound or perforation of the gall-bladder operation 
 ought at once to be performed. Operation gives the only chance of 
 recovery. In every case of empyema of the gall-bladder operation is 
 indicated. Aspiration is only a temporary measure, and it is by no 
 means free from danger. 
 
 " In every case of dropsy of the gall-bladder, operation is indicated. 
 Aspiration may do no harm, and it may detect the presence of stone. 
 But it is useless towards the removal of stone, and, generally, it has 
 no beneficial effect on the disease. 
 
 " In cases of cholelithiasis, the indications to operate must Ije guided 
 by the effects produced by the disease. The dangeious sequences of 
 gall-stones are frequently recurring attacks of hepatic colic, which 
 wear out the patient's strength ; jaundice, proceeding to dangerous 
 cholajmia, and suppuration in the gall-bladder. The indication in 
 each instance is strengthened by the presence of an enlarged gall- 
 bladder. 
 
 " No general rule can be laid down as to the weight of the indication 
 arising from hepatic colic. After months or years of intense suffering, 
 many patients get well, and remain so. On the other hand, a patient's 
 life may be rendered miserable, or .his active existence as a bread- 
 winner may be cut short, by persistently recurring attacks of hepatic 
 colic. A time then comes when patient and surgeon both agree that 
 it is proper to interfere. In all such cases the patient's desires must 
 have great influence with the surgeon. 
 
 " In cases of persistent obstructive jaundice, operation is, at the same 
 time, indicated and contra-indicated. Cholsemia, not only as weaken- 
 ing and depressing the patient, but also as predisposing to bleeding,* 
 is an unfavorable element. In only seven of Musser and Keen's 
 thirty-five cases of cholecystotomy was jaundicef present, and five of 
 these died — half of the whole mortality. That the jaundice had much 
 to do with this excessive death-rate there can be no dispute. This 
 suggests early operation, before the patient's condition is lowered by 
 cholsemia. 
 
 " Where evidences of suppuration appear in cholelithiasis, operation 
 is to be urged. Every daj' that passes brings increase of danger. 
 
 * Dr Musser and Dr. Keen (Amer. Journ. Med. Sci., October, 1884) state that wliere 
 long-continued jaundice ha* disorganized the blood there is a marked haemorrhagic 
 tendency. 
 
 t Mr. Tait {loc. supra cit.), having met with no history of jaundice in fifteen cases of 
 cholecystotomy, thus explains its absence. The common duct is not so long as the 
 books say (viz., 3 inches), and it is more easily dilated than the cystic, A stone passing 
 through the unyielding cystic duct causes great agony, but no jaundice. As soon as 
 it enters the common duct, the whole excreting force of the liver comes into play, so 
 that its passage is more rapid and gives no time for jaundice, which only occurs with 
 long obstruction of the common duct. 
 
710 OPERATIONS ON THE ABDOMEN. 
 
 " In cases of obstruction of the common or the hepatic duct, chole- 
 cystotomy may simply prevent death by permitting escape of the 
 biliary poison* Patients can live without escape of bile into the 
 intestines. But Tait has shown us how a stone in the common duct 
 can be crushed, so that even in these cases cure may be effected. 
 
 " In cases of obstruction of the cystic duct, operation in the majority 
 of cases will not only relieve pain, remove danger of suppuration in 
 the gall-bladder, but will also, in all probability, bring about complete 
 
 cure." 
 
 Operations.— Tapping and incising the gall-bladder, and removal 
 of calculi may be considered together. It may be stated at once that 
 aspiration by itself should not be practiced. It is attended with much 
 danger,t and the information given in doubtful cases can be more 
 safely given by a small exploratory abdominal incision. 
 
 The operation of cholecystotomy is usually performed in one stage. 
 The abdomen having been cleansed (p. 581), the parts relaxed, one of 
 the following incisions is made use of The l>est one is a vertical one, 
 o to 4 inches long, either over the fundus if the tumor is prominent, 
 or straight down from the tip of the cartilage of the tenth rib, or one 
 in the right linea semilunaris ; finally, in the case of those large and 
 doubtful swellings, due to distended gall-bladder, the incision should 
 be made in the linea alba. The peritoneum lieing reached, any vessels 
 which have been closed with Spencer Wells' forceps are secured with 
 chromic gut. The peritoneum is then picked up and opened, and an 
 index finger introduced to feel for the gall-bladder, to which calculi 
 are often a guide. If there is difficulty in this stage, the liver edge 
 should be used as a guide.J Some trouble may be given now by the 
 
 * As in cases where the mischiel is not due to impacted calculi, but to atresia, etc., 
 after ulceration. 
 
 t Thus in two cases (quoted by Mr. Greig Smith), in one of which Dr. Harley 
 explored with a fine aspirator-needle, after a short interval, the patient died with 
 ertteritis and peritonitis. In a case of Dr. Keen's not a little iiseinorrhage and con- 
 siderable local peritonitis followed tlie nse of a hypodermic syringe. Furthermore, 
 the utility of this step is doubtful, for the point of the needle may easily miss the stone. 
 Mr. Greig Smith condemns this step, and Mr. Meredith (Did. of Sarg., vol. i. p. 284) 
 considers it " not altogether devoid of risk." On the other hand, Mr. Morris seems to 
 consider it safe, and quotes a case of Dr. Dixon's {Pract., April, 1&76), in which the 
 gall-bladder was tapped five times with great relief in a case of obstruction of the 
 common duct with cancer, a total of87^ ozs. being withdrawn with the aspirator. 
 
 I In one case of Dr. Parkes's { Trans. Avier Surg. Assoc., vol. iv. p. 2S)9), in which 
 there had been a two-years' history of biliary colic, " the most careful and diligent 
 search failed to find the gall-bladder, the proper location of which was plainly outlined 
 and felt with the finger, with reference to the transverse fissure and ligament, showing 
 the entire absence of the gall cyst; but close to, and partly encroaching upon, the 
 transverse fissure was found an elevated, resisting tumor, the exact nature of which 
 cq,uld not be determined, but probably containing biliary concretions." It was 
 
CHOLECYSTOTOMY. 7 1 X 
 
 intestines concealing the gall-bladder, or by the hver, if enlarged, de- 
 scending with respiration and requiring to be pushed up. The 
 intestines must be kept out of the way by the use of carboHzed sponges 
 or a towel (p. 655). When the gall-bladder is found, the next thing 
 is to bring it into the wound.* If this can be effected, any fluid con- 
 tents are withdrawn with the aspirator to diminish the size of the 
 swelling. The puncture being enlarged,t a finger is inserted to feel 
 for calculi. Any that are well in reach are removed by small scoops 
 or forceps,t while escape of any fluids into the peritoneal cavity is 
 prevented by the careful packing of carboUzed sponges or towels, and 
 by an assistant keeping the edges of the wound in the abdomen and 
 gall-bladder carefully together. Before extraction of any difficult 
 calculi is attempted, the edges of the gall-bladder should be sutured 
 to those of the abdominal wound with a continuous suture of car- 
 bolized silk, or with separate ones at short intervals, and intervening 
 ones of horsehair or fishing gut. The parietal peritoneum must be 
 carefully taken up, and the sutures passed at a sufficient distance from 
 the edges of the gall-bladder and the incision in the abdominal wall 
 to ensure a good hold. The sutures should pass through any bleeding 
 points in the cut gall-bladder, and, as the stitches are inserted, the 
 sponges are withdrawn. A drainage-tube is then inserted and the 
 dressings applied. These may require frequent changing at first. 
 
 Some surgeons have preferred to open the gall-bladder by two 
 stages, exposing it first and suturing it carefully to the edges of the 
 wound, closing the angles of this exactly, and opening the gall-bladder 
 a few days later. 
 
 A few points still require attention. The difficulty of finding the 
 gall-bladder and of getting it up into the wound has been already re- 
 ferred to. In one case, in which Dr. Parkes (loc. supra cit.) met with 
 this latter difficulty, owing to the thickening and matting of the gall- 
 bladder, he detached some of its adhesions to the liver and passed a 
 silk suture through opposite sides of the thickened fundus, as far from 
 each other as possible. The gall-bladder was then opened by cutting 
 between the sutures, and forty-three stones removed. The opening 
 in the gall-bladder was then closed, leaving an orifice at the tip to in- 
 
 too near the large bloodvessels to admit (jf any interference with it. Post-mortem 
 examination revealed remains of the shrunken gall-bladder, but with no sign of bile in 
 it. A gallstone lay at the junction of the hepatic and common dncts. 
 
 * Mr. Tait draws up the fundus of the bladder into the wound cautiously with a pair 
 of forceps. Great care must be taken not to rupture a bladder much distended, or to 
 cause sloughing. 
 
 t The escape of bile into the peritoneal cavity io prevented by packing sponges 
 (previously counted, around the gall-bladder, and holding one under it in clamp- 
 forceps. 
 
 J Several special forms have been invented by Mr. Tait. 
 
712 OPERATIONS ON THE ABDOMEN. 
 
 sert a large drainage-tube, some of the highest sutures being passed 
 through the abdominal wall. 
 
 Extraction of all the calculi is often most difficult, especially of any 
 very far down in the cystic duct, or of such a one as Mr. Tait thus 
 describes (Lancet, August 29, 1885). The stone was probably pear- 
 shaped, and impacted at the orifice of the duct. " From the loag, 
 narrow, funnel-like cavity in which it was lodged, and from the 
 mobility of the bladder, it was very difficult to seize, and, when at last 
 I did get hold of it, I found it adherent to the mucous surface. I had 
 then to consider the extreme hkelihood that in removing this impacted 
 stone I might tear the walls to which it was attached, and thus cer- 
 tainly kill my patient. I therefore performed a very careful and pro- 
 tracted lithotrity, chipping little fragments off the stone regularly all 
 over its exposed surface, till I had the satisfaction of lifting out its 
 nucleus. I then passed the blade of a fine pair of forceps on each side 
 of it, and by a gentle squeeze broke up the remainder." Frequent 
 washings out were then employed. While forceps are thus used, one 
 forefinger is placed over the stone to guard the parts from undue vio- 
 lence, and to dislodge any fragments. 
 
 In another case of a stone which he could neither extract with for- 
 ceps nor dislodge, the same surgeon very ingeniously crushed the stone 
 in situ by means of carefully padded forceps applied outside the duct 
 walls, and then dislodged the fragments by finger-pressure. 
 
 The resulting biliary fistula will probably close in a few weeks if 
 the ducts are now pervious.* Through it further attempts may be 
 made to get rid of any remaining calculi. t If the wound, after closing, 
 breaks open and discharges mucus, a stone is probably left behind in 
 the gall-bladder. 
 
 While primary closure of the gall-bladder has been successful in a 
 few cases, it is not so safe a method, and involves the risk of leaving 
 one or more stones behind. 
 
 Difficulties of the Operation. 
 
 1. In this class of patients the anaesthetic may be taken badlj-. 
 
 2. A very large amount of fat, and thus a very deep wound. 
 
 3. Crowding up of the intestines. 
 
 4. The gall-bladder may be much thickened and tied down, thus 
 difficult to find and impossible to bring up into the wound. 
 
 * Dr. Parkes {Amer. Journ. Med. Sci , July, ISS'i), in one case, in which a month 
 after the cholecystotomy there was no evidence of bile entering the intestine, manipu- 
 lated a steel sound (No. 11), guided by a finger in the peritoneal cavity, through the 
 common duct, into the intestine. 
 
 t Mr. G. Smith (loc. supra cii., p. 549) remarks that, if the gall-bladder is adherent 
 to the abdominal walls, any stones which may subsequently form can be safely removed 
 through the old scar. 
 
OVARIOTOMY. 713 
 
 6. The gall-bladder may be much shrunken, a smooth hard tumor 
 being all that is felt in its situation.=i= 
 
 6. A stone may be impacted very far back. 
 
 7. An enormous number of small stones. 
 
 CHOLECYSTECTOMY. 
 
 Extirpation of the gall-bladder was performed in five cases by 
 Langenbeck, four being successful, and one fatal from ulceration of 
 the bile duct brought about by an undetected calculus. Mr. Greig 
 Smith thus writes of the operation: "The indications given by 
 Langenbeck are dropsy, cholelithiasis, and empyema. These indica- 
 tions are probably too broad. I should hmit the indications to two— (1) 
 where the bladder, containing one or more calculi, is so contracted 
 that its fundus cannot be sutured to the parietes without tearing its 
 walls; (2) where there has been perforation after ulceration and em- 
 pyema, and the tissues are so thin or so much inflamed that they will 
 not bear suturing. The operation need not be difficult. Separation 
 from the liver is begun at the fundus and carried down to the cystic 
 duct. This is divided between two ligatures, and the bladder removed. 
 A suture passing through the outer coats will more thoroughly close 
 the divided end of the duct. The incision will be at least 11 inch 
 longer than in cholecystotomy ; if additional room is wanted, Cour- 
 voisier's plan of dividing transversely the muscles a little below the 
 ribs may be adopted. If the bladder is intimately attached to the 
 liver, a good deal of heemorrhage may be expected ; most of the 
 bleeding may be checked by forcipressure, but a few ligatures may be 
 called for. During the operation, the edge of the liver is pulled up- 
 wards by a retractor, and the area of operation is isolated by means 
 of sponges." 
 
 CHAPTER X. 
 
 OPERATIONS ON THE OVARY. 
 
 OVARIOTOMY.— REMOVAL OF THE UTERINE APPEN- 
 DAGES. 
 
 OVARIOTOMY. 
 
 One or two practical points will be alluded to before the opera- 
 tion itself is described. 
 
 * In one case, piibli.slied by Dr. Keen (PhiJad. Med. Times, jSTovember 14, 1885; 
 Ann. of Surg., January, 1886), the gall-bladder being displaced, the dnodenum was 
 opened by mi.stake, and sutured. The gall-bladder was finally found far posterior to 
 its proper site, much shrunken, and closely contracted over two gall-stones. The patient 
 died, fifteen hours after the removal of these, from shock and a small amount of after- 
 hsemorrhage, presumably from vessels injured in lifting to the surface the mass in 
 which the stones were situated. 
 
714 OPERATIONS ON THE ABDOMEN. 
 
 Question of Adhesions— It there is free mobility of the cyst from side 
 to side, there are no parietal adhesions. In testing this, both hands 
 should be employed. Does the tumor descend with a deep inspira- 
 tion ? Here a good light and careful percussion are needed. These 
 movements are seen best when the surface of the cyst is uneven. 
 Presence of intestine in front of the cyst can be made out by careful 
 palpation and percussion. The history of pain (pointing to attacks 
 of local peritonitis) and any previous tappings, together with the size 
 and duration of the tumor, will also help in deciding as to adhesions. 
 But it is often impossible, before the abdomen is opened, to say 
 whether the operation will be easy or no. 
 
 Date of Operation.— li the patient defers this, she should be warned 
 of the importance of an early one. The certainty of increasing ad- 
 hesions and difficulty, the greater annoyance of the tumor (especially 
 in unmarried women), the attacks of peritonitis with their pain, the 
 risk of twisted pedicle and its results, must all be remembered. The 
 patient must decide between living a year or two with the above risks 
 before her and the growing misery of the tumor, and submitting to 
 an operation the risks of which are but small, nowadays, in an 
 average case whicli is taken early. 
 
 The condition of the viscera, kidneys, lungs, etc., the habits of the pa- 
 tient, her amenability, her digestive powers, must all be considered. 
 
 The amount of sJdll of the surgeon, though a delicate matter, must not 
 be left without mention. No one should operate on these cases who 
 has not had good opportunities of seeing otliers operate frequently, 
 and no one should undertake a case whose ovariotomies are, at the 
 most, likely to bo but two or three in liis lifetime. 
 
 Preparation of the Patient. — For a week before, the jjatient 
 should be kept quiet, have a gentle aperient every other night, and a 
 bath once in the twenty four hours. The solids of the diet should be 
 somewhat restricted, and all the food taken easih' digested and 
 nutritious. Sufficient fluids should lie given to ensure a healthy 
 clearing out of the kidneys, a little sound spirit, well diluted, being 
 as suitable as any stimulant. If needful, one of the salts of lithia 
 may be given three times a day. On the morning of the operation 
 an enema should be given, a light breakfast taken earlj^ and some 
 good beef-tea or soup about 11 if the operation takes place about 2 
 P.M. When the patient, warmly clad, especially as to her extremities, 
 comes in to take the ana-sthetic, only two or three faces that are 
 familiar to her should be present. It is best to begin with chloro- 
 form, but ether should always be at hand to go on with, save in those 
 cases where the condition of the lungs is against this course. When 
 the patient is under the anaesthetic, a catheter should always be 
 passed, but not by the operator or any of his immediate assistants. 
 
OVARIOTOMY. 7] 5 
 
 Preparation of Instruments, etc.— The room, which has been 
 thoroughly cleansed and not rendered too comfortless for the sake of 
 ventilation, etc., should have a temperature of about 65°. A good 
 light, and one likely to last, should be secured. The table should be 
 sufficiently high to save the operator stooping, and only just wide 
 enough to hold the patient comfortably. A dozen new Turkey 
 sponges, chosen for their even softness of texture, should be thus pre- 
 pared:* All the sand is got out of them by beating them over a 
 sheet or a towel, a process which requires to he repeated again and 
 again by trusty hands. When they are really sandless, they should 
 be placed in carbolic acid solution (1 in 20, and to be kept renewed), 
 and in a solution of 1 in 40 for a few hours before the operation. 
 During this they should be cleansed in a solution of the same strength. 
 One or two fiat ones should be provided, not, as is often the case, too 
 large. A few small sponges fit for use on holders should be provided, 
 to leave no excuse for the dividing of sponges during the operation, a 
 course to be unhesitatingly condemned. The number of the sponges 
 should be accuratel}' known. 
 
 The following should be in readiness : Two scalpels ; blunt-pointed 
 bistoury; steel director ; Key's director; at least six pairs of Spencer 
 Wells' forceps ; omentum clamp-forceps ; cyst-forceps ; Spencer Wells' 
 vulsellum-trocarf and tubing ; blunt-pointed scissors ; needles, both 
 twelve straight, two being threaded on each suture of stout silk for 
 closing the abdominal wound, and fine ones, both straight and 
 curved, for underrunning any bleeding point or introducing fine 
 sutures if any of the contents of the abdomen are unavoidably in- 
 jured ; two aneurism-needles ; plenty of silk and chromic-gut ligatures 
 of varying sizes, and the material carefully prepared, including some 
 stout enough for the pedicle ; two pairs of dissecting-forceps ; a probe ; 
 dressing-forceps ; drainage-tubes, both glass and rubber ; Paquelin's 
 cautery ; some solid perchloride of iron ; abundance of carbolic and 
 boracic acid lotion ; a foot-pan to stand under the table ; another to 
 wash the sponges in ; a carbolic spray ; a larj'ngeal mirror. The in- 
 struments should stand, in two trays or pie-dishes, by the window close 
 to the operator's right hand; the ligatures and sutures should be in 
 separate porringers, all covered with carbolic acid (1 in 40). 
 
 In addition to the anassthetist, three assistants should be present — 
 one to tie off vessels, etc., as they are taken up, help with the tumor, 
 
 * Mr. Doran {Ann. of Surg., May, 1888), in a very practical paper on "The Details 
 of Ovariotomy," points out that, if the sponges are whitened as well as cleaned in a 
 solution of snlphnrous acid (1 in 5 of water), they will readily show any foreign 
 matter clinging to them. He advises that a sponge be kept in Douglas' poiicli during 
 the operation. 
 
 t One or two smaller trocars should also be in readiness. 
 
716 OPERATIONS ON THE ABDOMEN. 
 
 etc., another to keep the edges of the wound over the intestines if 
 needful, and a third to hand instruments. Two nurses should be at 
 hand to cleanse the sponges. Within reach of the operator should be 
 a porringer of carbohc acid (1 in 60) for him to dip his fingers in 
 occasionally. The abdomen of the patient should be shaved and 
 cleansed (p. 581) just before the operation; mackintoshes are care- 
 fully packed around so as to cover all save the field of the operation, 
 or the mackintosh with the oval opening bound with adhesive plaster 
 may be used.* 
 
 The Operation.— An incision,t reaching from just below the 
 umbilicus to within 2 inches of the pubes, is made in the linea albaj 
 rapidly down to the peritoneum. Before this is incised, Spencer 
 Wells' forceps are applied to every bleeding point, and tied off, if 
 needful,§ with fine chromic gut. The peritoneum, readily recognized, 
 when healthy, by its delicate fasciculation and translucency, is care- 
 fully hooked up so as to take up nothing else, and opened. Occa- 
 sionally large veins lie superficial to it, just in the operator's way. 
 •All bleeding must be arrested, especially at the lower angle of the 
 wound. The peritoneum is next slit up on two fingers, to the length 
 of the incision, and the pearly glistening cyst comes into view. The 
 above applies to an easy case without parietal adhesions. But if the 
 peritoneum is thickened and adherent to the cyst, there may be the 
 greatest diflEiculty in deciding when this is reached. The best way to 
 solve the doubt is to prolong the incision upwards to the left of the 
 umbilicus, till a spot free from adhesions is found. While the oper- 
 ator is in uncertainty, on no account are apparent adhesions to be 
 
 * The value of the spray is not finally settled. It renders the operation safer in 
 large hospitals, and it is said to make effusions more harmless, and thus to diminish 
 the need of drainage. On this point I have Btill grave doubts; the power of carbolic 
 acid to render discharges innocuous is, I tliink, more than counterbalanced in ab- 
 dominal surgery by its tendency to cause eflfusions of sero-sanguineous fluid during 
 the first few hours after an operation. Its use should be certainly combined with 
 extra carefulness in the " toilet." Finally, no amount of attention to antiseptic details 
 will replace personal experience, fertility in expedients, and resourcefulness in 
 meeting difficulties. 
 
 t This should be from 2 to 3 inches long at first. Mr. Doran {loc. supra cit.) thinks 
 a mistake is often made in not bringing the incision near enough to the pubes, which 
 may cause much trouble when the pedicle has to be drawn out, and greatly impede a 
 thorough exploration of the pelvis. With regard to wounding the bladder, the 
 operator should trust neither to the position of the lower end of the wound, nor even 
 to the catheter, but solely to the appearance of structures exposed. 
 
 X If the linea alba is missed and the rectus or pyramidalis cut into, the middle line 
 will be found by pushing a probe inwards under or through these muscles. 
 
 J Forcipressure should be trusted to as much as possible, the forceps being left on 
 for five or ten minutes. Many ligatures weaken the cicatrix, and may cause actual 
 suppuration. 
 
OVARIOTOMY, 717 
 
 separated, or the parietal peritoneum may be detached from the ab- 
 dominal wall. When the cyst is reached, it is examined with two or 
 three fingers, which will give some information as to visceral and 
 posterior adhesions. As soon as the cyst-surface is really made out 
 it is best to tap it. To separate the adhesions before tapping it is, in 
 Mr. Thornton's* words, "bad practice, because, if they are separated 
 while the parietes and cyst-wall are both stretched by the fluid, all 
 the little vessels in them bleed, and very serious hfemorrhage may 
 occur out of sight during the subsequent emptying of the cyst; 
 whereas, if the cyst be first tapped, the contraction of both parietes 
 and cyst-wall closes the smaller vessels." 
 
 The cyst is tappedf by carefully plunging in a Spencer Wells' trocar, 
 then guarding the point with the inner tube, and attaching the claws to 
 the cyst so as to keep this on the trocar as forward traction is made. 
 If it is clear from the bulk of the cyst remaining unaffected that it is 
 multilocularl or solid, the surgeon must reduce it before attempting 
 to extract it. If it be multilocular, it must be tapped again in two or 
 three more places, by removing the trocar, and closing the puncture 
 with cyst-forceps, and then, while the cyst is dragged forwards and 
 steadied, the first trocar or a smaller one is thrust in at other spots 
 where fluid is still present. This is better practice than thrusting the 
 trocar from the first puncture into other parts of the cyst in the dark. 
 If the bulk of the cyst be solid, the trocar puncture being enlarged, 
 and clamp-forceps firmly keeping forwards the edges, the surgeon first 
 introduces two or three, then perhaps all the fingers of one hand, and 
 scoops out the solid material till the bulk of the cyst is sufficiently 
 reduced to come through his incision. During the tapping one or tAvo 
 sponges must be kept under the trocar to prevent leakage into the 
 peritoneal cavity. 
 
 If the wound requires enlargement, this is best done with a blunt- 
 pointed, straight bistoury, and the use of two fingers as a director, the 
 incision being carried to the left of the umbilicus so as to avoid any 
 still open vessel in the round ligament. As the cyst comes forward 
 any adhesions must be dealt with. The commonest are to the 
 omentum, the small intestine, and transverse colon. The separation 
 must be effected, bit by bit, with the finger-nail or steel director, each 
 bleeding point being caught with jDressure-forceps and tied. Another 
 method is to underrun bleeding points, especially any obstinate ones 
 in the perietal peritoneum. Any persistent oozing may be touched 
 
 * Diet, of Surg., loc. infra cit. 
 
 f Great care must be taken to ensure all the fluid escaping well away from the 
 wound, and with sponges under the trocar, and by turning the patient on her aide, to 
 prevent any contamination of the peritoneal cavity. 
 
 X If the cyst is multilocular, the largest should be first chosen (Galabin). 
 
718 OPERATIONS ON THE ABDOMEN. 
 
 with Paquelin's cautery or the h-on perchloride. Mr. Thornton thus 
 advises the use of the Litter : " The surfaces to be touched should be 
 dried with a sponge; then a small sponge, well wrung, should be 
 smeared lightly with the solid perchloride, and firmly pressed against 
 the bleeding surface till the oozing stops ; a large flat sponge should 
 be spread under the surfaces thus treated, to prevent any of the acid 
 serum, which runs away immediately after the application of the 
 iron, getting on to the intestines. Oozing surfaces in the pelvis are 
 treated in the same way, the intestines being first drawn out of the way 
 and protected bj^ sponges." 
 
 While adhesions* are being dealt with, the sides of the wound must 
 be kept Avell approximated by an assistant, and a sponge placed in the 
 lower angle to prevent fluid entering here. As the cyst comes forward, 
 its posterior surface will either be free or attached to the small intestine. 
 In either case the projection of any coils must be prevented by the use 
 of a large flat sponge wrung out of carbolic acid (1 in 40), green pro- 
 tective, or a clean towel cut in two and soaked for half an hour in the 
 above solution of carbolic acid. 
 
 When the cyst has been sufficiently brought outside, the pedicle is 
 dealt with. The intra-peritoneal method is now almost universally 
 adopted. t 
 
 The centre of the pedicle being found by unfolding it, an aneurism- 
 
 * Sometimes these are so broad as to require separation bit by bit, and the applica- 
 tion of a pre.ssure-forceps to each bleeding point. 
 
 t Mr. K. Thornton (Diet, of Surg., vol. ii. p. 155) thns describes the method of 
 enucleation for cases with no pedicle: "Cases are n)et witli in which the liase of the 
 tumor is so situated between the layers of the broad ligament, or so pushes its way 
 under the peritoneal covering of the uterus, or of the pelvic floor, that cautery and 
 ligatures are alike inapplicable, or, at least, ligatures can only be applied after much 
 previous enucleation. When this is the case, an incision should be made through the 
 peritoneal capsule of the tumor, and careful enucleation practiced with the fingers. It 
 is well, if possible, so to direct this process as to isolate, at an early stage, the parts of 
 the broad ligament which would form the pedicle in an ordinary case, and then to 
 transfix and tie them in the usual way. After this, the chief blood-supply of the tumor 
 is under control, and the rest of the enucleation may be more rapidlv and boldly made. 
 Shreds of capsule which bleed should all be secured in pressure-forceps, and ligatured 
 with or without transfixion after the tumor is completely shelled out. Usually, the 
 capsule falls together and no ooziug occurs, but sometimes this is troublesome from n 
 large surface, and Paquelin's cautery or the solid perchloride of iron may be applied 
 
 [vide supra] In perftuuiiug these enucleations, the operator must always bear 
 
 in mind the fact that the capsule is often the pelvic parietal peritoneum, and that he 
 is consequently brought into dangerously close relations with bladder and ureters, 
 rectum and sigmoid flexure, or ca'cnm and appendix (the latter is very frequently ad- 
 herent in these cases), and, as it lilceds very much when torn, requires careful handling 
 and often repair with a fine neeille and silk. The large iliac vessels are also occasion- 
 ally incorporated with the capsule." 
 
OVARIOTOMY. 719 
 
 needle loaded with stout silk (No. 1) is made to perforate it here at a 
 spot devoid of vessels. The loop of silk being drawn through and the 
 needle withdrawn, the loop is cut, and the two ligatures tied firmly 
 round the two halves of the pedicle. To make the silk hold, it is well 
 to loop the ligatures round some blunt instruments, so as to tie them 
 with sufficient force. When they are both tied, one is cut short, while 
 the other is thrown round the Avhole pedicle and tied again. The cyst 
 is then cut away not more than i inch, and not less than i inch from 
 the hgatures. When this is done, the cut end is carefully examined, 
 and any point that oozes tied with fine silk or chromic gut. The 
 pedicle is then allowed to drop in, and the finger, following it down to 
 the uterus, finds and hooks up the other ovary. If this is found en- 
 larged, it must be removed. 
 
 The operator now scrutinizes the parts carefully, removes any jagged 
 omentum, arrests any still bleeding points, and removes any sponges 
 which he may have inserted, and has them all counted. 
 
 The next step is the so-called " toilet," to sponge out most thoroughly 
 the pelvis, the spaces in front of and behind the uterus, and those on 
 either side of the vertebral column. This is effected by introducing 
 again and again warm sponges, well wrung out, on clamp-forceps, 
 until they return dry and colorless. 
 
 A flat sponge being now introduced to catch any blood, the abdomi- 
 nal wound is closed hy means of sutures of stout silk with a needle 
 at either end. Each needle is passed from within outwards through 
 the peritoneum first, and then through the skin, at least 1 inch from 
 the edges of the wound.* The sutures are inserted about '. inch from 
 each other, and a few of horsehair may be put in quite superficially 
 as well. Before they are tightened, the flat sponge is withdrawn. 
 When they are all tied, a little iodoform is dusted on, the abdomen 
 cleansed, and dry-gauze dressings (sal alembroth or iodoform) applied. 
 
 The question of drainagef must depend mainly upon the complete- 
 ness of the " toilet " of the peritoneum, the probability of any sub- 
 sequent oozing, especially if deep in the pelvis, and the possibility of 
 any septic fluid having entered the peritoneal cavity. A Keith's glass 
 tube should be the one used, one end resting at the bottom of Douglas 
 pouch without pressing oil the rectum, the other passes through a thin 
 sheet of india-rubber, its neck being grijjped firmly by a button-hole 
 in this. Sponges changed frequently are placed over and around this 
 end of the tube. 
 
 * They should not be tied too tightly, else points of suppuration will result. 
 
 f Mr. Qreig Smith's words should be remembered: " The question of drainage is a 
 very difficult one to speak about in theory. In practice, a good rule to follow is — 
 ' When in doubt, drain.' " 
 
720 OPERATIONS ON THE ABDOMEN. 
 
 Accidents during Ovariotomy. 
 
 1. Fainting. This will be best met by preventive treatment. If it 
 occur during the operation, ether must be given, the head lowered and 
 kept warm, and subcutaneous injections of brandy given. 
 
 2. Vomiting. This chiefly harasses by straining the intestines out 
 of the abdomen. If prolonged, the operation must be completed as 
 soon as possible, an assistant keeping the abdominal walls pressed 
 against the viscera, or dragging the former forward after pulling them 
 between his finger and thumb. 
 
 3. Separation of the parietal peritoneum. This has already been 
 spoken of, p. 717. 
 
 4. Rupture of the cyst. This accident may be expected when the 
 walls are thin, rotten, or softened by recent peritonitis. In such cases 
 careful handling, keeping suspicious spots well out of the wound or 
 packed around with sponges, and additional care with the "toilet" if 
 any fluid has got into the peritoneal cavity, are indicated. 
 
 5. Injury to viscera. Of these the bladder, small intestine, rectum, 
 and ureter are most likely to suffer. In the case of the bladder, the 
 surgeon must decide, by the time of the injury and the amount of 
 damage, as to whether he will complete the operation after closing 
 the wound, or defer it. In the case of injury to the intestine the 
 directions given at pp. 665, 671 will be found useful. In the case of 
 the ureter, it will usually be wisest to ligature the lower end, if possible, 
 bring the upper out of the wound, and to perform neiDhrectomy 
 subsequently, as in Simon's case. 
 
 6. Leaving in instruments — e.g., sponge or forceps. The fact that 
 this accident has occurred with operators of the largest experience 
 should make all careful. It is best met bj' having a sufficient, definite 
 number to begin with, counting carefully afterwards, and allowing no 
 tearing of sponges. 
 
 After-treatment. — I have no sjDace for going carefully into de- 
 tails, but I should like to take this opportunity of saying that, critical 
 as the first forty-eight hours undoubtedly are, I believe there is often 
 needless enforcing of rules. Less should be done in the way of fre- 
 quent catheterism,* the amount of urine being now small, and less 
 routine in the matter of morphia if the patient is not restless or wake- 
 ful, and less rigor in enforcing a dorsal position. During the above 
 time little should be given by the mouth save cracked ice, and occa- 
 sional teaspoonfuls of barley-water, or Valentine's meat-juice, with a 
 few drops of lirandy if required. Mr. K. Thornton advises the fol- 
 
 * On the whole I prefer a metal catheter with a single large eye. This can be kept 
 in dilute carbolic acid, and, being shorter than a gum-elastic, there is less danger of its 
 being pressed too far and thus causing irritation and most vexatious cystitis. 
 
REMOVAL OF THE UTERINE APPENDAGES. 721 
 
 lowing enemata: About six hours after tlie operation, or sooner if tlie 
 patient Le very weak, 3 ozs. of strong beef-t«a, just warm, and witliout 
 salt, are injected into the rectum. This is to be repeated cverj' tlirce hours 
 (every two if the patient is very wealv), and every six hours twenty 
 drops of laudanum are added. Before each injection, the female pipe 
 of a Higgenson's syringe is placed in the rectum, with the bottom of 
 an ordinary soap-dish under it, so that the flatus and refuse may pass 
 away; it remains in ten minutes, and then the fresh injection is given. 
 The chief questions that arise are, how best to act in threatening or 
 actual peritonitis. \Miere only flatulence and some distension are 
 present, they may yield to the passage of a long rectal tu1)e, and the 
 injection of a pint of water, with or without turpentine. These fail- 
 ing, relief may still be given by the passage of a stomach-tube; and, 
 if the vomiting and tympanites continue, o]3ening the wound below 
 and irrigation of the peritoneal cavitj' with 2 per cent, of warm boracic 
 acid lotion should be tried. 
 
 REMOVAL OF THE UTERINE APPENDAGES. 
 
 * 
 
 Indications. — Before giving these, I would state that there is no 
 operation in which it is more necessary to consider each case on its 
 own bearings, to explain the object and results with honorable care- 
 fulness to the friends and, whenever possible, to the patient herself, 
 and to remember that this is above all one of those operations which 
 should never be entertained if there are any honest doubts as to the 
 patient's health being really impaired beyond the aid of other treat- 
 ment, and the impossibility of otherwise restoring her to usefulness in 
 the position in life in which she has been placed. 
 
 The following classification of jjossible indications for the operation 
 (always subject to the above remarks) I have taken from Mr. Greig 
 Smith.f His detailed consideration of each of them will well repay 
 study. 
 
 "A. The Appendages. 
 
 " (1) The ovaries : 
 
 (a) Inflammation— acute, chronic, and suppurative (abscess). 
 (6) Displacement (prolapse, hernia), 
 (c) Cirrhotic and cystic ovaries. 
 
 " (2) The Fallopian tubes : 
 
 (a) Inflammation ; salpingitis. 
 
 (b) Pyo-salpinx. 
 
 (c) Hsemato-salpinx. 
 
 * This term ha-i been used here for convenience' sake, as more comprehensive than 
 "oopliorectomy," etc. Moreover, it is as yet not certain whether removal of the 
 ovaries withont the Fallopian tnbe will be sufficient to arrest menstruation. 
 
 f Loc supra cit., p. 1 52 . 
 
 46 
 
722 OPERATIONS ON THE ABDOMEN. 
 
 (d) Hydro-salpinx. 
 
 (e) Fallopian pregnancy. 
 " B. The Uterus. 
 
 (a) Uterine myoma.* 
 
 {b) Errors of development — absence or mal-development of uterus 
 with menstrual raolimen. 
 
 (c) Incurable displacements with severe nerve symptoms. 
 
 (d) Insuperable obytruction to menstrual flow (may reside in 
 
 vagina). 
 
 "C. The Nervous System. 
 
 (a) Mania, puerperal mania, menstro-mania, nympho-mania, etc. 
 (6) Epilepsy, hystero-epilepsy, convulsions, cramps, dancing fits, 
 
 etc. 
 (c) Hysteria.f 
 
 Operation. — It will be more useful to my readers if I quote here 
 from one who has had more experience of this operation than myself.^ 
 
 "When the Afpendages are Avatoinicnlly NarmnI, or nearly so. — The 
 incision, made in the ordinary median position, need not be longer 
 than 13 or 2 inches — enough to admit two fingers easily. As the pari- 
 etes are not thinned and distended by a tuirior, the linea alba is very 
 narrow, and it is not often that it can be divided without exposing 
 one or both recti. A small opening is made in the fascia ; if it is in the 
 linea alba, well and good ; if not,§ the layers are pushed to one side or 
 the other, and, when the situation of the fibrous septum is found, the 
 fascia is slit up to the length of the wound by the jjoint of the knife 
 cutting forwards. The muscular fibres are pushed to one side with 
 the handle of the scalpel, and the sub-peritoneal fat exposed. This 
 is caught upon two catch-forceps, and carefully divided between them. 
 .... The peritoneum is easily recognized ; a small opening is made 
 in it while it is thus everted ; the finger, inserted into this opening, 
 acts as a director upon which the division is completed, preferably by 
 scissors. By this method, which is Tait's, there is no danger of wound- 
 ing the bowels ; as each fold of tissue is pulled up and made tense, it 
 is cut on its folded edge by the knife held horizontally ; and when the 
 
 * " Those varieties of fibroids which are liable to continue growing after the meno- 
 pause — that is to say, soft, non-enc:ipsi]led fibroids, and fibro-cystic tnmors — are likely 
 also to be unaffected by oopliorectomy " (Galabin, Dis of Women, p. 24-1). 
 
 f Many will demur to some of the indications given under this heading. With 
 regard to " piierfjeral mania," Mr. Greig Smith thiiilcs that the operation is "espe- 
 cially indicated if the disease has occurred after a second confinement." With regard 
 to " hysteria," even if associated with "dancing fits," all will agree with him that 
 "the attacks would have to be very troublesome indeed, and the ca.se would have to be 
 surroimded with every conceivable inducement to operate, before interference could 
 be contemplated." 
 
 X Greig Smith, he. supra eit., p. 166. J P. 716. 
 
REMOVAL OF THE UTERINE APPENDAGES. 723 
 
 very smallest opening has been made in the peritoneum the air rushes 
 in, and the bqwels, if they have been dragged forward by suction, fall 
 back at once 
 
 " The two first fingers are now inserted into the wound. If omen- 
 tum covers the bowels, it must be dragged upwards ; if not, the fingers 
 are pushed straight down to the fundus uteri. The fingers, one on 
 each side of the broad ligament, and grasping it between them, are 
 now carried outwards till the ovary is felt; it is then lifted out of the 
 wound with its mesovarium and oviduct. Still held in this position 
 with the left hand, the Fallopian tube is pulled out as far as it will 
 readily come, and the pedicle spread out for ligature. The parts to 
 be removed are the ovar}' with its mesovarium, and the Fallopian 
 tube in its outer three-fourths, with the double peritoneal fold in 
 which it lies, and which contains also the parovarium and the vascular 
 erectile tissue known as the bulb of the ovary. The ligature is placed 
 double by transfixing with a blunt needle. The inner pedicle con- 
 tains the utero-ovarian ligament, the Fallopian tube somewhere near 
 its isthmus, the spermatic artery and veins, and the small branch 
 which accompanies the Fallopian tube. The outer ligature lies at the 
 retiring angle where the infundibulo-pelvic and infundibulo-ovarian 
 ligaments meet, takes its half of the mesovarium, and also constricts 
 the spermatic artery. In most cases, no method of ligature is, in my 
 
 opinion, superior to Tait's Staffordshire knot The parts are 
 
 then cut away by successive snips of scissors at a distance of about i 
 inch from the ligature. Before making the last cut the surface must 
 be carefully inspected to see that there is no bleeding. The pedicle is 
 
 then dropped in The same proceeding is then carried out with 
 
 the appendages on the opposite side. 
 
 "A small, thin, flat sponge is placed over the bowels under the 
 incision, and the sutures, four or five in numljer, are introduced. 
 
 ^'When the xlppendages are Inflamed and Adherent. — The previous 
 
 operation is a very simple one But it is a very different thing 
 
 if the appendages are adherent or inflamed, or suppurating or matted 
 together, as in inflammatory diseases. Then the operation may be 
 one of the most difficult in surgery. Even in the hands of surgeons 
 of the highest skill, it has not infrequently been abandoned as im- 
 practicable. The first difficulty met with is, probably, that the 
 appendages are fixed and cannot be drawn to the surface. They may 
 be represented by an irregular conglomeration of cystic and cicatricial 
 material, and sessile on the broad ligament or in Douglas.'s pouch, and 
 perhaps intimately adherent to bowels. They are beyond the reach 
 of sight, however much the abdominal walls are depressed. To deal 
 with such a state of affairs one of two courses is open. The first is to 
 enlarge the incision to 3 or 4 inches ; to pull the bowels out of the 
 
724 OPERATIONS ON THE ABDOMEN. 
 
 pelvis, and keep them in the abdomen by one or more sponges packed 
 under them; to pull the parietes apart by spatula, and seek by a 
 strong light to expose the parts to view, and operate by the aid of 
 light. This may be safe, but it is clumsy and difficult. If the pari- 
 etes are muscular and firm, considerable force may be required to 
 crowd the bowels into the abdomen, and to keep them there is still 
 
 more difficult The other course is that followed bj^ Tait, as a 
 
 result of his unrivalled experience. Tait has come to the conclusion 
 that it is best to depend entirely on the fingers to deal with such a 
 condition, relying on the skilled sense of touch to guard against the 
 dangers of tearing bowels or other structures. To control bleeding he 
 recommends sponge packing. Firstlj', the fingers map out the actual 
 limits of the diseased organs; then these are gently separated from 
 all surrounding parts, and gradually the mass is unfolded upwards 
 from behind till the only attachment left is the proper pedicle of the 
 parts to be removed. Even as thus separated, the appendages will 
 probably be found sessile on the broad ligament, so that they can be 
 little more than brought within the range of sight. The broad liga- 
 ments are stretched tightly across the pelvis, and dragging on the 
 appendages may tear them. The pedicle ligature may have to be car- 
 ried under the diseased parts at a considerable depth from the surface. 
 If possible the tissues are gathered together in one pedicle, or by the 
 Staffordshire knot; but the puckering produced may drag upon the 
 opposite ligament so much as to cause tearing. To tie in two parts 
 almost of necessity tears open the tissue between them. It has hap- 
 pened to me in one case, while pulling on a ligature, that the broad 
 ligament was torn clean away from the side of the uterus for a distance 
 of more than an inch.* .... 
 
 '' The bleeding in these cases is sometimes described as truly alarm- 
 ing, and I have had j)ractical experience of this fact. Sponges are 
 packed in everywhere as the adhesions are separated. If, after the 
 appendages have been removed, bleeding still goes on, a little solution 
 of iodine on a sponge may be applied to the raw surfaces. Of course, 
 visible bleeding points are dealt with by ligature or forcipressure. 
 And it may sometimes be good practice to leave forceps attached to 
 bleeding points for twenty-four hours or so, their handles being left 
 outside. In all such cases the insertion of a drainage-tube for a day 
 or two is advisable. 
 
 " If abscesses exist, extra care is necessary to avoid rupture of the 
 abscess-wall. It may be wise, before beginning separation, to aspirate 
 the contents, and place a pressure-forceps on the opening so made. 
 
 * Mr. Greig Smith (loc. svpra ciL, p. 170) thinks that an india-rubber bag inflated 
 in the rectum might, by raising the pelvic floor, be sometimes of use. 
 
ABDOMINAL SKOTION FOR MYOMATA. 725 
 
 In such cases the placing of sponges all round the diseased parts is 
 peculiarly necessary. 
 
 " For Uterine Myoma.— For small myomata the proceeding may be 
 in no way different from the simplest operation. In fact, as the 
 appendages are raised with the fundus, and the broad ligaments are 
 usually soft and distensile, the operation may be rendered easier. 
 
 "When the tumor is large, and especially when it is adherent, the 
 difficulties may be great, even insuperable. Not a few such opera- 
 tions, begun as oophorectomy, have to be finished as hysterectomy. 
 If the tumor grows away from the uterus, being sub-peritoneal and 
 near the fundus, the appendages may be deep in the pelvis. Where 
 the growth lies between the broad ligaments the ovaries will be elevated 
 and squeezed between the tumor and the parietes. In an unsym- 
 metrical growth one ovary may be quite conveniently near the surface, 
 while the other lies out of reach and behind. Indeed, we must expect 
 an endless variety of situation, and in some cases be prepared not to 
 find ovaries at all.* 
 
 " When one ovary is found, we must, before proceeding to remove 
 it, find the other ; and before removing one we must be certain that it 
 is possiole to remove both. Having decided to remove the appendages, 
 we rotate the tumor to one side so as to bring the parts first to be 
 
 removed as close as jjossible to the surface Thornton's plan of 
 
 not cutting off the first ovary till all manipulations are over with the 
 second is a good one; it minimizes the risk of bleeding from the 
 divided pedicle." 
 
 . CHAPTER XI. 
 
 OPERATIONS ON THE UTERUS. 
 
 REMOVAL OP MYOMATA BY ABDOMINAL SECTION. 
 —REMOVAL OF A CANCEROUS UTERUS BY AB- 
 DOMINAL SECTION.— REMOVAL OF A CANCEROUS 
 UTERUS PER VAGINA M. 
 
 REMOVAL OF MYOMATA BY ABDOMINAL SECTION. 
 
 Indications. — These are thus laid down by the chief authority on 
 this subject, Dr. T. Keith.f 
 
 1. In very large rapidly growing tumors of all kinds in young 
 
 * Prof. Simpson (Edin. Med. Journ., vol. xxx. p. 444) has practiced with benefit 
 ligature of the broad ligaments in cases where removal of the appendages has been 
 foimd impossible. 
 
 t Hysterectomy for Fibrous Tumora of the Uterus. 
 
726 OPEEATIQNS OX THE ABDOMEN. 
 
 women. By a large tumor is meant one of upwards of 20 lbs. 2. In 
 all cases of real fibro-cystic tumors, if they can be removed ; also in 
 all cases of suppurating tumors. 3. In most cases of soft, oedematous, 
 fibrous tumors. These often grow to an enormous size, far larger than 
 any ovarian tumor. 4. In cases of large bleeding fibroids of any age, 
 provided that the patient is not approaching fifty, that her life is prac- 
 tically useless, and that further experience in the operation shall show 
 that the mortality of hysterectomy is likely to diminish. 5. In certain 
 cases of tumor surrounded by free fluid, the result of peritonitis, pro- 
 vided that the fluid shows a tendency to re-accumulate after two or 
 three punctures. 
 
 Mr. Greig Smith (Abdom. Surg., p. 201) adds another— viz., where an 
 operation with a view of removing the uterine appendages has been 
 found impracticable, and examination proves that the myoma, with 
 or without the uterus, can be removed ; in such a case the major 
 operation may be proceeded with. 
 
 Operation. — The preparations, etc., are much as have been given 
 for ovariotomy (p. 714), but the following instruments will be wanted 
 as well — viz., two clamps of Koeberle's pattern, or Keith's large clamp, 
 additional large clamp-forceps, and serre-nceud pins. 
 
 An incision is made in the linea alba from the umbilicus downward 
 so as to admit the hand and examine the tumor. If it is decided to 
 proceed, the incision is prolonged upward to the left of the umbilicus 
 sufficiently freely to allow of the tumor being brought out without 
 bruising of the incision or undue force. Any adhesions to the parietes 
 or omentum, intestines or stomach being dealt with, the growth is 
 lifted forwards by one or two of Tait's screws. This is often rendered 
 very difficult if the lower part of the growth be firmly fixed in the 
 pelvis. As it comes out the surgeon must take care that he is not 
 pulling dangerously on viscera behind to which the growth may still 
 be attached, and which he cannot see.* The relation of the bladder 
 to the tumor must now be carefully made out. If the growth has 
 extended into the pelvis or between the layers of the broad ligament, 
 its connection with the bladder may be very intimate. Thus, the 
 relations of the bladder must be defined, and, if needful, the two 
 must be separated by careful dissection, a step made easier by not 
 emptying the bladder before the operation. 
 
 The next step is to examine into the condition of the pedicle and to 
 decide how to treat it. Of the two methods, intra- and extra-perito- 
 neal, the former is now rarel^^ used, owing to the risk of haemorrhage 
 from shrinking of the uterine tissue, or of sloughing and septicaemia. 
 
 * Mr. K. Thornton {Did. of Surg., vol. ii. p. 746) points out that much more care 
 is required in securing adhesions now, as a solid tumor allows of much more haem- 
 orrhage than a collapsed ovarian cyst. 
 
ABDOMINAL SECTION FOB MYOMATA. 
 
 727 
 
 Extra- Peritoneal Treatment of the Pedicle.— The following are the chief 
 means employed : 
 
 1. Wire constriction (Koeberl^, Tait). (Fig. 118.) 
 
 2. Clamps (Keith). 
 
 3. Forcipressure and ligature of vessels (Spencer Wells). (Fig. 119.) 
 
 4. Elastic ligature (Martin and other German surgeons). 
 6. Enucleation. 
 
 (1) Wire Constriction.— This is the form most usually employed. 
 The loop is adjusted either round the narrowest part of the attachment 
 
 Fig. 118. 
 
 Fia. 119. 
 
 KoeberWs serre-noeud. (Galabin.) 
 
 Temporary forcipressure in the removal of a uterine 
 tumor. (Spencer Wells.) 
 
 of the tumor, or, if it be needful to open the cavity of the uterus, just 
 above the internal os. If it be possible to include the appendages in 
 the loop this is done ; in other cases the broad ligaments must be tied 
 separatel}^ after transfixion. When the loop is tightened in position 
 it is screwed up slowly, for the shrinking of the tissues will allow of 
 further tightening of the wire later on. One or two pedicle-pins are 
 
728 OPERATIONS ON THE ABDOMEN. 
 
 now thrust through the tumor just above the loop, it being intended 
 that the broad and protected ends of these shall, by resting on the 
 abdominal walls, keep up the stump in position. During the above 
 steps sponges will have been applied so as to stop any fluids from 
 going into the peritoneal cavity. Fresh ones are now carefully packed 
 around, and the growth is cut away sufficiently beyond the pins to 
 allow of paring down a little later. After this has been effected, the 
 wire is finally tightened. The stump thus pared down and painted 
 with iron perchloride or a strong solution of carbolic acid, and dusted 
 with iodoform, is retained in situ by the pins and by the first of the 
 sutures closing the abdominal wall, which is put in immediately above 
 the stump. 
 
 Any oozing points are now finally looked to, the peritoneal cavity 
 cleansed, and the rest of the abdominal wound closed with the pre- 
 cautions given at p. 719. Dry gauze strips dusted with iodoform — 
 these being distinct from those over the rest of the abdominal wound 
 — are carefully packed around the stump, and some are placed under 
 the ends of the pins. 
 
 The wire is tightened when the dressings are changed — about every 
 two days — fresh strips and the iron perchloride being applied as a 
 little of the stump is clipped away.* If the wire has not made its 
 way through in about two weeks it may usually be divided and 
 removed at this time. 
 
 (2) Clamp. — Dr. Keith uses one of these made very large and .thin, 
 as likely to cause less sloughing than the wire, as it spreads out the 
 pedicle more. Tlie stump is treated in the same way as above given. 
 
 (3) Forcipressiire and Ligahire of Vessels. — This mode of making 
 temporary compression has been employed by Sir S. Wells with his 
 powerful forceps. " Temporarily compressing the neck by two pairs 
 of large forceps, as shown in the woodcut, the tumor was cut away 
 about i inch above the forceps. Transfixing between the points of 
 the two forceps with a large needle carrying a double strong silk 
 ligature, each ligature was tightened below the forceps, and as the 
 forceps were successively removed the ligatures were still further 
 tightened before the second knot was made. A third ligature was 
 then applied close behind the other two. The peritoneal edges of the 
 stump were then brought together by a few points of uninterrupted 
 suture of fine silk." In other cases Sir Spencer has dispensed with 
 
 * As this process is repeated great care must be taken not to cut into tissues which 
 are still living. The tendency of the pedicle to sink back into a cone-shaped de- 
 pression just above the pubes must also be remembered, the adhesions here remaining 
 for some time very weak, and daily attention being required to keep the parts in a 
 dried aseptic condition with iron perchloride and iodoform. 
 
ABDOM[NAL SECTION FOR CANCEROUS UTERUS. 729 
 
 ligatures, taking up the vessels with pressure-forceps and tying them 
 one by one as the large forceps were removed. 
 
 (4) EiaMic Ligafiire.—This method has been largely used by Ger- 
 man surgeons, especially Prof. Hegar, of Berlin. Dr. Lee,* of New 
 York, thus describes its application. The base of the pedicle is 
 surrounded " as low down as possible with Kleeburg's elastic ligature, 
 which is tied while on the stretch. Above this a double ligature is 
 passed through the stump, tied firmly in two sections, and all above 
 that cut away. Now, drawing up this stump into the lower angle of 
 the abdominal wound, the parietal peritoneum is stitched securely to 
 the peritoneal covering of the pedicle, just below the elastic ligature. 
 The first suture above the stump is passed through the parietal peri- 
 toneum, then under the elastic ligature and through the peritoneum 
 on the opposite side ; when this is tightened it closes in the stump 
 with peritoneum completely. Two more sutures are passed first 
 above this through the peritoneum only, and the rest of the wound is 
 
 closed as usual About the tenth day the elastic ligature is 
 
 carefully cut away, and good union is obtained in a fortnight. 
 
 REMOVAL OP A OANOEROUS UTERUS BY ABDOMI- 
 NAL SECTION. 
 
 This operation, introduced by Freund of Strasbourg, has been 
 largely abandoned on account of its fatality. It is contrasted with 
 the vaginal, and the indications are given later on, p. 733. 
 
 Operation. — The abdomen being opened iii the usual way, as 
 close down to the symphysis pubis as is safe,t the intestines are drawn 
 out of the pelvis into the abdomen, and if it be needful to get more 
 room, are brought out and covered with carbolized towels kept warm 
 (p. 655). The uterus is now caught with a powerful vulsellum, and 
 dragged first to one side and then to the other, while the broad liga- 
 ments are transfixed by three ligatures which are made to interlock 
 when tied. These are thus described by Mr. Thornton {loc. supra cit.) : 
 " The first loop passes through the ovarian ligament and edge of the 
 peritoneal covering of the Fallopian tube, and secures the ovarian 
 vessels; the second loop passes through the round ligament and se- 
 cures the pampiniform plexus. When the first two loops have been 
 tied on each side, the ovaries and tubes are cut away, and the uterus 
 is firmly drawn out of the pelvis, and a transverse incision is made 
 through the peritoneum between the uterus and bladder ; the latter is 
 then peeled back| and the incision carried through into the vagina. 
 
 * Intern. Encyd. of Surg., vol. vi. p. 841. 
 
 t Dr. Lee advises partial detachment of the recti from their pubic insertion if the 
 abdominal walls are very tense. 
 
 J During this a sound may be kept in the bladder. 
 
730 OPERATIONS ON THE ABDOMEN. 
 
 The uterus is then held forwards, and the peritoneum divided trans- 
 versely behind to the same extent as in front, and the vagina opened 
 into through the pouch of Douglas. The uterus is now merely held 
 by small portions of tissue on each side, which contain the uterine 
 arteries, and the third loop of the broad ligament ligatures is passed 
 through on each side into the vagina, or from the vagina by a special 
 curved needle, and tied round the tissues containing the uterine 
 arteries; these small bridges of tissue on each side are then cut 
 through and the uterus removed." Mr. Thornton recommends that 
 where the vagina allows of it the uterus should be drawn out here, 
 as less likely to contaminate the peritoneum and cut tissues with 
 cancerous discharge than when it is taken out of the abdominal 
 incision. Any bleeding points are now secured, a large T drainage- 
 tube is placed in the wound with its central part brought out through 
 the vagina. The edges of the cut peritoneum are then, as far as 
 possible, united, the parts finally sponged out, and a little iodoform 
 dusted in. The abdominal wound is then closed in the usual way. 
 Prior to this operation the vagina must have been carefully cleansed 
 by the precautions given below. 
 
 REMOVAL OF A CANCEROUS UTERUS PER VAGINAM. 
 
 Preparatory Treatment.— For some days before the external genitals 
 are thoroughly cleansed, the vagina washed out with solution of 
 carbolic acid or mercury perchloride, and a plug of iodoform wool 
 inserted. If any very foul granulations are present, strong carbolic 
 acid may be aj^plied to them. The bowels are also thoroughly 
 cleared out. 
 
 Operation. — The patient being in lithotomy position, supported by 
 Clover's crutch, the uterus is strongly dragged down with a vulsellum, 
 sufficiently powerful, but with no larger handles than is needful. 
 The parts are dilated for the surgeon by an assistant with a duck-bill 
 speculum held posteriorly, by another dragging over the uterus as 
 directed, and also by the left hand of the operator. With scissors 
 the mucous membrane is next cut through circularly, well clear of 
 the disease. As Mr. Greig Smith remarks, the normal relations of the 
 uterus to the bladder and rectum have been altered. The rest of my 
 account is quoted from the above surgeon : " The mucous membrane 
 is now elevated from the cervix, the connecting cellular tissue being 
 divided by forefinger and scissors. A catch-forceps placed on the 
 anterior flap and handed to the assistant, who pulls it forward while 
 he depresses the cervix with the vulsellum, will facilitate the dissec- 
 tion in front, while a reversed manipulation will be of equal advantage 
 behind. Laterally, no cutting must be made after the mucous mem- 
 brane is divided. The cellular tissue must be pushed up as high as 
 
VAGINAL EXTIRPATION OF A CANCEROUS UTEItUS. 731 
 
 possible by the finger without tearing it; frequently the ujjiward 
 limit will be defined by a feeling of pulsation in the uterine arteries. 
 .... When the mucous membrane has been cleared from the cervix 
 as high up as the peritoneum, that membrane is perforated in front 
 and behind, and the abdominal cavity is entered. The forefinger is 
 the best perforator. Above the internal os, the peritoneum is closely 
 adherent to the uterus anteriorly and posteriorly, wliere the finger 
 may be pushed through it by a little judicious manipulation. If it 
 is more than ordinarily tough, and it seems to be yielding and 
 stretching in front of the finger, a Lister's sinus-forceps sharply 
 pushed through it will, after separation of the blades, make an open- 
 ing large enough to admit the finger. The opening is enlarged in 
 front and behind by tearing with the finger on both sides as far as 
 the broad ligaments. A soft sponge is now pushed through into the 
 posterior cul-de-sac and left there. It serves to protect the bowels 
 and keep them out of the way, while it absorbs any fluids and lies 
 between the general cavity and any possible infection from the 
 cancerous uterus." 
 
 The most diflicult and delicate step in the whole proceeding is the 
 separation of the uterus from the broad ligaments, and the securing 
 of its vessels against bleeding. Mr. Greig Smith, having alluded to the 
 endless variety of plans devised to meet this difficulty, thinks that the 
 best and simplest means is afforded by a clamp which he has devised. 
 It is a straight one with long handles and grooved laterally so as to 
 guide a small knife in cutting through the clamped ligaments. It is 
 thus employed : " Through the posterior opening the forefinger is car- 
 ried over the top of the broad ligament, hooking it down as far as pos- 
 sible. The posterior blade is now carried upwards along the finger at 
 a distance of about i inch from the uterus, and the end looped over 
 the top of the ligament. Its handle is pressed backwards on the 
 perineum. The anterior blade is introduced in front of the ligament, 
 parallel to the posterior blade, and its end locked by a simple mechan- 
 ism. The clamp is then closed and screwed up tightly outside the 
 vulva. A second clamp is similarly applied on the opposite ligament. 
 A knife is run up the grooves and the ligament divided on the uterine 
 side of the clamps, when the uterus is freed." The instruments may 
 be easily removed at the end of two or three days, without haemor- 
 rhage. 
 
 For cases unsuited for the damps— e.g., enlarged uteri— the same 
 surgeon recommends the plan of turning the uterus upside down, and 
 using forcipressure or ligatures. "Complete rotation of the uterus 
 on its long axis materially shortens the depth of the broad ligaments, 
 brings them more fully within the field of operation, and leaves the 
 most important stage of the proceeding — division of the uterine arte- 
 
732 OPERATIONS ON THE ABDOMEN. 
 
 ries— to the last, when it is also rendered more easy. It matters little 
 whether the uterus is turned backwards or forwards. If rotation can 
 be performed by the finger alone, it i.s most easily carried out in the 
 backward direction, with the finger in the posterior opening, hooked 
 over the fundus. If the finger does not suffice, anterior rotation by 
 means of forceps may be carried out. A firm hold of the anterior 
 surface is taken hold of, and the uterus pulled down as much as pos- 
 sible ; a second hold is secured higher up, and so on, one above the 
 other, till the fundus is grasped, and the uterus pulled down and com- 
 pletely inverted. The fundus now lies in the vagina, and perhaps 
 presents at the vulva, and the upper insertions of the broad ligaments 
 
 are witliin sight and reach With an inverted uterus, deligation 
 
 of the broad ligaments presents no especial difficulties. Firstly, a 
 powerful Wells' forceps grasps as much as possible of one broad 
 ligament, close to the uterus, and a strong silk ligature is carried round 
 a corresponding depth of the ligament at a proper distance bej^ond. 
 The intervening tissue is divided with scissors. Two or three successive 
 pieces of ligament are so treated, and one side of the uterus is set free. 
 The other side is similarly treated, and the whole uterus is then re- 
 moved. The broad ligaments ai'e thus secured by three or four liga- 
 tures on each side, and they are cut short. If there is any doubt as 
 to the securing of the deligation at any jjoint, a catch forceps is j)laced 
 on the visible vessels, or the forceps are left hanging, and removed 
 next day or the day after. Ovaries and Fallopian tubes, if healthy, 
 need not he removed. When the uterus is pulled down, and particu- 
 larly if it is inverted, the broad ligaments are stretched and tense. As 
 soon as the uterus is cut off, the ligaments recoil, become flaccid, and 
 retract, tending to cast ligatures loose. Therefore these should be 
 tightly drawn and should have a considerable hold upon the tissues. 
 These precautions ought to be especially observed in the lower por- 
 tions of the ligaments, where the uterine arteries lie. And it must be 
 remembered that it is here wliere tlie risks of wounding the ureters, or 
 of including them in the ligatures, is greatest. These dangers are en- 
 hanced by inversion of the uterus. They are minimized by a thorough 
 separation of surrounding cellular tissue in the early stages, and by 
 keeping always as close to the uterus as possible." 
 
 No sutures should be employed. As the sponge is withdrawn the 
 flajis tend to fall together. A drainage-tube is inserted, and irrigation 
 is i)racticed by a catheter passed along this. Plugging of the vagina 
 is thought unnecessary. The genitals must be kept scrupulously clean. 
 If hsemorrhage occur, an ana?sthetic must be given and the bleeding 
 looked for and secured by forceps left attached. Oozing may be 
 checked by syringing with hot water. 
 
CiESARIAN SECTION. 733 
 
 Contrast of the Abdominal and Vaginal Operations.— 
 
 The former of these has been practically abandoned owin;;- to its 
 fatality, the mortality being about 70 per cent. J\[r. Greig Smith (loc. 
 supra cit., p. 181) gives the mortality of the vaginal method as under 
 27 per cent. The dangers common to the two methods, shock, septi- 
 CEemia, peritonitis, inclusion of the ureter, secondary hjemorrhage, 
 seem to be better avoided by the simple vaginal method. Mr. Greig 
 Smith thus expresses his belief that, in carefully selected cases, the 
 operation is both justifiable and proper. " The immediate mortality 
 does not forbid it. Recurrence is almost certainly not more rapid than 
 in other operations for cancer, and permanent recovery is just as likely 
 to be secured. And, finally, there seems to be an almost unanimous 
 opinion that death after recurrence is not attended with so much 
 suffering, that perforations of bladder and rectum are not so hable to 
 take place after the uterus is removed, and that existence is prolonged." 
 Mr. Thornton (Diet, of Snrt/., vol. ii. p. 753) thus concludes his ac- 
 count of the operation : " Time alone can decide whether complete 
 extirpation of the uterus for cancer is destined to establish for itself a 
 permanent place in surgery, or is to sink into oblivion again, as it has 
 already done in the past, after a very decided attempt to establish it, 
 though not on such a careful and scientific basis as in the j^resent 
 revival of the operation." 
 
 O^SARIAN SECTION.* 
 
 The preparatory treatment is much the same as in ovariotomy. The 
 same care must be taken to provide suitable sponges, pressure-forcei^s, 
 and a sufficiency of sutures and ligatures. 
 
 An incision, about 5 inches long, is made as in ovariotomy, but does 
 not descend within at least 2 inches of the pubes, for fear of injuring 
 the bladder. Especial care must be taken in opening the peritoneum 
 not to wound the uterus. If possible the placental site should be 
 made out (a matter often of great difficulty) before opening the uterus, 
 and avoided. The surgeon, having decided where to incise the uterus, 
 takes the following steps to prevent fluids escaping into the peritoneal 
 cavity : (1) By packing sponges (previously counted) carefully around 
 (2) By an assistant keeping the parietes firmly pressed against these 
 and the uterus. (3) By another with his hand behind the uterus causing 
 it to protrude into the wound, and firmly holding it there (Greig Smith). 
 
 An incision 4 to 5 inches long is then made in the uterus, first by 
 an incision partly through in the upper part, which is completed with 
 
 * I trust that in including the following short acconnt of this operation I shall not 
 be met with the criticism "ne sutor ultra crepidam." My excuse wonld be that this is 
 an operation which, in the country especially, any hospital surgeon may be sent for to 
 perform, and that without much notice. 
 
734 OPERATIONS ON THE ABDOMEN. 
 
 the finger, and then by carrying this downwards with scissors. The hand 
 being rapidly inserted partly closes the opening and finds the neck of 
 the child, which is extracted head first.* All this time the entrance 
 of blood and amniotic fluid must be prevented by the above-given 
 precautions. The cord being divided between two pairs of Spencer 
 Wells' forq^ps, the surgeon attends next to the bleeding and the pla- 
 centa. If the uterus is contracting well, hsemorrhage will cease and 
 spontaneous detachment will take place. If there is no time to wait 
 for this, the placenta must be carefully peeled away while bleeding 
 sinuses are comj^ressed with sponges, or, if needful, with Spencer 
 Wells' forceps.f 
 
 The most important step, closure of the uterine wound, remains. 
 The membranes being removed and the uterus contracted, superficial 
 and deep sutures of carbolized silk are then inserted by the Siinger- 
 Leopold method, which relies upon the iDcritoneum for the most per- 
 fect closure of the uterine wound. It is thus described by Mr. Greig 
 Smith : " The peritoneal covering is detached from the muscular fibre 
 for a little distance along the margins of the wound : in this way it is 
 possible to turn inwards a greater surface of peritoneum. Then the 
 deep sutures are jjlaced. They are made to enter about i inch from 
 the edge of the wound, passed obliquely through uterine tissue, and 
 made to merge near the bottom of the cut surface. No suture should 
 enter the uterine cavity. These deep sutures should be placed about 
 i inch apart ; and they should be carried, converging a little, beyond 
 the ends of the incision. Then the superficial sutures are placed, two 
 between each deep suture. The needle first pierces peritoneum and 
 muscle, coming out a little below the lip of the wound ; then it picks 
 up the free edge of the peritoneum on its own side, and finally pursues 
 the same course in the opposite direction with the other side." These, 
 also, arc carried a little way beyond the margins of the wound. The 
 superficial are first tied, then the deep. Finally, if apposition is not 
 perfect, a few more sutures, or a continuous one, may be used. While 
 the sutures are being inserted fresh sponges may be inserted. The 
 peritoneum is then most carefully dried and cleansed. Drainage 
 should be used, as after ovariotomy, if there is any suspicion of fluids 
 in the peritoneal cavity. And if much oozing has taken place from 
 the uterine walls, or if the discharges are foul, a tube should be passed 
 from the uterus into the vagina before the sutures are placed, ^^'hile 
 the abdominal wound is being closed, an assistant syringes out the 
 vagina with a Higgenson's syringe and plugs it with iodoform or sal 
 alembroth gauze. 
 
 * If the feet ure taken first, tlie uterus may contract around tlie Iiead. 
 
 t A Iiypoderjiiic injection of ergotin may be given, and the uterus firmly grasped. 
 
REMOVAL OP GROWTHS OF THE BLADDER. 735 
 
 CHAPTER XII. 
 
 OPEEATIONS ON THE BLADDER. 
 
 REMOVAL OP GROWTHS OP THE BLADDER.-LATE- 
 RAL LITHOTOMY. — SUPRA-PUBIO LITHOTOMY — 
 MEDIAN LITHOTOMY.-LITHOTRITY AND LITHOLA- 
 PAXY. — REMOVAL OP STONE IN THE PEMALE.— 
 CYSTOTOMY.— RUPTURED BLADDER. 
 
 REMOVAL OP GROWTHS OP THE BLADDER. 
 
 Practical Points in the Diagnosis.— Indications for Oper- 
 ation. 
 
 Hssmorrhage. — This is of much importance, both in diagnosis and 
 as bearing upon an operation. Thus, in the villous growth or fimbri- 
 ated papilloma it is this alone which kills. In these growths the chief 
 point is that the hsemorrhage extends over a long time * occurs spon- 
 taneously and suddenly, and ceases in the same way ; the periods of 
 intermission gradually become less, till the bleeding is constant, either 
 rendering the patients utterly anemic or adding to their misery by 
 bringing about cystitis. These last two conditions may be so marked 
 as to demand an operation. This symptom is most frequent in the 
 villous growth (fimbriated papilloma},t less so in the fibro-papilloma 
 
 * Mr. R. Harrison {Intern Encyd. Surg , vol. vi. p. 38) states that in the museum 
 of St. George's Hospital there is a specimen of a villous tumor attached to the neck of 
 the bladder of a gentleman aged eighty-one. The first attack of hsemorrhage had 
 occurred twenty years before death, and had lasted for eight months, an interval 
 of four years had followed this, and then a recurrence of hfemoi'rhage, which ulti- 
 mately proved fatal. Sir B. Brodie also states that the disease occasionally extends 
 over seven or eight years. In a case of Mr. Anderson's {Clin. Soc. Trans., vol. xviii. 
 p. 313), of papilloma, the first hsematuria bad taken place twelve years before; then 
 came an interval of a year, followed by recurrence of the hsematuria, the next in- 
 terval being sliortened to six months, after which recurrence took place fairly reg- 
 ularly every three months. 
 
 f Sir H. Thompson {loc. infra cil.) classifies tnmors of the bladder as follows: 1. 
 Simple mucous polypus or myxoma; 2. Papillomata— (a) Fimbriated papilloma or 
 villous tumor, [b) Fibro-papilloma; 3. Transitional tnmors, intermediate in structure 
 between the foregoing and the sarcomata; 4. Sarcomata, round and spindle-celled 
 (rare) ; 5. Scirrhous, encephaloid, and melanotic cancers; 6. Dermoid tumors (rare). 
 A more scientific classification is that given by Prof. Kiister in Volkmann's Clin. Lect., 
 Annals of Surgery, September, 1886 : A. New growths of the prostate— 1. Fibro-ade- 
 noma, 2. Myxoma, 3. Carcinoma. B. New growths of the bladder— i. New growths 
 from the mucous or sub-mucons coat: 1. Papilloma (including the two varieties of 
 Sir H. Thompson), 2. Fibrous polypi and myxoma, 3. Sarcoma ; ii. New growths 
 from muscular coat : 4. Myoma ; iii. New growths from the epithelial and glandular 
 tissues : 5. Adenoma, 6. Carcinoma. 
 
736 OPEEATIOXS ON THE ABDOMEN. 
 
 or in the " transitional " growths. Mr. H. Thompson* lays much 
 stress on the fact that, in these cases, the stream often begins without 
 or with little blood, and ends of a bright-red color. 
 
 Sound! luj.— This is usually said to be negative, but it should be 
 made use of thoroughly and carefully. In the case of a single fimbri- 
 ated papilloma, the sound may give no information unless it happens 
 to detach the growth. In more solid growths— f.j/., a fibrous papilloma, 
 a transitional or sarcomatous tumor — resistance may always be met 
 with at one spot in moving the sound.f In the raucous polypi of 
 children any movements of the sound may be prevented, and carcino- 
 mata, if ulcerated, may give a very distinct, uneven, rugged feel, while 
 the increase of pain afterwards is here very marked. But sounding 
 is of value beyond what it tells at the time. By using the sound with 
 judicious and gentle vigor, particles of a villous growth may be de- 
 tached for microscopical examination. This may perhaps be aided 
 by washing out with a lithotrity evacuator as suggested by Mr. Davies- 
 Colley. 
 
 Emmination of Urine. — This aid has been too much neglected be- 
 cause the naturally present " transitional " epithelium of the bladder 
 may so easily be mistaken for growth-cells. But in the case of villous 
 growths especially, careful examination of the urine should be fre- 
 quently made, and the patient directed to bring, at once, any white or 
 flocculent particles passed. The sediment of the urine should be also 
 frequently examined microscopically after sounding and washing out. 
 The delicate papillre, with their connective-tissue basis supporting 
 hosts of columnar cells with large delicate capillaries, are most char- 
 acteristic. 
 
 Examination per Rectum. — This is usually negative. Occasionally 
 pain, a tender spot, or thickening felt through the trigone, may point 
 to the position of the growth. In elderly men a rectal exan:inatien 
 should always be made to find out if any enlargement of the prostate 
 exists. 
 
 Eednsion of other Conditions — e.g., stone, tubercular and other forms 
 of cystitis. The need of this is so obvious, and it can usually be so 
 easily managed by carefulness, that merely mentioning it here will be 
 sufficient. 
 
 Failvre of Previous Treatment.— Gvo-wths of the bladder being inevi- 
 tably fatal, whether from haemorrhage, or pain, or obstruction results, 
 or from these combined, the surgeon is entirely justified in urging a 
 
 * Tumors of the Bladder, p. 66. 
 
 t Thus it may be easy to explore one side of the bladder by carrying the sound 
 over to tlie opposite thigh, while similar raanceuvres to e.taniine the other .side are 
 interfered with. 
 
REMOVAL OF GROWTHS OF THE BLADDER, 737 
 
 digital exploration to clear up the case and the question of removal. 
 While it remains as yet uncertain how many of the cases published 
 as cures are really and permanently so, even in the case of the villous 
 growth, it is an undoubted fact that an operation may result in arrest- 
 ing the hemorrhage completely for years. In otlier cases, hemorrhage, 
 pain, and frequency of micturition may all be very largely relieved. 
 Where little or nothing can be done in the way of removal, the free 
 escape given to the urine by a perineal or supra-pubic operation or 
 by dilating the neck of the bladder in a woman may give great relief; 
 where even this fails, the case has, at least, been cleared up. 
 
 Choice of Operauon.— Where the surgeon has to deal with a 
 large tumor, or with a number of tumors, the supra-pubic method will 
 be safest and give most room, and, in any case if the perineum be very 
 deep, if the prostate be enlarged, or, if the perineum be small and the 
 pelvis contracted, the above operation is indicated. So, too, in the 
 case of a recurrent growth, this method should be employed, as it 
 cannot be told how far the recurrence is widely diffused. 
 
 But where there is reason to believe that the growth is single, or 
 small, or near the neck, the bladder may be explored from the peri- 
 neum by opening the membranous urethra, and dilating the vesical 
 neck. 
 
 In most cases it will probalily be advisable to combine both opera- 
 tions, as the perineal opening enables the surgeon to use two 
 index-fingers in the bladder at the snme time, and also favors drainage. 
 
 Operation. — The surgeon first opens the membranous urethra on 
 a staff in the manner of a median lithotomj' (p. 756), and explores 
 the bladder after dilating the neck with his finger, which is made to 
 enter by a careful insinuating movement along the director, which is 
 then withdrawn. If no growth is felt near the neck, the surgeon, 
 rising, makes firm supra-pubic pressure, so as to bring the upper part 
 of the bladder into contact with Ins left index. On finding a growth, 
 he carefully ascertains its size, situation, shape, existence or not of a 
 peduncle, and whether this peduncle is narrow or not. Its structure 
 is also examined, whether polypoid and firm, or soft, fioating, and 
 villous.* If he decide that the growth can be removed by the perineal 
 wound, he must be provided with appropriate forceps, especially the 
 ones with serrated edges, straight, and of different curves, introduced 
 by Sir H. Thompson. A very small ecraseur with violin-string liga- 
 ture may perhaps be used in tliis way, or sharp spoons or scoops. Sir 
 H. Thompsont thus describes the use of the forceps:- Having, with 
 
 * A ragged ulcerated surface, large sessile tiuiiors, and multiple soft masses, are tlie 
 most unfavorable to deal witli. Beyond a palliative cystotomy tlie first admits of no 
 interference. 
 
 t Tumors of the Bladder, |>. 50 ; Brit. Med. Journ., 1883, vol. ii. p. 11'80'. 
 
 47 
 
738 OPERATIONS ON THE ABDOMEN. 
 
 his forefinger, first made himself familiar with the exact position and 
 size of the tumor, he inserts the forceps, guided only by the knowledge 
 thus acquired, and makes a decided snip on the tumor ; then, by 
 moving the forceps in different directions, he makes sure that he has 
 the growth within their grasp. "Above all things, he is not to pull 
 forcibly, but to press firmly the blades together, biting or chewing a 
 little, if I may use the terms, with the extremities of the blades with- 
 out changing the original situation of the bite or grasp. Then a little 
 twisting movement may help to disengage the mass, which, if accom- 
 plished, the forceps will be felt free, and may be withdrawn with their 
 contents, after which the finger enters to feel what remains and what 
 more must be done in order to complete the removal. Let me remark, 
 whenever the forceps has removed a portion, however small, the in- 
 strument should never be re-introduced until the finger has again 
 examined the interior." It is best to leave the detached pieces in the 
 bladder and to remove them together at the end with a scoop. 
 
 If the tumor has not been separated by the moderate use of the 
 forceps just described, it will probably be found, on introducing the 
 finger, so nearly severed that the actual division may be completed 
 with the finger nail or by one of Sir H. Thompson's serrated instru- 
 ments for this purpose. 
 
 The same surgeon thus draws attention to the great risk of making 
 strong supra-pubic pressure while forceps are being used : " If that 
 pressure is considerable, it forces the upper wall of the bladder into 
 its own cavity, and thus gives the growths a larger contour than they 
 possess, and makes them apparently salient to a much greater extent 
 than they really are. Thus, an eager or inexperienced operator, un- 
 aware of the effects of strong supra-pubic pressure, might he led to 
 seize the mass offered to the forceps through the influence of this pres- 
 sure, and, under the belief that it was a large growth, he might inflict 
 a fatal wound by crushing a double fold of the coats of the bladder, 
 and so make an opening in the peritoneum. To avoid such a catas- 
 trophe, it is only necessary, first, to decline the attempt to destroy any 
 growth which is clearly not sufficiently salient to admit of complete 
 or nearly complete removal ; and, secondly, never to employ the for- 
 ceps while forcible supra-pubic pressure is made — at least, no more 
 pressure than is desirable just to steady and support the bladder and 
 the parts adjacent." 
 
 When a growth has a sufficiently long and substantial pedicle, it 
 may be dragged out into the wound and cut away or twisted, or 
 divided with the 6eraseur in the way adopted by Mr. Davies-Colley* 
 and Mr. Pittst in their eases. 
 
 * Clin. Soc. Trans., vol. xiv. p. 104. f Ihid., vols xviii. p. 321 ; xx. p. 369 
 
REMOVAL OP GROWTHS OF THE BLADDER. 739 
 
 If the surgeon determine to make a supra-pubic opening as well 
 owmg to the growth being large, multiple, beyond reach, etc!, he will 
 first place a bag in the rectum and distend it with 10 or 12 ozs of 
 water. The bladder is then injected with 8 or 10 ozs. of Thompson's 
 fluid (p. 619) through the perineal wound by a large catheter, and 
 this wound is finally plugged around the catheter with sponges dusted 
 with iodoform, aided, if needful, by the finger of an assistant. The 
 supra-pubic opening is then made as at p. 753, with this exception, 
 that, when the bladder is distinctly reached, one or two sutures of car- 
 bolized silk are passed across the site of the intended opening into the 
 bladder with a curved needle in a handle. The opening into the 
 bladder is then made (carefully, so as not to divide the underlying 
 silk ), the silk is hooked up and divided ; by this means two or four 
 sutures are present— one or two on either side— which will serve to 
 raise up the bladder as required, and to keep it well open and within 
 reach during the manipulations needful for the removal of the tumor. 
 This may be effected by the finger-nail, one working from the upper 
 and another from the perineal opening, or by one of the instruments 
 already mentioned. 
 
 The galvanic ecraseur should never be used unless other instru- 
 ments have failed. The loop will, no doubt, shear away, without 
 hfemorrhage, large masses which, from their size, poorly marked 
 pedicles, and vascularity, are very difficult to deal with otherwise. 
 But its liability to introduce septic complications, and the difficulty 
 of manipulation in a deep contracted space, are grave objections to the 
 cautery.* If the surgeon is driven to use an ecraseur, he should 
 employ the ordinary wire one, on account of the above-mentioned 
 septic complications. With regard to the size of the tumor, it is re- 
 markable, if the anaesthetic is taken well, how much may be removed 
 by a process of quiet nibbling combined with careful torsion. Mr. 
 Bryant (Lancet, 1886, vol. ii. p. 1076) found the following method 
 useful in the case of a bladder which appeared to be filled with vil- 
 lous growth : A great deal having been removed bj^ forceps, the 
 bladder was scraped throughout, the walls being wiped rather roughly 
 with a new sponge tightly tied round a forceps. Haemorrhage recurred 
 six months later, persisting for a week ; it then stopped, and the man 
 was doing well eighteen months after the operation. Whatever 
 method is used, the surface left should be as smooth as possible, to 
 diminish the risk of phosphatic deposit. 
 
 DifiQculties during Removal of Bladder Tumors. 
 
 1. A very contracted bladder. 
 
 * In one cai^e brought before the Clinical Society {Lancet, December 3, 1887) Mr. 
 Parker used this method snccessfiilly, e.xamlning the base of the growth and every part 
 of the bladder with a small incandescent electric lamp introdnced for the purpose. 
 
740 OPERATIONS ON THE ABDOMEN. 
 
 2. Growths very large, or multiple and diffuse, or without pedun- 
 cles. Other difficulties connected with the growth may be its situa- 
 tion far back in the fundus, or its structure with long delicate filaments, 
 which, floating in fluid, are difficult to detect and catch. 
 
 3. Ha?morrhage. This may be very troublesome, and obscure the 
 field of operation. It usually yields, either spontaneously, after the 
 removal of the growth, or to sponge-pressure, injections of ice-cold 
 boracic acid, or dilute solution of iron ]ic-rchloride. 
 
 4. Infiltration of the bladder wall Ijy growth. 
 
 Causes of Death after Removal of Bladder Tumors. 
 
 1. Shock. Mr. R. Harrison {Lancet, 1884, vol. ii. p. 678) records a 
 case of a man, aged forty-two, who died somewhat suddenly, ap- 
 parently from shock, twelve hours after removal of a villous tumor by 
 the perineal method. The hajmorrhage, which had begun four years 
 before, had for a year been persistent and considerable.* 
 
 2. Surgical kidney. 
 
 3. Injury to the bladder and peritonitis. Mr. Bryant (Lancet, 1886, 
 vol. ii. p. 1077) mentioned a case in which a fibrous polypus was 
 drawn from the fundus into the perineal wound and snipped off. 
 The man died of peritonitis, and a small hole wa.s found in the 
 bladder at the site of the removed polypus. 
 
 4. Recurrence. 
 
 LATERAL LITHOTOMY (Figs. 120-2). 
 The lateral operation will be described under the following heads: 
 
 A. Preparatory Treatment, 
 
 B. Passing the Staff. Possible Diflaeulties. 
 
 C. Finding the Stone. Possible Diflaeulties. 
 
 D. Entering the Bladder. Possible Diflaeulties. 
 
 E. Extracting the Stone. Possible Diflaeulties. 
 
 F. After-Treatment and Possible Complications. 
 
 A. Preparatory Treatment.— For a week or so before the opera- 
 tion the diet should be bland, so as to tax as little as possible jaded 
 kidney's — cjj., milk, barley-water, light puddings, and a little fish. 
 If alcohol is needed, some sound spirit, well diluted, will be a good 
 form. Baths sliould be taken regularly, the bowels well moved, and 
 an enema given on the morning of the operation, and care should be 
 taken that all this has come awav. 
 
 * Mr. Ilairison, in illii.striitiiin of llie sudden and excessive bleeilinif to wliich villous 
 tumors are lial)le, eviMi wlien tliey appear eom[)aralively quiescent, has published 
 (Livrrpni)l Mill Chir. Joiirn , .July, 1884), a case where death took place from this 
 cause in nine hours. In this instance slight liffiinatiirin hail e.sisted for some months 
 previously, but no operation had been performed. 
 
LATERAL LITHOTOMY. 741 
 
 B. Passing the Staff.— This step, however simple anil easy, 
 usually presents occasional difficulties, the more trying, because per- 
 haps unlocked for ; they are — 
 
 (1.) Spasm, from the urethra not being used to instruments. 
 (2.) Stricture. 
 (3.) False passage. 
 (4.) Enlarged prostate. 
 
 (5.) An enlarged prostatic sinus, into which the end of the sound 
 passes. 
 
 C. Finding the Stone with Sound or Staff. Possible 
 Diflaculties. 
 
 (1.) The stone may have been passed.* This is not im]>ossible in 
 children with small, smooth, narrow calculi, and their sudden, stren- 
 uous micturition. 
 
 (2.) The stone may lie behind an enlarged prostate. Here the finger 
 of an assistant passed into the rectum may help. 
 
 (3.) The stone may be enveloped in folds of mucous membrane. 
 Injection of the bladder is here indicated. 
 
 (4.) The stone may be encysted. This is so rare as to have been 
 called the refuge of young lithotomists. The following ease of Prof 
 Humphryt shows well how embarrassing this condition may be: 
 
 A man, aged fifty-one, was cut, then submitted twice to lithotrity, 
 then again cut in the old scar three times, all within six years, for an 
 encysted calculus. On the fourth occasion of lateral lithotomy the 
 nature of the case was made out accurately. The stone was now felt 
 behind the prostate, attached to the bladder by a pedicle which seemed 
 to penetrate the coats of the viscus, and to be attached to another mass 
 beyond it. It was evidently a stone of hour-glass shape, part being 
 in the bladder and part in the sac. At each of the previous operations 
 the part within the bladder had broken off, the rest not being extracted, 
 owing to the size of the prostata. The symptoms recurring, urethro- 
 rectal lithotomy was performed. The stone being now within reach, 
 the edge of the mucous membrane around it was incised with a her, 
 nia knife, and a stone, the size of a walnut, and with a truncated stalk, 
 extracted. Death took place in two days, from pelvic cellulitis. 
 Though the bladder was otherwise but little diseased, the cyst seemed 
 to have originated from the protrusion of mucous membrane between 
 the muscular fibres, as another one existed, though without a stone. 
 The cyst communicated by a considerable opening with the foul, infil- 
 trated tissues. Prof Humphry asks whether this was due to his 
 manipulations of a delicate sac, and whether supra-puhic lithotomy 
 
 * Cf. the case mentioned by Mr. Flolme-i, Clin. Soe. Trans., vol. ii p. 67. 
 f Some Cases of Operaiion. Pamphlet. 1856. 
 
742 OPERATIONS OX THE ABDOMEN. 
 
 would not have been better. In another case Prof. Humphry was 
 able to remove a similar calculus successfully, by lateral lithotomy, 
 after repeated introduction of forceps and scoop. He points out that 
 these cysts may l)e (juite out of reach in lateral lithotomy. As their 
 walls consist only of cellular tissue, mucous membrane, and perhaps 
 a thin layer of muscular fibre, they are easily lacerated during an 
 operation, an accident almost certain to be fatal. The diagnosis is 
 usually to be made if the stone is always struck by the sound at one 
 spot, especially if, jier rectum, a lump is detected corresponding to 
 that spot.* 
 
 D. Entering the Bladder.— The time chosen for introducing 
 the staff varies with different operators. Passing the staff while the 
 patient is still recumbent is the easier ; passing it when the patient is 
 in lithotomy position is rather more difficult, but secures the operator 
 against the risk of the staff slipping out after the patient is brought 
 down into position, a risk which is greater with the straight staff. I 
 prefer to bring the patient's lower limbs over the edge of the table, to 
 pass the straight staff' while he is thus recumbent, and then to have 
 his limits only brought up into position. 
 
 The nates just projecting over the edge of the table, the sacrum being 
 flat upon it, the flexed thighs and legs being held well out of the way, 
 the surgeon, seated comfortably, and with his face on a level with the 
 perineum, directs an assistant so to hold the staff as to bring the mem- 
 branous urethra close to the surface of the perineum. If a curved staff 
 be used, this is easily done by inclining the handle strongly towards 
 tlie abdomen. By this manoeuvre, in Mr. Cadge's words {loc. supra 
 cit.) the point of the staff' " need not, and should not, be withdrawn 
 from the bladder, but if it were it would be of no moment, because it 
 would re enter it the moment the handle is raised ; the membranous 
 urethra, instead of being almost perjjendicular to the surface of 
 the perineum, as it is when the staff is held upright, is brought almost 
 parallel with it, and is much easier to find with the knife; there is no 
 inducement to open tlie urethra too far forwards, and consequently no 
 risk of wounding the bulb or its artery. The staff' gets a steady rest 
 against the front of the pubes, and there is no danger to the rectum 
 at this stage."t 
 
 Having felt the staff thus presented towards him, having examined 
 into the depth of the ischio-rcctal fossa, the site of the tuber and ramus 
 
 * Ericlisen [Surgery, vol. ii. p. 945) adds lliat Uie l)eak Ciinnot be made to puss round 
 such a slotie, so as to isolate il. 
 
 t It thus combines tlie ndvuntages of ibe two very different methods usually given, 
 viz., either to hold the staff" well np finiily under the pubes and thus away from the 
 bowel, but also away from the stone; or closely down \ipon the latter and in proximity 
 to the rectum also. 
 
LATERAL LITHOTOMY. 
 
 743 
 
 ischii, the surgeon, pressing up the junction of the scrotum and raphg 
 so as to make tense the parts just about to be cut, enters his Imife from 
 I inch to 11 inch from the anus, just to the left of the raphe, and very 
 
 Fig. 120. 
 
 (Fergusson.) 
 
 likely hits the groove at once. The knife is then drawn outwards and 
 backwards with a rapid sawing movement, to a point midway between 
 the anus and tuber ischii, thus making an incision of 2 to 3 inches, 
 according to the age of the patient and size of the stone. Again in- 
 
 FiG. 121. 
 
 (Fergusson.) 
 
 serting the knife into the upper angle of the wound, the surgeon makes 
 out exactly with his left index finger the groove in the staff, and ex- 
 poses this, beyond doubt, in the wound. The next steps differ some- 
 
744 
 
 OPERATIONS ON THE ABDOMEN, 
 
 what, accordingly as the curved or straight staff is used— they will be 
 given separately. 
 
 (a) With the Curved Staff —When the knife-point is felt firmly 
 lodged in the groove, its handle is a little depressed, the blade, at the 
 same time, turned a little to the left, is pushed steadily along the 
 groove till a gush of urine or a sense of resistance ceasing, or both 
 together usually, announce that the neck of the bladder has been suf- 
 ficiently divided with the knife. The finger is now wormed into the 
 bladder over the concavity of the staff. 
 
 (6) With the Straight Staff.— When the point of the knife is 
 felt to be safely lodged in the groove, the surgeon takes the handle 'of 
 the straight staff from his assistant, brings it down, and still keeping 
 his knife in the groove, lateralizes the staff slightly to the left, the 
 handle of the knife being now depressed so as to form a sufficient 
 
 Fiu. 122. 
 
 Lateral lithotomy with a straight sta£f (Key). 
 
 angle with it, and make an adequate wound, the surgeon runs it along 
 the groove steadily, till he knows by the above-given evidence that 
 the neck of the bladder has been sufficiently cut. 
 
 The left index finger is next wormed over th(^ edge of the staff, the 
 straight stafi' being held by the surgeon himself, in his right hand, 
 the curved one being held by an assistant, till he feels that he has 
 entered the bladder and placed the finger tip, if possible, in contact 
 with the stone. Entrance into the bladder is known by feeling the 
 finger surrounded with a smooth cavity, lined with mucous mem- 
 brane, while the finger itself is girt by a fibrous ring. The stone 
 being felt, or the bladder cavity distinctly gained, the staff is with- 
 drawn, and the surgeon, while taking his lithotomj' forceps, dilates 
 the opening into the bladder with his finger, which, at the same time, 
 pulls down and steadies the nock. 
 
 Failure to Enter the Bladder.— This most vexatious and embarrassing 
 
LATERAL LITHOTOMY. 745 
 
 difficulty is most likelj^ to be met with under two widely different 
 conditions— (1) most frequently, in little children ; (2) in old patients 
 with very fat deep perinea, and enlarged prostates. Each must be 
 considered sejDarately. 
 
 (1) In Little Children.— The causes here are, the small size, delicacy, 
 and mobility of the neck of the bladder and urethra, and the fact 
 that the bladder lies high up above the pelvis. Mr. Cadge quotes the 
 following from Sir W. Fergusson : " The point was, as usual, placed 
 on the staff and pushed gently towards the bladder. The finger went 
 on, but I was aware that it had not got between the urethra and the 
 staff. With an insinuating movement (much to be appreciated by 
 the lithotomist who, as I do, professedly makes a small incision in 
 this locality!, I endeavored to get its point, as usual, into the urethra 
 and neck of the bladder. But here I felt convinced that I had failed, 
 and was aware that the finger was getting deeper as regards the depth 
 of the perineum, but that I was not inaterially nearer the bladder. 
 I could feel a considerable space at the point of the finger, and was 
 convinced that the upper part of the membranous urethra, as well as 
 the sides, had given way to the pressure, and that now, as the finger 
 was getting deeper into the wound, I was only pushing the prostate 
 and neck of the bladder inwards and upwards. These parts seemed 
 to recede before the smallest imaginable force, whilst I felt that I 
 could, in a manner, make any amount of space around the bare part 
 of the staff. I had no difficulty in distinguishing between the surface 
 of this space and that of the mucous membrane of the bladder. More- 
 over, I knew that I had never crossed that narrow neck which is always 
 felt as the finger passes into the bladder when a limited incision is 
 made. An impression came over me that I was about to fail in getting 
 into the bladder, and I had an idea that, unless I could open the 
 urethra in front of the prostate more freely, I should probably never 
 reach the stone. This I effected with great caution, and then I could 
 appreciate the passage of the finger as usual through the neck of the 
 bladder. The stone was easily touched and removed, but I was 
 forcibly impressed with the idea that I had nearly failed in the per- 
 formance of the operation." The child here was four years old. 
 
 Mr. Cadge thus met the same difficulty in an infant of one year and 
 a half: '' I felt the impossibility, even with a fair incision, of distend- 
 ing the wound with my finger ; it was like trying to get it into the 
 orifice of the urethra. I therefore desisted before doing any harm, 
 and. taking a pair of common dressing-forceps, I passed them easily 
 along the staff into the bladder; by opening the blades gently but 
 firmly, room was gained, and the finger entered and made room for 
 small lithotomy-forceps. But I have repeatedly, after passing the 
 
746 OPEHATIOKS ON THE ABDOMEN. 
 
 dressing-forceps, withdrawn the staff and removed the stone with 
 them, and without introducing the finger at all." 
 
 Difficulties and Mistakes during this Stage of entering the 
 Bladder. — This is so important a part of the operation that the 
 following may be enumerated here : 
 
 1. Finding the staif. This is not likely to jwesent difficulties in the 
 case of a curved staff if it be held as advised at p. 742. Hitting a 
 straight staff in a fat child is not always easy, owing to the small size 
 which is needful. Attention must be paid to entering it at the root 
 of the scrotum only just to the left of the raphe, when the finger-nail 
 will detect the staff at once. 
 
 2. Not exposing the staff. Everything which lies over the staff in 
 the upper angle of the wound must be clean cut. The tissues here, 
 including the membranous urethra, are lax and delicate, and, unless 
 the knife is clearly in contact with metal, the groove will not be fol- 
 lowed. 
 
 3. Losing the groove. This most serious accident may be due to 
 not getting the knife cleanly into the groove, not keeping it sufficiently 
 firmly in contact with it, and, thirdly, by forgetting to depress slightly 
 the handle of the knife. 
 
 4. Cutting the prostate too freely as the knife is brought out. This 
 can easily be avoided by keeping the knife sufficiently near to the 
 staff. 
 
 6. Cutting into the rectum. This ma}- be due to neglect of the 
 following precautions : (1) Keeping the staff up away from the bowel; 
 (2) guarding the bowel with the left forefinger in the wound; (3) 
 when the knife is lateralized, cutting away from the gut. 
 
 Mr. Cadge (foe. supm cit.) points out that the usual place of punc- 
 ture is the dilated part just aliove the internal sphincter, and that this 
 communication may be made secondarily by sloughing after extrac- 
 tion of a large stone, or after the use of a plug for arresting hfemorrhage. 
 His experience is that " Nature seldom fails to bring about a cure, or 
 so to contract the wound as to leave but trifling inconvenience." 
 
 6. Wounding the posterior wall of bladder. Sir S. ^Vells, at the 
 discussion on Sir H. Thompson's paper (J/«/.-C7nV. Soc, April 2, 1878), 
 mentioned a case in which Mr. Tyrrell wounded the back of the bladder, 
 and hence always advocated a short knife. 
 
 E. Finding and Extracting the Stone.— The surgeon's left 
 
 index finger, liaving passed into the bladder along the convexity of 
 the staff,* finds the stone, hooks this down as near to the neck as 
 possible, and at the same time it steadies the neck while it dilates the 
 incision in it and in the prostate. This combination of movements 
 
 * This is only willidrawn when the stone is felt, not before. 
 
LATERAL LITHOTOMY. 747 
 
 requires most careful attention to each of its details separately. The 
 most important of these is the dilatation of the neck and prostate. 
 If the stone is found to be a large one the deep part of the wound 
 must be sufficiently free. It is well known how much has been 
 written on this njatter. The surgeon should begin by dilating the 
 neck of the bladder carefully and ofjually in every direction, using a 
 considerable amount of force in an adult, but not throwing this on 
 any limited portion of the wound. It may be accepted as a certain 
 fact that the wound in the prostate may extend through the whole of 
 this body, without risk of cellulitis, if only the recto-vesical capsule 
 is not torn through. As long as the finger is girt by a fibrous ring 
 this mischief has not been done. Whether an extensive wound in the 
 prostate had better be made l\v dilatation and laceration or by free 
 incision will jorobably never be settled. The wise surgeon will avail 
 himself of a safe use of both — that is to say, after dilating with forcible 
 but equal pressure all around the original wound in the neck, he will 
 introd\ice a blunt-pointed narrow-bladed bistoury flat against the 
 pulp of his finger, and nick the remaining constriction at one or two 
 places, cutting rather than nicking tow'ards the right side. 
 
 Next to the size of the stone the age of the patient must here be 
 considered. After middle life the cellular tissue around the neck of 
 the bladder is not only loose, but abounds in enlarged veins. Hence 
 the risk of causing not only cellulitis but septic phlebitis by dilating 
 an inadequate opening by the tearing, bruising exit of the stone, 
 instead of by the finger and knife combined. 
 
 The deep opening being thus made sufficiently free, the surgeon 
 having selected his forceps, introduces them along the finger (thus 
 further dilating the wound), the latter being withdrawn as the forceps 
 enter. These held at first in one hand (the thumb in the ring) are 
 fully introduced closed, then opened widely transversely, and by a 
 quarter turn of the handles, the lower blade is made to scoop or sweep 
 along the floor of the bladder, which will almost surely catch the 
 stone. If this step fail it is repeated, and if the stone is still not 
 caught, the surgeon feels again for the stone either with the closed 
 forceps or by again inserting his finger, which will bring down the 
 stone, push off projecting folds of mucous membrane, etc. Differently 
 curved foceps, supra-pubic pressure, and a finger in the rectum, may 
 all help now. 
 
 The stone being caught, the finger again feels if it is held in its 
 shorter axis ; if so, it may at once be extracted, if moderate in size, 
 by steady deliberate traction downwards and outwards. As long as 
 the stone advances all is well, if not gentle rotation may again start it 
 on its way. In less easy cases Mr. Cadge's words should be remem- 
 bered. " Should there be much resistance and no sense of gradual 
 
748 OPERATIONS ON THE ABDOMEN. 
 
 yielding, the surgeon will ask himself whether this is due to an insuflfi- 
 cient opening, or to the projection of the ends of an oval stone laterally 
 beyond the bladder. This latter may be known by observing that the 
 bladder is brought l.odily down, so that the prostate, which is probably 
 large, is visible near the external wound ; in this case the stone must 
 be liberated, the finger again introduced, and a fresh hold taken. If 
 the obstruction is due to a large stone and too small a wound, the 
 latter is to be enlarged in the direction of the first incision ; this, in 
 the opinion of the writer, is preferable to making the division of the 
 neck of the bladder on the opposite side, and preferable, too, to using 
 undue traction and force." 
 
 In some cases a scoop will facilitate extraction, the stone being 
 firmly held between the pulp of the left index finger and the concavity 
 of the scoop. In children one finger in the rectum and one in the 
 bladder will often serve the purpose. 
 
 The stone being out, the bladder is carefully explored with the 
 finger, or a short-beaked staff, aided by pressure above the pubes, or 
 from within the bowel, for anj' other calculi or fragments. Multiple 
 calculi will have been indicated by facets upon the first. 
 
 Any bleeding vessels are now secured, and the jjatient, wrajDped up 
 in blankets, is removed to bed. 
 
 Difficulties during the Stage of Extraction of the Stone. 
 
 (1) The position of the stone. This may be out of reach owing to 
 its being at the posterior i^art of a dilated bladder, above the pubes, 
 or to the patient liaving a very fat and deei3 perineum. Pressure 
 above the pubes and the use of long forceps are here indicated. 
 
 (2) An enlarged prostate. This interferes with reaching the stone 
 both with finger and forceps. Curved forceps passed in along the 
 staff, or a gorget, if the perineum be very deep, will be helpful here, 
 and perhaps a bag in the rectum would aid in raising up the stone 
 within reach in difficult cases. An enlarged middle lobe of the pros- 
 tate, or a separate adenoma of this gland, may also cause trouble by 
 getting between the blades of the forceps. Tearing away of these 
 portions of the gland has often occurred and is sometimes certainly 
 beneficial.* 
 
 (3) Breaking up of the stone. Tliis may occur with hard calculi 
 from too much force being used with the forceps, but it much more 
 often hapi>ens with soft phosphatic calculi. In such cases every 
 
 * It is doubtful if this is always so. Thus Mr. Cadge [Inc. supra cit.) thinks " that 
 it is probable that a careful examination of the subsequent condition of such patients 
 would show that, although it may not have endangered life, it has not infrequently 
 been followed by partial inability to retain uriue. Prof. Gross {Trans. Philaii. Path- 
 Soc, vol. iv. p. I. 53) thought that in one ease the cavity left behind became a suppu- 
 rating pouch, and increa-sed the difficulty in micturition. 
 
SUPRA-PUBIC LITHOTOMY. 749 
 
 fragment must be cleared out, a matter of souie difficult)^, as small 
 ones are readily concealed in clots or folds of mucous membrane. 
 After all the larger ones are picked out, a catheter of appropriate size, 
 attached to a Higgenson's syringe, is inserted, and the bladder thor- 
 oughly and forcibly washed out with diluted Tliompson's fluid (1 in 
 6 or 8) (p. 619). In a week or ten days the bladder should again be 
 carefully sounded, and examined with the finger, and any fragment 
 extracted, this being especially needful if pain lias persisted after the 
 operation.* If fragments still persist a little later, an evacuating- 
 tube and washing-bottle, aided if necessary by a, flat-bladed lithotrite, 
 must be employed. I may here express my lielief that multiple cal- 
 culi are not quite as rare as has been supposed. 
 
 (4) Size and shape of the stone. Mr. Erichsen writes on this 
 subject: " A calculus about 11 inch in its shorter diameter will be 
 hard to extract through an incision of the ordinary length (not ex- 
 ceeding eight lines) in the prostate, even though this be considerably 
 dilated by the pressure of the fingers ; and I think it may be safely 
 said that a calculus 2 inches and upwards in diameter can scarcely 
 be removed by the ordinary lateral operation with any degree of force 
 which it is safe to employ." Most will agree with Mr. Cadge that 
 stones weighing upwards of 3 ozs. will be dealt with by the improved 
 supra-pubic method. 
 
 SUPRA-PUBIO LITHOTOMY (Figs. 123-5). 
 Indications. — I may quote here from a paper which I read before 
 the Royal Medico-Chirurgical Society ,t and which concluded with 
 the following proi^ositions : 
 
 1. "That supra-pubic lithotomy, as recently modified, has a future 
 of renewed usefulness before it, and that while, as an operation, it 
 can never contrast with the rapid brilliancy of the lateral operation, 
 it will be found of great value by those who only have to deal with 
 stone occasionally, and by those who find themselves face to face 
 with calculi of considerable size in adults. 
 
 2. " That to give other and more individual instances, the operation 
 will be found useful in (a) many cases of hard stones of IJ inch in 
 diameter ; (b) in multiple hard stones ; ( c) in cases of calculus not 
 phosphatic, occurring with enlarged prostate ; (d) in some cases of 
 foreign body in the bladder with abundant calculous deposit (Sir H. 
 Thompson). 
 
 * "Recnrrence of stone witliin two years almost alwa,ys means that a fragment has 
 been left after the o|)eration. No greater disappointment than tliis, both to the sur- 
 geon and patient, can happen. No one, probably, has cnt fifty patients without 
 having to admit and lament its oceiirrence, but it is especially liable to occur to the 
 inexperienced" (Cadge). 
 
 f Trans., vol. Ixix. p. 377. 
 
750 OPERATIONS ON THE ABDOJIEN. 
 
 " In the rarer cases of (e) a state of urethra which will not admit 
 the use of a lithotrite; (/) in a very deep perineum; ig) in a child 
 with deformed pelvic outlet ; (h) in a patient with ankylosed hip- 
 joint not admitting of his being placed in the usual lateral lithotomy 
 position (Sir H. Thompson). 
 
 3. " That at present, till a larger number of cases of the improved 
 operation have been collected, it will be wiser not to attempt to close 
 the bladder with sutures. 
 
 4. " That in reviving an abandoned operation these two questions 
 call for an answer : 
 
 " (a) Do we stand in a better position towards the operation than 
 our predecessors did ? 
 
 " This question can only be answered in the affirmative after the 
 work done by Prof. Petersen and Sir H. Thompson. 
 
 "(6) On what grounds was the operation abandoned? The chief 
 of these appear to have been, (1) the absence of any means of cer- 
 tainly avoiding the peritoneum; (2) the difficulty of sufficiently and 
 painlessly distending the bladder in pre-an^sthetic days; (3) the 
 absence of antiseptic fluids; (4) the fact that the operation was 
 usually reserved for very large stones, and that it was often performed 
 for such stones after lateral lithotomy had been attempted either on 
 the same or the preceding day." 
 
 To the above remarks I would now add, speaking from a larger 
 experience, that the wound here is slower in closing, in fact, it may 
 not heal firmly, as long as the urine may be alkaline. (Jecasionally 
 it reopens, probably, as suggested by Petersen, from the linea alba 
 uniting before the bladder. 
 
 The greater trouble and the longer time which this operation en- 
 tails, both during its performance and afterwards, will not be grudged 
 in these days, when it is so much the rule to pay attention to the 
 details of surgery. Only time and a larger collection of cases will 
 show how far, with much simpler structures to cut, with these brought 
 safely into reach, and with modern antiseptic details at hand in the 
 after-treatment, this lithotomy is safer than the far more brilliant 
 lateral one. 
 
 Details of the Operation.* 
 
 A. Distension of the Rectum. — The bag used for this must 
 be (1) of sufficient strengthf; and (2) of appropriate size. Thus, it 
 
 * Tliese are largely taken troni a paper of mine {Brit. M(d. Jotirn., October 23 
 and 30, 1S8C). 
 
 t M. Gnyon {Ann. r/e Mill, des Organ. Genito win, t. i. p 97) mentions a, case in 
 wliicli tlie bug, licingof thin india-rnbber, did not snpport the bladder with sufficient 
 firmness; the bladder, thus yielding to pressnre, was difficnlt to open. Any addi- 
 tional handling of, or difficulty in opening, the bladder must increase the risks of 
 cellulitis. 
 
SUPEA-PUBIC LITHOTOMY. 
 
 751 
 
 FrG. 123. 
 
 should be of as soft rubber as is consistent with strength, with seams as 
 little prominent as possible * and flattened rather than pyriform in 
 shape. (3)Theamountoffluid. Aflatf 
 oval bag (Figs. 123, 11^4) well coated 
 with eucalyptus and vaseline, entirely 
 emptied of air and folded up, is intro- 
 duced well above the sphincters (the 
 bowels having, of course, been well 
 emptied). It is then carefully dis- 
 tended, by means of an easily working 
 syringe with water varying in amount 
 from 2^ to 3 ozs. in a child of five, to 
 10 or 12 ozs. in an adult. Sir H. 
 Thompson gives the amount in the 
 adult as 12 to 14 ozs. I would advise 
 operators to be content with the 
 smaller amount at first, adding a little 
 more later on, if needful, and only to 
 use the larger amounts in special cases 
 — e.g., large stones, J doubtful cases, 
 or where a growth is present and it 
 is desired to give extra elevation and 
 steadying to the bladder. 
 
 It is evident that with such large 
 amounts as those recommended by 
 some — e.g., M. Guyon — serious risk is 
 run of damaging the rectal mucous 
 membrane. That this is no idle fear 
 is proved by a case which came to the 
 knowledge of Mr. Cadge, in which 15 
 ozs. in the rectal bag caused a distinct 
 tear of mucous membrane. 
 
 B. Distension of the Bladder. 
 — The urine being first drawn off, 
 8 to 10 ozs. of Thompson's fluid (borax, 1 pt., glycerine, 2 pts., water, 
 2 pts.), diluted 1 in 6, carbolic acid 1 in 80, mercury perchloride solu- 
 tion 1 in 1000, are generally thrown in by means of a syringe which 
 
 * In two of my earlier cases a little blood-stained mncns followed the withdrawal 
 of the empty bag; no ill resnlts ensued, and as this did not occur in four later cases, I 
 think it may be attributed to the use of the earlier bags of pyriform shape, stout 
 rubber, and prominent seams. 
 
 t The pyriform bags tended to raise only the centre of the base of the bladder, 
 leaving two lateral sulci, in which it might be troublesome to find the stone. 
 
 t As in Sir Henrv's cases. 
 
 Oval rectal bag, empty. 
 
752 
 
 OPERATIONS OX THE ABDOME.V, 
 
 works smoothly, and whose capacity is ]<nawn. In children from 
 two to five about 3 ozs. will be sufficient. The patient should be well 
 under the influence of the anrcsthetic at this time, and if any strain- 
 ing takes place the injecting must be stopped, the hypogastric region 
 supported with two hands, and some fluid allowed to run out if 
 needful. 
 
 It may not be out of place to remark here that the surgeon will do 
 well, when injecting rectum and bladder, to make sure that he is in- 
 
 FiG. 124. 
 
 Oval rectal bag.s, partly distended. A child's size ia shown below. 
 
 jecting fluids only. If he makes trial of the bag outside the bodj', 
 he will see how easy it is to send in air as well as fluids, and thus to 
 produce more distension than is intended, unless the bag is absolutely 
 emptied first, and unless the syringe acts jierfectly. By the double 
 distension of rectum and bladder, the latter will, if not visible to the 
 eye, be felt by the left hand of the ,<urgeon (which should most care- 
 fully keep touch of the supra-pubic region), reaching about two- 
 thirds of the way to the umbilicus. 
 
 In injecting the bladder, often irritable in these cases, the surgeon 
 must keep careful count of its resistance. M. Guyon's* words should 
 now l)e remembered. "On pent completcment supprimer la sensi- 
 bility au contact, mais jamais sa sensibilite t\ la distension." 
 
 After withdrawing the catheter, a Jaques' catheter or a draining 
 tube is tied round the penis to prevent the escape of the fluid. 
 
 * Loc. supra cit , p. 1 1 I . 
 
SUPEA-PUBIC LITHOTOMY. 753 
 
 In these cases of irritable bladder, where the contents are ejected 
 immediately & sound is introduced, attention must be paid for a few 
 days previous to the operation, to getting the bladder accustomed to 
 gentle distension, steps which will also promote an antiseptic condi- 
 tion of the wovmd. 
 
 C. The Operation Itself.— The pubes being shaved, the knees 
 slightly flexed, and the shoulders a little raised, an incision is made 
 about 3 inches Ion-;-, exactly in the middle line and ending over the 
 upper border of the pubes. The subcutaneous fat, oft-en plentiful in 
 amount, having been divided and any vessels secured with Spencer 
 Wells's forceps, the linea alba is identified,* nicked, and slit up for 
 2 or 3 inches. The transversalis fascia is then picked up at the 
 lower angle of the wound and divided. The retractors now drawing 
 the edges of the wound well apart, a layer of fat often abundant and 
 frequently having large veins in it will next come into view, lying 
 over and concealing the bladder. This must be torn through care- 
 fully and as cleanly as possible with the point of the director. Any 
 veins which cross the wound (and a transverse branch lies often just 
 opposite the site of puncture into the bladder), should be secured 
 with forceps. If one is opened at this stage the field of the operation 
 will be obscured by most troublesome hsemorrha.ge.t This must be 
 arrested, any pressure-forceps employed acting also as retractors; 
 prolonged manipulation in arresting haemorrhage here may be the 
 cause of that cellulitis later on which is so much to be deprecated. 
 The anterior surface of the bladder will now be recognized by its 
 pink color, the fibres of the detrusor urinaj, and by its fluctuating 
 under the finger. Veins often are met with again here on the bladder 
 itself, longitudinal, transverse and occasionally plexiform. A spot on 
 the anterior surface of the bladder having been chosen just above the 
 pubes, it is punctured, and the left index finger at once introduced to 
 feel for the stone. This is best removed by two fingers, or, if pre- 
 ferred, by forceps and scoop. The fingers, if successful, have the 
 advantage of not risking any injury to the mucous membrane. As 
 soon as the stone is removed and the bladder thoroughly explored, 
 
 * If, instead of exactly hitting off the linea alba at once, the surgeon exposes fibres 
 of a rectus orpyramidalis, he shonld go straight on through these with a director. 
 Any prolonged search for the linea alba will leave frayed fibrons tissne, which will 
 slough tediously, and become coated with phosphatic de|>06its if th-e urine be am- 
 moniacal. 
 
 t M. Gnyon in his second case met with most profiise hsernorrhage- "Nous 
 essayaraee, mais assez vainement, k nous opposer a I'evahissement de tnnte la plaie par 
 nne nappe de sang sans cesse renouvel<^e." After repeated and fruitless attempts to 
 arrest this hemorrhage, the bladder was opened and the stone removed. The haemor- 
 rhage ceased entirely on the removal of the rectal bag. The patient, aged sixty-nine, 
 died with purulent infiltration of the sub-peritoneai connective tissue. 
 
 48 
 
754 OPERATIONS ON THE ABDOMEN. 
 
 the fluid should be set running from the rectal bag, as emptying this 
 takes some time. Two or three carbolized-silk sutures are then in- 
 serted in the linea alba above, and cut short, and three or four more 
 to draw the edges of the skin together (Fig. 125). 
 
 Question of Sutures in the Bladder.— I have not used these in any of 
 my six cases. Whether their use is advisable or not is as yet unset- 
 tled. I am very strongly of opinion that they should never be used 
 (i.) where there is cystitis — the urine was ammoniacal in my first 
 five cases; (ii.) where the stone is large; or (iii.) where the extrac- 
 tion is delayed or difficult. I cannot but think that sewing up the 
 bladder runs a great risk. If sutures are used, either the voluntary 
 powers of expulsion or the catheter must be trusted to. If the 
 former fail and the latter be trusted to, there is much risk of the 
 catheter becoming blocked, and of the lesser evils of urethritis and 
 cystitis,, especially with the delicate mucous membranes of children. 
 In either case, whether the instrument is left in or not, it seems to 
 me most likely that, either by plugging of the catheter or by this not 
 being passed just when required, some urine, perhaps septic, may be 
 forced out between the sutures before the bladder wound is firmly 
 closed, a process which must take two or three days. If this extrava- 
 sation should take place deep down in a wound like this, especially 
 when the superficial part is closed, there is the gravest peril of a 
 fatal issue from purulent infiltration of the connective tissue of the 
 pelvis and abdominal wall. 
 
 I do not vnsh to appear to forget such a case as that of Dr. Pilcher, 
 who, after supra-pubic lithotomy in an adult, sutured the bladder 
 and used a catheter till the ninth day. The patient went out on the 
 eleventh, and was shown to the New York Medical Society on the 
 fourteenth day, "primary xmion having taken place throughout the 
 whole extent of the wound, without unpleasant symptoms of any 
 kind." Mr. R. W. Parker has had an equally successful case in a 
 child aged three. But, however satisfactory it may be thus to shorten- 
 time and trouble, I cannot but think, for reasons already given, that 
 the risk run is greater than any advantage gained. 
 
 A few words may be said here about the peritoneum. With such 
 distension of the bladder and rectum as has been advised, with an 
 incision not begun too high up and carried well down over the pubes, 
 with a moderate incision into the bladder, it is most unlikely that 
 anything will be seen of the peritoneum. It may be very indistinctly 
 felt at the upper part of the wound, but this is usually all. 
 
 If, after careful distension of the rectum and bladder the peri- 
 toneum still seems to encroach too far upon the anterior surface of 
 the bladder, it may be pressed upwards and held out of the way by 
 one or two fingers of an assistant, or, if needful, gently peeled upwards 
 
SUPKA-PUBIO LITHOTOMY. 
 
 ^55 
 
 off the bladder with a steel director * In elderly people with lax 
 tissues and large stones requiring free incisions, the peritoneum 
 covered with its fatty tissue is more likely to be seen rising and fall- 
 ing in the upper angle of the wound. 
 
 If, what IS most unlikely with the recent improvements in the 
 operation, the peritoneum should be punctured before the bladder 
 is opened, the puncture should be pinched up and tied around with 
 fine silk or chromic gut ; or the completion of the operation had better, 
 perhaps, be deferred, or lateral lithotomy performed. 
 
 If the opening is made after the bladder is openecf, the surgeon 
 must decide, according to the amount and character of the urine which 
 has escaped, between suturing the opening and enlarging it upwards, 
 so as to thoroughly sponge out or cleanse by irrigation with a 2 per 
 cent, solution of boracic acid, the peritoneal cavity. But these acci- 
 dents are most unlikely nowadays. 
 
 D. The After-treatment.— A little iodoform should be dusted in 
 and around the wound once in twenty-four or thirty-six hours, and 
 iodoform or sal-alembroth gauze and boracic lint applied externally. 
 The trochanteric and gluteal regions should 
 be kept well smeared with eucalyptus oint- 
 ment. If the above dressings are kept in 
 position with a many-tailed bandage, it only 
 takes a few minutes to renew them. This 
 will be necessary, at first, every three or four 
 hours ; in fact, the surgeon who wishes to 
 practice this operation successfully will find 
 that the local after-treatment will give him a 
 good deal more trouble than is usually be- 
 stowed on a case of lateral lithotomy, where 
 the patient simply lies on a mackintosh and 
 draw-sheet, and perhaps a lithotomy sponge, 
 ■with his knees tied together for the first few 
 
 hours 
 
 _ Supra-pubic lithotomy iucl- 
 
 It is only by keeping the wound aseptic by sion, seven days after ttie opera- 
 
 the frequent change of dressings, the use, if «°"- only the upper part of the 
 
 ^ ^ . wound was sutured. 
 
 needful, of some such fluid as that given at 
 
 p. 752, and by turning the patient on his side for three hours at a time, 
 after the first twelve hours, as recommended by Sir H. Thompson, that 
 the risks of cellulitis and extravasation can be prevented, the two points 
 
 Fig. 125 
 
 * At the Congress of German Surgeons in 1886, Gussenbauer, Sonnenberg, and 
 Kramer mentioned cases in which the peritoneum was found adiierent to the sym- 
 physis. In one case it was opened with fatal results; in another, the opening was 
 sewn up and the peritoneum safely separated from the pubes. 
 
756 OPERATIONS ON THE ABDOMEN. 
 
 in which this operation is said, rightly or wrongly, to be inferior to 
 the lateral method. 
 
 I have now operated by this method six times in the last two years, 
 the patients ranging from three to sixty-two years. None of the stones 
 were large. In two they were multiple. In the first five the urine 
 was alkaline and foul. One case was fatal— th'e sixth, a lad of nine- 
 teen, an orphan, in wretched condition of body, and in much misery 
 from pain. Perhaps I should have done more wisely to have waited 
 longer, in order to feed him up before operating. His pain, however, 
 was so severe that I operated a week after his admission into the hos- 
 pital. He did excellently for forty-eight hours, then symptoms of 
 pelvic cellulitis set in, proving fatal on the fourth day. 
 
 While on some points connected with the operation my mind 
 remains open, I am strongly of opinion that, with carefulness, it is a 
 safer operation than the lateral method for those who only perform 
 lithotomy occasionally, and for large stones— e..(/., over 3 oz. I do not 
 think any benefit is to be gained by substituting it for the lateral in 
 the case of children. 
 
 MEDIAN LITHOTOMY. 
 
 Disadvantages. 
 
 1. It gives very little room, and is unsuited to any save the smallest 
 stones. 
 
 2. The wound being small, the surgeon cannot bury his knuckles 
 in it or reach the bladder as easily as in the case of the larger lateral 
 wound (Cadge). 
 
 3. The rectum on the one hand, and the bulb on the other, are in 
 greater danger than by the lateral method (Cadge). 
 
 4. Troublesome bleeding is more frequent (Cadge). 
 
 Mr. Cadge, having operated on fifty or sixty cases bj' the median 
 method, has given it up for the above reasons, and also because his 
 mortality has been rather higher. 
 
 Advantages. — Recovery is ofteii extremely rapid; the urine 
 quickly resumes its natural route; and the wound, instead of gaping 
 and healing slowly as the lateral wound does, heals almost by first 
 intention. 
 
 The above do not, however, compensate, in Mr. Cadge's opinion, for 
 the disadvantages. He would avoid it, especially in children, in whom 
 it is by some preferred, as in them a free incision is necessary to facil- 
 itate the passing of the finger into the bladder, while here the limit 
 of space for the knife is very small indeed. 
 
 The opc'ration is suited for prostatic calculi, but, if these are asso- 
 ciated with any larger one in the bladder, the surgeon must either 
 crush this before he can extract it through his small incision, or per- 
 form a supra-pubic operation. 
 
MEDIAN LITHOTOMY. 757 
 
 Operation.— If a curved * staff be used, one with a wide groove is 
 chosen, and j^assed and held with its handle inclined towards the 
 umbilicus (p. 742), the patient being in lithotomy position. The sur- 
 geon passes his left forefinger into the rectum so as to steady with its 
 tip the staff in the membranous urethra and also to guard the rectum 
 from puncture, while at the same time note is taken of the depth of 
 tissues between the knife and the finger. A straight and very sharp 
 bistoury is then pushed, with its back downwards, through the skin 
 i inch above the anus straight on into the groove in the staff, which 
 is now held well hooked up against the pubes. The knife, 'having 
 distinctly exposed the groove, is pushed a little onwards so as to nick 
 the apex of the prostate, and next, as it is withdrawn, it is carried 
 upwards in the raphe so as to divide the soft parts for 1 inch or more 
 according to the size of the stone. The finger would now be passed 
 into the bladder and the staff withdrawn. As, however, the staff 
 occupies too much room in the limited wound to allow of this, a 
 director is passed in along the groove, the staff withdrawn, and then 
 the finger introduced along the director through the neck of the blad- 
 der. This is dilated sufficiently, and the scoop or forceps introduced. 
 
 Some surgeons prefer to make the incision from above downwards, 
 but cutting from below upwards would seem better to protect the 
 bowel. 
 
 If a straight staff" be used, the surgeon, introducing his knife as 
 above, and having cut upon the staff distinctly both to himself and 
 the assistant who is holding it, takes it into his left hand, and, having 
 brought it down into an oblique position, runs his bistoury along the 
 groove so as to nick the prostate; the enlargement of the wound and 
 the rest of the operation are conducted as above. 
 
 Complications and Causes of Death after Lithotomy. 
 
 1. Shock. — This is rarely severe, save in patients much pulled down, 
 and after prolonged operations. Children, as a rule, however reduced,t 
 rally well after the operation (Sir J. Paget, Clin. Essays, p. 404). 
 
 2. Hemorrhage. — If milder methods fail, this is best met by plug- 
 ging the wound with the umbrella-plug, or by leaving in situ a pair of 
 Spencer Wells's forceps, Avhich will also aid the drainage. 
 
 3. Pelvic cellulitis. — This, the most frequent cause of death, is due 
 either to extravasation of urine, probably septic, or to laceration of 
 
 * Mr. Erichsen recommends a rectangular staff, the angle of which rests against the 
 apex of the prostate, and is thus much easier to find in the perineum. This special 
 stafi'is, however, often difficult to introduce, and a curved one, held so a.s to project its 
 curve in the perineum, will be easily found. 
 
 t Occasionally, however, even nowadays, where the histor}' is of long standing, and 
 the kidneys much impaired, they are too far gone fur operation. See a case by Mr. 
 Hutchinson (Clin. Surg., pi. Ixxvi. vol. ii. p. 126). 
 
758 OPERATIONS ON THE ABDOMEN. 
 
 the deep parts, or both. It usually comes on within forty-eight 
 hours. 
 
 4. Peritonitis. — Usually combined with the above. 
 
 6. Septic complications.— Septicsemia may occur early with pelvic 
 cellulitis. Pyajmia, on the other hand, may come on later. 
 
 6. Surgical kidney. 
 
 7. Retention of urine.— Common enough a few days after from 
 swelling of the parts. Rarely more serious. 
 
 8. Suppression of urine. 
 
 9. A sloughy phosphatic state of the wound. 
 
 10. Sloughing of the rectum (p. 746). 
 
 11. Cystitis. — Rare. 
 
 12. Epididymitis. 
 
 13. Such causes as tetanus. 
 
 Later complications, rare, but troublesome : 
 
 14. Fistula. 
 
 15. Incontinence. 
 
 16. Sterility. 
 
 LITHOTRITY-OPERATION WITH SEVERAL SITTINGS 
 —RAPID OPERATION WITH ONE SITTING AND 
 E VAO UATION.— LITHOLAPAXY. 
 
 Choice of Operation — Lithotrity or Lithotomy. — It is hoped 
 that the following points, while they do not in the least exhaust the 
 subject, will be found of practical assistance. 
 
 1. Amount of experience of the surgeon. — Every attempt should he 
 made to become familiar with the use of the instruments, both outside 
 the body and also by passing a lithotrite for examination of a calculus 
 whenever one is felt on sounding. No surgeon who has not had abun- 
 dant opportunities of practicing the needful manipulations will do 
 wisely in attempting to crush a hard stone which weighs an ounce. 
 
 2. Size, kind, and number of stones. — As to size, up to 1 oz. or li 
 oz. it is probable that, with the majority of stones, in fairly jaracticed 
 hands lithotrity is immensely superior to lithotomy as far as imme- 
 diate mortality is concerned. I use the term '' immediate " advisedlj^, 
 because of the more frequent recurrence, with its results, a fter lithotrity, 
 and would refer my readers to the remarks on this point at p. 761. 
 With calculi from IJ to 3 oz., to quote Mr. Cadge's words, "it yet 
 remains to be seen whether litbotomy by any method can be applied 
 with more safety and success than lithotrity." 
 
 The difficulty of a decision sometimes met with here is well ex- 
 pressed by the words of Sir W. Fergusson, that the greater is the 
 experience of the surgeon the greater will sometimes be his doubt. 
 
 Sir H. Thompson, speaking of hard calculi and litholapaxy {R.C.S. 
 
LITHOTRITY LITHOLAPAXV. 759 
 
 Led., 1884, p. 127), states that the lar-est he has dealt with weic^hed 2i 
 oz., the operation Listing seventy minutes. As the outcome of a very 
 especial e^cperience, the same Lectures show (p. 138) that with Sir H 
 Thompson the proportion of lithotomy to lithotritv has fallen from 1 
 in 4 to 1 in 30. 
 
 More important than the size of the stone is its composition. There 
 is, of course, no comparison between a pure lithic acid or oxalate of 
 hme stone on the one hand and an alternating stone with a good deal 
 of phosphate or urates in its composition, as a test of skill and en- 
 durance both on the part of the surgeon and his instruments. Dr. 
 Hingston,=i= of Montreal, points out that sometimes the apparent soft- 
 ness of a stone is most misleading. Having found an enormous stone 
 in a patient, he employed lithotrity, as the stone seemed soft. After 
 getting away a large quantity of phosphatic matter, he was driven to 
 perform lithotomy, and removed, by the lateral method, a calculus 
 weighing over 5 oz., consisting mainly of oxalate of lime and uric 
 acid. 
 
 There are several fallacies in addition to the above in gauging the 
 size and number of calculi. Thus the lithotrite may again and again 
 seize a stone which only weighs i oz. in its long diameter, if flattened, 
 of 2 inches. Testing by passing a staff around or rubbing it over a 
 calculus is often most fallacious, and examining per rectum may, if the 
 bladder be thickened, give evidence of a stone apparently much larger 
 than it really is. Mr. Cadge (foe. siqym cit.) points out a fallacy with 
 regard to multiple stones. " When more than one stone is present, it is 
 customary to seize one, fix it in the instrument, and proceed to sound 
 afresh ; this, however, may mislead, for a stone, having been grasped 
 by the tips of the blades and moved about in the bladder, will some- 
 times rotate a little in the blades of the lithotrite and communicate a 
 grating feel to the hand which is very like touching a second stone." 
 3. Condition of the urethra. — Two points have to be considered 
 here — (a) how far will the urethra admit instruments, ?,e., how far is 
 its canal normal or diminished by stricture; (6) how far, even if 
 normal in calibre, will the urethra tolerate instruments. With regard 
 to the first, a stricture, if admitting of dilatation, is not an obstacle to 
 lithotrity; on the other hand, an old stricture with surrounding indu- 
 ration and fistulje, or a less severe form which produces rigors and 
 fever at each attempt at dilatation, are best submitted to lithotomy, 
 which gives the best chance for the stone, and at the same time offers 
 the much needed relief of rest to the stricture. Mr. Cadge gives the 
 following practical hint in these cases of stone combined with stricture : 
 " Sometimes a stone is detected in the urethra behind the stricture, as 
 
 * Intern. Encyel. ofSurg.,vo\. vi. p. 311, in his article on Litliotrity. 
 
760 OPERATIONS ON THE ABDOMEN. 
 
 well as one or more in the bladder, or it may be partly in the bladder 
 and partly in the urethra, and in these cases median lithotomy will 
 not only remove the stone, Ijut may go far to remedy the stricture by 
 external division." 
 
 With regard to an irritable urethra, i.e., one without a stricture and 
 only admitting instruments with the aid of anesthetics— the chief 
 points to consider are the size of the stone and the ability of the sur- 
 geon to deal with it by litholupaxy. If the calculus cannot be evacu- 
 ated at once, or requires more than one sitting, lithotomy should be 
 preferred, owing to the results of the passage of instruments and pro- 
 longed voiding of fragments. 
 
 4. Condition of the prostate. — An enlarged prostate is of great im- 
 portance, not only from its power of obstructing the operation, but 
 from the changes which it brings about in the bladder. Thus it in- 
 terferes with the efficient use of instruments, the picking up of a stone 
 even with blades reversed, and the finding of the last fragment. Again, 
 the use of the lithotrite and the passage of evacuating tubes readily 
 lead to haemorrhage, and this again Ity clots prevents the free and easy 
 use of the evacuator. Later on, phosphatic deposit, imperfect evacua- 
 tion, residual urine, and recurrence of stone symi^toms are all frequent' 
 accompaniments of enlarged prostate. 
 
 5. Condition of the bladder. — Formerly it was held needful to 
 operate with several ounces of fluid in the bladder, and some sug- 
 gested to draw off the urine and inject 8 or 10 oz. of fluid. This 
 amount has now been reduced to something more like 4 or 6 oz. As, 
 if the urine is healthN', no fluid is more suited to the bladder, the sur 
 geon should content himself with following Sir H.' Thompson, and 
 " ask the patient to retain his urine for a little less than his accustomed 
 period before the sitting; that is, if he is naturally able to retain his 
 urine for about an hour, he is requested to pass it fortj' minutes before 
 the time of the visit." 
 
 Some other changes in the bladder require mention, (a) Saccula- 
 tion pouches or sacs, whether mere hollows behind or at the sides of 
 an enlarged prostate, or hernial 2:)rotrusions of the mucous membrane 
 between the muscular fibres, may be the starting-point of calculus- by 
 entangling debris or tiny fragments. In Mr. Cadge's words: "The 
 imprisoned fragment first fills up the cyst, then, by continual accretion 
 of phosphates, it grows up into the bladder like a mushroom, and is 
 probably again and again nibbled off by the lithotrite, each time with 
 temporary benefit, until the patient dies, worn out with chronic cystitis 
 and pyelitis." Mr. Cadge goes on to say : " By turning the aperture 
 of the evacuating catlieter towards these pouches, and by the free use 
 of the aspirator in all directions, the fragments may be washed out of 
 them and all removed, but it cannot be denied that it is always a se- 
 
LITHOTEITY LITHOLAPAXY. 761 
 
 rions matter to shatter a stone into innumerable fragments in a bladder 
 of this description."' (6) Atony, whether with or without an enlarged 
 prostate. The importance of this is obvious, as tending to recurrence 
 of stone by some small fragments not being expelled in spite of the 
 vigorous use of the aspirator, and also to cystitis from imperfect 
 emptying of the bladder. 
 
 6. Condition of the kidneys. — Here I may again quote a veteran's 
 opinion, that of Mr. Cadge : '' What is to be said of stone complicated 
 with kidney disease, such as albuminuria and chronic j^yelitis and 
 atrophy ? In these cases all operations are fraught with danger, but 
 it is probable that the least danger will be met with from a carefully 
 conducted one-sitting lithotrity. So, too, in those cases of constitutional 
 disease combined with stone, such as diabetes, tabes, and other spine 
 disease, it will be well to avoid the shock and hremorrhage of lithotomy, 
 and proceed, if any surgical proceeding is allowable, by lithotrity." 
 The surgeon, in considering an operation in any of the above diseases, 
 will weigh well the size of the stone, his ability to cope with it at one 
 sitting, and the amount of suifering which it causes the patient. 
 
 7. Age. — Here, especially, age is not to be reckoned by years alone. 
 Recurrence. — As no one, to my knowledge, has spoken out on 
 
 this subject with such helpful candor as Mr. Cadge, with his experi- 
 ence of 300 cases of stone, I make no apology for quoting once more 
 from his writings.* " Although the immediate and direct mortality 
 of lithotrity is small, the recurrence of stone is lamentably frequent. 
 In my own list of 133 cases, there were 18 in which recurrence, one or 
 more times, took place, being about 1 in 7. Sir H. Thompson, with a 
 much larger number of cases, gives about the same proportion. I am 
 disposed to infer, however, that recurrence is more frequent even than 
 this, because it is not likely that all who get relapse apply to the same 
 surgeon again. Living, as I do, in a local centre, and drawing cases 
 chiefly from a limited area, I am probably more able to trace, and 
 more called on totreat, those who suffer a second and third time, than 
 he who lives in the metropolis and draws his cases from great distances. 
 Patients may, and frequently do, apply to the same operator once or 
 twice ; but, after a time, they either apply to their own surgeon, or 
 they decline further treatment, and too often their subsequent history 
 is one of painful endurance of chronic bladder disease and gradual 
 exhaustion. If, moreover, there be added to the list those numerous 
 cases of phosphatic deposit or concretions so frequently noticed after 
 lithotrity, the relapses would, I believe, reach to nearly 20 per cent. 
 This seems a heavy indictment to bring against lithotrity, but I am 
 afraid there is no gainsaying it; and, if so, it would be wrong to pass 
 
 * Brit. Med. Journ., July 3, 1886. 
 
762 OPERATIOXS ON THE ABDOMEN. 
 
 it over or make light of it. Many of these relapses might be prevented 
 if the patients would observe directions and persevere with treatment. 
 It certainly is so with the unenlightened and uncomplaining hospital 
 patient. Feeling himself well, or what he considers well, he goes to 
 his work, and neglects the use of the catheter and other means ; and, 
 instead of returning in a month or so to have his cure certified, or a 
 minute remaining fragment removed, he toils away as long as he can, 
 and returns, perhaps in a year or two, with a fresh uric-acid stone, or 
 with chronic cystitis and a phosphatic one. The educated, sensitive, 
 private patient, on the other hand, will watch his symptoms narrowly, 
 and return if the slightest indication of the old mischief should 
 
 reappear This frequent recurrence must be due either (1) to 
 
 the descent of a fresh stone from the kidneys, or (2) to a fragment of 
 stone having been left at the first operation. As to the descent of a 
 fresh stone: there can, of course, be no doubt as to the occasional 
 occurrence of this cause, just as we see it occur after lithotomy. The 
 bladder being entirely cleared of stone, there will be the same liability 
 to the descent of a fresh renal calculus after one operation as after the 
 other. What, then, let me ask, is the fact as to lithotomy ? I have 
 already shown that there were only 21 cases out of more than 1000 of 
 lithotomy at the Norwich Hospital in which recurrence was clearly 
 traced to perfectly fresh formations coming, like the first, from the 
 kidney, or about 1 in 50; whereas, in Sir H. Thomjjson's list of about 
 600 persons treated by lithotrity, he mentions 61 cases in "which he 
 operated twice, 9 three times, 3 four times, and 2 five tim^s — 75 in all, 
 or about 1 in 8. The inference from these data seems to me to be in- 
 evitable that relapse of stone after lithotrity is chiefly due to other 
 causes than the descent of a fresh stone. To my thinking, the majority 
 of recurrences is caused by the great difficulty in ensuring the complete 
 removal of all the debris; I have already referred to this in old per- 
 sons with enlarged prostate and feeble atonic bladder, and it is this 
 class of patients who are especially liable to relapse." ]Mr. Cadge goes 
 on to show that the tendency to phosphatic deposit after lithotrity is 
 not due to vesical incompetence and residual urine alone without 
 some overlooked fragment, and that the improved method with re- 
 peated washings will still fail to discover a last fragment in some 
 bladders. 
 
 Operation (Fig. 126). — The preparatory treatment has been much 
 simplified. It is now recognized that the best course is to remove 
 the stone: previous passage of sounds, and injections of the bladder,* 
 
 * Tlie amount of urine to be held, in most cases, has already been mentioned (p. 
 760). 
 
LITHOTRITY — LITHOLAPAXY. 763 
 
 are now but little used. A few days' rest, bland unirritating liquid 
 diet, mild aperients, and securing sleep are the chief indications. 
 
 The instruments required will be gathered from the following 
 account. The patient being anffisthetized and lying on a firm couch 
 or mattress close to the right side of the bed or table, with his pelvis 
 raised, and body and limbs well protected from chill, the surgeon, 
 standing on the right side with his instruments close to him, intro- 
 duces his lithotrite. In doing this care must be taken not to get the 
 blades hitched either just in front of the triangular ligament or in the 
 roof of the prostatic urethra. This will be secured by not depressing 
 the instrument till very late — in fact, not till it is just about to enter 
 the bladder. The instrument, well warmed and oiled, is held at first 
 horizontally over the groin or abdomen, the penis being drawn over 
 it,. the shaft being all the time gradually brought into the vertical 
 position as the instrument finds its way by its own weight into the 
 bulbous, membranous, and prostatic urethra. Now, and not before, 
 the handle is somewhat depressed, and the instrument glides quickly 
 into the cavity of the bladder. If the prostatic Urethra is enlarged 
 and lengthened, the surgeon may think that he has reached the 
 bladder, but the fact that the gentlest lateral movement of the litho- 
 trite is interfered with will show him his mistake. Pressure with the 
 instrument is alone allowable at the meatus; some rotation maybe 
 called for in guiding the instrument through the triangular hgament 
 or past an enlarged prostate. In this latter case also the handles 
 must be further depressed, and a finger in the rectum may give help. 
 
 When the lithotrite has entered the bladder it should be allowed to 
 slide, very gently, down the trigone, being now held very lightly so 
 as at once to detect the site of the stone, which it now often touches, 
 but must not displace. 
 
 If the stone is felt on one side, the instrument is gently turned to 
 the opposite one, opened, and then turned towards the stone. If it 
 be not felt, the handles of the instruments being slightly raised, and 
 the blades very gently depressed and then opened, the stone will often 
 drop into them. 
 
 If this fail, the instrument is turned, open, first obliquely, then 
 more horizontally, first to the one side, then to the other. In the 
 event of the stone still eluding the lithotrite, which is most unlikely, 
 it should be sought for with blades depressed. To effect this, the 
 blades, closed, are raised ofi" the bladder floor by depression of the 
 handle, carefully reversed, and then depressed again so as to sweep 
 lightly over the floor. They are then gently opened and closed, 
 vertically first and then obliquely, so as to complete the examination. 
 
 During the above, the following points must ever be borne in 
 mind : 
 
764 OPERATIONS ON THE ABDOMEN. 
 
 (a) The handle and shaft of the lithotrite are to be kept as steady 
 as possible, so as not to jar the sensitive neck of the bladder need- 
 lessly. 
 
 (6) All movements are to be executed at or beyond the centre of the 
 vesical cavity, the proper area of operating, without hurry, rapid 
 movement,* or any other which partakes of the nature of a jerk or 
 concussion (Sir H. Thompson, loc. supra clt., p. 296). 
 
 The male blade is never to be brought into contact with the neck 
 of the bladder, unless this is rendered necessary by the position of 
 the stone. 
 
 The stone being seized by one of the above manoeuvres, the buttonf 
 moved, and the screw connected — the screw is gradually turned at 
 first to make the jaws bite, since a sharp turn at this time may drive 
 the stone out either to right or left — the calculus is then carried to the 
 centre of the cavity, which will show whether a fold of mucous mem- 
 brane has been seized. As the screw is applied more and more forci- 
 bly, one or other of the following will be noticed. If not well caught, 
 and if hard, it will be pushed out of the jaws; if a hard calculus and 
 well gripped, it is felt to split into fragments ; if soft, and held, it 
 crumbles down. If extremely hard, as a pure lithic acid or oxalate, 
 any attempt at advancing the screw is met b}- this distinctly recoiling 
 instead of advancing. Each surgeon must now decide for himself, 
 according to his knowledge of his instruments and reliance on his 
 power to deal with large hard fragments, whether to continue or at 
 once to perform lithotomj'. If he continue, the resistance will be felt 
 to give way, in the case of a very hard stone, by a sudden sharp crack ; 
 in one less hard, more gradually. In overcoming much resistance 
 the surgeon either screws up the male blade as hard as he can and 
 keeps it so, or, having gently unscrewed it a little, screws it up again 
 with a series of light jerks so as to communicate blows to the stone. 
 Cracking of the stone having taken place, the fragments will usually 
 fall close to the original site. Thus the lithotrite has only to be kept 
 as immovable as possible to ensure, on drawing out and again closing 
 the male blade, the seizure of a fragment.^ This is crushed, and the 
 process repeated again and again till sufficient debris is formed. The 
 lithotrite is then withdrawn firmly screwed up. 
 
 * "Ri(|)id inovements produce currents wliieli keep the stone more or less in 
 motion, so tliiit it is less easily seized than when tlie surrounding fluid is in a slate of 
 rest" (Thompson). 
 
 f In this respect Prof. Eigelow's lithotrite seems inferior to Sir M. Thompson's, the 
 working of the lintton in the hitter being smoother and le^s vibrating. 
 
 I It is not always easy to distingnish between a piece of soft stone enveloped in 
 concrete mncns and the lining membrane of the bladder. 
 
LITHOTEITY LITHOLAPAXY. 765 
 
 An evacuating straight or curved* tube, No. 16 for a stone of mod- 
 erate size, and 18 for a large one, is then introduced, the evacuator, 
 filledf with a warm solution of boracic acid or dilute Thompson's 
 fluid (p. 752), is connected, the meatus being first incised with a 
 narrow probe-pointed bistoury downwards by the side of the froinum 
 if needful. While his left hand supports the evacuator, with his right 
 the surgeon gently but quickly squeezes the bag with sufficient force 
 to send in about 2 oz. of fluid. On relaxing the pressure an outward 
 current takes place, bringing with it crushed fragments. Sir H. 
 Thompson recommends that, after the bag has expanded and the 
 current apparently ceased, the surgeon should wait a few seconds, 
 " as at that precise time it is quite common for one or two of the 
 larger fragments to drop into the receiver which would have been 
 driven back perhaps by too rapidly resuming the pressure." 
 
 If, after several washings, the outflow stops, and the bag no longer 
 expands, the end of the evacuator is blocked either by a.fragment of 
 stone, or a small calculus, a clot of blood, or the mucous membrane 
 of the bladder. If it be a fragment, as is usually the case, or a clot, 
 dislodgment may be effected l)y sending in quickly a gush of fluid, or 
 by the use of a gum-elastic stylet, after unscrewing the tube. Impact 
 of the bladder generally takes place when a curved evacuator is turned 
 upwards, and when the bladder is empty. The sensation given may 
 be a kind of flap, simulating the click of a fragment; more often it is 
 a dull vibrating thud, easily recognized. More fluid must be at once 
 injected. 
 
 If a large fragment is felt striking against the tube, or if the surgeon 
 is certain that several good-sized fragments remain, he removes the 
 tube and evacuator, and, while an assistant withdraws the blood- 
 stained fluid and fragments and re-charges the evacuator, he intro- 
 duces a small lithotrite and crushes up sufficient debris to go on again 
 with the washings. 
 
 All the time the surgeon must keep before his eyes a mental picture 
 of the interior of the bladder, perhaps diseased, the ureters, perhaps 
 
 * The tube, if curved, should be held downwards at first, but not quite on thebladder 
 floor; then to one side or the other; then upwards, washings being carried on at the 
 time that these movements are made. A straight tube should lie with its orifice just 
 within the neck of the bladder. 
 
 t Dr. Keyes (Intern. Encycl. of Surg., vol. vi. p. 244) gives this precaution as to 
 getting rid of air entirely : '' The urine, having trickled away through the tube, 
 leaves the latter full of air, an element fatal to nicety of washing. This air may be 
 disposed of most simply. The tube is withdrawn until its eye is in the prostatic 
 sinus, the washing-bottle is attached, and the stop-cock turned, but no further suction 
 made. In an instant, the air contained in the tube is heard ascending through the 
 stop-cock and mounting into the top of the evacuator, where it does no harm, and 
 whence it cannot possibly return into the bladder. 
 
(66 
 
 OPERATIONS ON THE ABDOMEN. 
 
 dilated, leading up to kidney pelves enlarged, and remember that the 
 effects of any squeeze of his hands are felt, not only all over the 
 bladder, but perhaps in the ureters and kidneys as well. 
 
 Detection and Seizure of Last Fragment.— This is, as is well 
 known, a matter of much difficulty, owing to the facility with which 
 
 Fig. 126.* 
 
 The operator is here supposed to be sitting between the thighs of the patient. The expansion 
 of the compressed bulb will aspirate a part of the abundant d&bris suspended in the fluid. The 
 fragments, being too abundant, have been dispersed. (Bigelow.) 
 
 small fragments get hidden in some folds of mucous membrane or 
 enveloped in blood-clot. As long as there is any ''clicking" against 
 the tube, the surgeon must persevere in his attempts at complete 
 removal. If, after several washings, nothing comes out into the 
 receiver, the surgeon should listen carefully over the bladder, as thus 
 advised by Dr. Keyes tf " The tube is turned in various positions, 
 and the operator listens. The swash of the water as it rushes in and 
 out is heard with startling distinctness, and, if the management of the 
 
 * The above evacuator is now old fashioned. Mr. Golding Bird's pattern, or Mr, 
 B. Hill's modification of Clover's, will be found the most handy. 
 
 t Loc. supra cit., p. 246. The whole of this account, with its vigorous life-like lan- 
 guage, will well repay perusal. 
 
IJTHOTEITY LITHOLAPAXY. 767 
 
 tube is skilful, any fragment of stone lying loose in the bladder is sure 
 in a sliort time to be driven against the metallic tube so as to announce 
 its presence by a characteristic click, quite distinct from that emitted 
 by the flapping of the bladder Avail against the eye of the instrument. 
 Fine sand and thin scales of stone make no sharp click, and all such 
 may be left to pass by nature's efforts, but any piece large enough to 
 require the lithotrite can hardly escape detection by tlie educated 
 ear." 
 
 Time occupied in Litholapaxy. — This may be, on an average, from half 
 an hour to an hour and a half. Prof. Bigelow (Amer. Journ. Med. Scl, 
 January, 1878) operated continuously for upwards of three hours, 
 removing 744 grains, the patient making a good recovery. Mr. R. 
 Harrison (Brit. Med. Journ., August 10, 1882) removed a 2} oz. stone 
 in two hours and ten minutes. Sir H. Thompson {Syst of Surg., vol. 
 iii. p. 298) says that it is rarely needful to prolong an operation beyond 
 fifty or seventy minutes. 
 
 The Old. and the New Operation of Lithotrity briefly- 
 contrasted. — Old lithotrity advocated short sittings, brief use of in- 
 struments, and left the expulsion of fragments, etc., as much as pos- 
 sible to nature. It probably requires less skill, and, in Mr. Cadge's 
 words, "is gentler, milder, less formidable altogether; no anaesthetic 
 
 is probably required ; no extra assistance A nervous, timid 
 
 patient may prefer this to the more heroic and rougher, if more ex- 
 peditious, method." It might be added that it is less tiring to the 
 surgeon. But these advantages are trifling as compared with its 
 disadvantages, which are done away with by the new operation, of 
 which the chief are the prolonged passage of fragments, often rough 
 and angular, along a bruised urethra. 
 
 The new method of litholapaxy, introduced by Prof. Bigelow, 
 resulted from, and was led up to by, several achievements of modern 
 surgery. Without anaesthetics, without the knowledge of the large 
 instruments admitted by the urethra, without the pitch of perfection 
 and power to which modern instruments have been brought, lithola- 
 paxy would still be an impossibility. Owing to its brilliant success, 
 the rapidity with which it relieves the patient, the single-sitting method 
 has practically rendered the other obsolete. 
 
 After-treatment. — The chief points here are : rest in bed, the 
 patient turning on his side to pass water, for the first four or seven 
 days; hot fomentations to the abdomen, and hot bottles at first; 
 morphia subcutaneously, if indicated ; warm milk, barley-water, min- 
 eral waters or lemonade, a little whiskey or brandy being given, if 
 needful ; all chills should be carefully avoided. 
 
 In addition to the above, the putting the patient frequently in hot 
 hip-baths for a quarter of an hour, the occasional passage of a soft 
 
768 OPERATIONS ON THE ABDOMEN. 
 
 catheter, and the rendering the urine alkaline will give much relief. 
 The urine should always be strained through muslin to collect the 
 debris. 
 Complications during Lithotrity and Litholapaxy. 
 
 1. Escape of Urine.— This may take place during or after the pass- 
 age of the lithotrite. The penis should be compressed against the 
 lithotrite, and a pause made while the patient is got more fully under 
 the anesthetic. If this fail, tying a tape round the penis and instru- 
 ment, injecting a little fluid, or putting off the operation till the 
 bladder is in a more fitting state after the use of instruments, injec- 
 tions, and such drugs as belladonna and subcutaneous injections of 
 morphia, may be made use of. 
 
 2. Hemorrhage.— Sufficient blood to stain the fluid in the evacuator 
 during the operation, and the urine for a day or two after it, is not 
 uncommon. If the haemorrhage during the operation is severe, the 
 surgeon must decide whether it is due to damage to the bladder or 
 urethra, to his having scratched the latter by withdrawing a fragment 
 in the evacuator's eye, to bruising of an enlarged prostate, or to coex- 
 istent growth. In this last case the supra-pubic operation will prob- 
 ably have to be performed either at the time or later ; in the other 
 cases the surgeon must decide on completing or deferring the crushing 
 by the amount he has already effected, his experience, and the amount 
 of the bruising inflicted. 
 
 3. Clogging or Fracture of the Lithotrite. — Clogging or impaction is 
 liable to happen with a non-fenestrated instrument with weak and 
 narrow blades. With one properly made, with as broad blades as 
 possible, and the male one blunt, roughened, and laterally bevelled 
 off, the accident is unlikely. When it occurs, it must be met by per- 
 cussing the in.«trument, if opening and closing the blades, and thus 
 freeing them in the fluid, is impossible. If the impaction persist, the 
 blades must be withdrawn as far as possible by safely maintained 
 traction. If no force that is wise will withdraw them, they should be 
 cut upon in the perineum, thrust out, unloaded, and withdrawn, and 
 the rest of the stone removed as by a median lithotomy. If, owing to 
 any defect in the instrument, the blades, though not clogged, cannot 
 be screwed up, they must be cut upon as above, thrust through, and, 
 if possible, filed off. If a blade break off, it must either be caught 
 and withdrawn by another lithotrite, or the patient cut at once. 
 
 4. Injury to the Bladder or Urethra. 
 
 Complications after Litholapaxy and Lithotrity.— These 
 are much the same as those already given at p. T57 as occurring after 
 lithotomy.* The chief differences are the greater liability to rigors 
 
 * The same want of space that caused me to treat these, above, too briefly, prevents 
 my going into them again here. 
 
LITHOLAPAXY IX MALE CHILDREN". 769 
 
 and urinary fever, and the greater frequency of epididymitis. Bruis- 
 ing of the urethra has also to be remembered, whether by the instru- 
 ments or, after the old-fashioned lithotrity, by the passage of fragments. 
 
 LITHOLAPAXY IN MALE CHILDREN. 
 
 The advisability of this mode of treating stone is still .nth judice. It 
 has been strongly advocated by Surgeon-Major Keegan,* who, after a 
 wide experience of large stones in India, is inclined to think that the 
 objections usually made to litholapaxy in boys are not valid. Thus— 
 (1) as to the smnllnesg of the bladder, the bladder of a boy of even only 
 three or four is, as a rule, (luite roomy enough to "permit of the 
 efficient working of a small lithotrite and a medium or full-sized 
 aspirator if gently worked. The bladders of boys with stone are, as a 
 rule, healthy, and will stand more distension proportionately to 'their 
 capacity than the bladders of old men. (2) The extreme sensitiveness of 
 the mucous membrane of the bleidder and urethra. Dr. Keegan thinks 
 that, with an ana?sthetic, this may be safely disregarded. (3) The 
 liability to laceration of the mucous memhraue of the bladder and urethra. 
 This objection is, he thinks, a theoretical one only. (4) The small 
 calibre of the urethra. Dr. Keegan states that not only is the calibre of 
 the urethra in boys of six or eight not very small, but that of boys of 
 only three or four is sometimes very large. As in men, the true calibre 
 of the urethra cannot be told unless the meatus, which is sometimes 
 very small, is incised. Speaking generally, the urethra of a boy from 
 three to six will admit a No. 7 or a No. 8 lithotrite (Eng. scale), and 
 that of a boy of eight or tenf will admit a No. 10, a No. 11, and even 
 sometimes a No. 14. " AMth a No. 8 Ifthotrite and a No. 8 evacuating 
 catheter it is, I find, quite feasible to dispose of a mulberry calculus 
 weighing between two and three hundred grains in an hour's time. "J 
 
 Dr. Keegan insists upon the completely fenestrated lithotrite as being 
 the only perfectly safe instrument to use, as, with any other, clogging 
 of the blades is a very likely and a most dangerous complication. 
 
 With regard to the two principal reasons for which Dr. Keegan 
 advocates litholapaxy in male children, rapidity of cure and absence 
 
 * Litholapaxy in Male Children and Male Adults (Churchill, 1887) ; Lancet, 1886. 
 
 t Mr. Walsham brought before the Clinical Society {Trans., vol. xix, p. 240) a case 
 of lithotrity at a single sitting in a boy aged ten. The stone here was very small, 
 weighing 15 grains, and lateral lithotomy had been performed abont six months before. 
 
 X Dr. Keegan has had constructed by Messrs. Weiss a lithotrite, Xo. 6 in the stem 
 and in the angle, which will readily pass through the urethrseof the great majority of 
 boys of between two and three, and is perfectly capable of disposing of stones weighing 
 up to 2 drachms. A rather larger one is No. 6 in the stem and No. 8 in the angle. 
 Dr. Keegan advises any one wishing to give litholapaxy in boys a fair trial, to provide 
 himself with a set of completely fenestrated lithotrites running from No. 6 to No. 10 
 (Eng. scale). 
 
 49 
 
770 OPERATIONS ON THE ABDOMEN. 
 
 of a cutting operation, I thinli that the first of these advantages is rather 
 specious than real. In the thirteen cases in which I have performed 
 lateral lithotomy in children I have not seen any of " the suffering, 
 annoyance, and personal inconvenience " of which Dr. Keegan speaks 
 as following this operation. I may be wrong as well as old-fashioned 
 in this matter, but I think that a child's urinary apparatus just freed 
 from a stone would be all the better for two or even three weeks' rest- 
 The absence of a cutting operation has, no doubt, much to recom- 
 mend it in a country like India, where the surgeon's knife has greater 
 terrors with parents than with us. 
 
 It is with the utmost unwillingness that I seem to say anything 
 depreciating Dr. Keegan's (;xperionce and authority,* but it seems to 
 me that one point, the most important of all, has been left undealt 
 with by him, and that is the percentage of recurrence in children. I 
 have already (p. 761) drawn attention to the frequency of this in 
 adults, even in hands so especially skilled as those of Sir H. Thompson 
 and* Mr. Cadge. It must be, no doubt, enormouslj' difficult to follow 
 up cases in India, but till this is done the chapter of litholapaxy in 
 male children must be considered very incomplete. I must conclude 
 this notice of the subject with two remarks. One is that it must not 
 be forgotten that these fifty-eightf cases of litholapaxy in male chil- 
 dren were performed on Indian patients ; the other, that such an 
 individual experience can scarcely he thought to furnish a rule to 
 those who only meet with stone at comparatively rare intervals. For 
 these reasons, especially, I doubt if, in Great Britain, lithotomy in 
 male children will be replaced by litholapaxy. 
 
 TREATMENT OF STONE IN THE BLADDER IN THE 
 
 FEMALE. 
 Practical Points. — The absence of any jjrostate or of a fixed 
 smooth trigone surface is of importance here, especially with regard 
 to lithotrity. The aid given by a finger in the vagina, the dilatability 
 of the urethra, the association of calculi with foreign bodies, are also 
 well known. It is only occasionally that enlargement of the uterus 
 or prolapse of the vaginal wall of the bladder interferes with the 
 treatment of stone. 
 
 Operations. 
 
 A. In Adults. — Wc have here the following four methods to 
 consider : 
 
 1. Dilatation. — When the stone is small — i.e., the size of a filbert, 
 
 * No one who saw the series of crushed calculi which Dr. Keegan showed at the 
 Association meeting at Brighton in August, 1887, could have helped envying him his 
 opportunities, and admiring the skill with which he had made use of them. 
 
 t Of these, only two ended fatally; in neither was the result due to the operation. 
 
STONE IN THE BLADDER IN THE FEMALE. 771 
 
 a stone not exceeding i inch in its largest diameter — it may be safely 
 removed by rapid dilatation with Weiss's instrument guarded with 
 fine drainage-tube * followed by a finger (the little one first). 
 
 2. Litholapaxy. — By this means calculus in the female bladder 
 may be most frequently and efl!iciently treated. Thus, hard stones 
 under an ounce, and phosphatic ones of a much larger size, may be 
 dealt with at one sitting. The character of the ring or sound with 
 the staff, the bite of the lithotrite, and the condition of the urine will 
 aid here. A shorter instrument will be found much more convenient 
 to work with. Where there is much irritability of the bladder much 
 difficulty will be met with in keeping fluid in it, owing to the ab- 
 sence of a prostate and the shortness and directness of the urethra. 
 The pelvis must be well elevated, the patient placed fully under the 
 anaesthetic, and the finger of an assistant should make pressure on the 
 urethra. In other respects the operation resembles that already fully 
 given for the male (p. 762). The dilatable urethra admits a full-size 
 evacuating tube. 
 
 3. Lithotomy. — This operation is called for but rarely — e.g., when 
 the stones are multiple,t when one is too large, especially if mainly 
 hard as well, when there is a foreign body as a nucleus,! when there 
 is great irritability with ulceration of the bladder, or when a growth 
 co-exists. 
 
 * Sii as to avoid the i-isk of splitling the soft parts. It is not meant b_v the above 
 remarks that imich hirger stones have not been snccessfully passed and removed from 
 the female bladder. Thus, Dr. Yelloly {Med. C'hir. Tram., vol. vi. p. 574) gives a 
 case in whicli a stone, weigliing 3 ozs. 3J drs., was extracted: incontinence followed. 
 Where large calculi — e.g., of 6 oz. — have come away spontaneously, it has been usually 
 by a process of prolapsus and ulceration combined. We do not yet know what is the 
 greatest dilatation which the female urethra will safely bear. Perhaps the limitgiven 
 above is, if anything, too small. Erichsen (Surgery, vol. ii. p. 1024) gives "8 or 10 
 lines in diameter" as the size of a stone which can be safely extracted by this means. 
 Sir. H. Thompson iSyst. of Surg., vol. iii. p. 308) says " dilatation should never be 
 employed for any calculus larger than a small nut or a large bean in an adult, which 
 limits its application to very few cases." Mr. Bryant (Surgery, vol. ii. p. \20) states 
 that, "in children, a, stone f inch in diameter, and in adults 1 inch, may be fearlessly 
 removed from the bladder by rapid dilatation and extraction, with the patient under 
 the infl.ience of chlorof<irm. I have removed larger calculi, 2 inches in diameter, by 
 this means, without any injurious after-effect, but it is probably not wise to make the 
 attempt; the surgeon possessing in lithotrity an efficient aid or substitute." Dr. Keyes 
 (Intern. Encyd. of Surg., vol. vi. p. 297) recommends not dilating the urethra more 
 than f inch. 
 
 t As in Dr Galabin's case (Obifi. Soc Trans., April 7, 1880), in which twelve large 
 calculi and about fifty smaller ones were removed successfully by vaginal lithotomy 
 from the bladder of » woman aged sixty-one. 
 
 X As in the large stone formed round a hair-pin, and figured (p. 579) by Hart and 
 Barbour in their Manual ef Oynoxology. Here the projection of the hair-pin on 
 either side of the stone would indicate, nowadays, the supra-pubic operation. 
 
772 OPERATIONS ON THE ABDOMEN. 
 
 Of the following methods— (a) vaginal, (6) supra-pabic, (c) urethral, 
 and (d) the lateral method of Buchanan— the first two only need be 
 alluded to. 
 
 Vaginal Lithotomy— This method will be but briefly described here, 
 as it is probable that for stones requiring it— i.e., those above enumer- 
 ated—the supra-pubic operation is better suited. The risk of a vesico- 
 vaginal fistula, always present in the operation, is especially to be 
 remembered in cases where phosphatic urine is present — a condition 
 frequently met with in the case of large stones in women, or where 
 the edges of the wound are bruised during extraction. The greater 
 readiness with which a catheter is passed and the bladder drained 
 will probably make the modern supra-pubic operation safe in women. 
 
 By vaginal lithotomy is meant extraction of a stone through an 
 incision in the anterior vaginal wall, behind the vesical orifice of the 
 urethra, and thus not interfering with this canal at all. 
 
 This anterior wall is about 4 inches long in the adult ; in relation 
 with it is anteriorly the urethra, to be felt as a cord through this wall, 
 behind this the bladder, and farther back the os and cervix uteri. 
 No peritoneum is normally in relation with this wall, as this mem- 
 brane leaves the uterus half-way down to pass directly on to the 
 bladder. No important vessels or nerves are met with. 
 
 Operation. — The patient being in lithotomy position and the vagina 
 well opened by a duck-bill speculum held backwards and downwards 
 against the posterior vaginal wall, the surgeon introduces a short 
 grooved staff, and, having made the groove project so as to be felt 
 through the bladder and vagina, cuts straight down upon it with a 
 sharp-pointed straight bistoury, making an incision in the middle 
 line from i to 2 inches long between the os uteri and the urethra, 
 taking care not to cut into this or the neck of the bladder. He then 
 introduces his finger and hooks out the stone with this or with scoop 
 or forceps. 
 
 Another and a simpler* method, if the stone is easily caught, is to 
 seize it with small forceps passed by the urethra, and so to hold it 
 that it projects through the vaginal wall, and to cut ui^on the stone 
 itself instead of upon a staff.f 
 
 If the wound remains a clean-cut one, unbruised during the extrac- 
 tion of the stone, if the urine is sweet, the edges should be closed at 
 once with silver wire, or better with well-soaked salmon-gut, and the 
 case treated as one of vesico-vaginal fistula. Under less favorable 
 
 * T. Smith and Walsham, Man. Oper. Surg., p. 109. 
 
 t Dr. Keyes {loc. supra eil., p. 299), advises free irrigation of the bladder from the 
 urethra, the vaginal wall being held open till all fragments, clots, etc., have been 
 removed. 
 
STONE IN THE BLADDER IN THE FEMALE. 773 
 
 conditions closing the wound may have to be deferred till the parts 
 are quite healthy. 
 
 Sapra-pubic Lithotomy.— This, has been fully described at p. 750. 
 The fluid is retained in the bladder by finger-pressure upon the orifice 
 of the urethra. 
 
 B. In Children.— 1 cannot do better than quote here the following 
 conclusions which Mr. Walsham has drawn in a very helpful paper.* 
 
 " 1. That for small stones, both rapid and slow dilatation of the 
 urethra, in children as in adults, are good operations. 2. That of these 
 two rapid dilatation under chloroform is perhaps the better, as caus- 
 ing less annoyance and inconvenience to the patient. 3. That mod- 
 erate- and even large-sized stones have been removed by dilatation, 
 but that, as incontinence has frequently followed from over-distension, 
 it is not justifiable to subject the patient to this risk. 4. That, after 
 limited dilatation, should the stone appear larger than was antici- 
 pated, it may be crushed with safety, but, should crushing be con- 
 sidered unadvisable or impossible, it is better to perform vaginal 
 lithotomy than subject the patient to any risk of incontinence by over- 
 dilatation. 5. That it is not safe to aid the dilatation by incising the 
 urethral walls. 6. That incision of the urethra alone, without dilata- 
 tion, in whatever direction practiced, is frequently attended with 
 incontinence, and should therefore be abandoned. 7. That mod- 
 erate and even large stones can be easily removed from young 
 children by vaginal lithotomy, aided, if necessary, by dilatation 
 of the vagina, incision of the fourchette, and crushing of the 
 stone by the wound made through the septum, without any risk 
 of a permanent vesicovaginal fistula so long as the edges of the in- 
 cision are not bruised in the extraction. 8. That the incision in the 
 septum should be very free, but not involve the walls of the urethra ; 
 and should that first made be found too small, it should be enlarged 
 before any attempts at extraction are undertaken. 9. That should a 
 fistula remain after this operation, even when carefully performed, it 
 can be readily closed. 10. That, after the incision has been prolonged 
 to the hniits of safety, the stone still appearing too large for easy re- 
 moval, and crushing being considered unadvisable or impracticable, 
 it is better to open the bladder above the pubes than, by lacerating 
 the sides of the wound by forcible extraction, to subject the patient 
 to the possible danger of a permanent vesico-vaginal fistula. 11. 
 That the lateral operation, as practiced by Dr. Buchanan, appears well 
 adapted to children suffering from a small stone, or perhaps one of 
 moderate size ; and that, as it has been successfully practiced in India 
 and Glasgow, it is deserving of further trial in this country. 12. That 
 
 * " Stone in the Bladder of Female Children," Si. Barthol. Hosp. Reports, vol. xi. 
 p. 129. 
 
774 OPERATIONS ON THE ABDOMEN. 
 
 very large stones can only be removed by hypogastric or vaginal lith- 
 otomy ; and that as the latter proceeding would in this case probably 
 be followed by a permanent vesico-vaginal fistula, it is better to choose 
 the more dangerous operation than subject the patient to this loath- 
 some affection. 13. That the supra-pubic operation, when carefully 
 performed is possibly much safer than is generally supposed ; but 
 that, as it may be followed by death, it should only be undertaken 
 when all other alternatives threaten permanent incontinence." 
 
 Mr. Walsham considers each of the above separately and supports 
 them with evidence. I think that this tends to show, in the case of 
 vaginal lithotomy, that, though a stone may be extracted in this way 
 after dilatation of the vagina, division of the fourchete, and destruc- 
 tion of the hymen, it is by no means easy in these latter cases to 
 insert sutures satisfactorily. It will be wiser, I think, to make use of 
 the supra-pubic operation in female children for all save the very 
 smallest stones. Lithotrity is by no means easy in these small blad- 
 ders, and the risk of vesico-vaginal fistula has already been shown to 
 be very great. 
 
 I would refer my readers to a case of supra-pubic operation by 
 Mr. Barwell in a child aged nine, from whom a stone weighing 2\ ozs. 
 was successfully removed. It is interesting to note that Mr. Barwell 
 was led to adopt the supra-pubic operation from his having had 
 within seven months no less than three cases of vesico-vaginal fistulse 
 originating in the extraction of calculi during infancy and youth by 
 different surgeons {Med. Chir. Trans., vol. Ixix. p. 342). 
 
 CYSTOTOMY. 
 
 Indications. — The operation of opening the bladder, apart from 
 such cases as exploring for growth, foreign body, etc., may be re- 
 quired in — 
 
 1. Some cases of cystitis. When the urine is fetid and slimy. 
 When pain in the bladder and penis is intense, leading to loss of sleep 
 and appetite. When there is a high temperature and other evidence 
 of imminent septicemia. When all other treatment has failed, and 
 when washing out is insufficient or unendurable. 
 
 The operation here, for the sake of the kidneys, must not be put off 
 too late. Much benefit may be obtained by irrigating the bladder 
 freely, and afterwards mopping it out with a small sponge and a solu- 
 tion of silver nitrate, 3ss or 3j — gj. 
 
 2. Some cases of great irritability of the bladder persisting after 
 dilatation of a stricture. Mr. R. Harrison* believes that the continu- 
 ance of the irritability in these cases is due to the muscular hyper- 
 
 * Smy. Dis. of the Urin. Org., p. 201. 
 
RUPTURED BLADDER. 775 
 
 trophy which the bladder has undergone in its constant endeavors 
 to force urine through the obstruction in front of it, and that tlic 
 cystotomy is curative by bringing about atrophy or lose of that mus- 
 cularity. 
 
 3. Some cases of tubercular cystitis. Here the bladder may be 
 drained to give relief from intense suffering. 
 
 4. As part of other operations. Thus, in i)lastic operations about 
 the urethra, to keep the parts dry, the bladder may be opened. I 
 have done this in a case of epispadias. 
 
 5. As this operation will not again be alluded to, I may remind my 
 readers that cystotomy, or, rather, opening the prostatic urethra on a 
 staff, has been recommended by Sir H. Thompson in those few but 
 most distressing cases of enlarged prostate leading to hourly cathe- 
 terism, cystitis, loss of sleep, and other aggravated symptoms.* 
 
 The above are instances of cases calling for cystotomy. The sur- 
 geon will have to choose between three operations— viz., median and 
 lateral cystotomy and external urethrotomy. The median operation 
 is almost always to be preferred to the lateral, but it is probable that 
 external urethrotomy (pp. 737, 783) will be sufficient as to drainage, 
 and it is certain that this operation is less risky from shock, cellulitis, 
 and secondary hfemorrhage. The great object is to drain the cavity 
 thoroughly. 
 
 Supra-pubic cystotomy is employed occasionally in Hunter's 
 method of treating stricture by passing a sound from the bladder up 
 to the perineum. 
 
 RUPTURED BLADDER. 
 
 The treatment of this hitherto most fatal injury has of late years 
 been cleared up.f Exploratory operations and suture of the bladder 
 will be increasingly successful in favorable cases — i.e., those seen early 
 and those in which the injury is limited to the bladder. 
 
 Two forms of rupt. '.re are recognized — the intra- and extra-peritoneal. 
 It may be well to state succinctly the symptoms. 
 
 Intra-peritoneal Rupture. — (1.) History of a likely injury, (2.) In- 
 ability to pass water.J This power has, however, been preserved in 
 both varieties ; naturally it is seen most frequently and in greater 
 perfection in extra-peritoneal cases. It is very rarely normal in the 
 intra-peritoneal ruptures. (3.) A little bloody urine drawn off with a 
 
 * Dis. of the Prostate, p. 176. 
 
 t Especially by Sir W. MaoCormac's paper, with two successful cases, Lancet, 188fi, 
 ¥ol. ii. p. 118. 
 
 J Thus the rent may be valvular or blocked by intestine, etc. On all these and 
 many other points the reader should refer to Mr. Rivington's writings (Diet, of Surg., 
 vol. i. p. 152) and Bupture of the Urinary Bladder, for exhaustive completeness and 
 Jielpful information. 
 
776 OPERATIONS ON THE ABDOMEN. 
 
 catheter. (4.) Difficulty of manipulating an instrument in a con- 
 tracted bladder. (5.) If the catheter, hitting off the rent, be passed 
 beyond the bladder, a much larger quantity of blood-stained fluid is 
 withdrawn, partly urine, partly serum, from irritation of the peri- 
 toneum.* (6.) Speedy (usually) supervention of peritonitis. (7.) 
 Perhaps fluctuation and dulness in the flanks. 
 
 Extra-peritoneal Rupture— (1.) History of a likely injury. (2.) In- 
 ability to pass water (vide supra). (3.) A little bloody urine drawn off. 
 (4.) The catheter finds the bladder contracted. (5.) No tapping of a 
 larger amount of fluid. (6.) Evidence of extravasationf rather than 
 of peritonitis. 
 
 It must be remembered that the following may mislead : There may 
 be very little pain complained of; no sickness ; a normal temperature > 
 the patient may be able to walk ; upwards of half a pint of urine may 
 be drawn off night and morning, and yet the peritoneal cavity may 
 contain much fluid. Peritonitis may be absent post-mortem, though 
 tympanites be present during life, and though fluid be found in the 
 peritoneal cavity. The patient may live flve days, apparently im- 
 proving, and then die suddenly. 
 
 Operation. — -The patient being under an anaesthetic, the abdomi- 
 nal wall cleansed and shaved and the parts relaxed, J; a free incision, 
 5 or 6 inches long in the adult, is made in the middle line. The linea 
 alba being divided, the recti retracted and partly detached if needful, all 
 bleeding-points secured, the lower angle of the wound and the parts 
 behind the pubes are carefully examined for ecchymosis, extravasation, 
 etc. If neither of these nor any collection of fluid is found outside the 
 peritoneum, this is opened, when a large gush of fluid may be decisive. 
 The surgeon now introduces one finger to feel the rent, and the detec- 
 tion of this may be facilitated by passing a short-beaked sound. The 
 rent will vary in site and length,! ^^'^'^ ^^so as to regularity, thickening, 
 etc. If it be a long one, and reach downwards towards the recto- 
 vesical cul-de-sac, the introduction of a rectal bag (Figs. 123, 124, pp. 
 751, 752) may be of assistance. Sir W. MacCormac also found that 
 the bladder came up more readily after the parietal peritoneum had 
 
 * If the flow through the catheter is markedly increased by inspiration and dimin- 
 ished by expiration, the rent is probably a large one. 
 
 t Thus, if the rent is in front, the urine may be localized there with circumscribed 
 dulness; or widely diffused, mounting up towards the umbilicus, between the abdom- 
 inal muscles and the peritoneum ; or passing into the iliac fossse, or by the canals into 
 the scrotum and thighs. 
 
 { In Mr. VVillett's case (St. Burlhol. Hasp. Reports, vol. xii. p. 209) much difficulty 
 was met with from the rigidity of the abdominal walls, and tlie great distension of the 
 intestines, which kept crowding out of the wound, and were mast difficult to replace. 
 Peritonitis had set in here, twenty-fonr hours having elapsed since the injury. 
 
 \ In Sir W. MacCormac's cases the rents »ere 4 and 2 inches long. 
 
RUPTURED BLADDER. 777 
 
 been transversely divided on each side. An assistant with carefully 
 cleansed hands may render service at this time by hooking up the 
 bladder with two fingers, while the intestines are kept back with 
 sponges. The rent, being now in view, is cleansed, and sutures of 
 fine carbolized silk inserted. Sir W. MacCormac used sixteen of these 
 in one case and twelve in another, and his success is largely due to the 
 great care with which they were inserted. Thus, they are put in i 
 inch apart, after Lembert's method (Fig. 107, p. 665), including the 
 serous and muscular coats only, beginning at the lower part, and the 
 first and last sutures being inserted well beyond the limits of the 
 injury so as to prevent leakage from the extremities. The following 
 precautions are taken in passing them: Fine curved needles are used 
 on holders; the serous surfaces are carefully inverted. The sutures 
 are passed through the serous and muscular coats only. This avoids 
 the risk of traversing the mucous membrane, which in animals has 
 nearly always proved fatal, because— (1) on tightening the sutures, 
 the mucous membrane falls between the edges of the wound and 
 hinders union; (2) the urine may find a channel through the points 
 of passage of a suture, and so into the cavity of the peritoneum ; (3) 
 the loop of suture within the bladder is a foreign body, and salts may 
 be deposited on it. 
 
 Wherever a gap appears, another suture should be inserted. If there 
 is time, a few of chromic gut may be inserted through the serous coat 
 only,* but Sir W. MacCormac regards the double row as unnecessary ; 
 8 or 10 oz. of boracic acid are then injected into the bladder, to see if 
 it is water-tight; or a colored fluid, such as Condy's lotion, may be 
 used. A few more sutures may be required till this fact is absolutely 
 certain. The peritoneal cavity is now most carefully sponged out with 
 sponges on ovariotomy clamij-forceps, pushed well down into the 
 pelvis and the flanks till they come out clean and dry on squeezing. 
 Sir W. MacCormac made use of another method of cleansing the pieri- 
 toneum which proved simple and eflicient — viz., irrigating the perito- 
 neal cavity with 2 gallons of a 1 per cent, solution of boracic acid 
 dissolved in boiled water, and used at a temperature of 98°. The 
 tubing to which the nozzle or catheter is attached should have a 
 stop-cock, that the flow may be regulated. All the fluid should be 
 got out again by turning the patient over, holding the edges of the 
 wound apart, etc. 
 
 In one of Sir W. MacCormac's cases a drainage-tube was passed 
 from the centre of the wound into the recto-vesical cul-de-sac. In 
 one case a catheter was tied in; in the other (the slighter case), in 
 
 * Sutures through the serous coat, only, invariably give way. 
 
778 OPERATIONS ON THE ABDOMEN. 
 
 which no catheter was left in, urine was jDassed involuntarily a few 
 hours after the operation ; this went on at short intervals till the third 
 day, when the control became complete. 
 
 PUNCTURE OF THE BLADDER. 
 
 The following methods will be considered here: 
 
 i. The Aspirator. 
 ii. Supra-pubic Puncture. 
 iii. Puncture per Rectum. 
 iv. Puncture through the Prostate. 
 
 i. The Aspirator. — This may be used in cases of great urgency, 
 when the surgeon is compelled to relieve retention without regard to 
 the cause; when he is without the means of carrying out other and 
 perhaps better methods ; it is especially suited to those cases in which 
 there is reason to believe that urine will again, in a few hours, be 
 passed by the urethra. Thus, in gonorrhoea! retention where a catheter 
 cannot be passed, having perhaps been clumsily used, and where relief 
 is urgently required, where retention has supervened on a stricture of 
 only two or three years' standing it may be used successfully, giving 
 time for warm baths and opium to act. In an old stricture, in one of 
 traumatic origin, or in a case of enlarged prostate, it can only be a 
 temporary measure, and should only be used when other instruments 
 are not available. 
 
 The question arises, How far will aspiration hear repetition f This is 
 quite uncertain. On the one hand, in a case of prostatic retention not 
 admitting a catheter, the patient being throughout in a most grave 
 condition, Dr. Brown {Brit. Med. Journ., May 23, 1874) used the aspi 
 rator fifteen times between January 2d and 12th, " with immediate 
 relief on every occasion, and without the smallest inconvenience or 
 injury from the punctures." Mr. Hague (Lancet, 1885, vol. ii. p. 385), 
 in a patient, aged ninety, with prostatic retention of forty-eight hours' 
 duration, aspirated, and continued to do so daily for nearly five weeks, 
 as no catheter could be passed. Such numerous aspirations, caused no 
 ill effects. 
 
 On the other hand, in a case of mine of prostatic retention in which 
 the aspirator had been used only three times, on the death of the 
 patient from bronchitis on the fourth day, the third and last puncture 
 was found to be leaking. Dr. Campbell {Brit. Med. Journ., February 
 21, 1886) records a case in which the bladder had been aspirated 
 twice, internal urethrotomy was performed, "progress was good for a 
 day or two, when some inflammation appeared at one of the punctures, 
 an abscess formed, peritonitis came on, and the man died." Where 
 
PUNCTURE OF THE BLADDER. 779 
 
 aspiration is to be used, the condition of the bladder walls and of the 
 urine must be taken into account* 
 
 If aspiration be made use of, a fine needle should be employed, and 
 introduced just above the pubes while an assistant steadies the blad- 
 der by pressure on either side. The bladder must not be allowed to 
 become much distended before the puncture is repeated, otherwise 
 urine may be forced out. 
 
 ii. Supra-pubic Puncture.— This operation has the advantages 
 of being easily performed, of giving permanent relief if desired, and 
 of being safe. 
 
 The two objections brought against it are that (1) it gives bad drain- 
 age and (2) it is liable to extruvasation.f Neither of these is borne 
 out by facts. While the patient is in bed, good drainage can be pro- 
 vided by turning him on his side- and attachiiig tubing to the cannula ; 
 when the patient is up (and a cannula so placed is no drawback 'to 
 this), the power of micturition will probably have returned. In a few 
 cases of enlarged prostate the patient will be compelled to pass his 
 urine this way for the rest of his life, but as soon as the parts are consoli- 
 dated around the cannula, or the catheter which has replaced the can- 
 nula, micturition, though tedious, will be effected satisfactorily. 
 
 I may allude to three cases in which I have used this method in the 
 last six months — two of retention with stricture, one of prostatic reten- 
 tion. I consider it the best all-round method, and the one of widest 
 application that we have. Its relief is immediate, safe, and simple 
 withal. The two cases of stricture were men under forty, admitted 
 with a history of catheterism, bleeding urethras, and recent false 
 passages. On the fifth day, with the aid of ether, I was able to get a 
 No. 7 silver catheter into the bladder. For some cases of older 
 strictures, especially if with fistulas and damaged perineum, a longer 
 rest is required, and Mr. Cock's or Mr. Wheelhouse's operation are 
 indicated. 
 
 Operation. — This is most simple. A median puncture being made 
 through the skin just above the shaved jDubes, I prefer a curved trocar 
 and cannula,J the latter carrying tape-holes, but a straight trocar and 
 
 * Mr. Bennett read a case before the Medico-Chirnrgical Society [Lancet, vol. i. 
 1888, p 418) of extra-peritoneal rnpture of the bladder after aspiration in a patient long 
 the subject of stricture. The opinion of most surgeons present seemed to be that aspi- 
 ration was dangerously liable to leakage, especially in unhealthy bladders. 
 
 t Mr. T. Smith {St. Barthol. Sosp. Reports, vol. xvii. p. 291 writes: " I have seen 
 no such tendency to extravasation ; occasionally there is some inconvenience from 
 leakage; this may be met by leaving out the cannula for a few hours, which allows 
 recontraction to take place." 
 
 X A very useful form is made by Arnold. The cannula appears too long, but is not 
 so for very fat abdominal walls. It is easily retained in place by tapes, and the urine 
 runs ofl' by tubing. To keep the cannula firm at first, I insert a silver suture in the 
 
780 OPERATIONS ON THE ABDOMEN. 
 
 cannula may be used, through which an 8 or 9 guna-elastic catheter 
 or, better, a Jaques's catheter is inserted ; in four hours the cannula 
 can be removed, and a larger catheter, a 10 or 12, introduced * 
 
 iii. Puncture per Rectum —This has the advantage of draining 
 a bladder well, but there are such serious disadvantages connected 
 with it that the supra-pubic operation is always to be preferred to it. 
 Thus (1"), it is difficult and most unpleasant to the patient to retain 
 the cannula during defalcation and passage of flatus — the retention of 
 a cannula is liable to cause troublesome tenesmus and diarrhoea ; (2) 
 when the cannula slips out it is difficult to replace it ;t (3) the patient 
 is kept in bed ; (4) this method is not applicable to cases of enlarged 
 prostate. I am aware that ]\Ir. Bryant {Surgery, vol. ii. p. 153) states 
 that " an enlarged prostate is no real obstacle to its performance, for 
 this, if necessary, may be perforated with impunity." I cannot at all 
 agree with the above, in spite of llr. Bryant's authority. Being one 
 of those who look upon an enlarged prostate, especially when congested 
 with retention and surrounded by an enlarged venous plexus, as a 
 structure to be treated with great respect, I think that there is an 
 undoubted risk that perforating it may lead to septic phlebitis and 
 abscess, and to suppuration in already impaired kidneys. 
 
 Mr. Bryant (toe. svjira cit.) speaks very highly of puncture per rectum, 
 and says that the objections raised against it are theoretical only — 
 viz., abscess between the bladder and rectum, persistent fistulous 
 opening, injury to the vesiculse seminales or the peritoneum. I do 
 not deny that these injuries are rare, but, as compared with supra- 
 pubic puncture, the drawbacks which I have given above are practical 
 and undoubted. 
 
 Operation. — If this method is employed, Mr. Cock's instruments 
 should be made use of — viz., a very sharp and a blunt pilot trocar, and 
 a cannula with inner tubes to keep the cannula in position and to 
 admit of its being cleansed. The patient being in lithotomy position 
 and the Tectum emptied, the surgeon feels for the distended bladder, 
 behind the prostate, with his left index finger. This being kept in situ, 
 he introduces the cannula and blunt pilot along the finger up to the 
 point he intends to puncture. The pilot being withdrawn, the sharp 
 
 puncture, cover this with iodoform and collodion, and pack some strips of dry gauze 
 around. I generally give a little anaesthetic, but this is not needed. The skin punct- 
 ure is alone painful. 
 
 * If an aspirator has been used, and it is desired to replace it with a catheter, a 
 catgut bougie should be passed through the cannula, and, this being withdrawn, a small 
 gum-elastic catheter, with an eye in its point, is passed over the bougie. Larger ones 
 can soon be got in, passing them with terminal eyes over the smaller ones, or by means 
 of a stylet (T.Smith). 
 
 t Thus, there are two specimens in Guy's Hospital Museum proving, by the double 
 puncture present, that this is the case. 
 
RUPTURED URETHRA. 781 
 
 trocar^ is^ introduced, and, when it is nearly up to the hilt in the can- 
 nula, it is depressed and then driven on in a direction upwards and 
 forwards, as if aiming for the umhilicus. The trocar is then withdrawn, 
 the inner tubes inserted, and the whole secured with tapes. The urine 
 is best conveyed away by tubing. 
 
 iv. Puncture through the Prostate.— Mr. R. Harrison * has 
 advocated this method, and published a most successful case in a 
 patient, aged eighty-four, with prostatic retention. A special straight 
 trocar was introduced in the middle line f inch in front of the anus 
 and pushed steadily through the prostate into the bladder, the left 
 index being retained in the rectum. The cannula was removed in 
 nearly three months, natural micturition gradually returning. Atro- 
 phy of the enlarged prostate appeared to follow, and the symptoms 
 were much relieved. 
 
 I cannot but think that this method runs the risk of septic phlebitis 
 {vide supra). Another objection is that the patient is kept in bed. 
 Micturition becomes natural much more quickly after supra-pubic 
 puncture. 
 
 CHAPTER XIII. 
 
 OPERATIONS ON THE URETHRA AND PENIS. 
 
 RUPTURED URETHRA.— EXTERNAL URETHROTOMY. 
 —CHOICE OF OPERATION FOR RELIEF OF STRIC- 
 TURE-RETENTION. — INTERNAL URETHROTOMY. 
 —EPISPADIAS.— HYPOSPADIAS.— CIRCUMCISION — 
 AMPUTATION OF PENIS. 
 
 RUPTURED URETHRA. 
 
 In a small number of cases the surgeon may succeed in passing a 
 catheter into the bladder. If he do so in a case where there has been 
 much bruising f of the peritoneum and extravasation of blood , a median 
 incision should still be made to allow of relief to tension and escape 
 of clots as they break down, and so to give good drainage. If this is 
 not done, the probability is great that a little later, owing to damage 
 of soft parts, tension of blood-clot, and a little escape of urine by the 
 side of the catheter, this step will be required, at a time when, from 
 the presence of traumatic fever, and the condition of the extravasated 
 blood, the occasion is less favorable. Again, though a catheter can be 
 
 * Intern. Encycl. of Surg., vol. vi. p. 414. 
 
 ^ Intern. Uncycl, oj aurg., voj. vi. p. 414. 
 
 f Complete rupture of the urethra may coexist with a mere contusion of the peri- 
 neum, especially if much tenderness is present. 
 
782 OPERATIONS ON THE ABDOMEN. 
 
 passed at the time, it by no means follows that when, owing to its 
 being plugged, or from some other reason, it requires removal in a few 
 days that a fresh one can be inserted. An incision will then have to 
 be made, and, as already stated, under conditions less favorable. 
 
 When, as is usually the case, a catheter cannot be passed into the 
 bladder, the patient is placed in lithotomy position, and the parts 
 being shaved and cleansed, a grooved staff of as full size as the parts 
 will admit is passed as far as it will go— i.e., to the site of the rupture, 
 it is then made to project in the perineum, and the surgeon entering a 
 straight sharp-pointed bistoury in the middle line at a point 1 inch to 
 I2 inch above the anus, pushes it on till it strikes the groove, and then 
 cuts along this, both upwards and downwards, so as to expose freely 
 the spot at which the urethra is ruptured. As the knife is brought out 
 the skin wound is enlarged till this is about 11 inch long, the lower 
 end being i inch above the anus. 
 
 With the finger clots are now turned out, and retractors being 
 inserted deeply, the wound is sponged out thoroughly. A good deal 
 of bleeding may now take place from some wounded vessel, hitherto 
 closed by extravasated blood, or from the crus penis, detached on one 
 side by the violence which ruptured the urethra, especially if there be 
 a fractured pelvis. This ha;morrhage will yield to firm pressure or to 
 forcipressure. The anterior end of the urethra is next readily found 
 by the end of the staff,* which projects through it, the finding of the 
 deeper or vesical end, often difficult, will be facilitated by careful 
 sponging, a mirror, and reflected light, pressure above the pubes, and 
 the use of fine probes or straight gum-elastic catheters. This end often 
 projects as a small clot or bleeding-point, at other times it resembles 
 a partly twisted artery. 
 
 If it be found, a catheter of as large size as possible should always 
 be introduced, if practicable, from the meatus, and then through the 
 vesical end of the urethra into the bladder, guided by a finger in the 
 wound, a Brodie's probe, or a Teale's gorget (Fig. 129). If this be 
 found impracticable, a catheter should be passed into the bladder from 
 the wound. One of these methods should always be made use of, if 
 possible, as it enables the patient to be kept dry by tubing attached 
 to the catheter. 
 
 But if no catheter can be got into the bladder, either along the penis 
 or from the wound, the surgeon need not worry himself as long as a 
 free exit has been given for the urine and extravasated blood. In 
 these cases it is not unusual for the bladder to become somewhat dis- 
 tended (luring the first two or three days, owing to the urine not 
 
 * Tlie fartlier bacls the tear, the greater, of course, the difficulty in finding the 
 urethra. 
 
EXTERNAL URETHROTOMY. 783 
 
 escaping with sufficient freedom, or to the closure of the vesical end 
 of the urethra from swelling after the injury and the manipulations 
 to find it, or from the patient, if a child, shrinking from passing his 
 water. This difficulty will usuallj' he met by hot flannels frequently 
 applied to the abdomen, a few doses of laudanum, but if it be evident 
 that the urine does not escape with sufficient freedom, the surgeon 
 must again examine the wound with the aid of an anassthetic, clean 
 out any fresh clots, and again try to find the vesical end of the urethra, 
 aided now perhaps by a better light. 
 
 If this fail, supra-pubic taiJping or aspiration, or, if the patient's 
 condition be good, making a small supra-pubic opening into the 
 bladder and thence passing a short curved staff into the perineum 
 and so finding the vesical end of the urethra, must be resorted to. 
 
 Urethritis and cystitis are not uncommon in children. They are 
 best met by, as soon as possible, leaving out the catheter for a while. 
 
 With regard to the advisability of trying to use sutures, it is always 
 advisable, if possible, to draw the ends of the urethra together on the 
 catheter, with a fine curved needle on a holder, and chromic gut or 
 carbolized silk. But this will be often found a matter of great diffi- 
 culty, and even impossible. When effected, it does not diminish the 
 need of subsequent regular use of catheters. 
 
 EXTERNAL URETHROTOMY. 
 
 This operation includes the different forms of perineal section with 
 or without a guide — viz., Syme's, Wheelhouse's and Cock's operation. 
 
 By some, external urethrotomy is reserved for those cases such 
 as Syme's, in which a staff can be passed through the stricture, and 
 " perineal section" for those in which no such help is available — 
 e.g., Mr. Cock's operation. As, however, these terms are readily con- 
 fused by students, and as in Wheelhouse's operation a staff is used, 
 though it cannot be passed through the stricture, I think it preferable 
 to employ the term external urethrotomy, specifying which operation 
 is meant by using the author's name — viz., Syme's external urethro- 
 tomy, etc. 
 
 Syme's External Urethrotomy. — Here the stricture is divided 
 
 on a fine staff {vide infra) passed through it. 
 
 Indications.— This excellent operation is strongly indicated in (1) 
 cases of stricture which do " not yield to dilatation, or, rather, con- 
 tinue to present symptoms after being dilated "—in other words, to 
 contractile, irritable, and resilient strictures, in which dilatation is 
 accompanied with much pain, or in which it is found that a No. 7 can 
 perhaps be passed one day and only a No. 3 a day or two after ; (2) 
 cases in which rigors and constitutional disturbance follow any attempt 
 at dilatation. 
 
 Operation.— The patient, being prepared by mild aperients and 
 
784 OPEEATION8 ON THE ABDOMEN. 
 
 bland liquid diet for the operation, is brought under an anaesthetic, 
 and while the legs hang over the end of the table, the surgeon intro- 
 duces a Syme's staff. This has a narrow terminal portion, which 
 passes through the stricture, a shoulder which rests upon the face of 
 the stricture, and a wider, stouter part above the shoulder to make 
 the instrument easier to find in the perineum. The patient being 
 placed, in a good light, in lithotomy position, and the parts cleansed 
 and shaved, the surgeon makes an incision exactly in the median 
 line down upon the staff, exposing the wider portion above the 
 shoulder. When the surgeon is certain that this is laid bare, he runs 
 the knife forwards along the groove, so as to divide the stricture com- 
 pletely. The staff is now withdrawn, and the rest of the treatment 
 must vary somewhat. If the condition of the patient admits of it, a 
 full-sized gum-elastic catheter should be passed from the meatus into 
 the bladder, guided by a finger in the wound or in the rectum, or by 
 a grooved director passed from the perineum. If the irritability of 
 the parts does not admit of this, a gum-elastic catheter must be 
 inserted from the perineum, cut short, and kept in situ with tapes, 
 the urine running off, by tubing attached, into a basin containing 
 carbolic acid; or Prof. Syme's curved perineal catheter may be 
 employed. 
 
 As soon as a catheter can be passed from the meatus, it should be 
 kept in for two or three days, and changed, if needful, with an anses- 
 thetic at first. As soon as possible, it should be passed twice a day, 
 and the patient should be clearly told of the absolute necessity which 
 exists of keeping up the good effects of the operation by passage of an 
 instrument at regular intervals, and of occasionally reporting himself 
 to his surgeon. 
 
 Wheelhouse's External Urethrotomy.— Here the stricture 
 
 is first found by a staff passed down to it, and then divided on a fine 
 probe-pointed director passed through it. 
 
 Mr. Wheelhouse (Brit. Med. Journ., June 24, 1S76) recommends his 
 method as having "the advantage of greatlj^ increased precision; it 
 renders an operation, confessedly hitherto one of the most difficult 
 in surgery, a comparatively easy one, and one wliich, in my hands 
 and those of my colleagues, has given results infinitely more favorable, 
 with an immediate and ultimate effect upon our cases, than we had 
 ever seen before its introduction." 
 
 Operation. — " Tlie patient is placed in lithotomy position, with 
 the pelvis a little elevated, so as to permit the light to fall well upon 
 it, and into the wound to be made. The staff* (Fig. 127) is to be 
 
 * This is fully K'foved tlirougli the greater part, but not through the whole of its 
 extent, the last half inch of the groove being "stopped" and terminating in a round 
 button like end. i 
 
wheelhouse's external urethrotomy. 
 
 r85 
 
 introduced with the groove looking toward the surface and brought 
 gently into contact with the stricture. It should not be pressed much 
 against the stricture, for fear of tearing the tissues of the virethra and 
 causing it to leave the canal, which would mar the whole after-pro- 
 ceedings, which depend upon the urethra being opened a quarter of an 
 inch in front of the stricture. Whilst an assistant holds the staff in this 
 position, an incision is made into the perineum, extending from opjjo- 
 
 FiG. 127. 
 
 Fig. 128. 
 
 i 
 
 '^^JK 
 
 (Wheelbouse.) 
 
 (Wheelhouse.) 
 
 site the point of reflection of the superficial fascia to the outer edge of 
 the sphincter ani. The tissues of the perineum are to be steadily 
 divided until the urethra is reached. This is now to be opened, in 
 the groove of the staff, not upon its point, so as certainly to secure i inch 
 of healthy tube immediately in front of the stricture. As soon as the 
 urethra is opened, and the groove in the staff fully exposed, the edges 
 of the healthy urethra are to be seized on each side with straight- 
 bladed nibbed forceps and held apart. The staff is then to be gently 
 withdrawn until the button-point appears in the wound. It is then 
 to be turned round, so that the groove may look to the pubes and the 
 button may be hooked on to the upper angle of the opened urethra, 
 which is then held stretched open at three points thus (Fig. 128), and 
 the operator looks into it immediately in front of the stricture. While 
 
 50 
 
r86 
 
 OPERATIONS ON THE ABDOMEN. 
 
 thus held open, a probe-pointed director* is inserted into the urethra, 
 and the operator, if he cannot see the opening of the stricture, which 
 is often possible, generally succeeds in very quickly finding it, and 
 passes the point outwards through the stricture towards the bladder. 
 The stricture is sometimes hidden amongst a crop of granulations or 
 warty growths, in the midst of which the probe-point easily finds the 
 true passage. The director having been passed into the bladder (its 
 entrance into which is clearly demonstrated by the freedom of its 
 movements), its groove is turned downwards, the whole length of the 
 stricture is carefully and deliberately divided on its under surface, and 
 
 Fig 129. 
 
 Fig. 130. 
 
 (WheelhoHse.) 
 
 (Teale.) 
 
 the passage is thus cleared. The director is still held in the same 
 position, and a straight probe-pointed bistoury is run along the groove 
 to ensure complete division of all bands or other obstructions. These 
 being thoroughly cleared, the old difficulty of directing the point of a 
 catheter through the divided stricture and onwards into the bladder 
 is to be overcome. To efi'ect this, the point of a Teale's probe-gorget 
 (Fig. 129) is introduced into the groove in the director, and, guided 
 by it, is passed onwards into the bladder, dilating the divided stricture, 
 and forming a metallic floor, along which the point of the catheter 
 cannot fail to pass securely into the bladder. The entry of the gorget 
 into the latter viscus is signalized by an immediate gush of urine along 
 it. A silver catheter (No. 10 or 11) is now passed from the meatus 
 down into the wound, is made to pass once or twice through the 
 
 * Or a common blunt-pointed probe may be used. Occasionally a bougie (No. 2 or 
 3) is useful. 
 
cock'8 exteenai. urethrotomy. 787 
 
 divided urethra, where it can be seen in the wound, to render certain 
 the fact that no obstructing bands have been left undivided, and is 
 then, guided by the probe-dilator, passed easily and certainly along 
 the posterior part of the prethra into the bladder (Fig. 130). The 
 gorget is now withdrawn, the catheter fastened in the urethra and 
 allowed to remain for three or four days, an elastic tube conveying 
 the urine away. After three or four days the catheter is removed," and 
 is then passed daily, or every second or third day, according to circum- 
 stances, until the wound in the perineum is healed ; and after the parts 
 have become consolidated, it requires, of course, to be passed still from 
 time to time to prevent recontraction."* 
 
 This will be found a most effectual operation, but I have found the 
 hitting off of the mouth of the stricture to be a less simple matter than 
 would be gathered from Mr. Wheelhouse's account. This is especially 
 the case when the parts are engorged and softened, as the free oozing 
 which is met with under these conditions may be most difficult to 
 arrest even with firmly applied sponges on holders, the slightest 
 trickling of blood being sufficient to obscure the orifice of the stricture. 
 A false passage at the site of the stricture may complicate matters very 
 much, and a stricture in the penile portion of the urethra may prevent 
 the passage of the staff altogether. A good light, gentleness and 
 patience are at all times requisite. 
 
 Cock's Operation. — An external urethrotomy, which opens the 
 urethra behind the stricture, and without a guide (Fig. 131). The 
 following, in the words of its deviser, are the advantages of this oper- 
 ation so well known to Guy's men if " The bladder is reached without 
 any unnecessary mutilation of the perineum. The communication is 
 effected in nearly a straight line from the exterior to the cavity of the 
 viscus, so that the cannula, which is inserted and retained, can be 
 removed whenever necessary, and can be easily replaced. The func- 
 tions of the entire urethra are suspended, and may be kept in abey- 
 ance for an unlimited period. The urine no longer finds its way 
 abnormally through the stricture and sinuses of the perineum. The 
 tissues are no longer subjected to constant irritation from infiltration. 
 The constitutional symptoms are relieved, and time and opportunity 
 are given for the removal by absorption of those adventitious products 
 which obstructed the urethra, indurated the perineum, and rendered 
 the introduction of an instrument impossible. The pressure on the 
 kidneys is removed, and, if expedient, the bladder may be readily 
 
 * The wound should be irrigated (jccasionally during tlie operation with a solution 
 of boracic acid, or Thompson's fluid, and a little iodoform dusted in at the close. If 
 any bleeding is going on, the wound should be plugged around the catheter with strips 
 of iodoform or sal alembrotli gauze. 
 
 t Guy's Hasp. Reports, 1866, vol. xii. p. 267. 
 
788 OPERATIONS ON THE ABDOMEN. 
 
 washed out, until its lining membrane assumes a healthy character. 
 The strictured and damaged portion of the urethra, being no longer 
 subjected to the constant pressure of urine from behind, maj' probably 
 so far recover itself as to allow of restoration by the ordinary means 
 of dilatation ; or, should the canal have become permanently oblit- 
 erated, the patient still retains the means of emptying his bladder 
 through the artificial opening without difficulty or distress, and at very 
 moderate inconvenience to himself" 
 
 The following are the cases to which the operation is well suited : 
 Where the stricture has existed for a number of years; where the 
 urethra has become permanently obstructed or destroyed by the con- 
 stant pressure of urine from behind, and by reiterated attempts, 
 generally fruitless, to introduce an instrument; where extravasation 
 into the perineum has again and again taken place, causing rej)eated 
 abscesses and their consequences, the formation of urinary sinuses 
 and fistulse, until the normal textures of the perineum become oblit- 
 erated, and are rejjlaced by an indurated, gristly structure ; where the 
 bladder has become thickened and contracted by the constant action 
 of its muscular coat until little or no cavity is left, and where the 
 urine is constantly distilling bj' drops, either through the urethra or 
 through one or several fistulous openings, which clot the surface of the 
 perineum, penetrate through the indurated scrotum, and even find 
 their way to the nates below, and the region of the pubes above. If 
 unrelieved, these cases invariably terminate fatally. 
 
 The keystone of the whole proceeding is the fact that, " however 
 complicated may be the derangement of the perineum, and however 
 extensive the obstruction of the urethra, one portion of the canal 
 behind the stricture is always healthy, often dilated, and accessible to 
 the knife of the surgeon. I mean that portion of the urethra which 
 emerges from the apex of the prostate- — a part which is never the sub- 
 ject of stricture, and whose exact anatomical position may be brought 
 under the recognition of the finger of the operator." 
 
 This operation has the following advantages : A catheter is readily 
 retained and replaced. The urine, no longer finding its way through 
 sinuses, the indurated tissues are absorbed. Such entire rest is given 
 to the damaged urethra that it usually recovers itself. The bladder 
 is easily washed out. 
 
 Operation. — " The patient is to be placed in the usual position for 
 lithotomy ; and it is of the utmost importance that the body and pel- 
 vis should be straight, so that the median line may be accurately 
 preserved. The left forefinger of the operator is then introduced into 
 the rectum, the bearings of the prostate are next examined and ascer- 
 tained, and the tip of the finger is lodged at the apex of the gland. 
 The knife is then plunged steadily, but boldly, into the median line 
 
cock's external urethrotomy. 789 
 
 of the perineum, and carried on in a direction towards the tip of the 
 left forefinger, which lies in the rectum. At the same time, by an 
 upward and downward movement, the vertical incision may be carried 
 
 Fig. 131. 
 
 Mr. Cock's Operation. (Bryant.) 
 
 in the median line to any extent that is considered desirable. The 
 lower extremity of the wound should come to within 2 inch of the 
 anus. 
 
 " The knife should never be withdrawn in its progress towards the 
 apex of the prostate, but its onward course must be steadily main- 
 tained, until its point can be felt in close proximitj' to the tip of the 
 left forefinger. When the operator has fully assured himself as to the 
 relative position of his finger, the apex of the prostate, and the point 
 of his knife, the latter is to be advanced with a section somewhat ob- 
 liquely, either to the right or the left, and it can hardly fail to pierce 
 the urethra. If, in this step of the operation, the anterior extremity 
 of the prostate should be somewhat incised, it is a matter of no con- 
 sequence. 
 
 " In this operation it is of the utmost importance that the knife be 
 not removed from the wound, and that no deviation be made from its 
 original direction until the object is accomplished. If the knife be 
 prematurely removed, it will probably, when reinserted, make a fresh 
 incision and complicate the desired result. It will be seen that the 
 wound, when completed, represents a triangle ; the base being the 
 external vertical incision through the perineum, while the apex, and 
 constantly the point of the knife, impinges on the prostate. This 
 shape of the wound facilitates the next step of the operation. 
 
 " The knife is now withdrawn, but the left forefinger is still retained 
 in the rectum. The probe-pointed director is carried through the 
 wound, and guided by the left forefinger, enters the urethra, and is 
 
790 OPEUATIONS ON THE ABDOMEN. 
 
 passed into the bladder. A No. 12 gum-elastic catheter, straightened 
 on its stylet, is slid along the director, the stylet then removed, the 
 catheter cut short, and secured in position with tapes." 
 
 While most fully alive to the excellence of this operation, both as 
 to speediness of relief and the perfect rest it gives to damaged parts, 
 I should like to point out to those who are only likely to perform it 
 occasionally, (a) that it is not such an easy operation as it appears; 
 (b) that it is a severer operation than the size of the wound would 
 suggest. Hfemorrhage is not very uncommon from the engorged con- 
 dition of the parts, and a low form of septic phlebitis is not very 
 infrequent after the operation. For these reasons I would I'estrict it 
 to the cases mentioned at p. 788. 
 
 Complications and Causes of Failure after External 
 Urethrotomy. 
 
 1. Ha?morrhage (p. 787). 
 
 2. Rigors. These should be met by warmth, leaving out the cath- 
 eter or substituting a softer one ; plenty of diluent drinks, washing 
 out the bladder with diluted Thompson's fluid (p. 751). Dover's 
 powder, or injections of morphia, if the condition of the kidney admits 
 of these. Five or ten grains of quinine may be given in milk every 
 two or three hours, if it does not excite vomiting. 
 
 3. Septic troubles— c.gr., septic phlebitis. 
 
 4. Pelvic cellulitis. 
 
 5. Persistence of a fistulous opening in the perineum. 
 
 6. Recurrence of the contraction. 
 
 CHOICE OF AN OPERATION FOR THE RELIEF OF 
 STRICTURE-RETENTION.* 
 
 It will have been gathered from the remarks at p. 778 that supra- 
 pubic aspirationf may be used in very urgent cases, and may be 
 repeated safely once. For the large majority of cases of retention due 
 to stricture, especially where the patient is under forty five, and a few 
 days' rest will ensure the passage of a catheter, I believe that supra- 
 pubic tapping of the bladder will lie the safest and simplest operation. 
 This will be followed in four or five days by the passage of a catheter, 
 aided by an anesthetic, and guided by a little judicious force, com- 
 bined with a knowledge of anatomy. Wheelliouse's operation is very 
 highly spoken of by the Leeds surgeons, A good light and especial 
 instruments are essential. | The cases to which ]\[r. Cock's excellent 
 operation should be limited have been already pointed out (p. 78S). 
 
 * The supra-imbic tapping has been already recommended for retention due to an 
 enlarijed prostate. 
 
 t In the absence of an aspirator, an ordinary liydrocele trocar may be safely used. 
 X I ought to say that I have only nsed this operation twice. 
 
INTERNAL URETHROTOMY. 791 
 
 INTERNAL URETHROTOMY. 
 
 Indications.— Before specifying these I would say that with 
 regard to the question between external and internal urethrotomy, it 
 is chiefly a matter of personal experience. In other words, surgeons 
 who practice frequently some such operation as that of Prof. Syme, 
 and I confess I am of the number, will probably have as good results 
 as those who resort to internal urethrotomy. As it is a clean division 
 of the entire stricture which is required, this can be effected most 
 readily, and with less skill, and with simpler instruments, by external 
 urethrotomy. But it must be remembered that after all it is not so 
 much the division of the stricture, whether from without or within, 
 which will be curative, as the amount of perseverance which the pa- 
 tient shows afterwards. Again, at the commencement of internal 
 urethrotomy, each stricture must be dilated sufficiently to admit, in 
 the case of an instrument cutting from without inwards, a split sound 
 equivalent to No. 2 English, while in instruments cutting in the 
 opposite direction, the bulb is as large as No. 4 or 5. This being so, 
 the cases must be very few in which the surgeon does not find it 
 possible, and in which the patient does not prefer, to complete the 
 case bjr dilatation. 
 
 Amongst these few cases are — 
 
 1. Strictures localized and of the nature of annular, which (a) con- 
 tract rapidly after dilatation, or (/J) in which rigors persistently follow 
 attempts at dilatation. 
 
 2. Non-dilatable strictures — e.g., some traumatic ones. 
 
 3. Penile strictures. As these are very elastic and shrink quickly 
 after dilatation, and as incision of these strictures seldom causes 
 serious constitutional disturbance. 
 
 4. In some cases where time is an object Thus, in young subjects 
 whose disease has not existed long enough to alter the condition of 
 the kidneys, cutting may be admissible for a stricture that should be 
 simply dilated in an older patient whose kidneys have undergone 
 considerable degeneration.* 
 
 5. According to some,t urethrotomy affords a longer interval of 
 freedom from contraction than does any other plan of widening a 
 stricture. 
 
 Contra-indications. 
 
 1. Strictures not localized and ring-like, but extending over con- 
 siderable surface. 
 
 * Berkeley Hill, Did. of Surg., vol. ii. p. 727. 
 t Berkeley Hill, loc. supra cii. 
 
792 OPKBATIOXS ON THE ABDOMEN. 
 
 2. A '' stricture " in which the difficulty is mainly due to con- 
 gestion * though this is scarcely a stricture at all. 
 
 3. A stricture accompanied by urethritis. 
 
 I have endeavored to point out fairly the indications for internal 
 urethrotomy. I suspect that this is one of those operations of which 
 an increasingly frequent use is liable to lead to something very like 
 abuse. But however this may be I should like to point out first a 
 fallacy as it seems to me. Thus Sir H. Thompson (Dis. of Urin. 
 Organs, p. 40) speaks of a urethrotome as '' nothing more than a little 
 knife with a long blade .... used precisely as we use a scalpel any- 
 where else. Just as we should use a small knife in tenotomy, without 
 the sense of vision, where it is not necessary, but guided by the sense 
 of touch, so do I advise you to act in urethrotomy." No doubt this 
 comparison is correct as far as it goes, but its very simplicity is 
 misleading. There can be no real comparison, I maintain, between 
 division of a tendon which can always be practically made subcuta- 
 neous, and that of a stricture, perhaps 4 inches from the surface, 
 surrounded by vascular tissue, incision of which may easily lead to 
 hemorrhage or septic trouble, an incision which cannot from the 
 subsequent flow of urine be completed aseptically, and which impli- 
 cates other parts in such intimate sympathy with that operated on— 
 e.g., the kidneys. 
 
 Again, I would point out that internal urethrotomy is not the very 
 simple affair that it is sometimes represented to be. I would refer 
 my reader to the experience of one whose name is associated with this 
 operation. Mr. Berkeley Hillt speaks thus of a trial which he gave 
 to the method of treating early stricture by Otis's operation of internal 
 urethrotomy : 
 
 •' All the cases operated on were those of long-standing gleets, with 
 contraction in one or more parts of the spongy urethra, and had 
 undergone multifarious treatment. The number of patients is sixteen, 
 fifteen of my own, and one of Dr. Otis's. In five cases the gleet stopped 
 after the operation and the patient was, at the last report^taken 
 in none less than three weeks, in most some months, after the opera- 
 tion — able to pass a bougie of the estimated size of the urethra. In 
 short, they may be claimed as cures. But of these five the operation 
 was serious to two ; one had free bleeding for three days, the other 
 three attacks of rigors. Of the remaining eleven, among whom Dr. 
 Otis's own operation must be included, the gleet persisted in all; in 
 
 * As bearing upon the allied condition of "spasm,'' the above surgeon {Brit. Med. 
 Journ., 1879, vol. ii. i>. 856) states that if an apparently narrow bnlbo-membranous and 
 a penile stricture coexist, on the latter being properly divided, the former will dis- 
 appear, having been due to reflex muscular conlraction. 
 
 t Lancd, April 8, 1870, p. .524. 
 
INTERJJAL URETHROTOMY. 793 
 
 several the iirethra shrank again to its size before the operation, and 
 in some very serious complications ensued. In four bleeding lasted 
 several days, and in one was even alarming. Three patients had 
 rigors ; in two the shivering was unimportant, being that which 
 follows the first transit of urine along the incised urethra in certain 
 individuals, but is not repeated or attended by further consequences. 
 In the third patient the rigors preceded abscess in the buttock. One 
 patient had orchitis. Thus, in seven the operation might fairly be 
 termed a trifle, causing no pain nor any after-fever, but in five only 
 was the operation successful." 
 
 Complications. — (1) Hemorrhage. If severe this may be met 
 by pressure on the perineum, with a pad or a stick in the bed so that 
 the patient may keep up the compression himself. (2) Perineal ab- 
 scess. (3 j Sloughing and perineal fistula. These are very rare. (4) . 
 Extravasation. (5) Septicemia. (6) Epididymitis. The first five of 
 these are usuallj' due to cutting too deeply, or to the patient not 
 being sufficiently prepared or unfit for the operation. The last is 
 usually brought about by injudicious haste in the use of bougies. 
 
 The essentials of a good urethrotome are : (1) a guide through the 
 stricture into the bladder, usually in the form of a filiform guide- 
 bougie, or of ti curved terminal portion of the urethrotome, sufficiently 
 fine to pass through the narrowest stricture ; (2) a cutting edge which, 
 at first shielded, can be protruded by the surgeon as exactly and as 
 deeply as he desires ; (3) some means of steadying the mobile strict- 
 ure fibres as they are divided. 
 
 Two Chief Modes of Internal Urethrotomy.— The stricture 
 
 may be divided— (^0 From without inwards— 1.«., towards the 
 bladder, (b) From within outwards, away from the bladder. 
 
 A short account of the chief instruments will be given, and the two 
 methods briefly contrasted. 
 
 a. Those Cutting from Without Inwards.— By this means 
 narrower strictures can be divided than in the other method, in which 
 the instruments used are usually based on Civiale's pattern, in which 
 the bulbous end carries the knife (p. 795). 
 
 Most of the urethrotomes which cut from without inwards are 
 modifications of a Maisonneuve's pattern. A fine hollow staff being 
 guided through the stricture by a filiform bougie, along the hollow 
 staff a stylet carrying a triangular shield or wedge is run ; this pushed 
 against the stricture serves to steady it, while it is divided by a knife 
 concealed in the wedge or shield. 
 
 One of the best known of the recent instruments on this pattern is 
 Mr. B. Hill's. It consists of a narrow split sound, No. 2 English, 
 which can be guided through narrow tortuous strictures by being 
 
794 OPERATIONS ON THE ABDOMEN. 
 
 attached to a filiform bougie, previously passed into the bladder* 
 Secondly, a wedge runs along dovetail grooves between the halves of 
 the split sound. In this wedge is concealed a knife that can be pro- 
 truded between the halves of the split sound, when the stricture- 
 tissue prevents their separation sufficiently to allow the wedge to 
 pass on. The wedge,t pushed up to the situation of the stricture, in 
 separating the split sound tightens and steadies the stricture thor- 
 oughly, while the knife divides it to the width required by the wedge 
 to pass along.l If a wedge be chosen to expand the urethra to its 
 full natural capacity, the cut will not pass beyond the stricture into 
 the vascular erectile tissue external to it. The knife can be ajjplied 
 to the upper or under surface of the stricture as preferred. 
 
 Harrison's Urethrotome. — This also cuts from without inwards, but 
 • on a different plan ; this instrument ending in a catheter-hke ex- 
 tremity and thus dispensing with the filiform guide-bougie. Such a 
 pattern will be preferred by many surgeons, especially by those who 
 use fine metallic instruments in dilating strictures. The anterior 
 part of Mr. Harrison's urethrotome is sufficiently small to pass into 
 the narrowest strictures, behind this is a broad portion equal to a No. 
 10 bougie, and terminating anteriorly in an al_>rupt shoulder. Within 
 this broad portion is contained a lancet-shaped knife, which is made 
 to project by a spring in the handle and to run along a slit in the 
 narrow part of the instrument. The extent to which the blade can 
 be projected is regulated l)y a screw. ^Mlen the instrument is passed 
 down the urethra, the position of the stricture is indicated hy the 
 broad shoulder, against which it is pressed firmly as with Syme's 
 staff. The position of the stricture being thus ascertained and fixed 
 by the shoulder, the knife is projected and the stricture divided. 
 The knife being withdrawn, if the stricture has been completely 
 divided, the broad shoulder passes on readily into the bladder. The 
 stricture is, by tliis instrument, divided above and below. Dilatation 
 is maintained by the passage of laterally oval bougies. 
 
 B. Those cutting from within outwards. — A good represen- 
 tative of tliese instruments is Sir H. Thom]ison's modification of 
 Civiale's urethrotome. This liws a bulbous extremity, from which the 
 blade is protruded. The stricture being sufficiently dilated to admit 
 a No. 4 or 5 bougie, tlie bulb (which forms a useful sound) is carried 
 
 * If it is doubtful wlietlier the guide lias reached tiie bladder, Mr. Hill advices to 
 screw on a No. ^ flexible catheter to the guide, and to |msh the whole onwards till 
 the catlieter hns pa.ssed S inches inwanls. A small exhausting syringe is then applied 
 to the catheter, and a few drops of urine drawn through it. 
 
 t The meatus must be diviiUd, if too small to admit the wedge. 
 
 J After the first cut tlie knife i^ withdrawn within the wedge, and only protruded 
 when a tight band opposes the free [lassage of the wedge. 
 
INTERNAL URETHROTOMY. 795 
 
 about i inch beyond the stricture, the knife projected, and the in- 
 cision made by drawing it slowly and firmly outwards-to the dis- 
 tance of J to 2 inches-generally along the floor of the urethra so as 
 to mcise the stricture freely. A metallic bougie is then passed, and 
 if at any point it is held closely, there is still almost certainly some 
 spot which needs touching with the blade. 
 
 After-treatment.— This varies very much. Some surgeons-e g 
 Sir H. Thompson and Mr. Harrison -pass at once and tie in a fuU- 
 sized catheter for twenty -four or forty-eight hours, passing after this a 
 full-sized instrument at intervals. Others— e.j/., Mr. B. Hill— draw off 
 the urine with a full-sized catheter, after division of the stricture, but 
 tie none in. The patient is ordered not to micturate for seven or eight 
 hours if possible. By this time the incision is protected by clot and 
 plastic lymph, and when the bladder must be emptied, the patient 
 passes water in a hot bath, all pain, spasm, and risk of tearing open 
 the wound being thus avoided. The patient is kept in bed for ten 
 days, and about the eighth day a full-sized bougie is passed, this 
 period of rest being insisted upon to avoid pain, bleeding, and sup- 
 puration. 
 
 Comparison of the two Methods of Internal Urethrotomy. 
 — With the instruments which cut from witliout inwards, and guided 
 by a filiform bougie, narrower strictures can be attacked than by the 
 bulbous-ended urethrotome, cutting in the reverse direction. These 
 latter have been recommended as having the advantage of steadying 
 the fibres to be cut by their pulling forwards the parts which attach 
 the urethra to the pelvis, as the bulbous end of the instrument is 
 drawn out. The stricture is thus pulled on by the instrument until 
 the divided stricture gives free passage to the bulbous shield and the 
 knife protruded from it. Mr. B. Hill, however, considers that " re- 
 liance cannot be placed on the simple straining of these attachments 
 ensuring perfect division of the stricture-tissue. A Civiale's or any 
 other urethrotome which cuts from within outwards is very apt to 
 wriggle its way through a stricture, only scoring it, but not perfectly 
 severing its fibres, and to meet this difficulty the knife is often carried 
 more deeply than is necessary." Jlr. Hill further believes that by 
 cutting from without inwards there is less risk " of making an incision 
 through a thin layer of fibrous tissue into erectile tissue, in the belief 
 that a thick layer of fibrous tissue exists," and thus of causing free 
 haemorrhage. 
 
 While myself usually practicing what, on the whole, I believe to be 
 preferable, continuous dilatation aided, if need be, by external urethrot- 
 omy such as Prof. Syme's operation, I have, I trust, here freely dealt 
 with internal urethrotomy. Before leaving this matter I should like 
 to allude to the question of tlvie. Internal urethrotomy no doubt 
 
796 OPERATIONS ON THE ABDOMEN. 
 
 saves time and trouble also, hut it must not be thought that the 
 saving is such a very large one. Thus, with regard to time, Mr. 
 B. Hill writes :* " It is indispensable that the patient lie in bed 
 continuously for at least ten days, and keep his room for fourteen 
 days." Subsequent regular passage of a bougie is as needful after 
 internal urethrotomy as- any other mode of treating stricture. 
 
 ECTOPIA VESICA AND EPISPADIAS. 
 
 Owing to the misery which this condition entails the si^rgeon may 
 always be ready to operate in the hope, at least, of making the wear- 
 ing of a urinal easy and efficient, if he cannot secure the formation 
 of a sufficient cavity to retain fluid.; at the same time, from the con- 
 traction resulting from his operation, a partial or complete cure of 
 the herni;e, which not unfrequentl}- accorapanv this malformation, 
 may be secured. 
 
 Age. — The cure of the ectopia may be commenced after the child is 
 four or five, and should, be completed, if possible, by puberty. In 
 this case the epispadias may be taken in hand and completed before 
 adolescence, when the growth of hairs and sexual desires will inter- 
 fere much with the union of the flaps. 
 
 Unfavorable Conditions, t 
 
 1. Large size of the ectopia, with much bleeding and some puru- 
 lent discharge from the surface. 
 
 2. A sickly condition of the patient, pointing to poor powers of 
 repair, and a waddling gait to wide separation of the pubes. 
 
 3. Tendency to cough. This increases the protrusion. 
 
 4. Presence of large hernise. 
 
 5. Secondary dilatation of the ureters and pelvis of the kidney, 
 with degeneration of this viscus.|; 
 
 6. Obstinate eczematous rawness. 
 
 7. Small size of the scrotum. This is rare. 
 
 Preparatory Treatment.— If the patient has passed puberty, 
 and the hair is at all abundant, depilation should be practiced, and 
 nitric acid applied at intervals to the groups of hair-follicles. 
 
 It may be well also to try and diminish the size of the ectopia by 
 the means adopted by Mr. (.^reig Smith who, for some weeks previous 
 
 * Bid. of Surg., vol. ii. p. 729. See also the Lectures, alike candid and helpfnl in 
 detail, by the same surgeon {llril. Med. Jmi.rn., 1879, vol. ii. (ip. 7l)o, et seq.). 
 
 t For fn!l information on all these matters Mr. J. Wood's articles (Diet, of Surg., 
 vol. i. p. 425, and Med. Ghir. Trans , vol. Hi. p. .S5) shonld be consnlted. 
 
 X Mr. Wood (he supra eil.) shows tliat sometimes the above complication may be 
 recognized by the presence of more albuminnria than is accounted for bv the amount 
 of cystitis. In otiier case.s, no such signs are present. Out of forty cases, a fatal result, 
 chiefly from this cause ami undetected, followed in four cases. 
 
ECTOPIA VESICAE AND EPISPADIAS. 797 
 
 to operation, kept the patient on his back, and the exposed mucous 
 membrane protected with green protective coated with dextrine, 
 covering this over with boracic lint, and by this means, in one 
 case, the mucous membrane not only became less angry' but its 
 upper half, almost as low as the ureters, became covered with epi- 
 dermis almost as white as the surrounding skin.* 
 
 Operation.— An amrsthetic being given, a median flapf is raised 
 from the abdominal wall above the exposed bladder. Its shape re- 
 sembles that of the wooden portion of a fire-bellows, its length is 
 rather greater than the distance between the root of the penis and the 
 upper margin of the exposed bladder, while its root must be suffi- 
 ciently broad to ensure a sufficient blood-supply. In raising it, care 
 must be taken not to cut it too thin, and, at the same, not to go too 
 deeply with the point of the knife, as the tissues here are -extremely 
 thin, and the flat, tense, expanded linea alba beneath is >often very 
 thin, and thus the peritoneal cavity may easily be opened. 
 
 The two groin flaps are next made of rounded-oval shape, with 
 broad pedicles, the outer boundary of which is sufficiently carried 
 out on to the thigh, and then on to the root of the scrotum, to ensure 
 its containing the superficial epigastric and the external pudic arteries. 
 The inner margins of these flaps join those for the central flap at 
 about its centre, and are then continued down along the side of the 
 urethral groove for about half its length. 
 
 While these flaps must be cut fis thick as possible, care must be 
 taken to avoid any subsequent hernipe, and they must be sufficiently 
 detached to meet for their whole length without tension in the middle 
 line. In raising them they must be handled as carefully as possible, 
 whether with fingers or with bluntly serrated forceps, so as in no way 
 to impair their vitality. All bleeding being stopped, the flaps being 
 washed with boracic-acicl lotion, and their surfaces allowed to become 
 glazed,! the umbilical flap is first taken and folded down, with its 
 skin surface towards the bladder, evenly and without tension. It is 
 then stitched to the cut edge at the root of the penis. 
 
 The groin Haps are then drawn inwards, placed with their raw sur- 
 faces upon the raw surface of the umbilical flap, and carefully stitched 
 together. The sutures should be many and mixed, of wire, carbolized 
 silk, fishing-gut, and horsehair. Wire has the advantage of heiiig jioi> 
 
 * In anotlier ca=e, also siiccesKfully operated on, no preliminary treatment was of 
 any avail in diminishing the size of tlie ectopia. 
 
 f The shape and arrangement of the flapn is excellently shown in pi. ii. Figs. 1 and 
 2 accompanying Mr. Wood's paper (Med.-Chir. Tran?.. vol. lii.). 
 
 X Spencer Wells's forceps shoidd be left on for five or ten minutes to any bleeding 
 points, and all ligatures, even of fine clironijc gul^, dispensed witli^ if possible. Oozing 
 will yield to firm sponge-pressurfi- 
 
798 OPERATIONS ON THE ABDOMEN. 
 
 irritating and of keeping sweet in a wound which cannot be kept aseptic. 
 The sutures should be left in for a fortnight, and, in the case of chil- 
 dren, it may be well to give an antesthetic to take them out. 
 
 The raw surface from which the central flap was taken is then 
 closed, as far as possible, with long hare-lip pins and twisted sutures, 
 but the object here must be rather to take tension off the flaps than to 
 completely close this wound. 
 
 The parts are then painted with collodion and iodoform, and sal 
 alembroth gauze a];)plied, and the buttocks and hips smeared with 
 eucalyptus and vaseline. If any redness appear, wet boracic-acid lint 
 ■dressings should be made use of. 
 
 After-treatment.— The patient must be kept partly sitting, the 
 shoulders being well propped up and the knees flexed; a bandage 
 passed from the knees around the shoulders will facilitate this. Any 
 sudden straightening of himself by the patient is fatal to a good 
 result. For the first few days small opiates or injections of morphia 
 will be required. 
 
 HYPOSPADIAS. 
 
 It is impossible in a work like this to describe the operations for 
 this fully. I have only space to allude to some practical points which 
 may be useful to a surgeon when consulted about the advisability of 
 an operation. 
 
 Varieties. — These are three, viz. : 
 
 1. Glandular. — The opening is here merely further back than usual, 
 the frasnum is absent, the glans broad, flattened, somewhat recurved, 
 and the prepuce, often hood-like, always in a condition of partial 
 paraphimosis. 
 
 2. Penile. — Here the urethra is especially liable to open at one of 
 the three following sites : (a) Just behind the glans; (b) at the middle 
 of the penis; (c) at the junction of the penis and scrotum. 
 
 3. Scrotal.* — Here tlie cleft on which the urethra opens may be 
 either at the junction of the penis and scrotum, or involve the scrotum 
 and perineum, the former being called peno-scrotal, and the latter 
 perineo-scrotal. 
 
 When an operation is under consideration, with a view of rendering 
 micturition and coitus normal, the surgeon must take into due con- 
 sideration — (n) the degree of the deformity ; (,3) whether the penis is 
 fairly developed ; (y) whether it is much tied down; {S) whether the 
 testicles are present and descended ; (f) how far the patient's condition 
 is made miserable by rawness and eczema due to impeded micturition, 
 and by impeded coitus ; and how far there are reasonable hopes of 
 restoring these. 
 
 * The above is suuietiiues divided intu two, scrotal and perineo-scrotal. 
 
HYPOSPADIAS. 799 
 
 Operation.— I shall describe here that of M. Duplay, of the Lari- 
 boisiere Hospital. He divides the restoration into the following three 
 stages, which require, in order to be successful, much time and pa- 
 tience on the part of both surgeon and patient : 
 
 i. Straightening the penis and formation of a meatus; ii. Formation of a 
 canal from the meatus to the hypospadiac opening; iii. Junction of the old 
 and new canal. 
 
 i. Struightening the Penis.— In the penile, peno- and perineo-scrotal 
 varieties, the penis, often short, is recurved,* especially during erection , 
 by a band consisting partly of a muco-cutaneous ridge, corresponding 
 to the absent urethra, and reaching from the hypospadiac orifice to 
 the glans. M. Bouisson seems to have first pointed out the importance 
 of dividing this, which he did subcutaneously (p. 800). M. Duplay 
 recommends division by an open wound, carrying the incision as 
 deeply as needful, and states that the corpora cavernosa may be in- 
 cised to a very considerable depth, if needful to secure this end. 
 
 At the same time the above-named surgeon forms a meatus. This 
 is done by paring the two lips of the depression which represents the 
 meatus, and uniting these over a bit of catheter. If the depression be 
 very shallow, an incision upward into the glans-tissue, or two lateral 
 ones, may be needed before it is possible to insert a catheter, and to 
 apply sutures round it. 
 
 ii. Formation of a New Urethra.f —The penis being held up, two 
 incisions are made a little outside the lateral margins of the mucous 
 surface corresponding to the deficient urethra, and reaching from the 
 glans to the hypospadiac orifice. By making two transverse incisions 
 at either end, two narrow quadrilateral flaf)s| are dissected up towards 
 the middle line until with their mucous surfaces turned inwards and 
 their raw surfaces outwards, thej' meet without tension over, and thus 
 shut in a catheter passed from the previously restored meatus to the 
 hypospadiac orifice. These flaps are now united with sutures, partly 
 of fine chromic gut and partly of fine carbolized silk, cut quite short. 
 From the sides of the penis two similar flaps are dissected up from 
 within outwards, till they can be sufficiently drawn inwards without 
 tension to cover over the raw surfaces of the internal flaps. They are 
 then carefully united in the middle line. I much prefer horsehair and 
 , fishing-gut sutures here, well soaked previously in warm carbolic acid. 
 
 M. Duplay uses silver wire, and to prevent the sutures cutting 
 
 * This recurving is also in part due to thickening and shortening of the capsule of 
 the corpora cavernosa, and even of the septum. 
 
 + Several months, at least five or six, must elapse before the surgeon is certain that 
 no recurving will occur. This disappears very gradually. 
 
 t The formation of these flaps is well shown in Fig. 1349 in M. Duplay's article 
 [Intern. Encyd. of Surg., vol. vi. p. 500). 
 
800 OPERATIONS ON THE ABDOMEN. 
 
 through during erections, etc., he passes them through small leaden 
 perforated tubes, fixing the sutures with shot. Whichever method is 
 used the sutures should be fine, and put in sufficiently close to dis- 
 tribute the tension, but not too numerously, or tied too tightly, which 
 will cause sloughing. 
 
 iii. Joining the Old and New Urethra'.— As soon as the new urethra is 
 thoroughly established, quite closed, and shows no sign of contraction, 
 ■this Inst stage may be undertaken. The edges of the posterior end of 
 -the new urethra and those of the remaining orifice having been freely 
 vivified, and a catheter passed from the meatus into the bladder, the 
 opening is closed over it by sutures as in stage ii. A catheter — one of 
 Jaques's pattern is least painful— should be kept in the bladder if pos- 
 sible, till all is water-tight. 
 
 EPISPADIAS. 
 
 I am unable to find space for any really full account of the different 
 attempts to cure this rare condition. For some points of practical im- 
 portance I would refer my readers to the remarks on hypospadias 
 (p. 798). 
 
 Any attempt at curing epispadias should be divided into three 
 stages, thus : 
 
 i. Straiyldening the Penh. — While the penis is short, recurved, so as 
 to lie in contact with the abdominal wall, it is no use trying to com- 
 plete the defective urethra. Attempts should be made to straighten 
 the penis by dividing itsubcutaneously close to the pubes, each corpus 
 cavernosum being cut separately. In the only case in which I prac- 
 ticed this, in a patient aged seventeen, the hasmorrhage was easily con- 
 trolled by dry gauze and light pressure, but very sharp tenotomes 
 must be employed, as the erectile tissue offers much less resistance 
 than a tendon. Each corpus cavernosum should be divided com- 
 pletely, and as cleanly as possible. The penis must, for some time, 
 be kept fastened down, improvement in its position takes place grad- 
 ually, together with increase in its length, this being, eventually, more 
 marked the earlier the operation is performed. 
 
 ii. Completion of Deficient Urcthni from the Meatus to the Ejiispadiac 
 Opening. — The simplest way of effecting this is by the method of 
 Thiersch and Duplay, much as in hypospadias, to the account of 
 which I would refer my readers. Two narrow quadrilateral flaps ex- 
 tending from the meatus to the epispadiac orifice are marked out and 
 dissected up from without inwards on either side of the open urethra, 
 both being left attached in the middle line. These turned with their 
 muco-cutaneous surface inwards, over a small Jaques's catheter, to form 
 the new urethra, and their raw surfaces outwards, are united in the 
 middle line with numerous points of sutures cut short and buried (p. 
 
CIRCUMCISION, gOl 
 
 799). Thin flaps dissected up from within outwards from off the 
 dorsum and sides of the penis are then drawn inwards, raw surfaces 
 being thus opposed to raw surfaces, and liept ■//* sita bj^ numerous 
 points of sutures. 
 
 iii. Junction of the Old and New C<r,i(d by Clo-virc of the Ephpadior 
 Ope'/im(/.— This is effected by freely refreshing the surrounding parts 
 and suturing them carefully. Before the union is complete, several 
 operations may be required, both for this condition and hypospadias. 
 
 CIRCUMCISION. 
 
 Trivial as this operation seems, it is so important, especially in 
 adults, to secure speedy healing, that it will be briefly alluded to here. 
 
 Indications. — This operation is still not practiced often enough, 
 especially amongst poorer i)atients, amongst whom many practitioners 
 still treat phimosis as a matter of but little importance. Hospital 
 surgeons have, only too often, opportunities ol' seeing the following 
 results follow from the above course: in) Balanitis and adhesions. 
 (6) Paraphimosis, from the forcible retraction of a phimosed prepuce, 
 (c) From the impediment to micturition, urethral and vesical irritation 
 and even cystitis may be set up, simulating the symptoms of stone. 
 {d) Prolapsus recti and hernia, (c) The sexual feelings too early 
 induced, and bad habits. (/) Impediments to intercourse, ig) Inten- 
 sified gonorrhoea, chancres, etc. (/i) Eiiitlielioma.* 
 
 Operation. — This may be performed in many different ways, but 
 the following points must be remembered in every case ; ( 1) To remove 
 enough of the mucous layer of the prepuce. If this be not done, some 
 tension on the glans remains, and this leads, especially in adults, to 
 troublesome erections which interfere very much with the process of 
 healing; later on, some degree of phimosis is certain to persist. (2) 
 Not to leave too much tissue about the fra?num, Mr. Howsef has 
 drawn attention to the fact that the cellular tissue at this spot is loose, 
 and that the presence of the frsenal artery makes probable the gather- 
 ing of blood and inflammatory effusion at this spot. In children this 
 is a matter of less importance, but in adults it may lead to the forma- 
 tion of a tediously persistent lump, interfering with the function of 
 the oigan. (3) Not to remove too much of the prepuce. Thus, it is 
 always well, in adults especially, to leave enough to cover easily the 
 sensitive papillte with which the corona abounds. Again, in the 
 
 * Prof. Say re {Orthopadic Surgery, p. 14) describes cases in wliich paralysis of cer- 
 tain groups of muscles, leading to tiilipes and other deformities, followed on early 
 sexual excitement, due to phimosis. See also the case recorded by Mr. Hilton (Rest 
 and Pain, p. 276). 
 
 t Guys Hasp. Reports, 1873, p. 239. 
 
 51 
 
802 OPERATIONS OM THE ABDOMEN. 
 
 diminutive organ of infants, it is very easy to remove so much as to 
 flay, in part, the body of the organ. 
 
 The following is a very simple mode of operating : The prepuce 
 having been separated as much as possible from the glans with the 
 finder and thumb, or a stout probe, a pair of dressing-forceps is lightly 
 placed on the penis at a level with the corona ; the glans being allowed 
 to slip back, the forceps are closed, and all the prepuce in front of the 
 instrument is cut off with a sharp scalpel used with a rapid sawing 
 movement. The blades being at once removed, the mucous membrane 
 is then slit up with a director and scissrirs or a sharp-pointed bistoury,^ 
 this incision running up to, but not beyond, the corona. The mucous 
 membrane, if still adherent, is then peeled in two flaps from off the 
 glans, this detachment being affected by the finger and thumb, or by 
 a stout probe swept round. The cut edges of the prepuce are then 
 rounded off with scissors, which follow the curve of the glans as far as 
 the frtenum, the prepuce being left attached here. Enough prepuce 
 should be left to- cover over the corona-papillfe, and to admit of easy 
 stitching. Chromic gut and horsehair make the best sutures. Very 
 fine needles should be used, and the sutures passed quickly through 
 skin and mucous membrane with a stabbing movement, and without 
 bruising the edges with forceps. In passing the sutures any bleeding- 
 points must be transfixed, and the abundant cellular tissuef kept in 
 its place with the point of a prol>e. The frffiuum is now attended to, 
 the prepuce which is still attached here being cut away carefully by 
 V-shaped cuts, pointing forwards, ajid leaving just enough flaps to 
 carry the sutures and no more. The frajnal artery can usually be 
 secured by transfixing it with one of the sutures, if not, it is readily 
 tied with a fine chromic-gut ligature. 
 
 I much prefer interrupted sutures of the above-given materials for 
 circumcision; a continuous suture often gives good results in healthy 
 subjects, but the former have the great advantage that one or two can 
 be removed without interfering with the rest. 
 
 For adults, one of the two following dressings will be found the 
 best. When the parts are at all swollen or where erections are likely 
 to be troublesome, I use boracic-acid ch-essings, two layers of boracic- 
 acid lint wrung out of a saturated solution of the lotion. The deeper 
 layer has a hole cut to allow of micturition and is only removed by 
 the surgeon, the outer one envelops the whole penis, and may be 
 
 * It is well at this stiiyc to make tension on the loose prepuce with two pairs of 
 (lishei-ting forceps, and thus secure a clean section. 
 
 f This must on no account be cut awav, as in it run the vessels to ihe prepuce. \\\ 
 bleeding must be stopped, especially in adults, or extravasation of blood in the loose 
 connective tissue leads to tension, cutting through of sutures, or slovio-hing. 
 
AMPCTATION OF THE PENIS. gQS 
 
 removed and re-wetted by the patient from time to time, tliough 
 usually it is sufficient for him to keep it wet by dropping on a little 
 lotion from time to time * 
 
 After circumcision the patient should rest as much as possible. Thus, 
 an adult should stay in bed for forty-eight hours, and keep on the 
 sofa for a week, alternate stitches being removed at intervals. If he 
 insist on getting about too early, he must run the risk of the parts 
 remaining long o?dematous' and tender. And for this reason, with 
 hospital patients who have to come backwards and forwards, early and 
 complete healing is not to be expected. 
 
 AMPUTATION OP THE PENIS (Fig. 132). 
 
 Indication.— Epithelioma of penis. I would refer my readers to 
 the remarks made at p. 326 on the pre-cancerous stage in epithelioma 
 of the tongue. Though epithelioma of the penis is much less common, 
 lives are, here also, too often lost by allowing the case to get beyond ' 
 this stage. Any suspicious excoriation, ulceration, or wart should be 
 early destroyed with the acid nitrate of mercury or excised. Where, 
 after this treatment, satisfactory healing does not take place, early and 
 thorough removal of the part should be performed. There should be 
 no dangerous waiting, because the surgeon is unable to satisfy himself 
 whether the case is one of inflammatory induration or infiltration from 
 new growth. In such cases, especially where there is a doubtful his- 
 tory of syphilis, much valuable time has been often lost with drugs, 
 which, even if the lesion does date back to some long-past syphilis, are 
 quite useless if epitheliomatous ulceration has set in. Furthermore, 
 the longer ulceration continues, the more extensively will the inguinal 
 glands be involved. In such cases, though the penis may be satis- 
 factorily operated upon, disappointment will speedily follow, owing to 
 the outbreak in the inguinal regions. It maj' be added that scarcely 
 any surgical case presents a close more distressing, both to the patient 
 and those around him, than one of breaking down of epitheliomatous ■ 
 glands, owing to the hideous ulceration, the noisome discharge, and 
 the steady decay of bodily strength. 
 
 In a very few cases, when the disease commences around the meatus, 
 it may still be jjossible to remove the affected part without interfering 
 with the body of the penis. It seldom happens, however, that we see 
 the case early enough for this, and it is usually necessary to remove 
 
 ^ Mr. Ballance {St. Thomas's Hasp. Reports, vol. xvi. p. 198) advises a dry dressing 
 of gauze, the outer and larger covering being of a single layer, and its margins kept in 
 position by collodion. This simple and ingenious mode of dressing will be found most 
 effective in a very large nunjber of cases besides circumcision — e.g , amputations, 
 removal of breast, partial thyroidectomy, etc. In addition to the above advantages, it 
 is cool and light, dispensing, as it does, with bandages, and inexpensive as well. 
 
804 OPERATIONS OX THE ABDOMEN. 
 
 the whole of the glans and more or less of the corpora cavernosa. 
 Before doing this, the prepuce, unless it admits of being retracted, 
 should invariably be laid open, so as to expose the growth and make 
 quite sure of its real nature. 
 
 Operations. 
 
 I. Galvanic Cautery. — I am as much against this method here 
 as in the case of the tongue (p. 338). The dread of hfemorrhage still 
 induces some to resort to it; it is not, however, a sure preventive. 
 Sharp bleeding has followed a few hours after the operation, and also 
 later on during the detachment of sloughs ; furthermore, this operation 
 leaves a much more troublesome and sloughy wound than the knife. 
 This may be a matter of but slight importance in patients who are 
 comparatively young and robust, but where, as frequently happens 
 with these patients, they are advanced in years or prematurely aged, 
 pulled down in health, and often depressed in mind, tedious healing 
 of the wound (which it is difficult to keep sweet), involving, as it does, 
 a prolonged keeping the patient on his back, with the risks of broncho- 
 pneumonia, erysipelas, etc., is not a light matter. The need of a 
 special expensive instrument, and the unpleasant foetor of the operation, 
 are also objections. 
 
 If the surgeon make use of it, a No. 4 or 6 catheter should first be 
 passed ; the loop of wire is then tightened around the penis, well 
 behind the disease, and kept there by one or two pins. When the 
 current is passed, care must be taken that, by tightening the wire very 
 slowly, and watching the amount of heat, the vascular structures are 
 not severed too quickly ; otherwise hemorrhage, very difficult to 
 arrest on a seared surface, is certain to follow. The catheter is cut 
 through by the heated wire, and the urethra, thus maintained patent, 
 is slit up and stitched as directed below. 
 
 II. Circular Amputation of Penis.— This method gives good 
 results, though not equal, in my opinion, to those which follow on the 
 flap method. The vessels being commanded by a clove-hitch, or by 
 the clamp which bears Mr. Clover's or Mr. Durham's name, the skin 
 is drawn a little forward to prevent any superabundance afterwards, 
 and the amputation is effected liy a single sweep of the knife. The 
 vessels and the urethra are treated as directed below. 
 
 III. Flap Amputation (Fig. 132). — This method has been fol- 
 lowed by rapid healing, and has given an excellently covered stump 
 in the four cases in which I have made use of it. Haemorrhage being 
 provided against by one of the above-given means, the surgeon enters 
 a narrow-bladed knife, at a point well behind the disease, between 
 the corpus spongiosum and the corpora cavernosa, and then cuts 
 forwards and downwards for about i inch. From this small inferior 
 
AMPUTATION OF THE PENIS. 805 
 
 flap the urethra is dissected out. A flap of skin is now cut from the 
 dorsum and sides of the penis, resembling in miniature the upper 
 skin-flap in amputation of the thigh. This flap being held back, the 
 corpora cavernosa are divided vertically upwards on a level with the 
 point of transfixion. Any vessels which can be seen are now tied 
 with chromic gut or carbolized silk. On removal of the clamp or 
 
 Fig. 132. 
 
 
 Flap amputation of the penis. The appearance of the stump, with the urethra slit up and 
 stitched in sUu is shown above. The raw surface from which the dorsal flap has been raised 
 should have been shown in the lower figure. 
 
 clove-hitch, and securing any spirting vessels, free oozing often per- 
 sists for a few minutes, but ceases spontaneously. All hajraorrhage 
 being arrested, the ujaper flap is punctured, and the urethra drawn 
 through the face of the flap, slit up, and stitched in situ. The two 
 flaps, upper and lower, are then united by a few points of carbolized- 
 silk and horsehair suture. 
 
 This method secures a natural skin-covering for the severed corpora 
 cavernosa, and prevents the delay and irritation which healing by 
 granulation entails. A circular operation was long ago suggested by 
 Prof Miller of Edinburgh, but this surgeon cut his flap from below. 
 If, as I have recommended, the flap is taken from above, the skin will 
 be found to fall into position more readily over the raw surfaces of the 
 corpora cavernosa. 
 
 Occasionally, severer operations are entirely justifiable. Thus, 
 where the penis is involved as far back as the scrotum, the entire 
 penis should be extirpated, if the inguinal glands are not seriously 
 involved, and if the powers of repair are satisfactory. The patient 
 being in lithotomy position, the scrotum is to be split deeply along 
 the whole length of the raphe, and the corpus spongiosum carefully 
 dissected out. This step may be faciUtated by passing a large sound. 
 Where the triangular ligament is exposed, the above instrument is 
 removed, and the corpus spongiosum which has been dissected out is 
 
806 OPERATIONS ON THE ABDOMEN. 
 
 cut through, enough being left to bring out in the perineum. By 
 means of a blunt dissector, the crura are then detached on either side 
 from the pubic arch, and the incision being prolonged around the 
 penis above, the suspensory ligament is divided, and the dorsal 
 arteries secured. The cut end of the corpus spongiosum is now slit 
 up and stitched in the posterior part of the scrotal incision, and all 
 the rest of the wound closed by sutures. Drainage must be provided 
 by a small tube, or by horsehair drains. Similar operations to the 
 above have been performed on several occasions, but the imijortant 
 modification of dissecting off the crura, and thus ensuring complete 
 removal of the cancerous organ and its capsule, was brought before 
 the notice of English surgeons by Mr. Gould.* 
 
 Question of Removing Enlarged Glands. — These should 
 always be extirpated as soon as it is probable that the enlargement is 
 not merely inflammatory. A week's watching, with rest, lead lotion, 
 or the inunction of mercury oleate (10 per cent.), aided by pressure, 
 will settle this point. As long as the glands are involved only b_y 
 growths, hard and separate from each other, careful dissection will 
 often succeed in shelling them out, and thereby add materially to the 
 prolongation of the patient's life. But where they contain not only 
 secondary deposits, but also inflammator\' matter, owing to ulceration 
 having set in at the seat of the primary lesion, satisfactorj' removal of 
 the glands is always a matter of great difficulty and often imi^ossible, 
 owing to their softness and tendency to break down, to their adhe- 
 sions to their capsules, and the matting of these to the surrounding 
 parts, the vascularity of which is increased, and tendency of the over- 
 Ijdng skin to become adherent. 
 
 In all such operations the parts should be disturbed as little as 
 possible, as erysipelas, sloughing, and superficial gangrene are very 
 likely to follow these operations where planes of fascia are much inter- 
 fered with, and where the blood-supply is but poor. 
 
 I strongly advise the use of the spray in these cases. AVhere, owing 
 to the presence of sinuses, it is dispensed with, the wound should be 
 syringed from time to time during the operation with a solution of 
 mercury perchloride, glycerine and water, 1 in 1000. 
 
 Iodoform and sal alembroth gauze dressings, or boracic-acid lotion, 
 if erysipelas is feared, will be found the best. 
 
 * Lancet, May 20, p. 821. 
 
RADICAL CUBE OF HYDROCELE. 807 
 
 CHAPTER XIV. 
 
 OPERATIONS ON THE SCROTUM AND 
 TESTICLE. 
 
 RADICAL CURE OF HYDROCELE.-VARICOCELE.- 
 
 CASTRATION. 
 
 RADICAL CURE OF HYDROCELE. 
 
 In a paper written eleven years ago* I drew attention to the uncer- 
 tainty of the radical cure of hydrocele by iodine injection as usually 
 practiced. Thus, out of forty-four cases treated with solutions of iodine 
 and potassium iodide at Guy's Hospital, I found that the treatment 
 failed in eight cases, and that in two it failed twice. 
 
 Latterly, I believe that surgeons have recognized that the risk of 
 recurrence is greater than that of excessive inflammation, and stronger 
 solutions have been made use of— :■.,(/., the Edinburgh tinctureof 
 iodine — and some of the injection has been allowed to remain. As it 
 is still a fact, however, that no method of cure can really be relied 
 upon as radical for this troublesome complaint, the three following 
 will be mentioned here — viz. : 
 
 i. Iodine Injection, ii. and iii. Antiseptic Incision or 
 Excision. 
 
 i. Iodine Injection. — Supposing the patient be healthy, not pre- 
 maturely aged, and amenable to directions, the surgeon naturally 
 begins with this as less painful, necessitating no open wound or 
 dressing, and finally, as necessitating much less of the recumbent 
 position. 
 
 I have already drawn attention to the frequency with which recur- 
 rence is liable to take place if dilute injections are used. Elsewhere I 
 have written as follows : " While I believe that the absolute certainty 
 of iodine injection has been over-estimated, yet there is no doubt that 
 failure is too often courted by want of the following precautions : 
 (a) The use of a too-dilute solution ; (/;) Not bringing the solution 
 in contact with the whole of the sac ; (c) Not withdrawing all the 
 hydrocele fluid ; (rf) Injecting large hydroceles immediately after 
 they are emptied; (e) Making use of iodine in unsuitable cases — viz.. 
 hydroceles with thick walls." 
 
 The method of injection with iodine should be carried out 
 as follows : The patient's bowels are cleared out for a day or two 
 before, and it is well for him to rest with his hydrocele well supported 
 
 * Lancet, Sept. 1, 1877 : Incision of Hydrocele Antiseptically aa a Means of Kadical 
 Cure in Certain Cases. 
 
808 OPERATIONS OK THE ABDOMEJf. 
 
 for twenty-fonr hours previous to the injection. The fluid is first 
 most carefully drawn off with a medium-sized trocar * the surgeon 
 then by means of a syringe with a platinum nozzle accurately fittmg 
 the cannula injects steadily 2 to 3 oz. of the tincture of iodine {Edin. 
 Phnnn.), taking care first that the cannula is well within the cavity of 
 the tunica vaginalis. I now plug the cannula with a small wooden 
 spigot, while the affected side of the scrotum is gently manipulated 
 and shaken so as to bring the fluid in contact with all the interstices 
 and folds of the serous membrane. In five or ten minutes the can- 
 nula is withdrawn, as in most cases it is quite safe to leave in the 
 above given amount of iodine. The puncture is kept carefully closed 
 around the cannula while this is taken out, and then closed with 
 iodoform and collodion. A feeling of heat is noticed during the in- 
 jection, sometimes amounting to sickening pain, referred also to the 
 inguinal and lumbar regions, and the neck of the bladder. Faintness 
 is not very infrequent, and it is tlms well to tap and inject the patient 
 while he stands at the end of a sofa. 
 
 The after-treatment depends on the amount of inflammation. In 
 most cases there is too little rather than too much of this. It usually 
 appears within two or three hours, and if it be slight or delayed, the 
 patient should be told to walk about a little, and the sac again fre- 
 quently manipulated. The patient should be kept to his bed or sofa 
 for a day or two, the scrotum supported, and plain diet given. There 
 should be no hurry to employ ice, this being only made use of if the 
 swelling promises to be great. Morphia may be given freely. Within 
 four or five days usually the patient may get about wearing a suspen- 
 sory bandage. He should be prepared for a return of the swelling 
 after the injection, otherwise he will be disappointed at what he con- 
 siders a recurrence of his disease. The swelling, as a rule, disappears 
 in three to four weeks. 
 
 In the case of a double hydrocele, if the patient be healthy, and 
 not advanced in years, it is quite safe to inject both sacs at the same 
 time, but in elderly or weakly subjects, antiseptic incision will be the 
 safest course if the patient desires an operation, otherwise an interval 
 should be allowed between tlie two tappings. 
 
 ii. and iii. Antiseptic Incision and Excision of the Sac. 
 
 — This method has the advantage of being more certain than that of 
 injection. While rendered safe, nowadays, l)y aseptic treatment, it 
 has the disadvantage of being more severe. Thus an ana\sthetic is 
 required, an open wound is present and several dressings are needed. 
 It would appear especially apjdicable to cases («) of previous failure 
 with iodine; (<ft) with a sac very large, or with very thick walls; 
 
 * By some a solution of cocaine is now injected. I prefer not to use tliis, if possible, 
 that no dilution of the iodine injection may ciccur. 
 
RADICAL CURE OF HYDROCELE. 
 
 809 
 
 (c) where, on account of ill-health or premature age, the risk of inflam- 
 mation after iodine-injection is especially to be dreaded ; (d) in cases 
 of congenital hydrocele (Fig. 133) a careful incision with (Fig. 134) 
 antiseptic precautions will be safer than any other method, if the 
 pressure of a truss for the obliteration of the peritoneal communication 
 cannot be persevered with ; (e) where the surgeon is desirous of ex- 
 ploring the sac of the tunica vaginalis, as in cases where enlargement 
 
 Fig. 133.* 
 
 Fig. 134.* 
 
 of the testis, of a doubtful nature, coexists with hydrocele, and does 
 not yield to ordinary treatment ; (/) where two hydroceles coexist— 
 e.g., vaginal and encysted hydroceles ; (g) in some cases of hydrocele 
 complicated with hernia— e.gr., where the bowel is irreducible, and 
 where, especially in unhealthy patients, there is a risk of the inflam- 
 mation set up by the iodine extending to the hernial sac. 
 
 Incision. — The parts being shaved and cleansed, an incision, quite 
 2 inches long, is made, with strict antiseptic precautions, over the 
 lower and front part of the hydrocele, which is made tense with the 
 left hand. This incision goes down to the tunica vaginalis, and 
 the next opens this cavity freely. This is most essential, as, the 
 fluid having gushed out, the long-stretched dartos at once contracts, 
 closing up at once an apparently free incision, inverting the 
 edges of the scrotal skin and throwing the cavity of the tunica 
 vaginalis into a number of folds. To facilitate the introduction of 
 drainage-tubes, and thus the obliteration of the sac from the bottom, 
 the cut edges of the tunica vaginalis and the skin are now united by 
 
 * Large congenital hydrocele in a boy of twelve before and after antiseptic incision. 
 To close the communication with the peritoneal cavity, a, truss was worn for a week 
 before the operation. In order to get at the neck of the swelling, to ligature the pro- 
 cessus funicnlaris as high up as possible, and thus prevent any risk of subsequent 
 hernia, the incision was made higher up than in incising the ordinary hydrocele 
 of later life. 
 
810 OPERATIONS ON THE ABDOMEN, 
 
 numerous points of chromic gut. Unless this is done the action of the 
 dartos so puckers together the folds of the tunica vaginalis that some 
 of these remain unaffected, and recurrence of the hydrocele may 
 easily take place. These sutures should pass through any bleeding- 
 points in the incision. After the insertion of one or two drainage- 
 tubes, iodoform is dusted on and gauze dressing applied. The scrotum 
 must be kept well suspended, and a separate pad of carbolized tow or 
 iodoform wool placed in the perineum to shut off the anus. The 
 dressings will require changing once in three days, or whenever they 
 are loose, and the drainage-tube must be gradually shortened. In 
 about ten days the granulating spot that remains may be dressed with 
 resin ointment. For the first few days some amount of orchitis is 
 usually present, when this subsides the patient may get on to the 
 sofa.* 
 
 Excision. — This method is indicated in cases of previous failure, 
 and in those where the tunica vaginalis is much thickened, or the seat 
 of calcareous plates. This operation will rarely be required if that of 
 incision is carefully carried out, so as to secure alteration of the whole 
 of the lining membrane. The hydrocele being opened freely, the 
 parietal part of the tunica vaginalis is stripped away from the scrotum, 
 much as the sac of a hernia is dissected out. It is cut away close to 
 the testis and ejaididymis, and all bleeding-points tied with chromic 
 gut.f The upper part of the wound is then closed, and the lower left 
 open for drainage. 
 
 It cannot be too strongly pointed out that a certain number of 
 hj^droceles will be found most rebellious to attempts at radical treat- 
 ment. 
 
 Thus, in one case of mine, recurrence followed after injection with 
 undiluted Edin. tincture of iodine, and again after incision and drain- 
 age. A cure took place after again incising the sac, and wiping over 
 the interior with a stick of nitrate of silver. 
 
 Mr. Morris has lately, in a paper read before the IMedico-Chirurgical 
 Society (Lancet, March 3, 1888), drawn attention to this matter. He 
 has met with two cases in which recurrence actually took place after 
 excision of the sac. 
 
 At the discussion on the above paper the president, Mr. Pollock, 
 mentioned a case under his care which had been tapped and injected 
 twice, and followed by recurrence. A seton was then passed through 
 
 * Out of eleven cases of antiseptic incision two recurred. One of these is men- 
 tioned in the text. In the other, a case of bilateral hydrocele, the recollection was 
 small, and had remained so in a stationary condition when I saw the patient two 
 years afterwards. 
 
 t These are often numerous, especially if a previous injection with iodine has 
 failed. 
 
VARICOCELE. gjl 
 
 and kept in for three weeks : this likewise failed. The sac was then 
 incised and dressed with lint from the bottom, causing profuse sup- 
 puration. On allowing the wound to heal, the hydrocele again 
 returned, and it had since been treated by simple tapping. Mr. 
 Treves put the failures after incision and excision as high as 25 
 per cent. He now practiced incision and swabbing out the sac with 
 crude carbolic acid, which destroyed the endothelium and set up 
 suppuration. 
 
 Causes of Failure and Trouble after Operations for 
 Radical Cure.— These fall mainly into two classes : 
 
 (1.) Recurrence.— This is often due to the use of too-diluted in- 
 jections (p. 807), more rarely to the inveteracy with which some 
 hydroceles recur {vide supra). 
 
 (2.) Septic troubles.— These should be practically unknown now- 
 adays. Their importance formerly is shown by two cases given by 
 Sir A. Cooper in his work on the testis, in which fatal cellulitis 
 followed very quickly after he had tapped a hydrocele. 
 
 VARICOCELE (Fig. 135). 
 
 Indications.— While palliative treatment will be sufficient in the 
 great majority of cases, if, at the same time, due attention is paid to 
 the general health, the occupation and habits of the patient, and, 
 where this is required, to his sexual hygiene, an operation will be 
 justifiable in the following cases : (1) Where, in spite of treatment, 
 a varicocele steadily increases, and where it is accompanied by much 
 annoyance, distress, and pain; (2) where the patient is prevented 
 from entering one of the public services, or any active life in which 
 he has good prospects ;* (3) where the surgeon has satisfied himself 
 that the testis is undergoing atrophy. 
 
 The choice of operation is a very large one, but the following 
 will be found the simplest and most efficient. The first is far the 
 safest, and will replace all others : 
 
 i. Antiseptic Excision (Fig. 135).— This plan ensures obfiteration 
 of the varicose veins without risk of septic cellulitis and secondary 
 haemorrhage, or fatal thrombosis and pya3mia. We owe it to my 
 colleague, Mr. Howse.f The bowels having been cleared out, the 
 parts duly shaved and cleansed, the vas is carefully isolated and 
 given to an assistant to hold. An incision IJ to 2 inches long is 
 now made over the varicocele thus made prominent, usually begin- 
 ning about i inch below the external abdominal ring. The overly- 
 ing tissues should be carefully incised until the veins bulge bare 
 
 * As in the case of two of my patients, a goods-guard and a policeman, 
 t Guy's Hasp. Reports, 1887, vol. xxiii. p. 468. 
 
812 OPERATIONS ON THE ABDOMEN. 
 
 into the wound.* An aneurism needle, threaded with chromic gut, 
 is now passed at the upper and lower angle of the wound, so as to 
 include a portion of these veins, proportion- 
 '^'^' °' ate to the size of the varicocele. The liga- 
 
 tures being tied and cut short, the included 
 bundle of veins is clipped out with blunt- 
 pointed scissors. The remaining veins and 
 the vas deferens are then carefully replaced. 
 Every care should be taken to disturb the parts 
 as little as possible, especially the connective 
 tissue about the vas, as in this run a num- 
 ber of small veins which, if undisturbed, are 
 quite sufficient to carry on the circulation.! 
 The testis should also be kept down, by the finger of the assistant 
 who has charge of the vas deferens, as it has a tendency to protrude 
 when the vas is pulled upon. A little iodoform is then dusted on, 
 a horsehair drain inserted, the wound united with carbolized silk 
 and horsehair sutures, and aseptic gauze dressings applied. Strict 
 antiseptic precautions are required throughout. The wound should 
 be dressed on the fourth day, to remove the drain, and again about 
 four days later, to remove the sutures. The recumbent position 
 should be maintained for three weeks. 
 
 Some of the scrotal skin may now be removed, if very redundant, 
 and any enlarged scrotal veins tied ; but neither of these steps are of 
 the least service without ligature of the varicocele itself. 
 
 I have not described any other operation chiefly because they in- 
 volve suppuration, and, though subcutaneous, are operations in the 
 dark. An account of the operations, practiced with wire and pins, of 
 Mr. Erichsen and Mr. Curling, will be found in my article above 
 quoted ; they are briefly alluded to below. 
 
 ii. Mr. Erichsen'st Modiflcation of the Operation of Vidal 
 de Cassis. — The vas deferens, readily distinguished by its cord-like 
 feel, is first separated from the veins and entrusted to an assistant to 
 hold : an incision about 2 inch long is then made in tlie front and 
 back of the scrotum, a needle, so threaded with silver wire that the 
 wire will follow without dragging, is then passed between the vas and 
 the veins, and brought out behind ; the needle is then re-entered and 
 carried out in front, but this time is passed between the veins and" the 
 skin, thus including the veins in a loop of wire, without implicating 
 
 * Care must be taken to e.xpose the veins thoroughly, otherwise difficulty will be 
 experienced in passing the ligatures. 
 
 t See Fig 113, p. 560, of my article on The Diseases of the Male Organs, Syst. of 
 Surg., vol. iii. 
 
 J Surgery, vol. ii. p. 960. 
 
VARICOCELE. gl3 
 
 the scrotum. The loop is then tightly twisted so as to constrict the 
 enclosed vessels. From day to day the wire is tightened up afresh, 
 until it has completely made its way through the veins by ulceration', 
 a process which takes about seven or ten days. Meanwhile there is 
 much plastic matter thrown out around the veins, which finally con- 
 tracts and obliterates them. 
 
 iii. The following is the operation by ligature and pins of Mr. 
 Curling:* The vas being separated from the veins a straight pin is 
 passed between the two, about 2 inches above the testicle, and about 
 f inch below this point another pin is passed. A piece of card is 
 then applied over the pins so as to guard the skin from ulceration, 
 and a stout silk ligature applied in a figure-of-eight form. The sharp 
 ends of the pins are then nipped off, and the operation is completed 
 by freely dividing the veins subcutaneously with a narrow tenotome 
 half-way between the pins. On the sixth day the pins are removed. 
 A few days later the patient can usually get up wearing a suspensory 
 bandage. 
 
 Difficulties and Causes of Trouble in the Radical Cure 
 of Varicocele. — These ftill into two classes. 
 
 1. Sepsis and its Results. — The risk of these is always present with 
 the old subcutaneous operation. A good instance of these has been 
 recorded by Mr. H. Lee.f Here erysipelas, repeated hasmorrhages, 
 sloughing of the skin of the scrotum and penis, and multiple ab- 
 scesses, followed on Mr. Lee's operation performed by himself. It is 
 certain that others have not been so candid. As Mr. Lee mentions 
 local abscess, destruction of a small portion of skin, and on two 
 or three other occasions, arterial hfemorrhage, controlled by intro- 
 ducing a third pin, as having happened with his experienced hands, 
 surgeons will prefer the open and aseptic operation. The small 
 wound made here usually requires only three dressings. In both 
 cases a suspensory bandage will be required till all trace of the 
 inflammatory thickening has disappeared ; this will take six to eight 
 weeks. 
 
 2. Inclusion of too many Veins. — That this is a real danger is 
 shown by a case of mine which I have published. J The patient here 
 had a double varicocele, that on the left side being truly enormous. 
 This was my third case, and was operated on with the same precau- 
 tions as to the vas and asepsis given at p. 811. Owing to the huge, 
 size of the varicocele three bundles of veins were removed, and even 
 then a large number appeared to be left, the varicocele being now a 
 quarter of its former size. The case did well up to the eighth day, 
 when the wound opened and the lower half of the testis, evidently 
 
 * Tends, p. 513, Fig. 44. 
 
 t Clin. Soc. Trans., vol i. p. 73. 
 
 X Syst. nf Surg., vol. iii. p. 571. 
 
814 OPERATIONS ON THE ABDOMEN. 
 
 gangrenous, presented itself. This was cut away after the application 
 of a chromic-gut ligature. Though, at the close of the operation, it 
 did not appear that too many veins had been removed, such must 
 have been the case. 
 
 Since this I have had seven cases which have all done excellently. 
 
 CASTRATION (Fig. 136). 
 
 Indications. 
 
 I. Growths of the testicle. 
 
 1. Sarcomiita.—The following practical points deserve allusion. 
 The varieties of round, spindle, and mixed-cell sarcoma are all met 
 with here, together with the sub-variety of the first called lympho- 
 sarcoma or lymijhadenoma, from the likeness of its cells to those of 
 lymphatic tissue. Of the above, the spindle-cell sarcoma is the one 
 most frequently associated with other structures of the connective- 
 tissue group— viz., cartilage, myomatous, adipose, and even muscular 
 tissue. While pure forms of sarcoma are not often met with in the 
 testicle, the round-cell variety is the one most often met with in the 
 unmixed form, thus accounting for its far more rapid growth, more 
 marked tendency to secondary deposits, and thus its shorter duration. 
 Cystic Sarcoma. — This is occasionally spoken of as a distinct disease; 
 it means, I believe, only an early stage of sarcomatous disease, a 
 stage of varying duration, but one that is very liable to be followed 
 by rapid increase locally, and probably by secondary deposits else- 
 where. The combination of cysts and sarcoma is very common, and 
 is met with in two quite distinct forms : (a) Simple cysts, with a fibro- 
 cellular Mall and a lining of tessellated epithelium, and contents 
 serous, viscid, or mixed with blood. This is the variety which is 
 often called " cystic disease," and which is looked upon as innocent. 
 While I grant that this form may remain long quiescent, I think it 
 should be looked upon as an early stage of sarcoma, though the date 
 of its taking on dangerous growth is quite uncertain, and may be 
 long deferred, (b) Proliferous cysts. Here the cysts contain sprout- 
 ing, foliaceous or papillomatous growths, myxo-sarcomatous in struc- 
 ture, while the inter-cystic disease is also frequently myxomatous or 
 myxo-sarcomatous. 
 
 2. EnclwiidmiiKL — I have elsewhere* expressed my belief that this 
 is merely a variet}^ of sarcoma, and being never really innocent, 
 should be treated accordingly. Most frequently cartilage occurs in 
 the testicle in combination with sarcomatous and cystic disease. 
 Another, and, at first siglit, quite a distinct form, is that in which the 
 cartilage occurs in hyaline masses, and apparently without cysts and 
 
 * Syst. of Surg., vol. iii. p. 54U. 
 
CASTRATION. 815 
 
 sarcomatous material. I believe that, clinically, it is extremely 
 doubtful whether these apparently simple enchondromata may not, 
 at any time, become sarcomatous. No doubt we occasionally meet 
 with cases of enchondromata of the testicle which have been growing 
 slowly for perhaps three or four years, and in which there may be no 
 recurrence during the four or five years in which the patient remains 
 under observation, perhaps for the rest of his lifetime. But when the 
 close relations of cartilage to the other tissues of the connective type 
 are considered, and when it is remembered how narrow is the border 
 line between these tissues and sarcomata, especially when, submitted 
 to irritation or inflammation, the former tend to recur to their embry- 
 onic forms, it may well be doubted if an enchondroma of the testicle 
 ever really deserves the term " innocent." 
 
 3. Cystic Disease. — This has been already referred to, p. 814. 
 
 4. Fibroma or Fibro-myoma .—These are so rare as to need no further 
 remark. 
 
 6. Dermoid Cysts. — These are also extremely rare. 
 
 6. Carciniima.— The encephaloid, a soft variety, is not unfrequently 
 met with in the testicle. Of scirrhus a few authenticated cases are on 
 record. Encephaloid carcinoma may make its appearance at any 
 time of life but is most common in the first half of adult \iie—i.e., 
 from twenty to forty. It is rare after sixty, and practically unknown 
 in infancy. It is usually rapid in all its stages, its average duration 
 being from eighteen months to two years. 
 
 Diagnosis of Malignant Disease of the Testis.— As the records 
 of surgery contain many instances of mistakes under able hands— 
 hasmatoceles removed for malignant disease, and malignant testes 
 opened for hematocele, a few hints may not be out of place here on 
 the subject of castration. Sarcomata and carcinomata will betaken 
 together. In the early stage these are liable to be confused with chronic 
 inflammatorv enlargements of the testicle, owing to their often possess- 
 ing, at this period, an oval shape, a smooth outline, and a certain degree 
 of hardness. A little later the indistinct fluctuation which accompa- 
 nies the softening of the growth, coupled perhaps with the presence 
 of fluid in the tunica vaginalis, causes a deceptive resemblance to an 
 old hydrocele and ha?matocele, with thickened walls, especially where 
 transparency is entirely wanting, and the tumor feels heavy and flue- 
 
 tiiitps obscurGlv* 
 
 The following are amongst the points on which most rehance 
 may be placed-(l) Continuously progressing solid enlargements 
 without inflammation. (2j Unequal consistence of the swelling at 
 difi"erent parts. (3) Entire absence of translucency. (4) Tendency 
 of the scrotal veins to become enlarged, and of the scrotal tissues to 
 become adherent. (5) Increasing aches or painfulness. (6) In doubtful 
 
816 OPERATIONS ON THE ABDOMEN. 
 
 cases additional information should be at once sought for by an anti- 
 septic tapping or exploratory incision. The latter is preferable, as it 
 gives more certain information, and is the best treatment in those 
 cases of hsematocele which are liable to be mistaken for malignant 
 disease. Puncture of a malignant growth usually gives vent to blood- 
 stained fluid, which is not large in amount, or to sero-mucous fluid, 
 which is not blood-stained. On puncture of a hsematocele there usu- 
 ally escapes either grumous altered blood or fluid blood, which flows 
 for some time, producing a distinct alteration in the size of the swell- 
 ing. (7) Enlargement of the cord, and a fortiori, that of the lumbar 
 glands. 
 
 Results of Castration in Malignant Disease. — These may be 
 considered from three points of view — (a) The danger of the operation. 
 (b) The chances of cure, (c) The amount of relief which it gives when 
 a cure is not afforded. 
 
 (a) The Danger of the Operation. — This is extremely small. The wound 
 heals most rapidly if aseptic precautions are taken, and if no risk has 
 to be run (as is very seldom the case) of encroaching on the peritoneum 
 by slitting up the inguinal canal, (b) The Chances of Cure. — Perma- 
 nent successes are very rare. This is mainly owing to the time lost in 
 the early stage in administration of drugs and in strapping, and to the 
 unwillingness of the patient to submit to castration. A few cases are 
 on record which have been sufficiently watched to show how lasting 
 may be the cure. Thus, Mr. Curling* mentions four cases in which, 
 after removal of the testis for soft malignant disease (whether sarcoma 
 or carcinoma, is not stated), life was prolonged for fifteen, five, nine, 
 and twelve years, the patients in the last three cases being still alive 
 when the last report was received, (c) The Amount of Relief. — Even 
 when the cure is not permanent, castration may prolong a useful life, 
 the patient, rid of a wearisome encumbrance, is made more comfortable, 
 and, towards the close, death from internal deposits is not accompanied 
 with the same distress, both to the patient and those around him, as 
 when the disease is situated externally. 
 
 Contra-Indications. — Castration should not be performed when 
 the cord is extensively involved ; when masses can be felt deep seated 
 in the iliac fossa and lumbar region ; when there is any evidence that 
 the liver or lungs arc involved ; or when the jaundiced, sallow tint, and 
 rapid emaciation point to the disease having become general. In 
 cases at all advanced, though the patient might be rid of an encum- 
 brance, the operation would be very liable to be followed by a low 
 form of iieritonitis, or, before the wound was healed, swelling would 
 
 * Dis. of the Testis, pp. 341, 342. 
 
CASTKATIOX. 817 
 
 probably appear in the inguinal region, and a protrusion of the growth 
 take place from the upper extremity of the wound. 
 
 II. Tuheradar Testiclc.~l am of opinion that castration should be 
 performed much earlier in this disease than is usually the practice. 
 Natural cures are so few, dissemination is so frequent and so grave, 
 whether to bladder and kidneys, vesiculaj seminales, or prostate, or to 
 the lungs,* while, on the other hand, castration is, nowadays, so safe 
 an operation, that it should not be deferred. 
 
 Indications.— 1. Failure of previous treatment. 2. Hernia testis. 
 3. Persistence of a discharging sinus affecting the general health, in- 
 terfering with the out-door exercise so necessary to these cases.f 4. 
 Commencing enlargement of cord, slight thickening of vesicute semi- 
 nales. Nodules in the prostate still hard and craggy. J 
 
 III. Syphilitic Tc^ttift. — Here, owing to the specifics which we possess, 
 castration is much more rarely called for. The indications can readily 
 be judged of from those above given. 
 
 IV. Ohl Hseinatoceh. 
 
 Indications. — Failure of previous treatment, especially in a man of 
 middle life whose activity — c.(j., in riding— is much interfered with.§ 
 
 V. Retained Testis. 
 
 Indications.— 1. When such a testis is the seat of malignant disease. 
 2. When it seriously cripples the patient by the recurrent attacks of 
 inflammation associated with it. 3. When a coexisting hernia cannot 
 be kept up by a truss, owing to the presence of the testis. 
 
 Much rarer indications! | are : VI. Insanity, chronic epilepsy, etc., kept 
 up by onanism. VII. Injury. VIII. The radiccd cure of hernia — i.e., 
 when the operation cannot be completed without removal of the testis, 
 owing to the firm adhesions of the sac to the cord, especially when this 
 occurs in a patient approaching middle age. It is always well, here, 
 to obtain leave for castration. 
 
 * Mr. Bennett, in a paper brought before the Medico-Chinirgical Society {Brit. Med. 
 Journ., January 28, 1888), .showed that in each of his five cases the spinal cord becanrie 
 affected before any of the parts in the immediate neighborhood of the testis, and that 
 this spinal disease was markedly insidious. I shonld have thonght the above coinci- 
 dence of spinal disease with tubercular testis a rare one. 
 
 t Early phthisis should not interfere with removal of n tubercular testis, which 
 resists treatment and prevents the patient getting open-air exercise, and weakens his 
 health by discharge. Owing to the condition of the lungs, chloroform shonld be here 
 given, instead of ether. 
 
 X Tubercular disease of the prostate is a source, usually, of such extreme misery, 
 that any existing cause in the testis should be removed very early. 
 
 § The frequency with which malignant disease follows on repeated injury and irri- 
 tation of the testicle is well known (Rindfleisch, Path. Hist., vol. ii. p. 197). 
 
 II On these subjects I may refer my readers to my article already quoted from Syst. 
 of Surg., vol. iii. 
 
 52 
 
818 
 
 OPERATIONS ON THE ABDOMEN. 
 
 Operation (Fig. 136).— The absence of any hernia on the side 
 operated on having been ascertained, and the parts duly shaved and 
 cleansed, the surgeon protrudes the testicle with his left hand so as to 
 make the overlying tissues tense, and divides them from the external 
 abdominal ring to the bottom of the scrotum so as to ensure free and 
 easy drainage. In cases where the skin is involved by a growth, or 
 
 Fig. 136. 
 
 "X*-- 
 
 ■ * 
 
 
 ■b*. 
 
 ./ 
 
 ulcerated by a hernia testis, two elliptical incisions should be made, 
 well wide of the disease, and meeting above and below. The first in- 
 cision having exposed the cord above, this is defined, and the scrotal 
 tunics are quickly shelled off with the right hand, while the testis is 
 still further protruded with the left.* The spermatic cord is now iso- 
 lated as high as may be needful, the inguinal canal being carefully 
 opened upon a director, if this is necessary to get above the disease. 
 An aneurism needle, threaded with a double ligature of carbolized silk 
 or stout chromic gut, is passed through the cord, the loop of the liga- 
 ture cut, the needle withdrawn, and, the cord having been thus tied 
 in two halves, the ends of one ligature are cut short, while those of the 
 others are tied round the whole end to ensure that no vessel escapes. 
 The ends of this also are then cut short. The ligatures being thus im- 
 bedded in the cord substance, there is no risk of their slipping, and if 
 they be tied as tightly as possible (by looping the ligatures round two 
 pairs of scissors or forceps), tliere is no risk of causing the patient any 
 
 * There is often an adhesion behiw and between the testis and the fnndns of the 
 scrotum (Fig. 136). This represents, according to some, tlie remains of the mesorchium. 
 
FISTULA. 819 
 
 suffering. Other methods consist in securing the vessels alone, singlv. 
 hy torsion, or by chromic gut, or by fixing the cord in tlie upper angle 
 of the wound with a clamp. The mode of ligature above given is 
 much more speedy and also, I think, efficient.. Securing each vessel is 
 tedious, as it is needful to make sure of every one, even when they are 
 not enlarged, a condition not infrequent in growths. If any of the 
 arteries are left unsecured, dangerous bleeding, when the cord retracts 
 upwards, calling for laying open of the canal, with the risk of cellulitis, 
 is very probable. 
 
 The cord, being secured, is severed at least i inch above the disease, 
 and the mass removed. The wound is then examined in the cise of 
 a soft, rapid growth, and where a tubercular testis has threatened to 
 fungate, any suspicious skin must be clipped away or a sharp spoon 
 freely used. 
 
 A few scrotal vessels, notably one in the septum, may require se- 
 curing. The wound is then closed with carbolized silk and horsehair, 
 pains being taken to meet the tendency of the scrotal edges to invert. 
 
 Drainage should be carefully provided, and every precaution taken 
 during and after the operation (including the spray, or irrigation with 
 hydr. perch, and g]3'cerine) to promote rapid healing, esjiecially in 
 hospital practice. Patients who have to submit to castration are often 
 reduced in health, and are thus liable to erysipelas, and in septic cases 
 a low form of peritonitis is very likelj^ to follow, especially if the canal 
 has been opened up, while septic thrombosis is very likely to follow 
 on a wound made on a region so abounding in lymphatics and loose 
 cellular tissue. 
 
 CHAPTER XV. 
 OPERATIONS ON THE ANUS AND RECTUM. 
 
 FISTULA — HEMORRHOIDS - FISSURE— PROLAPSUS - 
 EXCISION OF THE RECTUM— IMPERFORATE ANUS— 
 ATRESIA ANI-IMPERFECTLY DEVELOPED RECTUM. 
 
 FISTULA. 
 
 Varieties.— As these have a very practical bearing upon the oper- 
 ation they must be alluded to here. 
 
 i. Complete. 
 
 ii. Blind External— Here an external opening only exists, though in 
 a considerable number of cases the internal opening is overlooked. 
 
 iii. Blind Internal— An opening through the mucous membrane is 
 
820 OPERATIONS ON THE ABDOMEN. 
 
 here the only one* This is the rarest, but an important variety, as, 
 if overlooked, it is certain to be troublesome. 
 
 Situation of Opcirivf/s.— Both of these are usually within an inch, more 
 often 2 inch, of the anus. The internal one may be detected as a slight 
 depression or papilla by the finger, or by the speculum, or, in obscurer 
 cases, by Mr. Lund's method.f 
 
 Horseshoe Fistulas. — Here an external opening on either side commu- 
 nicates with a single internal one, often at the back. This is an un- 
 common but an important variety, for if it is found necessary to cut 
 through the sphincter ani at both sides, some loss of power is very likely 
 to ensue. This risk should be explained to the patient, and the shal- 
 lower fistula should be scraped, while the deeper is freely incised. If 
 it is necessary to cut the sphincter on both sides, the knife should be 
 employed on two distinct occasions, time being given for the first to 
 heal.t' 
 
 Multiple Fistulse. — This condition should always cause a suspicion 
 of stricture, or extensive ulceration — e.g., dj'senteric, etc. 
 
 Fistuht u-ith Phthisis. — Where a fistula presents an external opening 
 with undermined, livid edges, Avhere the tubera ischii stand out 
 prominentl}- from emaciated nates, and where the hair of the part is 
 long and curled, phthisis is always to be suspected, even if no history 
 of cough or ha?moptj'sis be given. 
 
 Question of Operating on Phthisi<:al P<dients. — While each case must 
 be decided by itself, the following remarks may be useful : 
 
 Where the phthisis is advanced, the cough incessant, the fistula 
 multiple or branched, an operation is out of the question. On the 
 other hand, where the physical signs are little marked, night sweats 
 slight or absent, where the fistula interferes with the patient taking 
 the all-essential exercise, where the power of repair is good, an ope- 
 ration is indicated. 
 
 In cases intermediate between the above each one must be decided 
 upon its own merits. 
 
 Before operating, the surgeon should remember that repair is here 
 often sluggish, the mental condition much depressed. He should do 
 all he can to improve the general condition before and after the ope- 
 
 * A discolored (lot (ir patch of skin sdiiietiriies mai'l<s llie place where an external 
 opening may occur. Mr. Lnnd (Hunt, Led., p. 8S| relates a case in which a very 
 chronic and slowly advancing lilind internal fistula had excited, by its extreme end, 
 just enough inflammatory thickening of tlie skin as to imitate a keloid growlli, for 
 which it was at first mistaken. 
 
 t See foot- note, p. oO.". 
 
 X Mr. Cripps (Du. of Bectam and Anux, p. 165) shows that if, in women, the 
 sphincter is cut through anteriorly where it decussates with the sphincter vaginse, incon- 
 tinence of faeces is very likely to take place. 
 
FISTULA. 821 
 
 ration. And if this can be performed in sunny weather, or, better 
 still, at the sea-side, so that the patient can soon have fresh air in the 
 recumbent position, so much the better. 
 
 Operation. — For a few days before the operation the diet should 
 be restricted, and the bowels emptied by aperients. The hour of the 
 operation should be so arranged as to give time for the enema which 
 should be given to come away. The patient being under an anaes- 
 thetic, and either on his side with the knees well flexed, or in lithot- 
 omy position, the surgeon introduces lightly a fine Brodie's probe. 
 In the case of a complete fistula, the internal opening being hit off 
 (p. 820), the point of the probe is felt for by the finger and hooked 
 out of the anus. If, after careful examination, the surgeon is satisfied 
 that no internal opening exists, he makes one by finding the exact 
 spot at which the coats of the bowel are most thinned, thrusting the 
 point of the probe through here. 
 
 In the case of a blind internal fistula the internal opening must be 
 found with a speculum and the probe, curved, passed from this so as 
 to project beneath the skin. In every case the whole length of the 
 sinus between skin and bowel must be completely laid open. When 
 this has been done, very careful examination is made for other sinuses 
 by the introduction of the probe, and by pressure with the finger, 
 which squeezes out any discharges, and feels for indurated tracks. 
 Wherever these run, they must, if possible, be laid open. I have 
 already (p. 820) alluded to the question of dividing the sphincter in 
 two places. If any sinus seems to run dangerously high, ha3mor- 
 rhage may be avoided by dividing it with a small 6craseur, or, more 
 gradually, by the elastic ligature. Every attempt, however, should 
 be made with the aid of a good light and forcible dilatation of the 
 sphincter to lay open every sinus with bistoury or scissors, extra care 
 Deing taken, the higher the incision has to be carried, to arrest all 
 bleeding with carbolized silk ligatures. 
 
 While the sinuses are being followed up, any old gristly tissue must 
 be completely divided, all pyogenic or granulation tissue entirely 
 scraped out, and all ill-nourished flaps and tags of undermined skin 
 cut away. 
 
 If any troublesome piles coexist they should be tied and cut away 
 at the. same time, p. 823. 
 
 As a dressing I prefer a little twisted cotton wool dusted with iodo- 
 form, as I find this adapts itself more easily to the diff"erent wounds. 
 Less and less should be applied, daily, as granulations become estab- 
 lished. Daily plugging with strips of lint out of carbolic oil only 
 makes the wounds irritable and oedematous. After the first week 
 little more is needed than daily cleansing of the wound with a camel's- 
 hair brush, or a dossil of cotton wool on a Playfair's probe. If the 
 
822 OPERATIONS ON THE ABDOMEN. 
 
 edges of the wound close too soon they should be separated with a 
 probe from time to time, or any redundancy may be painted with 
 cocaine and snipped away.* 
 
 Finally, no operation better exemplifies the truth of Mr. Curling's 
 saying, that the surgeon should be here his own dresser. 
 
 HEMORRHOIDS. 
 
 Indications. 
 
 1. Continuance of ha3morrhage or discharge, and persistent liability 
 to descent of piles in spite of judicious treatment. 
 
 2. Absence of albuminuria, diabetes, hepatic (probably, cardiac) 
 disease. 
 
 3. Amenability on the part of the patient.f 
 
 Operations. 
 
 Ligature. — Cautery. — Crushing. — Acid. — Whitehead's 
 Operation. 
 
 i. Ligature.— I have placed this first, from a strong belief that, if 
 properly used, it is, on the whole, the best method and the one most 
 generally applicable. Here, as elsewhere, that surgeon will have the 
 best results who has thoroughly familiarized himself with the details 
 of one operation. The following appears to me to be a fair way of 
 putting the merits of ligature and the other operations : 
 
 1. The ligature is more generally suited to all cases. Thus it can 
 be more easily applied to piles high up than can the cautery. 2. No 
 special instruments are needed. 3. A ligature applied is done once 
 for all ; the cautery may have to be reapplied more that once if bleed- 
 ing follows when the clamp is unscrewed. 4. The ligature is free 
 from the objections to the cautery in private practice. 
 
 On the other hand, the recovery after the cautery is usually a little 
 quicker, as no ligatures have to be detached. If, however, the liga- 
 tures are properly applied, there is, practically, very little difference. 
 As to the risk of secondary hfemorrhage, most surgeons will feel more 
 absolute security after using the ligature, aide<l bj^ the use of iodo- 
 form, etc. 
 
 * Another excellent dressing, later on, is dilute nitric acid lotion, 10 minims to 1 
 oz. This needs changing every four or si.'c ho'irs, 
 
 t In Mr. Cri|)ps's words {loc. supra oil., p. 99) : " The sniiilhiess of the risk should 
 not lull the surgeon into a sense of absolute security, and he should spare no efTort in 
 ascertaining the generi\l constitutional condition of his patients. . . . The amount of 
 risk, slight as it is, should be clearly laid before the patient or his friends. If a man 
 is to have some grave o]ieration performed, such as the removal of a cancer or the 
 amputation of a limb, both he and his friends are well aware of the risk involved, and 
 are accordingly prepared. It is, therefore, in the smaller operations, regarded by the 
 surgeon and public as free from danger, that a fatality, when it does occur, becomes 
 so tragic from being unexpected." 
 
HAEMORRHOIDS. 823 
 
 Operation.— The preparatory treatment is that given at p. 821. 
 The patient being on his left side, or in the lithotomy position, the 
 anns must be dilated, if sitting for a quarter of an hour over hot 
 water has not brought down the piles sufficiently. This may he done 
 by introducing, and then separating laterally, the two thumbs, the 
 pressure being steadily maintained so as not to rupture the mucous 
 membrane; after a few minutes a sensation of giving rather than of 
 tearing is perceived, or the whole hand may be introduced in the form 
 of a cone. Another method is to introduce a large hi- or multi- 
 valve vaginal speculum, and to withdraw this expanded.* When the 
 sphincters are thoroughly dilated the largest pile is drawn down with 
 a vulsellum or tenaculum forceps, and the surgeon, with blunt-pointed 
 scissors, curved on the flat, cuts a groove around the lower two-thirds 
 of the pile. In the lower piles this groove should commence in the 
 sulcus, which marks the junction of skin and mucous membrane 
 close to the anus. The object of this groove is two-fold. It forms a 
 bed in which the ligature can be sunk tightly, and above all, it leaves 
 a very small pedicle of tissues to be strangled. The groove, more- 
 over, can be cut without risk of htemorrhage, as, however large the 
 pile, its vessels enter it from above, running into its upper part 
 just beneath the mucous membrane. The surgeon then ties round 
 each pile, which is now still further dragged down, a ligature of 
 well carbolized silk, the strength of which he has previously tested. 
 Sinking this into the groove he tightens it up as in the case of cas- 
 tration with the aid of blunt instruments (Fig. 136). About two- 
 thirds of the pile are then cut away, enough being always left to en- 
 sure a safe hold for the ligature. After every internal pile has been 
 carefully treated in this way, the external ones are clipped away, care 
 being taken not to encroach upon the junction of skin and mucous 
 membrane, and not to remove subcutaneous tissue for fear of subse- 
 quent contraction. If any bleeding-points still persist, they should 
 now be tied. The ligatures are all cut short, and lastly the stumps of 
 the piles, smeared with iodoform ointment after some of the powder 
 has been well rubbed in, are returned. A pad of lint well smeared 
 with the same ointment is then applied and firm pressure made with 
 a T-bandage and the aid of a pad of salicylic wool, carbolized tow, or 
 " tarred cotton." 
 
 ii. Clamp and Cautery.— This method has been perfected by 
 Mr. H. Smith.f The preparatory treatment and position of the patient 
 
 * Eversion of the rectal mucous membrane by a finger in tlie vagina will often 
 be most helpful in bringing piles within reach, 
 
 t Mr. H. Smith {Si/st. of Surg , vol. ii. p 810) has almost entirely discarded the use 
 of scissors, removing the clamped piles with heated cauterie-i instead. Three of the^e 
 are figured. 
 
824 OPERATIONS OX THE ABDOMEN. 
 
 are those already given. The piles being sufficiently protruded, with 
 or without forcible dilatation of the anus, they are drawn well down, 
 one by one, with vulsellum forceps, and enclosed within the blades 
 of the clamp, which is screwed tightly up. With scissors curved on 
 the flat the pile is then so cut away as to leave a sufficient stump. 
 This is then carefully and thoroughly seared down with a Paquelin's 
 cautery, carefully kept at a dull red heat. If the iron sticks at any 
 moment, owing to its cooling down, it should not be pulled away, but 
 loosened by heating it up a little. The clamp-screw is then slightly 
 relaxed, and if any bleeding takes place it is at once tightened up, 
 and the cautery re-applied. Every care must be taken to burn down 
 the stump thoroughly at the first attempt, for if this fail, and oozing 
 take place, it is not easy to stop the bleeding from the tendency of 
 the stump to slip through the slackened clamp. Each pile having 
 been successively dealt with in this way, the stumps are smeared with 
 iodoform ointment and pushed well up with a finger coated with the 
 same. 
 
 iii. Crushing. — This method has recently been brought before the 
 notice of the profession by Mr. Pollock* and Mr. Benham. It is 
 believed to be less painful than the ligature, and to leave a mere thin 
 and superficial fringe of dead tissue, instead of the slough of the clamp 
 and cautery. The patient being under ether each pile is drawn down, 
 and its base tightly and firmly clamped. The projecting part is then 
 cut away, and the clamp left attached for from two to four minutes 
 according to the size. Ligatures must be applied to any points which 
 still bleed, but they are stated to be rarely required. 
 
 iv. Acid, — This method, formerly much over-rated, should be 
 reserved for that rare variety of pile, sessile, perineal usually in posi- 
 tion, and with a florid, granular surface. Vaseline being applied 
 around, the surface of the pile is dried, and carefully rulibed over 
 with fresh, strong nitric acid, or acid mercury nitrate, this being 
 thoroughly applied with a glass rod or pointed bit of wood. The acid 
 should be rubbed in and in, the pile being kept dry and the acid not 
 allowed to run. Every atom of the fiorid surface must be converted 
 into a brownish, shaggy slough. 
 
 Whitehead sf Operation. — This extensive operation is intended 
 to bring about a radical cure, its object being not only to remove any 
 existing piles, but also all the mucous membrane in the lowest part 
 of the rectum, which is the seat of piles, owing to the tendency of its 
 veins to become dilated. Though Mr. ^\'llitehead has performed it in 
 three hundred cases without a fatal result or any drawback, I cannot 
 
 * Lancet, vol. ii. 1880, p. 1, f( passim. The clamp used is here figured. 
 t Brit. Med. Joiirn., February 26, 1887. 
 
HEMORRHOIDS. §95 
 
 but consider it needlessly extensive and severe, especially in patients 
 of middle life, and in a part which cannot be kept sweet, even with 
 the aid of iodoform. The operation by ligature, or by clamp and 
 cautery, carefully performed, gives most excellent results, and in 
 ' answer to Mr. Whitehead's argument, that as long as this diseased 
 area is left to reproduce piles over and over again, no permanent cure 
 can be expected, I may say that T have always found that, after one 
 of the above operations has been properly carried out, the patient can 
 easily prevent any recurrence by attention to common-sense details 
 in daily life. 
 
 Operation.— The sphincters being thoroughly dilated, and the 
 hf^morrhoidal area of mucous membrane made to prolapse, the line 
 of junction of skin and mucous membrane* is looked for, and the 
 latter divided along it all round the anus with blunt-pointed scissors. 
 The cut mucous membrane is theu dissected up, with forceps and 
 scissors, from off the external and (in fact) the internal sphincter till 
 the whole of the pile-producing area of mucous membrane can be 
 drawn outside the anus. It is then cutaway, bit by bit,t transversely 
 at its still attached upper border, each portion as cut being at once 
 attached to the cut skin with carbolized silk sutures. In this way the 
 diseased area is removed as a complete ring of mucous membrane. 
 Each bleeding-point is secured by torsion or forcipressure. Iodoform 
 is dusted over the wound. The sutures are allowed to come away of 
 themselves. 
 
 Causes of Failure and Trouble after Operations for Hsem- 
 orrhoids : 
 
 1. Hcemorrhage.— This will not occur if the ligature method be 
 carefully employed. If the surgeon be called upon to meet it, the 
 best means, in a severe case, is Mr. AUingham's i^Dis. of the Rectum, p. 
 122). Through a conical sponge a silk ligature is threaded from apex 
 to base. The sponge, well dusted with iodoform and steel sulphate, 
 is pushed 4 or 5 inches into the bowel, and the whole of the space 
 below it is plugged with aseptic gauze. The sponge is now pulled 
 down by the two ends of the ligature while the gauze is pushed iip. 
 The plug should be left in as long as possible, the patient being kept 
 under the influence of laudanum. 
 
 2. Tedious Ulceration. — This is usually due to the patients getting 
 up too soon. They should remain in a bed a week or ten days, and 
 then be content to pass another ten or fourteen days upon the sofa. 
 
 3. Septic troubles. 
 
 4. Contraction. ^This is only likely to occur when, in cutting away 
 
 * The " white line " of Mr. Hilton {Best and Pain, p 289, Figs. 51 and 52 1. 
 
 f So as to diminish tlie haemorrhage, which would otlierwise be free at this stage. 
 
826 OPERATIONS 0:S THE ABDOMEN. 
 
 piles, especially external ones, the junction of skin and mucous mem- 
 brane is trenched upon. 
 
 FISSURE.*-ULCER. 
 
 The operative treatment of these is so simple and so eminently 
 successful, that it should be resorted to early in these cases. 
 
 Operation by Incision.— The preparatory treatment and the 
 position of the patient are the same as those already given. The 
 division of the ulcer may be performed in one or two ways — (a) From 
 without, (b) From within the rectum. 
 
 (a) From ivitfwut.—Here the ulcer being fully exposed with a specu- 
 lum—and the one which bears Mr. Hilton's name, with a movable 
 valve, will be found the best — a small sharp-pointed bistoury is 
 inserted a little beneath the base of the ulcer, and its point made to 
 protrude in the bowel above it; the parts are then divided from 
 without inwards through the centre of the ulcer. 
 
 (h) Prom ivithin.—Here the ulcer being also exposed, either by 
 stretching the parts with two fingers or with a speculum, a straight 
 blunt-pointed bistoury is drawn across the whole of the sore, through 
 its centre.f Mr. Curlingj' has drawn attention to an important point 
 here, and that is, that the fibres of the muscle at the extremity of the 
 ulcer near the verge of tlie anus should be divided rather more freely 
 than those above, so as to avoid any ridge or shelf on which thefseces 
 would lodge. 
 
 There is usually no haemorrhage to speak of, and the whole opera- 
 tion is so simple that it may be performed after an injection of 
 cocaine, or with nitrous oxide gas, unless anything else — e.g., attention 
 to piles— is required. I prefer, however, to operate with ether or 
 chloroform. 
 
 Of the two methods, I generally make use of the first, following 
 Mr. Hilton. I consider it the more certain, and have never known 
 of anything like incontinence in the nine cases in wliich I have used 
 it. The second is rather the slighter operation, and also gives good 
 results. 
 
 The position of tliese usually club-shaped ulcers is posterior. If 
 one is met with anteriorly in a woman, it would be wiser to try the 
 appHcation of acids, or the actual cautery. See foot-note, p. 820. 
 
 The surgeon must be careful, when examining into the amount of 
 repair a week or two later, not to do any damage with a speculum. 
 
 * This condition, often called ii lissiire, nearly always amounts to an ulcer when it is 
 carefully examined and the (jarts nnlulded. 
 
 f Mr. Cripps {Dis. of Rectum and Anus, p. 176) says, ''so as to divide about a third 
 of the fibres of the external sphincter." 
 
 X Dis. of the Rectum, p. 12. 
 
PROLAPSUS. 827 
 
 Operation by Dilatation of the Sphincter.— This is not only 
 rough but uncertain, and should not be employed. 
 
 PROLAPSUS. 
 
 Indications.— Failure of previous treatment Large size and long 
 duration of prolapsus. Altered condition of the mucous membrane— 
 viz., thickening or ulcers, the latter giving rise to ha?moErhage. Incon- 
 tinence of faeces, especially when fluid, or of flatus. 
 
 Operations. 
 
 Acid.— Cautery..— Excision. 
 
 1. Acid.— Of these I prefer the acid ;nitrate of meroury. This 
 method is especially applicable to the obstinate cases of prolapsus in 
 children, where the bowel is constantly down. Though, if the appli- 
 cation is made properly, only a sensation Oif burning is complained of, 
 an anfesthetic should alway;^ l)e given. The patient being in the 
 lithotomy position or on one side, the prolapsus is carefully dried of 
 all mucus, and the surgeon rubs in the acid with the aid of a glass 
 rod or pointed pieces of wood, the adjacent skin being protected "with 
 vaseline. 
 
 Care must be taken not to rul < in the acid too long or too vigorously, 
 for, if the inflammatory process set up affects deeply the submucous 
 tissue, a most troublesome stricture may xeadily result. 
 
 It is well to warn the patients that a -second application ma,y be 
 required in severe cases. 
 
 The after-treatment is that given below. 
 
 2. Cautery. — In severer cases, or where the acid has failed, the 
 following will be found efficient. The position of the patient is the 
 same as that a'bove gi?ven but it is best to apply the cautery to the 
 bowel m sitiL, though this may lie used when the bowel is prolapsed. 
 
 Thus, the patient being in lithotomy position, and a duckbill- 
 speculum introduced and held in contact with tb'- anterior wall of the 
 rectum, the blade of a therrao-cautery is drawn edgeways along the 
 lower three or four inches of the opposite surface of the gut. The 
 speculum being shifted, the anterior and lateral .aspects are similarly 
 treated in severe cases. 
 
 Care must be taken not to go through the m^ucous membrane, or 
 septic mischief and sloughing may be set up in the cellular tissue 
 beraeath. 
 
 3. Excision. — In severe cases, in adults, when other methods have 
 failed, this method should be resorted to, but even with the improve- 
 ments of the present day there must always be a difficulty in keeping 
 wounds here aseptic. 
 
 The patient being in lithotomy position, the prolapsus reduced, and 
 
828 OPERATIONS ON THE ABDOMEN. 
 
 the parts exposed by a duckbill-speculum, two or more elliptical 
 pieces of mucous membrane are removed by pinching them up with 
 a vulsellum-forceps and cutting them away with a very sharp scalpel 
 or scissors. Any bleeding vessels are then tied with chromic gut, and 
 the edges of the wound united with horsehair or fishing-gut sutures, a 
 horsehair drain being inserted first. Iodoform is then carefully dusted 
 on, and the parts smeared with an ointment of the same. 
 
 The insertion of sutures has the advantage of preventing hemor- 
 rhage, and hastening the cure. The disadvantage is that an anajsthetic 
 will probably be required for their removal. Especial care will be 
 needed now not to break down the union with the speculum. The 
 wounds must be well washed daily with a small Higgenson's syringe. 
 
 After-Treatment. —After any operation for jirolapsus, the patient 
 must rest for three weeks on the sofa to allow of firm consolidation 
 and cicatrization taking place. Light diet — mainly, milk — should be 
 allowed at first, and the bowels should only be allowed to act every 
 three days, and, if possible, while the patient is on his side. 
 
 EXCISION OF THE RECTUM. 
 
 Indications. Suitable cases. 
 
 1. Malignant disease of anus — e.g., papilloraata, or old condylomata 
 becoming epitheliomatous,or epithelioma originating in some neglected 
 fistula. 
 
 2. Malignant disease of rectum. — The extent and fixity of this must 
 be most carefully investigated. If limited to the posterior wall of the 
 rectum even 4 or 4i inches of bowel may be removed. If the disease 
 have attacked the sides or the circumference, three inches in the male, 
 but less- than this in the female, may be removed as long as the bowel 
 is fairly movable on subjacent parts. This i>oint, especially in the 
 male, is rather difficult to decide, as even a normal rectum is closely 
 connected to the prostate and uretlira and base of the bladder. Mr. 
 Cnp\}»^ {D Is. of Rectum rmd Alius) thinks, that though the bowel in 
 contact with the prostate may be diseased, it is a long while before the 
 prostate itself becomes infected ; in women, on the contrary, when the 
 disease is on the anterior part of the bowel, the vagina and uterus 
 quickly become implicated. 
 
 Mr. AUingham (Intern. EiicijcL (>f Surg., vol. vi. p. 122), from an 
 
 * This surgeon, wlio lias had large e-^cperience of this operation, writes : '' It is well 
 to remember in tlie femiile how near to the perineum the peritoneal membrane 
 ileseends, it being much more commonly at a shorter distance than 3 inches than at a 
 diotance in excess of that measurement. In the male, however, 3} to 4 inches from 
 the anus is the common site for the reflection of the peritoneal membrane. 
 
EXCISION OF THE RECTUM. 829 
 
 experience of thirty-six cases * considers that " extirpation of the 
 rectum may be imdertalven in any form of cancer which does not 
 necessitate the removal of more than 4S or 5 inches in th« male, and 
 about 1 inch less in the female."" 
 
 Most surgeons will, however, not care to remove more than 3 inches 
 of the bowel, as beyond this limit the risks increase rapidly. It is not 
 only that the limit of the peritoneum varies normally, but further, it 
 can never be told how far the carcinoma has drawn this downwards. 
 The risk of opening the peritoneum is referred to below. 
 
 After all, measurements are of small service here. The chief points 
 are — (1) Can the finger be got well above the disease without feeling 
 any scattered nodules here? (2j Is the disea.te movable on adjacent 
 parts ? 
 
 3. There must be no enlargement of liver, or peh'ic or inguinal 
 glands. 
 
 4. The patient's general condition must be sufficiently good to meet 
 the calls of what may be a very severe operation. 
 
 Comparison bet-ween Excision of tlie Rectum and Co- 
 lotomy. — The chief points calling for attention are — (i) The mortality 
 of the operation, (ii) The duration of life after it. (iii) The amount 
 of comfort given by it. 
 
 Ci) The Mortality of the Operation. — In instituting a comparison on 
 these heads between colotomy and excision of the rectum it must, I 
 think, always be reme7ubered that in one respect the latter operation 
 is never performed under those unfavorable conditions of obstruction 
 which, owing to the operation being often deferred till too late, render 
 the mortality of colotomy such a high one. Turning to the mortality 
 of excision by itself without comparison with any other operation, we 
 find that Mr. But!in,t who has collected one hundred eases from 
 various sources, gives a mortality of 35. This death-rate of one-third 
 he regards as far too high, and as capable of reduction by one-half, or 
 even more, by attention to antiseptic details and also by abandoning 
 the practice of drawing down and suturing the cut bowel, a practice 
 
 * Of 36 cases operated on since 1874, Mr. AUingham has been able to trace 26. Of 
 tliese — 
 
 1 died about 4 years after tlie operation. 
 
 1 " " 3" " 
 
 2 " "2 " " 
 
 5 " over 18 months " " 
 
 V " about 1 year " " 
 
 5 " from tlie direct consequences of the operation, 
 5 are known to be still alive. 
 ' f Oper. Surg. Mallg. Dig., p- 241, 
 
830 OPERATIONS ON THE ABDOMEN. 
 
 which has been, largely followed at Vienna, and which, by causing 
 retro-peritoneal suppuration, has greatly increased the mortality. 
 While Mr. Butlin's criticism' iff, no doubt, a sound one, I venture to 
 think that another point has been overlooked which will prevent any 
 real reduction in the death-rate of excision. In this, as in every other 
 novel and important ojix^ration, a large number of unsuccessful eases 
 will remain uniDublished, while every successful cas« is reported at 
 once. 
 
 (ii) Duration of Life.. — With regard to, this point, I think a larger 
 number of cases will show that if the surgeon decides to advise, and 
 the patient is willing to run the risk of, the mere serious operation, the 
 prolongation of life will be greater here than after colotomy. Excision 
 of the rectum, if it does not extirpate the disease completel}', may do 
 so locally,, leading to a more merciful death by visceral deposits.. 
 Again, excision of the rectum, if only temporarily successful locally, 
 and recurring, may be repeated if tlie recurrence is detected early, and 
 it may also be supplemented by colotomy, each of these fresh opera- 
 tions giving addition of life in properly selected cases. I think that 
 the above is borne out by the results of the statistics which we have. 
 It is rare for patients after colotomy for carcinoma to survive more 
 tlian one year and a, half. Making due allowance for the advanced 
 date at which cases of rectal cancer too often come under treatment, 
 for the fact that excision will usually be performed in selected cases, 
 and that thus colotomy will be reserved for those less favorable, I think 
 the published cases of excision show a greater prolongation of life. 
 Mr. Cripps speaks of six cases known to have been well at periods of 
 two to four years after the excision, one of these showing the value of 
 a second operation. Mr. Allingham's cases (p. 829) show that in four 
 death took place over two years after the operation, and that nine sur- 
 vived over eighteen months. Mr. Butlin quotes two cases of Fischer's 
 claimed as complete cures, one of six yer.rs' duration, the other of three 
 years and ten months. 
 
 (iii) Amount of Comfort Afforded. — After this operation, as after 
 excision of the larynx, a distinction must be drawn between mere 
 survival and what deserves the name of recovery. The amount of 
 comfort enjoyed by the patient will depend on— (1) The amount of 
 contraction that takes place. (2) How far he has control over his 
 motions. Where the whole circumference of the bowel has been 
 removed, a matteir refemed to below (p. 8S3), it is obvious that there 
 must be a great risk of contraction in the scar-tissue which replaces 
 the mucous memljrane. This tendency will be most marked in the 
 lower inch or two, for Mr. Cripps finds that the severed end of the 
 bowel is drawn considerably downwards during the process of healing. 
 
EXCISION OF THE KECTUM. 831 
 
 This renders it easier for the patients to pass a bougie from time to 
 time, the need of which must be firmly impressed upon them. 
 Another means of securing the patency of the bowel is by wearing a 
 vulcanite tube, as recommended by Mr. Allingham. These are 3 or 4 
 inches long, with one end conical, and with the other ending in a 
 broadish flange to prevent its slipping into the bowel, and also to 
 enable it to be stitched to a bandage which keeps it in place. Patients 
 begin to wear it about a fortnight after the operation, and, save for 
 taking it out when the bowels act, retain it constantly for some months, 
 some having to wear it for the rest of their lives. 
 
 As to the power of retaining faces, incontinence is always present 
 at first, but control is usually regained after a time. Mr. Cripps {loc. 
 supra cit.) states that incontinence was present in only seven out of 
 thirty-six cases which he collected. As he points out, the last few 
 inches of the rectum are empty in health during the greater part of 
 the day, faeces being only occasionally brought into contact with the 
 sphincter either by diarrhoea, or by straining of the abdominal mus- 
 cles. As therefore the normal condition of the last few inches is, dur- 
 ing health, one of emptiness, a narrow, long, valve-like chink may be 
 found efficient after operation, especially if tortuous. 
 
 Operation of Excision of Rectum in its Entire Circumfer- 
 ence. — The bowels being well emptied by mild purgatives and an 
 enema,* the patient, under the influence of ether, is placed in lith- 
 otomy position, and the surgeon rapidly makes an oval incision into 
 both ischio-rectal fossae, around the bowel, then prolonging this oval 
 backwards so as to reach the coccj'x. 
 
 This backward prolongation is much needed in order to give addi- 
 tional room for meeting h8emorrhage,t and for providing drainage 
 later on. The fingers, aided if needful by the knife or blunt dissector, 
 separate the bowel at the sides and posteriorly as high as the levator 
 ani ; the haemorrhage in this stage is usually not severe, and can 
 be readily arrested by pressure-forceps, or sponges pushed into the 
 
 * Mr. Barker (Man. of Surg. Oper., p. 313) reTOmmends, in addition to copious ene- 
 mata on the morning, an enema of brandy before the operation, as a general stimulant 
 and an antiseptic. 
 
 t If this incision has to be carried as high up as 3 or 4 inches, the h?emorrIiage will 
 be free, as the superior haemorrhoidal artery here divides into two terminal branches. 
 The free incision, well opened ont with retractors, will admit of easily dealing with 
 this vessel. Another method is to begin by a free posterior incision, made by guid- 
 ing a curved sharp bistoury well above the disease in the posterior wall, bringing out 
 the point at the tip of the coccyx, and then cutting all the intervening tissues into the 
 bowel. This exposes well the limits of the growth. If the first method is made use 
 of, the bowel must be laid open subsequently, to investigate the npper limits of the 
 disease. 
 
832 OPERATIONS ON THE ABDOMEN. 
 
 incision. Tlie separation of the bowel in front varies with the sex of 
 the patient. In the male a full-sized metal sound being passed into 
 the bladder * the surgeon carefully dissects away, partly with his 
 finger and partly with scissors, between the bowel and urethra and 
 prostate. These parts are naturally adherent, and this dissection must 
 be carefully conducted as any opening into the bladder or urethra 
 will much increase the shock. In the case of a woman the surgeon's 
 left index, or the finger of an assistant in the vagina, will give the 
 best warning of his knife or scissors getting too near the vaginal 
 mucous membrane.! If this be encroached upon it must be removed 
 without hesitation, in the hope that the cloaca thus formed will be 
 much diminished by contraction, or that it may be closed subse- 
 quently. If the disease has extended up the recto-vaginal septum 
 the peritoneum must be looked out for, and the greatest care taken 
 not to open this cavity at the upper part of the dissection. The 
 levator ani being carefully cut through, the rectum, now separated 
 everywhere save above, is dragged down by an assistant or by the 
 operator with his left hand. While this tension is kept up, the sur- 
 geon with his finger, aided by scissors, frees the bowel sufficiently 
 above the disease to admit of drawing it safely. Frequent examina- 
 tion of the interior of the bowel should be made at this stage to tell 
 when the upper limit of the disease has been reached. 
 
 When the bowel has been safely isolated above the disease it must 
 be divided either with the wire loop of an ecraseur, as recommended 
 by Mr. Cripps, or by scissors. A\Tien the patient is in good condition, 
 where little blood has been lost, and where the operation has not been 
 much prolonged, division by scissors is to be recommended, as these 
 give a mugh cleaner-cut surface, and one therefore less liable to slough, 
 and they furthermore avoid the risk which is inseparable from the use 
 of the ecraseur — viz., its gradually encroaching, as it is tightened, 
 more and more closely upon the diseased area. 
 
 If the surgeon is unprovided with an fecraseur he may divide the 
 rectum with a Paquelin's cautery. But, as remarked by Mr. Cripps, 
 the use of any form of cautery during the operation makes it ex- 
 ceedingly difficult to distinguish between the hard nodules of burnt 
 tissue and portions of the disease left behind. 
 
 The bowel having been removed, all bleeding-points are most care- 
 fully looked for, and the wound is thoroughly dusted over with iodo- 
 
 * Prof. Macleod (loc supra cit.) advises that, if the disease is low down, it matters 
 little whether Ijie bladder is full or emptv ; if a higher portion has to he dealt with, as 
 Dupuytren showed, tho urine sholild be retained, so as to raise the rectovesical pouch. 
 
 f Subsequent sloughing here is not unlikely. 
 
EXCISIOX OF THE RECTUM. 833 
 
 form, painted over with this antiseptic and ether * and lightlv plugged 
 with strips of aseptic gauze. f " 
 
 If the peritoneum has been opened, either a drainage-tube packed 
 around with gauze, or a tampon of gauze, must be made use of. 
 
 Mr. Cripps considers that any attempt to bring down the edges of 
 the cut rectum and to stitch them m »ita around the anus is perfectly 
 useless, as the sutures are certain to cut their way out, and harmful, 
 as likely to prevent the escape of discharges. As this runs the very 
 serious risk of septicajmia, the advantages which suturing the bowel 
 would give, if it were safe, of preventing subsequent contraction, must 
 be put aside. 
 
 Question of Partial Removal.— If any of the mucous mem- 
 brane, even a mere strip, can be sufrly left, the amount of subsequent 
 contraction will be less, but here, as in all other operations for malig- 
 nant disease, every consideration must give way to the chief object, 
 that of extirpating the growth. 
 
 Partial operations should be reserved only for cases where the dis- 
 ease is very localized in amount, and admits of extirpation, together 
 with a very wide margin of bowel. Where the disease implicates 
 one-half of the bowel, even if apparently not disseminated in the 
 mucous membrane, the whole circumference should be removed. Mr. 
 Allingham thus condemns partial operations : " The partial removal 
 of the circumference of the bowel is, in my opinion, most unsatis- 
 factory. In all the cases in which I have removed only part of the 
 wall, there has been either a return of the disease in the rectum, or in 
 the glands in the groin, or in some internal organ, mostly the liver." 
 
 If the surgeon decide on a partial operation, he must be prepared 
 for some increased difficulty, owing to the diminished room for work- 
 ing, and meeting the hasmorrhage. Perhaps only one semilunar inci- 
 sion around the anus will be required. Mr. Cripps thus advises the 
 use of the ecraseur : " A strong, blunt-pointed, slightly curved needle, 
 4 inches in length, armed with strong string, is then thrust in at the 
 upper angle of the curved lateral incision, at a point opposite the 
 posterior preliminary incision, or further round if the disease has 
 encroached at all on the anterior wall. The needle is made to traverse 
 the tissues external to the muscular coat of the bowel to a sufficient 
 height, and the point, guided by the finger in the rectum, is thrust 
 through the coats into the cavity of the bowel. The loop of string 
 thus passed through is seized and drawn out at the anus, while the 
 
 * Throughout the operation the wound should be well syringed with a solution of 
 mercury perchloride (1 in 2000). This should be used hot, if tliere is troublesome 
 oozing. 
 
 f If it is necessary to do this firmly, the plugs should be removed, by soaking, as 
 sot)n as possible, in order to allow of escape of discharges. 
 
 53 
 
834 OPERATIONS ON THE ABDOME.V. 
 
 needle is withdrawn through the hole at which it entered. By means 
 of this loop one end of an ecraseur wire is drawn back into the bowel 
 and out again at the puncture made by the needle. This, together 
 with the other end of the wire which hangs out of the rectum, are fixed 
 to the ecraseur, and the intervening tissues cut through. The strip 
 of bowel between the posterior incision and the one just made by the 
 ecraseur can now be separated by the finger from its lateral connec- 
 tions, the separation, of course, commencing from the semilunar in- 
 cision round the anus. In this way the rectangular flap of bowel in 
 which the disease is situated is detached from the surrounding connec- 
 tions, except at its upper margin. It is then drawn down and cut off 
 by the ecraseur or scissors. It can be readily understood how the 
 steps of this operation must depend upon the portion of bowel in 
 vvhich the disease is situated. If it be in tlie middle line behind, the 
 disease, or a portion of it, will probably have been split by the first 
 incision, in which case a strij) cf bowel must be removed on either 
 side; or again, if it be on the anterior wall, the ecraseur wire will 
 have to be twice jjassed bj- the thread and needle, once in each side 
 of the disease, or instead of the ecraseur all the cutting can be done 
 with scissors if preferred." 
 
 After-treatment. — The cliief points here are to keep the wound 
 sweet by frequent syringing with dilute mercury perchloride solutions, 
 or Condy's fluid, and the insufflation of iodoform. The catheter will 
 probably be required, and a mild aperient may be given about the 
 sixth day, if needed. The finger should be occasionaUy passed with 
 the utmost gentleness, and after a week or ten days, a tallow candle, 
 succeeded later by a bougie. 
 
 Causes of Trouble and Failure after Excision of the 
 Rectum. 
 
 1. Shock. 
 
 2. Haemorrhage. This will rarely be difficult to deal with at the 
 time, or met with later, if the surgeon has plenty of Spencer Wells's 
 forceps, good assistants, and if he does the operation steadily, con- 
 trolling each vessel as met with.* This, aided Ijy hot injections (p. 
 833) and firm sponge pressure, will usually prevent any secondary 
 hajmorrhage. If this should occur, Prof. Macleod's advice should be 
 followed— viz., to pass a largo tube into the bowel for the escape of 
 flatus, etc., and to pack carbolized sponges, or strips of gauze, firmly 
 round this. 
 
 3. Suppuration. Cellulitis and other septic troubles. 
 
 * Mr. C'rii>|iH has shown (hat, as most of the bleeding comes from vessels sitiialed in 
 tlie walls of the rectum, dragging down the bowel with a firm grasp will not only 
 greatly facilitate the operation, but also prevent haemorrhage. . 
 
IMPERFOEATE ANUS AND RECTUM. 
 
 835 
 
 4. Peritonitis. 
 
 5. Exhaustion. 
 
 6. Recurrence. 
 
 IMPERFORATE ANUS.-ATRESIA ANI.-IMPERPECTLY 
 . DEVELOPED RECTUM (Figs. 137-143). 
 
 A surgeon, when called upon to explore these cases, will do well to 
 bear in mind the following natural and practical classification, because 
 on this depends his treatment: 
 
 TiDO Main Varietief< : 
 
 A. Cases in which no normal anus exists — Imperforate Anns. 
 
 B. Cases in which a normal anus exists, but the gut is obstructed 
 higher up, or undeveloped— //)y«';;forrt/(? Rectum. 
 
 A. Im perforate Anus. 
 
 1. Anus partially closed— (a) by adhesions of epithelial surfaces, as 
 occasionally happens in the labia of a female infant; (b) by a mem- 
 brane. 
 
 2. Anus completely closed, but only by a membrane. 
 
 3. Anus completely closed by a membrane, but a fistula exists— (a) 
 on the surface of the body (c.gr., the raphe of the scrotum); (6) into 
 
 Fig. 137.* 
 
 Fig. 138. 
 
 Fi",. 139. 
 
 Anus absent. Rectnm open- Anus absent. Rectum com- Anus ending in cul-de-sac. 
 ing by fistula, close to uretlira. municating with vagina. Rectum opening into urethra 
 (Rushton Parker.) (Rushton Tarker.) far back. A case for Littrfe's 
 
 operation. (Rushton Parker.) 
 
 the vagina, Fig. 138; (c) into the urethra or bladder. Figs. 137, 139, 
 143. 
 
 4. Anus imperforate and the rectum deficient as well. 
 
 B. Anus in natural position, but the rectum is deficient* — («) the 
 
 * This, and the ne.\t six figures, are taken (with a few alterations) from an article 
 by Mr. Rushton Parker (Liverpool Med. Ctiron., July, 1883). 
 
 t As Mr. Holmes has shown, these cases are important, as they are liable to be 
 overlooked till considerable distension has taken place. 
 
836 ■ OPEKATIONS ON THE ABDOMEN. 
 
 rectum is deficient for a short distance only, and separated from the 
 anus by a cul-de-sac, Fig. 141 ; (6) the rectum is deficient for a long 
 distance, or entirely, Fig. 142. 
 
 Treatment. 
 
 A. Those in which no natural anus exists. 
 
 1 and 2. If the atresia be due to epithelial adhesions, or to a more 
 or less complete membrane, the former should be broken down and 
 the latter snipped away with scissors, and the opening kept patent by 
 a small piece of oiled lint, the nurse's little finger being introduced 
 twice daily. 
 
 3. If the anus be imperforate, and a fistula open (a) on the surface of 
 the body, (h) into the vagina, or (c) urethra. 
 
 (a) A probe is passed from the skin-fistula (e.g., in the scrotum) 
 towards the proper anal site ; it is then cut down upon and the open- 
 ing established in the proper position. 
 
 Qi) If the fistula open into the vagina, the treatment will vary 
 somewhat with the urgency of the case, the size of the opening, and 
 the age of the child. 
 
 Thus, if the opening be very small and the retention urgent, a silver 
 director should be passed through the vaginal fistula back to the 
 proper site of the anus, and there cut down upon. If the bowel is 
 within reach, it should be drawn down and stitched in situ. The 
 orifice should be kept patent.* 
 
 If, owing to the size of the vaginal fistula, there is not much reten- 
 tion, and especially if the child be not very young, the following 
 operation may be performed, after the method of S. Rizzoli (quoted 
 by Mr. Holmes, Sj/st. of Surg., vol. iii. p. 7<SS) : An incision is made 
 from the vulva to the coccyx in the middle line, the rectum found by 
 most careful dissection, separated from the vagina, and then brought 
 down and fixed in its natural position. To aid in finding the rectum, 
 a probe will be passed from the fistula. 
 
 After the rectum has been brought down and secured, the incision 
 between the anus and vulva is united to form a new perineum. 
 
 (c) Fistula into the urethra or bladder. Two questions here arise: 
 How high up is the communication? How much of the bowel is 
 deficient? 
 
 If the perineum seem fairly developed, if the ischial tuberosities are 
 not in close contact, if any bulging can be detected at the natural site 
 of the anus, the communication is probably recto-urethral, and an 
 attempt may reasonably be made to find the liowel from the perineum 
 
 * In Kiicli a case, lluiiinh an anus is establislied in the proper position, it is very 
 doubtful if the vai,'iniil listiihi will close, and a further operation will probably be 
 required later on. I'lastit- operations should not be tried too early on account of the 
 softness of the tissues and the liquid condition of the fa?ces. 
 
IMPERFORATE AXUS AND KEOTUM. 
 
 837 
 
 (p. 838). If it is found, and can be brought down, an attempt may 
 be made to separate it from the adjacent urethra, but usually the sur- 
 
 FiG. 140. 
 
 Fig. 141. 
 
 Anus absent. Rectum could be reached by 
 dissection. (Rush ton Parker.) 
 
 Anus ending in cul-de-sac. Rectum readily 
 reached from this. (Rushton Parker.) 
 
 geon will have to be satisfied with a free opening, and with keeping 
 this patent, so as to encourage the urethral communication to close. 
 
 Fig. 142. 
 
 Fig. 14.3. 
 
 Anus absent. Rectum ending hig^h up. A case 
 for Littr^'s operation. (Rushton Parker.) 
 
 Anus and rectum deficient, the bowel ending 
 in the bladder. (Rushton Parker.) 
 
 If there appear no probability of the bowel being within reach, or if 
 this cannot be found, Littrfe's operation should be performed fp. 605).* 
 
 4. Anus absent and rectum deficient as well. Here the chief 
 question is how far upwards an exploratory operation may be safely 
 conducted. 
 
 External evidence. Genitals far back and close to the coccyx, and 
 ischial tuberosities close together, point to absence of the rectum. 
 
 * If ilie chilli survive, the bladder must be kept carefully washed oii( if any faeces 
 still find their way into it. Thus, in a case of Mr. Chitton's (St. Thomas's Hasp. Reoorls, 
 vol. xi. p 84!, a child about a month old died, sixteen days after Littre's operation 
 of suppurating kidney.s, due to the offensive purulent urine. 
 
833 OPERATIONS OX THE ABDOMEX. 
 
 In most cases the surgeon begins by exploring. The child being 
 under ether and in lithotomy position, with a small sandbag under 
 the sacrum,* the surgeon, seated at a comfortable level, makes a free 
 incision from the position of the anus back to the coccyx. Keeping 
 exactly in the middle line, and opening up the cellular tissue with his 
 finger-tip, aided by a scalpel and director, the surgeon works back- 
 wards towards the concavity of the sacrum, constantly taking note 
 with his finger-tip of the depth to which he has got, while an assistant 
 aids to bring down the bowel by supra-pubic pressure. 
 
 As a rule, two inches are a sufficient depth in a new-born child- 
 If still in doubt whether to proceed or no, the surgeon may make a 
 careful puncture with a morphia-syringe backwards, and note the 
 condition of the point; no puncture with a trocar is justifiable at this 
 depth. 
 
 Points to bear in mind. — 1. The rectum may end at the brim of the 
 pelvis. 2. If it end lower down it. may be floating with a long meso- 
 rectum. 3. Though the rectum may end within reach, the peritoneum 
 may, and not unfrequently does, extend low down on the bowel. 4. 
 Even if the rectum is successfully opened high up, without opening 
 the peritoneum, fatal cellulitis may be set up. by the escaping faeces, 
 or by the attempts to keep the liowel patent. 
 
 If the above exploratory operation fail, inguinal colotomy or 
 Littr6's operation should be resorted to, p. 605. 
 
 B. Imperforate Rectum. — The treatment here will be an exploratory 
 operation (p. 838), followed, in case of failure, by Littre's operation 
 (p. 605). 
 
 CHAPTER XVI. 
 
 RUPTURED PERINEUM (Figs. 144, 145). 
 
 The following account is taken from my colleague. Dr. Galabin :t 
 A. Operation for Partial Rupture (Fig. 144).—" The patient 
 is placed in the lithotomy position. The need for assistants to support 
 the thighs is avoided if ' Clover's crutch ' is used. By this the thighs, 
 just above the knees, are fixed liy circlet straps at the end of an iron 
 bar, the length of which can be regulated by a screw which fixes it in 
 any position. The thighs are then flexed to any required degree by 
 a padded strap which passes from one end of the bar round the neck, 
 and is then attached to the other end. Thus, the knees can be kept 
 
 * The bladder may first be emptied with a catheter. 
 
 t Dis. of Wumeii, pp. 130, 381. Any one inuking a trial of this'method will agree 
 with me as to its simplicity and excellent resnits. 
 
EUPTU]!ED PEKIXEUir. 
 
 839 
 
 widely apart while the operation is performed, and brought closer 
 together by altering the scre^y, when the time arrives for tightening 
 the sutures. ° 
 
 "The extent of surface to be freshened is indicated, to some extent 
 by the cicatrix left by the rupture. It is well, however, to go a little 
 beyond the limits of this in all directions, especially up the median 
 line of the vagina and towards the lower halves of the labia majora 
 both m order to secure, if possible, a perineal body somewhat larger 
 
 Fig. 144. 
 
 (Galabin.) 
 
 and deeper than the original one, and to allow some margin, in case 
 the surfaces do not unite completely up to the edges. To put the 
 mucous membrane on a stretch, an assistant at each side places one 
 or two fingers on the skin of the thigh, and draws the vulva outwards 
 (Fig. 144). The skin just beneath a, in front of the anus, may also 
 be seized by a tenaculum and drawn downwards. If still the mucous 
 membrane is not sufficiently on the stretch, from laxity of the vagina, 
 the posterior vaginal wall, some distance above b, should be seized by 
 long-handled tenaculum-forceps and pushed upwards. Incisions are 
 then made through the mucous membrane from b to A, in the median 
 
840 OPERATIONS ON THE ABDOMEN. 
 
 line of the vagina, and from a to c and d through the junction of 
 mucous membrane and skin. These should not be extended in the 
 direction of c and d further than the lower extremity of the nymphaj 
 at the utmost. There are then two triangular flaps, abc and abd. 
 These are to be dissected up from the apex a towards the base BC and 
 BD, the corner of the mucous membrane at a being seized with dis- 
 secting forceps. The dissecting should not be deeper than necessary, 
 and if it is done with the knife the surfaces are more ready to unite. 
 If, however, there is much tendency to bleed, scissors may be used. 
 The apices of the flaps are then cut off with scissors, leaving an 
 upturned border along bc and bd. When the surfaces are drawn 
 together these borders form a slightly elevated ridge towards the 
 vagina, and if there is any failure of union just along the edge they 
 fall over and cover it. 
 
 " The best material for sutures is the silkworm- or fishing-gut, which 
 should be stout, of the thickness used for salmon flies. It may be 
 stained with magenta, to render it more easily visible. This has all 
 the advantage of silver wire, as being non-absorbent, while at the 
 same time, it is easier to manipulate, and the exposed ends do not 
 cause discomfort after the operation, like those of wire. The sutures 
 are placed as shown in the figure. The most convenient needle is a 
 slightly curved one, hot too thick, mounted in a handle. This is 
 passed in, unthreaded, rather close to the edge of skin, brought out 
 on the raw surface, then threaded with the end of the suture, which 
 is so drawn through. By passing the needle in the same way on the 
 other side, the other end of the suture is drawn through. Another 
 mode is to use a more curved needle, and to bury the sutures, 1, 2, 
 and 3, in the tissues throughout their whole course. If, however, 
 they are brought out in the centre for spaces alternateh^ short and 
 long (Fig. 144), the surfaces are more easily brought into contact at 
 all levels without undue tension. In passing sutures 4, 5, 6, the 
 needle should lie brought out precisely on the margin along wliich 
 the borders of mucous membrane bc, bd, are turned up from the 
 vagina, not passing through the mucous membrane itself. The su- 
 tures are then tied in the order of the numbers from 1 to ti, care being 
 taken that the surfaces are brought just sufficiently into apposition> 
 and that no clots or blood are left between them. The bleeding, if 
 any continues, is arrested by bringing the surfaces together, and if 
 they are properly united there will be no secondary haemorrhage, 
 unless the sutures begin to cut from excessive tension. The sutures 
 may be left in from seven to ten days." 
 
 Operation for Complete Rupture (Fig. 145\— The prelimi- 
 nary steps are taken as above. " A point b in the median line of the 
 vagina, a sufficient distance above the apex of the rent in the septum, is 
 
RUPTURED PERIXEUM. 
 
 841 
 
 taken, and an incision through the mucous membrane is made from 
 B to G, and from g to E and f along the edges of the septum, between 
 the rectal mucous membrane and the cicatrix. Incisions are also 
 made through the skin from e to c and f to n, so that the freshened 
 surface may extend somewhat beyond the limits of the cicatrix, c or d 
 not to be higher than the lower extremities of the nympha;. The 
 quadrilateral flap egbc is then seized at e by dissecting-forceps, and 
 dissected up with the knife from the angle e, and afterwards from the 
 angle (:, towards the base bc. While this is done, the parts are kept 
 on the stretch by an assistant drawing down the skin below e with a 
 tenaculum. The flap is then cut away with scissors, except an up- 
 
 Fiu. 145 
 
 (Galabin.) 
 
 turned border, which is left along bc. The flap fgbd is treated in a 
 similar manner. If, as is usual, the ends of the sphincter at e and f 
 have retracted from the margin of the cicatrix, it is well to cut away 
 with the scissors a narrow strip of rectal mucous membrane, generally 
 somewhat everted, a short distance from e and f towards g, so as to 
 bring the freshened surface to the ends of the sphincter. 
 
842 OPERATIONS ON THE ABDOMEN. 
 
 " Sutures of silkworm-gut are then applied in the following manner : 
 First, rectal sutures, either two or three, according to the extent of the 
 rent in the septum, are applied. These are designed to be tied to the 
 rectum, and the ends left projecting through the anus. They are 
 best applied with a half-curved needle, held in a holder. The needle 
 is passed in a little distance from the margin of the rent, and brought 
 out almost at the very edge of the rectal mucous membrane, on the 
 line GF. The needle is then threaded at the other end of the suture, 
 and that is drawn through in the same way from without inwards, on 
 the margin eg. Next two suture^ at least are passed completely round 
 through the remnant of the septum, by means of a curved needle, 
 not too large, mounted in a handle. This is passed unthreaded, and 
 draws the suture back with it on withdrawal. The first of these (3, 
 Fig. 145) is passed in somewhat behind and below the angle f, so 
 as to take up, if possible, or at least go quite close to, the end of the 
 divided sphincter, and is brought out in a similar position near e. 
 Thus, when tightened, it brings together the ends of the sphincter, 
 drawing it into a circle ; but it often brings into apposition, not so 
 much the freshened surfaces above as the unfreshened rectal mucous 
 membrane. This serves as a barrier to keep out faecal matter, while 
 the next suture (4, Fig. 145) aids the rectal sutures in uniting the 
 freshened surfaces. The remaining sutures are passed as shown in 
 the figure (5-8, Fig. 145) by a slightly curved needle mounted in a 
 handle, in the same way as in the operation for incomplete rupture 
 (Fig, 144). The needle, unthreaded, is passed in pretty close to the 
 edge CE or fd, is brought out (except in the case of suture 5, Fig. 145) 
 on the line where the margin cb or db is turned up, and draws one 
 end of the suture back with it, the other end being afterwards drawn 
 through in the same way. The effect is, that when the sutures are 
 lightened, the margins bo, bt> are turned up into a slight ridge to- 
 wards the vagina, and afterwards fall over and cover any portion of 
 the vaginal border which does not unite quite up to the edge. Suture 
 5 (Fig. 145) may either be buried throughout, or brought out for a 
 very short space near the median line bg. 
 
 '' When all the sutures are in place, the sponge* is withdrawn from 
 the rectum, and the rectal sutures are tied first. Care must be taken 
 to draw up the whole of tiie slack in the centre, and bring the edges 
 EG, FG perfectly together. This will approximate the ends of the 
 sphincter to a great extent, and the approximation is completed b_v 
 tightening suture 3. The remaining sutures are then tied in the 
 order of the numbers, care being taken to allow no clots or blood to 
 remain between, and to tighten them just enough to bring the sur- 
 
 * This, secured witli tape, is introduced into the bowel, to prevent the descent of 
 imy faeces left hy an enema. 
 
RUPTURED PERINEUM. 843 
 
 faces in contact. The ends of the rectal sutures may be left mode- 
 rately long, to distinguish them, the rest cut pretty short. 
 
 " The perineal sutures are removed in seven days. The rectal sutures 
 may be left from ten to fourteen days longer, till the perineum is 
 consolidated. They are then removed through a small rectal spec- 
 ulum, care being taken not to break down any of the union in passing 
 it. By this operation the anus is generally much more completely 
 restored than by the use of quilled sutures, or the plan of making 
 deep lateral incisions to relieve tension. If there is much resistance 
 to bringing the surfaces together, the only thing required is to use 
 more numerous sutures, so as to diminish the tension on each. 
 
 " In some cases, by the primary operation after labor, onlj' superficial 
 union is secured, and a recto-vaginal fistula is left close to the part 
 united. The best jalan is then to cut through the bridge of union 
 with scissors at the time of the operation, and then proceed as in the 
 case of complete rupture. This is the only way to secure a firm and 
 thick perineum, and is less likely to fail than an operation on the 
 fistula alone." 
 
FART V. 
 
 OPEEATIONS ON THE LOWER EXTREMITY. 
 
 CHAPTER I. 
 OPERATION& ON THE HIP-JOINT. 
 
 AMPUTATION AT THE HIP-JOINT.-EXOISION OP 
 THE HIP-JOINT. 
 
 AMPUTATION AT THE HIP-JOINT. 
 
 This foriDidable operation has been much simplified of late j'ears 
 by the most important improvement of Mr. Furneaux Jordan * whose 
 method should replace all others in every possible case. It will be 
 described first here, and a few of the other methods, sufficient for all 
 practical purposes, mil be given afterwards. 
 
 Methods. 
 I. Furneaux Jordan. 
 II. Antero-posterior Flaps. 
 
 III. Lateral Flaps. 
 
 IV. Modified Lateral— viz., Antero-internal and Postero- 
 external — Flap&. 
 
 I. Furneaux Jordan's Method (Fig. 147).— By amputating 
 through the thigh as- low down as possible, and shelling out and dis- 
 articulating the femur, it is now possible to avoid, in large measure, 
 those dangers which were formerly inseparable from the operation — 
 viz. : 
 
 1. Shock, the limb- being removed much further from the trunk.- 
 
 2.. Htemorrhage. a. Abundant room is afforded for compression 
 of th.e common femoral, and the vessels behind, b. The large vessels 
 ean easily h&- secured on the face of the stump, c. The gluteal and 
 sciatic arteries- remain untouched, the haemorrhage from these, in the 
 older operations, being a source of serious danger. 
 
 3. Septic changes. By the other methods, the copious discharge of 
 
 * Judging from a letter from Prof. Oilier to Mr. Sliiiter {loc. infra cit.) the former 
 surgeon had recommended thiK method as long, ago- as 18.39, and performed such an 
 operation, once. 
 
AMPUTATION AT THE HIP-JoINT. §45 
 
 bloody serum from the large woimd * being poured out close to the 
 anus and genitals, was very liable to decompose. By this operation, 
 both the end of the stump and the wound on the outer side can be 
 more easily drained and kept aseptic. In making use of this amputa- 
 tion, especially for hip disease or failed excision, the surgeon should 
 not attempt too much to secure primary union.f 
 ^ 4. The stump is a better one. It is longer, more mobile, and occa- 
 sionally, as in amputation for acute periostitis or necrosis, it is possible 
 to preserve much of the periosteum from the upper half of the femur, 
 and a cord J will be left which will render the stump movable. 
 Whether in any case an artificial limb can be worn for more than 
 about half an hour at a time is very doubtful. 
 
 Methods of Controlling Hsemorrhage during Amputation 
 at the Hip. 
 
 1. Elastic Co III press inn by, Jordan Lloyd's Jirf/n»/ (Fig. 147).— This may 
 be applied at the junction of the limb and trunk, without interfering 
 with the operator, by the following method : AMien the patient is 
 passing under the anaesthetic, the limb is emptied of blood by elevation 
 and application of Esmarch's bandages as far up as the tissues are 
 healthy ; the patient is then rolled over on to his sound side, and a 
 
 * As will be shown below, ihe wound in a Furneanx .Jordan amputation is also a 
 large one, but much more happily placed for being drained and kept sweet. 
 
 t \'erneuil {Paris Acad, de Ned.. 1877). 
 
 X The committee of the Clinical Society appointed to examine Mr. Shuter's case of 
 subperiosteal amputation at the hip-joint reported (Trmia., vol. xvi. p. 89) (1) tliat, 
 though there was a firm, resisting cord of considerable size in the centre, which afforded 
 the nuiseies a common point of attachment, there was not sufficient evidence to enable 
 them to .state that this cord contained bone; (2) that the muscles were in a high state 
 of nutrition, the patient not only powerfully flexing, extending, abducting, and ad- 
 ducting his stump, but being able to communicate all these movements to the artificial 
 limb. 
 
 Mr. Shuter in his paper {he. supra cit.) says that his patient was able to wear an 
 artificial limb "for some hours nearly every day for a period of about five months. I 
 then forbade his wearing it for a time on account of a tender sinus which opened op- 
 posite to the acetabulum. In the notes of this case, quoted by Mr. Holden in his 
 obituary notice of Mr. Shuter {St. Barthol. Bosp. Reports, vol. xix. p. 3S), it is stated 
 that " the stump was sufficient to enable the patient to wear an artifirial limb for a time, 
 but he was obliged to leave it oflT on account of its weiglit." I have now performed, 
 this amputation <n\e time'.'' Four recovered, and, in one of my three cases in adults 
 a delicate girl of twenty has been able to wear a very light limb, made by Messrs. Maw 
 and Thompson, for three hours at a time. In such cases as these, where the patient is 
 much reduced by long-standing hip disease, and the periosteum is still adherent to the 
 wasted femur, it is not, in my 0[iinion,advisabIetospend time in strippingitoff. While 
 the shock of the hip-joint amputation is much lessened by this method, it cannot, of 
 course, be entirely removed. 
 
846 OPERATIONS OX THE LOWER EXTREMITY. 
 
 piece of rubber bandage about 2 yards long, and stout enough to re- 
 quire decided exertion to stretch it out fully, is doubled and passed 
 between the thigh and trunk, its centre lying between the anus and 
 tuber ischii. A white baiidage of appropriate size is then laid over 
 the termination of the external iliac artery. The ends of the rubber 
 bandage are now to be firmly and steadily drawn in a direction up- 
 wards and outwards, one in front of the groin and one over the buttock, 
 to a point above the centre of the iliac crest, sufficient tightness being 
 employed to stop all pulsation in the femoral or tibials. The front 
 part of the band passing over the white bandage occludes the externa'- 
 ihac and runs parallel k) and above Poupart's ligament. The posterior 
 part runs across the great sacro-sciatic notch and controls the branches 
 of the internal iliac. If the surgeon is short handed, instead of the 
 cords being held by an assistant, they may, by means of tapes strongly 
 stitched to them, be thus secured : When drawn with full tightness up 
 to the centre of the iliac crest, they may be crossed over to the opposite 
 side and tied firmly (over lint) midway between the crest and the top 
 of the great trochanter. If a strong and trusty assistant is forthcom- 
 ing, it will be better to leave the bandage in his hands, but in the case 
 of an adult whose tissues are not wasted, and on a hot day, the exer- 
 tion is not a slight one.* 
 
 Whether the bandage be held or tied, especial care must be taken 
 that it does not slip from off the external iliac nor over the tuber ischii. 
 It is a good plan to pass the ends of the india-rubber band over a slip 
 of wood, so as to diminish the prolonged pressure on the hands. To 
 prevent the bands slipping down in the way of the surgeon, two loops 
 of tape or bandage may be thus employed : Each, about 2 feet in 
 length, is placed longitudinally, before the elastic band is applied, the 
 one over the groin, the other well behind the great trochanter, the 
 centre of each being where the elastic band will go. When the band 
 has been applied, these form loops by means of which the band is kept 
 well out of the operator's way, both at Poupart's ligament and behind 
 the great trochanter (Jordan Lloyd, Lancet, ISSo, vol. i. p. 897). 
 
 2. Davy's Lei'er (Fig. 146,. — This ingenious instrument, introduced 
 by Mr. Davy, of the Westminster Hospital, consists of a smoothly 
 turned rod of ebony-wood or metal, from 18 to 22 inches long, with 
 the rectal end enlarged, bluntly conical and most carefully polished 
 and graduated, and the other forming the handle. 
 
 * As will be seen fi-oin llie description of the oper;ition lielow, this exertion is only 
 required during shelling ont of the femnr, a step often simpliKed by a previons excision. 
 During the circular amputation in the lower third of the thiyh, and the securing the 
 large vessels liere, there is abundant room to control these by an Esmarch's bandage 
 applied in the usual way. 
 
AMPUTATION- AT THE HIP-JOINT. §47 
 
 Oil being thrown into the bowel, the rectal end is introduced directed 
 towards the vessel to be compressed, and felt for over the situation of 
 the artery through the abdominal wall. Thus, if the right external or 
 common iliac is to be compressed, the handle is lowered and carried 
 over close to the adductors on the left side, so that its end drops over 
 the artery on the pelvic brim (Fig. 146 >. 
 
 Mr. Davy* claims for his instrument the following adr(in.tfific>< : 
 
 (a) More perfect control of both external and internal iliacs. 
 
 (6) It inflicts a minimum amount of disturbance on the respiratorv 
 movements and the circulatory system. 
 
 (c) It is generally and easily applicable. A strictured rectum is the 
 sole obstacle. [So also would be a short and tight mcso-rectum.J 
 
 id) The pressure applied is easily maintained, while the assistant in 
 charge of the lever is out of the way of the operator. 
 
 (e) Its application is quite safe in skilled hands, no injury having 
 ever resulted, and but little pain having been suffered. 
 
 (/) It is cheap and simple. 
 
 (g) It has been successful. ]Mr. Davy, in his paper above quoted, 
 had records of ten cases in which the lever had been employed; the 
 total amount of blood lost during the ten operations had been under 
 18 oz., and there had been 80 per cent, of recoveries. 
 
 Z>waf/n/(ito(/f.?.— Simple and ingenious as the above method is, it is 
 beyond doubt that it has caused a fatal result from injury to the peri- 
 toneal coat of the rectum. It is now likely to be replaced by the 
 Furneaux Jordan method. On account of the above risk I prei'er to 
 meet the hasmorrhage either by the above-mentioned method, or, 
 where this is impossible, bv securing the vessels before they are cut 
 (p. 853). 
 
 3. Compressing the common femoral or the termination of the ex- 
 ternal iliac by the fingers or hands, aided, if need be, by a weight. This 
 is only possible in the case of a child, and the assistant thus employed 
 is liable to be in the way of the operator. 
 
 4. Lister's Tourniquet^ — This means of compressing the termination 
 of the abdominal aorta is not a light matter, apart from the very grave 
 operation into which it enters. This is owing to the difficulty of mak- 
 ing sure of avoiding such important structures as the duodenum, 
 pancreas, solar plexus, and small intestines, and to its interference 
 with respiration and circulation. 
 
 5. Commanding the main artery during the operation either by seiz- 
 ing a flap (Fig. 150) or by securing the vessels before they are divided 
 (p. 853;. 
 
 * Brit. Med. Journ., 1879, vol. ii. p. 685. 
 
848 
 
 OPERATIOXS OS THE LOWER EXTREMITY. 
 
 Furneaux Jordan's Operation,*— The vessels in front and be- 
 hind being commanded in the manner given at p. 845,t the patient's 
 pelvis is brought to the edge of the table and his body rolled a little 
 on to the sound side, the surgeon standing usually to the right of the 
 diseased limh—i.e., inside on the left and outside on the right side— 
 
 Fig. 146. 
 
 Fig. 147. 
 
 Fig. 14fi.— (After Davy.) 
 
 Fig. U".— Fuineaux Jordan's amputation. Above is shown the means of controlling hsemor- 
 rhage described at p. 813. Lower down are seen the sinuses of an unhealed exci>ion, and the 
 method of shelling out of the femur, after a circular amputation has been performed, and the 
 large vessels secured. 
 
 draws up the soft parts forcildy with his left hand, and makes a cir- 
 cular incision through the lower third of the thigh, using his knife as 
 at p. 100, the assistant who is in charge of the limb rotating it so as to 
 make the tissues meet the knife. A circular cuff-like flap of skin and 
 
 * Every provision must be taken against sliock. The limbs should be bandaged in 
 cotton-woo], the body well wrapped up, the head kept low, etlier given, nutrient injec- 
 tions kept at hand, and subcutaneous injections of brandy or ether given from time to 
 time. lu bad cases the spray may be dispensed with, and the wound svringed from 
 time to time with mercury perchloride solution (1 in 1000). 
 
 t Before comtnencing the circular amputation, a little above the knee, I have the 
 limb elevated, an Esmarch bandage applied np to the knee, the thigh emptied of venous 
 blood by firm stroking, and a second Esmarch bandage then applied firmlv just below 
 tlie trochanters, and the lower one removed. The india-rubber band is also (p. 845) 
 placed, lightly, ready m .sito. The circular aniputatijn is then performed, and the 
 large vessels secured. The upper Esmarch is next removed, and tlie india-rubber 
 bandage firmly tightened while the femur is shelled out or, perhaps, disarticulated. 
 
AMPUTATION AT THE HIP-JOINT. 849 
 
 fasciae is then quicldj^ raised for about 2] inches * an assistant, who 
 stands opposite the surgeon, giving much help hereby, seizing and 
 everting the cut edge of the Sap, as the surgeon raises it. The flap 
 being drawn upwards outof the way, the soft parts are severed by one 
 or two vigorous circular sweeps down to the bone, and the lar^e vessels 
 and any others that can be seen are next secured. Pressuref is now 
 made with lint wrung out of carbolic-acid lotion on the still oozing 
 wound, and the patient being now rolled well over on to his sound side 
 the surgeon cuts along the outer side of the thigh, starting from the 
 circular wound and ending about midway between the iliac crest and 
 top of the great trochanter. This incision goes straight down to the 
 bone and runs into any excision wound, or sinuses which may exist 
 over the joint. The soft parts are then rapidly stripped off the femur, 
 partly with the knife, partly with the finger, the only difficulty met 
 with being along the linea aspera. If an excision has been performed, 
 the operation is rapidly completed, but if the head and neck remain 
 intact, the final steps will be rendered more diflScult, and the joint must 
 be opened from the outside by cutting strongly on the neck of the bone, 
 this being facilitated by the assistant moving the limb in accordance 
 with the surgeon's directions, as different parts require to be put on the 
 stretch, rotation of the femur strongly outwards, and dragging of the 
 head away from the acetabulum being required at the last. 
 
 Free drainage must be provided, for it must be remembered that 
 the wound left by this method is a very large one, though it has the 
 advantage of being farther removed from sources of sepsis. Thus, 
 especially if the tissues are riddled with sinuses, too much of the 
 wound must not be closed, and, if shock is present,! the surgeon must 
 not wait to insert many sutures, but trusting to firm bandages over 
 an aseptic dressing get his patient quickly back to bed. If disease of 
 the acetabulum be present, the surgeon will, if the patient's condition 
 admit of it, attend to this, the insertion of a drainage-tube through 
 this bone being specially required if pelvic suppuration be present. 
 
 Amputation by Different Flap Methods.— The following will 
 
 * The surgeon need not tronble to raise a larger circular flap. As the femur is 
 removed, the muscles lose their fixed point to contract from, and are thus easily 
 covered. 
 
 f Valuable time should not be wasted in tryingtosecureevery bleeding point, either 
 now or later. See the next foot-note. 
 
 X In some cases this is so from the beginning of the operation. This was most 
 markedly the case in one of the patients mentioned in the foot-note, p. 845, a very 
 delicate young lady of twenty-two. It was only by not waiting to do more than secure 
 the femorals, making firm sponge-pressure on the flaps, tilting up the end of the table 
 so as to keep the head low, inserting no sutures, but trusting only to firm bandaging 
 over dry gauze dressings, that a fatal result was averted. 
 
 54 
 
850 
 
 OPERATIONS ON THE LOWER EXTREMITY. 
 
 be given here, it being understood that in no case can any of them be 
 recommended if Fiirneaux Jordan's method is available. 
 
 II. Antero-posterior Flaps (Figs. 148-151). Methods of 
 Guthrie and Liston. — The patient being prepared against shock 
 (p. 848), and the main vessels secured b_y one of the methods already 
 given, the limb being brought over the table and supported in the 
 semi-flexed position by an assistant, Avhile the opposite limb is se- 
 cured over the table by a bandage, the surgeon standing outside the 
 left and inside the right limb, raises the tissues in front of Scarjja's tri- 
 angle with his left hand, enters his knife ( e.//., on the left side) midway 
 between the anterior superior spine and the toj) of the great trochanter, 
 and sends it across the limb so that it emerges close to the tuberosity 
 
 Fig. 148.* 
 
 Fi«. 149. 
 
 (Fergusson.) 
 
 of the ischium. In traversing the limb the knife should pass as close 
 to the capsule as possible, so as— (1) to get behind the large vessels; 
 and (2 ) to facilitate the opening of the capsule later on. As the knife 
 emerges, the surgeon will, of course, be careful of the scrotum and 
 the opposite thigh, and at this moment the point should be well de- 
 pressed, so as to include all the tissues possible in the anterior flap. 
 ^^'ith a rapid, sawing movement a broad flap is cut, 5 inches long, an 
 assistant thrusting his fingers into the wound as it is made, and fol- 
 lowing the back of the knife, to secure the large vessels (Fig. 149). 
 As he then draws up the anterior flap, the capsule is exposed, covered 
 with more or less soft parts, according to the skill with which the 
 knife has been first inserted ; the assistant in charge of the limb at 
 
 "■ The knife represented here is needlessly long. 
 
AMPUTATION AT THE HIP-JOINT. 851 
 
 this moment extending, depressing, and rotating out the femur, so 
 as to put the capsule on the stretch, the surgeon forcibly draws the 
 knife across the capsule, opens it freely, and divides the 'ligamentura 
 teres (Figs. 148,151). 
 
 The limb being now slightly flexed, adducted, and pulled away 
 from the body, the surgeon severs the parts attached to the great tro- 
 chanter, and the outer aspect of the limb, and i)a.ssing his knife behind 
 the bone, cuts a posterior flap about 4 inches long. The assistant in 
 charge of the limb will facilitate this step, and further the dislocation 
 of the femur, if he press the thigh upwards and forwards with one 
 hand placed at the back. A large sponge, wrung out of 1 in 20 car- 
 boHc acid, is at once pressed against the posterior flap while the femo- 
 
 FiH. 150. Fig. 151. 
 
 
 il.. 
 
 
 '> il 
 
 n . 
 A' 
 
 ^'7 I 
 
 V 
 
 ral vessels* are secured, or, if these are well in hand, those in the 
 hinder flap are taken first. The glutseal will be found on the glutseal 
 muscles, the sciatic with the nerve nearer the posterior margin of the 
 flap, and the circumflex and obturator closer to the acetabulum. 
 
 If the patient's condition admits of it, anj' sinuses are now laid 
 open or scraped out, the acetabulum examined, and, if perforated, 
 drained. If the amputation has been for growths, any outlying 
 masses are looked for and removed. Any nerves or muscles which 
 need it are now trimmed short, a large drainage tube inserted, and the 
 flaps carefully united. f 
 
 "X Of these the femoral lies superficially, the profunda more deeply, in the anterior 
 flap: they are shown much too close to each other in Fig. 150. 
 
 t If the patient's condition is one of grave shock, the head should be lowered and 
 no time lost in putting in sutures, any oozing being stopped by firm spica-bandaging 
 over thick dressings of aseptic gauze. The lower end of the bed should be kept raised, 
 and brandy given subcutaneously and per rectum (foot-note, p. 849). 
 
852 OPERATIONS ON THE LOWER EXTREMITY. 
 
 Advantages of this method. Chief of these is its rapidity. 
 Disadvantar/cs. 
 
 1. The hemorrhage which taltes place from the vessels from the 
 posterior flap may be considerable. 
 
 2. The large amount of sero-sanguineous oozing which takes place 
 from so many large muscles cut obliquely. 
 
 3. The fact that, in an adult, it requires a special long knife, not 
 always found in an ordinary collection of instruments. 
 
 DiffiadticK. 
 
 1. Not passing the knife deeply enough, and thus not exposing the 
 capsule. 
 
 2. IJassing the knife too deeply, and hitching its jjoint on the bone. 
 
 3. Getting the knife stopped in passing it behind the head of the 
 femur. 
 
 4. Fracture of the femur. 
 
 Guthrie's Method by Antero-Posterior Flaps.— Antero-pos- 
 terior flaps are again made use of, but here they are made from without 
 inwards, and thus can easily be rendered less bulky. A small knife — 
 i.e., one 4 inches long — suffices. 
 
 The preparatory steps being taken as before, the surgeon, standing 
 on the right side of either limb, marks out his anterior flap, about 5 
 inches long, by an incision, starting ( on the left lirilb) from just above 
 the great trochanter, passing across the thigh with a broadly curved 
 convexity, and ending just below the tuber ischii. A posterior flap is 
 then marked out by carrying the knife in a similar manner across the 
 back of the limb between the same points, the limb being raised and 
 the surgeon stooping somewhat. This flap should be about two-thirds 
 the length of the first. Both consist of skin and fascioe. The flaps 
 being held out of the way, the muscles first on the front and then on 
 the back are next cut obliquely from below upwards, the femoral 
 vessels, both superficial and deep, being secured as soon as they are 
 exposed, and before they are cut, either b\' underruni:iing them with 
 an aneurism-needle loaded nith silk, or by dividing them between two 
 pairs of torsion-forceps. The capsule being exposed, disarticulation 
 is performed as before. 
 
 III. Lateral Flaps. — The metliods of Larrey and Lisfranc need 
 not be more than alluded to here. In both, the flaps ;vere cut by 
 transfixion, and were about 4 inches long. Larrey tied the common 
 femoral as a preliminary step. Flaps made by either method are so 
 bulky as not to be recommended. 
 
 If the surgeon wishes to use lateral flaps, as in a case involved by 
 growth in front, he may make them, thus, from without inwards. 
 Standing on the right side of either limb, he, e.g., in the case of the 
 right limb, marks out an inner flap by means of an incision starting 
 
AMPUTATION AT THE HIP-JOINT. 
 
 853 
 
 from below the tuber ischii, carried downwards along the inner aspect 
 of the thigh for about 4 inches, and then curving upwards to the centre 
 of the grom and ending, a little below Poupart's ligament, to the outer 
 side of the femoral vessels ; next, without taking .off his knife, he then 
 marks out an outer flap by cutting between the same points but in 
 the reversed direction. This incision, as it passes downwards, out- 
 wards, and backwards, should leave the front of the limb about a 
 hand's-breadth below the great trochanter. The flaps being dissected 
 up, the soft parts are cut through from without inwards, the femoral 
 vessels being secured before they are cut, and disarticulation performed 
 last. 
 
 IV. Antero-internal and Postero-external Flaps (Pig. 15^). 
 —This is a modification of the last method, and may be useful in 
 cases of growth extending high up, where it is impossible to perform 
 
 Fig. 162. 
 
 a Furneaux Jordan's amputation. Some such flaps as the above may 
 be the only ones obtainable. They may be made as follows : The 
 precautions as to shock given at p. 848 having been taken, the patient's 
 pelvis having been brought well down to the edge of the table, and the 
 opposite limb being held aside, but not tied, the surgeon, standing to 
 the right of either limb, reaches somewhat over and marks out (in the 
 case of the right limb) an antero-internal flap, by cutting from a point 
 close to the tuber ischii to one a little below and internal to the anterior 
 superior iliac spine. The skin and fasciffi being dissected up, the 
 muscles are cut through till the femoral vessels are reached and 
 
854 OPERATIONS OX THE LO\VER EXTREMITY. 
 
 secured. Large carbolized sponges are now pressed into this wound, 
 and, the patient being rolled a little over, a postero-external flap is 
 marked out and dissected up from the gluteal region, passing between 
 the above points, but in the reverse order. The gluteal vessels are 
 next cut through, the chief vessels being secured by either torsion or 
 Spencer Wells's forceps ; the capsule is then opened, the round liga- 
 ment severed, and the limb removed. 
 
 EXCISION OF THE HIP. 
 
 Indications.— A. Disease. B. Injury, especially gunshot. 
 
 A. Disease. — The value of this operation still remains unsettled. 
 In spite of all the work done, in this direction, there is no other oper- 
 ation of equal importance on which there is still such extreme difference 
 of opinion on the chief questions which have been raised again and 
 again — viz.. Does it save life ? Does it shorten treatment ? 
 Is the limb a better one ? 
 
 Thus, to take two of the most recent writers on hip disease and the 
 subject of excision, Mr. Howard Marsh,* with his experience gained 
 from Ormond Street and the Alexandra Hospital for Hip Disease in 
 Childhood, and Mr. G. A. Wright,t of Manchester and the Pendlebury 
 Hospital for Sick Children. Mr. Marsh is strongly against excision, 
 for these reasons. He considers the results obtained by continued 
 rest to be such as to render excision totally uncalled for. Thus, con- 
 tinued rest gives a mortalitj^ of only 5 per cent., 70 per cent, of the 
 cases thus treated recovering with only slight lameness and loss of 
 movement. Even when suppuration has occurred, the mortality is 
 only 6 or 8 per cent. Again, at p. 309, Mr. Marsh writes : " The esti- 
 mate that I have been led to form is, (a) that, in the early stage of 
 the disease, although matter is developed, the operation is as unjus- 
 tifiable as it is to remove a testis, an ej'e, or a tooth for incipient but 
 still curable disease; (6) that the operation is generally uncalled for, 
 even when sinuses have formed; (c) that if hip disease has been 
 allowed to reach the stage in which the bones have become extensively 
 carious, in which matter has burrowed widely, and in which the 
 general health has become seriously affected, excision will be of very 
 doubtful benefit. The operation will be fatal in at least 10 per cent, 
 of the cases, while in another '20 or '2-i per cent, it will be followed by 
 no improvement in the patient's condition." 
 
 On the other hand, my old friend, (I. A. Wright, speaking from the 
 very large experience of over a hundred cases of excision, of which 
 only tliree, at most, died of the direct results of the operation, strongly 
 urges that the hip should be excised " as soon as there is any evidence 
 
 * Diseases of the Joints, p. 317. f Hip Disease in Childhood, p. 9S. 
 
EXCISION OF THE HIP. 855 
 
 of external abscess .... and still better results would, I believe, be 
 obtained by operating before the pus has escaped from the articulation. 
 The operation is discredited because it is put off until disease is so iar 
 advanced that no treatment can have more than a fraction of good 
 results, while timely excision cuts short the disease, saves pain, lessens 
 the time of treatment, and gives a better liml)." And again, at p. 97 
 of his book, Mr. Wright says : " While fully aware that abscesses dis- 
 appear and tuberculous lesions cicatrize under favorable circumstances, 
 I think that, in the case of the hip, delay is unwise amongst the hospital 
 class, with whom it is as yet impossible to deal on the same lines as 
 with the well-to-do. In almost every instance I have found much 
 more extensive disease than might be expected from the external evi- 
 dence, unless the pathology of the affection is borne in mind, and I 
 beheve that, once this chronic osteo-myelitis is established, nothing 
 short of excision can, in hospital cases, prevent the ultimate progress of 
 the disease to abscess, and too often to gradual exhaustion of the patient 
 by pain and discharge. Nature, of course, in many cases will, unaided, 
 get rid of the dead bone by slow and tedious processes, but the num- 
 ber of children who can survive the process of elimination is very 
 small, while the mortahty after early excision is not great, and the 
 failures are mainly in those instances where the operation has been 
 put off till too late. Where actual necrosis, or caries of the head of 
 the femur, with destruction of bone and cartilage, and often sequestra 
 of varying size in the acetabulum, or at least caries of it are known to 
 exist, I think few advocates of non-operative treatment will be found." 
 With reference to so wide a divergence of opinion between two author- 
 ities on the subject, it may be pointed out that Mr. H. Marsh has 
 worked under conditions more favorable than those which fall to the 
 lot of most hospital surgeons. Thus, at the Alexandra Hospital, cases 
 are kept under treatment as long as rest and extension are required ; 
 if an oi^eration is called for, the case is transferred elsewhere. While 
 every one must admire Mr. ^larsh's success, it is clear that the condi- 
 tions under which it has been gained must, as yet, stand alone. 
 
 My own opinion as to the advisability of excision in the ordinary 
 hip disease of hospital children is, that it should be resorted to by 
 surgeons chiefly when suppuration is present and has resisted a due 
 trial of rest, and antiseptic incision and drainage, this latter step giving 
 an opportunity, though a limited one, of investigating the amount of 
 disease present. But while I should thus advocate the performance 
 of the operation in the sectmd stage, I think that sufficient importance 
 has not been attached to the fact that disease of the hip-joint is, unless 
 not only seen but treated in the first stage, severe and i)rogressive, and, 
 per se, likely to end fatally ; if this be so, excision must not be too 
 much reproached with failure. 
 
856 OPERATIONS ON THE LOWER EXTREMITV. 
 
 The conditions which usually accompany obstinate suppuration, and 
 which thus call for excision, are those six given by the Clinical Society's 
 Committee on excision of the hip-joint — viz. : 
 
 i. " Necrosis, and separation of the entire head of the femur, and its 
 conversion into a loose sequestrum."* 
 
 ii. " The presence of firm sequestra either in the head or neck of the 
 femur, or in the acetabulum." This question is a most important one, 
 for as Mr. Marsh (p. 318) writes, "much difference of opinion exists 
 as to the frequency with which hard sequestra of any material size are 
 present in suppurative hip disease." He himself thinks that when 
 present sequestra usually consist of porous, friable bone. Their 
 structure is such that, should excision not be performed, they will 
 crumble away and disappear, and will not prevent repair.f A dis- 
 tinctly different opinion is held by Mr. Wright (loc. supra cit., p. 118) : 
 "here opening of abscesses, and, still less, expectant treatment, can 
 hardly be considered a satisfactory mode of getting rid of sequestra, 
 yet in no less than in 39 (out of 100) were there actual loose sequestra, 
 while in many others there were patches of bone which was practically 
 dead though not loose. The possibility of removing sequestra with- 
 out a formal excision is worth trying in some cases, but it is often 
 impossible to discover the presence of the sequestra until the end of 
 the bone has been removed, or to extract them if found. Moreover, 
 even after the removal of sequestra, others may exist and not be found, 
 and in other instances the disease progresses in the surrounding bone 
 and necessitates subsequent excision. There are often, too, other foci 
 of disease in the medulla, which are as great bars to recovery as the 
 sequestra themselves." 
 
 iii. " Extensive caries of the femur, or the pelvis, leading to prolonged 
 suppuration and the formation of sinuses." 
 
 iv. " Intra-pelvic abscess following disease of the acetabulum." 
 
 With reference to these conclusions, I should doubt myself whether 
 excision can be often justifiable, especially in the latter. Even if it 
 gave the desired drainage the patient's condition with disease of the 
 acetabulum is not one usually to give the required repair after excision. 
 
 * Mr. Marsh {loc. !>upra cit, Fig. 50, p. 383) thinks that these cases are not rare. 
 Mr. Hihon {Re«t and Pain, Fig. 63, p. 341) shows a similar specimen. 1 should have 
 thoiii;ht the condition a very luicommon one. 
 
 t " This seems to be proved bv the fact that in numerous cases in which profuse sup- 
 puration has been going on, so that tliere can be no reasonable donbt tliat extensive 
 bone disease has been present, all the sinuses will close, although either no bone has 
 worked out or been extracted. In these instances we must conclude either that no se- 
 questra were present, and in that case it would appear that sequestra are not so common 
 as some believe ; or that they often crumble away and are discharged, so that operative 
 interference is by no means essential for their removal" (Marsh, loc. supra cit., p. 319). 
 
EXCISION OF THE HIP. 857 
 
 " Extensive caries " of the pelvis certainly, and in many cases of the 
 femur, will require amputation, especially after childhood. 
 
 V. " Extensive and old-standing synovial disease and ulceration of 
 the articular cartilages, with persistent suppuration." This condition 
 is rarely met with in the hip-joint, where the disease, as usually met 
 with, starts not in the synovial membrane, as in the knee-joint, but as 
 a chronic osteo-myelitis in the neighborhood of the epiphyses, espe- 
 cially the upper one. 
 
 vi. " Displacement of the head of the femur on the dorsum ilii, with 
 chronic sinuses and deformity." 
 
 This condition will probably be more rarely met with, nowadays, 
 as earlier facilities for treating hip disease arise. I happen to have 
 performed excision five times for such cases ; of these four recovered 
 with sound and useful limbs,* but in one, a lad of eighteen, in which 
 the sinuses had closed some years before the operation, I should now 
 prefer to improve the condition of the limb by a Gant's osteotomy and 
 division of the contracted sartorius, tensor vagina, and adductor longus. 
 These patients seem to me to bear excision well, this being probably 
 due to their having good vitality, as shown by their survival, and the 
 amount of repair. Further, in running successfully the gauntlet of 
 the disease, they have escaped the dangers of lardaceous and general 
 tubercular trouble. The surgeon must here be prepared for a good 
 deal of trouble in dislodging the displaced head, after sawing through 
 its neck, owing to its being firmly matted down by old adhesions. 
 
 The Condition of the Limb. Is this a better one after Ex- 
 cision or after a Cure by Rest ? 
 
 Here, again, the divergence of opinion is marked and puzzling. Mr. 
 Marsh (loc. supra cit, p. 308) is of opinion that ■' the limb after excision 
 of either the hip or the knee is usually very inferior to the average 
 limb that is obtained after recovery has followed the treatment by 
 rest." Mr. Holmes {Syst. of Surg., vol. iii. p. 757, 1883) thinks that, 
 while recovery after excision of the hip-joint is very complete, as far 
 as the movements of the limb are concerned, " the shortening is gen- 
 erally greater than after the spontaneous cure, and the limb is less 
 firm, and, on the average, less useful." The Clinical Society's Com- 
 mittee reported on this subject that, after excision, " movement is more 
 frequently present, and also more extensive, but that patients often 
 walk more insecurely and with a considerable limp, while the limb 
 after treatment by rest and extension, though frequently more or less 
 fixed, is more firm and useful for the purposes of progression." While 
 feeling assured that the resulting usefulness in some cases treated 
 by excision far surpasses the best results obtained by rest, I consider 
 
 * The fifth has only just been operated oil. 
 
858 OPEEATIONS ON THE LOWER EXTREMITY. 
 
 that the average result obtained by rest is superior to that following 
 excision, cand that this is increasingly marked after childhood, the 
 limb, in adolescents recovering after excision, being very often flail- 
 like and useless. 
 
 On the other hand, Mr. Wright, whose large experience on this sub- 
 ject has already been referred to, has come to the conclusion (loc. supra 
 cit, p. 126j that "excision gives a better limb than the average result 
 obtained without operation ; " and again (p. 114) : " In my own expe- 
 rience, useless, flail-like joints are exceedingly rare, and Umited to those 
 cases where the excision was performed in very late stages of the disease ; 
 the powerless condition is, I take it, the result of the disease, not of 
 the operation." With regard to the two conditions which chiefly 
 interfere with the usefulness of the limb after hip-excision— viz., a 
 flail like state, and shortening, Mr. Wright's opinion on the former has 
 already been given. With regard to the latter, he considers (p. 108), 
 that, " though some shortening must necessarily result, this arises 
 mainly from the weight being borne upon the limb prematurely. 
 .... Growth in length of the femur takes place almost entirely at 
 its lower epiphysial line, hence the loss of length or true shortening 
 is only the distance from the line of section to the top of the head, 
 coupled with such arrest of growth as may result from impaired nutri- 
 tion, this last being, of course, a very inconstant quantity."* 
 
 Oonditions of Success in Excision of the Hip. — Amongst 
 these are : 
 
 1. Age. I consider the best six to fourteen. After eighteen excision 
 should rarely be performed, Furneaux Jordan's amputation taking its 
 place. Mr. Wright (p. 12i]j thinks that after fifteen excision should 
 be rejected in favor of amputation. 
 
 2. Absence of lardaceous disease. I cannot agree with the conclusion 
 of the Clinical Society's Committee {loc. supra cit, p. 233) that excision 
 is called for, '' when, in a ease of suppuration, enlargement of the liver 
 and albuminuria, indicating the presence of degeneration of the viscera, 
 is detected." Excision should be performed, in my opinion, before 
 only the appearance of lardaceous disease. When there is evidence 
 of this condition having set in, especially in the kidneys or intestine, 
 amputation is to be preferred. 
 
 3. Absence of advancing mischief in other joints, or of tubercular 
 lesions in the viscera — e.g., the lung. 
 
 4. The disease must be removed as entirely as possible. Thus, in 
 
 * On tliis matter Mr. Wright qmHes Prof. Ollier's {Rev. de Chir., 1881; Annals of 
 Surgery, .January, 1886) estimate tliat, up to five years of age, the growth of the femur 
 takes place about equally at its two ends ; that, after five, the rate of growth of the lower 
 end increases rapidly till it becomes three times that of the upper. 
 
EXCISION OP THE HIP. ggg 
 
 the femur at least, the section must pass hulow all foci of disease. 
 All sinuses should also be scraped out. 
 
 5. Adequate drainage. 
 
 6. Careful after-treatment, the wound being kept nseptic. 
 
 7. The patient must not be kept too long on his back in hospital air. 
 B. Gunshot Injuries. 
 
 Excision of the Hip-joint for Gunshot Injuries, contrasted 
 with Conservative Treatment, and Amputation at the Hip- 
 joint.— For the sake of convenience it will be well to take the above 
 three plans of treatment of gunshot injuries of the hip together. 
 As before, I shall avail myself of the laborious researches and the 
 unrivalled authority on this subject of Dr. Otis, He writes* that 
 the evidence collected during the American war shows that "of the 
 cases of undoubted intra-capsular shot-fracture of the hip treated by 
 conservation, VJS.S per cent, had a fatal teraiimition, that in sixty-six 
 cases treated by excision, the fatality w;!,s 90.9 per cent., and that in 
 sixty-six cases treated by exarticulation, it was 83.3 per cent.; but 
 from these results it should not be concluded that operative interfer- 
 ence was always indicated, and that amputation was preferable to 
 excision. On p. 1:21 of Circulur No. 2, I have already pointed out that 
 the question as to the most eligible treatment of shot injuries of the 
 hip-joint is not susceptible of a purely arithmetical solution, and that 
 the variety of the conditions under which the patients are placed, the 
 diversity in the extent of their injuries, and the inevitable imperfec- 
 tion of all surgical records, forbid any such rigorous comparison. No 
 less than nine of the sixty-six cases of excision were complicated with 
 such lesions of the pelvic walls and viscera as made any operative 
 interference useless; among the sixty-six coxo femoral amputations, 
 probably all successful cases have been recorded, while some fatal 
 cases may remain unpublished, and in the 3(J4 cases treated by con- 
 servation, the correctness of the diagnosis may be questioned in many 
 instances. The character of the injury must determine the choice of 
 treatment; but the general rules regarding shot wounds of the hip- 
 joint laid down in Circular 2 are uneontroverted : that expectant 
 treatment is to be condemned in all cases in which the diagnosis of 
 direct injury to' the articulation can be clearly established," that 
 " primary excisions of the head or upper extremity of the femur 
 should be performed in all uncomplicated cases of shot-fracture of the 
 head or neck ;" that " intermediary excisions are indicated in similar 
 cases where the diagnosis is not made out till late;" that " secondary 
 excisions are demanded by caries of the head of the femur or second- 
 ary involvement of the joint ;" that am|)utation should be performed — 
 
 * Med. and Surg. History iif the War of the Rehdlion, pt. iii. p. 16-3. 
 
860 OPERATIONS OX THE LOWER EXTREMITY. 
 
 " 1 . When the thigh is torn ofF, or the upper extremity of the femur 
 comminuted with great laceration of the soft parts, in such proximity 
 to the trunk that amputation in continuity is impracticable. 2. When 
 a fracture of the head, neck, or trochanters of the femur is complicated 
 with a wound of the femoral vessels. 3. When a gunshot fracture 
 involving the hip-joint is complicated by a severe compound fracture 
 of the limb lower down, or by a wound of the knee-joint." 
 
 It is possible that Dr. Otis's opinion as to the uselessness of expectant 
 treatment in gunshot injuries of the hip-joint will need alteration in 
 the future — /.e.,Prof L:ingenbeck,*from his experience in the Franco- 
 (xerman war, considered that the expectant treatment gave a larger 
 proportion of recoveries than excision, and still more than amputa- 
 tion, and advised that the expectant method should always be resorted 
 to save when disarticulation is rendered inevitable by the destruction 
 and shattering of the limb. Sir T. Longmoret thinks that this ques- 
 tion must be held to Ije " still subjudice, and surgeons must wait for 
 still more extended experience, under modern improved methods of 
 treatment, before any rule can be accepted as having yet been estab- 
 lished on this grave question.." 
 
 Examining into the dates at which, the excisions of the hip were 
 performed, D.r. Otis {loc. supra cit., p.. 126) gives the mortality rate as 
 93 per cent, for the primary, 96.6 per cent, for the intermediary, and 
 63. -i per ceat. for the secondary operations. Thus, " the excisions and 
 amputations practiced during the intermediary or inflammatory stage 
 are by far the most dangerous, and should never be performed except 
 as compulsory operations." 
 
 As to the dates of the exarticulations of the 254 cases, there were 82 
 primary, with 75- deaths (91.4; per cent, mortality); 55 intermediary, 
 with 52 deaths (94.5 per cent.) ; 40 secondary, with 33 deaths (82.5 per 
 cent.) ; reamputatioix-^, with 4 deaths (36.3 per cent.). Dr. Otis shows 
 from these statistics that " intermediary operations offer the least 
 chance of recovery, that the results of primary operations are more 
 favorable; that secondary exarticulations give one recovery in twelve 
 cases ; and that of the instances of re-amputation one in about three 
 
 proves successful Unless the nature of the injury is such that 
 
 the operation can be delayed till the secondary period, it is better that 
 it should be done at once, although it would ajipear that the dire results 
 of amputations at the hip performed during the Schleswig-Holstein 
 war of 18(i4, the Austro-Russian war of 1866, and the Franco-Prussian 
 war of 1870-71, have had a tendency to raise doubts regarding the 
 expediency of, especially the primary, exarticnlation of the hip." 
 
 » Arch.f. Klin. Chir., 1874, Bd. xvi. S. 309-316. The recoveries seem to have been 
 twenty-five out of eiglity-eight cases so treated. 
 t System ofSuryery, vol. i. p. 561. 
 
EXCISION OF THE HIP. ggl 
 
 Operation. — Two will be described here: A. By posterior 
 incision ; B. By anterior incision. 
 
 A. Posterior Incision (Fig. 153).-The chief advantao-e of this is 
 its better drainage, a point which outweighs, in my ojiinion, the 
 smaller interference with muscles entailed by the incision in front 
 (p. 863). 
 
 \\ hile the patient is being lirought under ether, a stirruj) is applied 
 if weight-extension is to be made.* The child being rolled over on 
 to his sound side, and the parts thoroughly cleansed, the surgeon 
 stands usually outside the limb, the patient's body being in either 
 case placed conveniently at the edge of the table, one assistant 
 supporting the limb, while another is opposite to the surgeon. An 
 incision, about 3] inches long,t is now made over the middle:|: of the 
 great trochanter, commencing about midway between the top of this 
 bone and the anterior superior spine, and ending over the shaft, just 
 below the trochanter. The incision should curve slightly forwards 
 and pass down to bone or cartilage, as the case may l)e, at once. Any 
 bleeding vessels lieing secured, the exact position of the head and neck 
 is now made out by an aseptic finger, aided by an assistant rotating 
 the limb. A second incision opens the capsule freely. 'With a peri- 
 osteal elevator, aided by a knife, the muscles attached to the great 
 trochanter are detached, the cartilage in young .subjects peeling oflf 
 with them in one or more ])icccs. The finger is now passed round 
 the neck of the femur, and the soft parts, including the periosteum, 
 detached as much as possible on the inner side. The finger now 
 feeling that the upper part of the trochanter and the neck of the bone 
 are free, and protecting the soft parts on the inner side,- the bone is 
 sawn through just below the top of the trochanter with an osteotomy, 
 metacarpal, or keyhole 6aw.§ This division should be thoroughly 
 and cleanly effected without splintering. If it be preferred, in addi- 
 
 * There is no occasion to apply an Esniarcli's bandage above the wound ; and 
 rendering the limb eva-^cnlar, save by elevation, is often rendered impossible by the 
 presence of an absce.ss or sinu.ses. 
 
 t This is usually siifKcient in a child. But it must be always remembered that a 
 small wound, by giving insufficient room, leads to bruising and difficulty. 
 
 X The advantage of going as far forward as this is, that the fleshy and vascular parts 
 of the muscles attached to the great trochanter are better avoided. 
 
 § The section of the bone should always be made while this is in eitu. The plan of 
 dislocating the head by adducting the limb, and then sawing it off, disturbs the parts 
 more, and runs the risk of fracturing the wasted femur of a little child, an accident 
 which I have seen occur in the hands of a verycarefnl operator. Mr. Wright {loe. 
 supra cit. p. 101) states that he had one case among his earlier operations, and that he 
 has also separated the lower epi|)hysis in an infant while manipulating the femur 
 during incision of the joint. He points out another objection — viz., the ease willi 
 which the periosteum may be stripped off if the head of the bone is thrust out. 
 
862 
 
 OPERATIONS ON THE LOWER EXTREMITY, 
 
 tion to. the protection of the finger on the inner side, a blunt dissector 
 may be passed behind the bone as well, but this is not essential : 
 retraction will protect the lii)S of the wound from the saw. With the 
 aid of the finger and an elevator, or with a lion-forceps, the head 
 and neck of the bone are levered out of the acetabulum, this being 
 often attended with smne difBculty unless the capsule has been very 
 
 Fig. 153. 
 
 Excision of the liip. Tlie saw is applierl rather lower down than usual. Above the great 
 trochanter the neck and head are seen indistinctly. 
 
 freely opened. The ligamentum teres is probably destroyed ; if not, 
 it must be divided. The acetabulum is then examined, and, if merely 
 roughened, left alone ; if pitting or erosion are present, gouging must 
 be resorted to.* 
 
 Any bleeding points are now looked to,t and drainage provided to 
 the very bottom of the acetaljulum. No sutures should be inserted. 
 
 Site of Section of the Femur. — Having tried both, I think that the 
 section through the great trochanter {i.e., jiist below its upper margin) 
 is preferable to one above it (i.e., through the neck). This has the 
 ii'Jvantges of disturbing and damaging the attachments of muscles 
 much less, and thus leads to more rapid healing and far greater mo- 
 bility of the limb. These, however, arc outweighed by the disad- 
 
 * Any sequestra present must be removed. If the ucetnbulum is perforated, and 
 pus present on its pelvic aspect, free exit must be provided by means of a gouge or 
 small trephine, and a drainiigetube passed through. 
 
 t The haemorrhage is usually very slight Firm plugging around the drainage-tube 
 with stri|is of .'^al alembroth or iodoform gauze will arrest troublesome oozing, and is 
 preferable to spending time in trying to secure vessels, unless these spring distinctly. 
 
EXCISIOIS OF THE HIP. 863 
 
 vantage which leaving such a large piece of bone as the trochanter 
 entails — viz., that after healing, this process gets drawn up against 
 the scar and constantlj^ frets it.* It is also said to check the escape 
 of discharges, and to render the patient liable to persistence or recur- 
 rence of the disease. I am doubtful as to the last two, but the first is 
 absolutely certain. 
 
 B. Anterior Incision. — Mr. R. W. Parker has advocated this 
 method from its interfering less with the muscles and the blood- 
 suppl_v. He expresses his belief {Clin. Soc. Tra??.?., vol. xiii. p. 108) 
 "that any incision which opens the hip-joint from behind is a little 
 unsurgical as an operation, for it must necessarily cut across a large 
 mass of Yerj important muscles ; and, furthermore, it must interfere 
 largely with the vascular anastomoses about the trochanter as well as 
 the joint. Thus the three gluta?i, the pyriformis, obturator internus, 
 quadratus femoris, and possibly some fibres of the adductor magnus 
 will be divided. "t 
 
 I doubt very much w'hether, if this method is largely tried, the 
 above advantages will be found to outweigh the serious disadvantage 
 of inferior drainage, and perhaps that of a good deal of In-uising of 
 the soft parts, owing to the greater difficulty in turning out the head 
 of the bone in this position. I ought, however, with regard to the 
 latter objection, to say at once that I have no personal experience of 
 this method : having used in my eighteen cases the posterior in- 
 cision, I should be very unwilling to give up what I think most 
 surgeons will consider the very superior drainage which this gives. 
 On this point we are in need of more information. Thus, of the six 
 cases given by Mr. Parker in his paper, one only was successful, and 
 this was operated on by the usual posterior incision. Of the two in 
 which the incision in front is stated to have been used, the cases were 
 progressing, but were still under treatment. Of the other three, in 
 one amputation, and not excision, was performed ; in the remaining 
 two excision was resorted to, but the kind of incision is not stated. 
 One of these had improved, but still had sinuses, and could not walk ; 
 the other had not improved. 
 
 Mr. Barker has recently advocated this method, regarding it " as 
 
 * About ten ypars ago I made use of this metljod in one case, snwing the bone 
 through the neck and leaving the trochanter entire. A rapid recovery took place, 
 and the boy quickly recovered power over the limb. He has long been able to run 
 and climb like other lads, and the movements of flexion, extension, abduction, and 
 adduction are extraordinarily perfect. He has, however, been under my care on 
 several occasions for suj)erficial ulceration of the scar, which is fretted by the very 
 prominent upper margin of the immediately subjacent trochanter. 
 
 t Mr. Barker (K.(J.S. Lect., vnfra cil.) claims another advantage for this method— 
 viz, that the wound being in front enables the patient to be placed on a double 
 Thomas's splint a week or so after operation, and to be more easily moved. 
 
864 OPERATIOJiTS OX THE LOWER EXTREMITY. 
 
 superior in every way to the older method, and as likely to become 
 the operation par excellr.nce in all early cases of hip-joint disease." 
 
 Mr. Barker, in his recently delivered Hunterian Lectures, gives the 
 following most interesting information on the above-alluded-to matter 
 of drainage. It will be understood that his remarks refer to operation 
 in early cases. While it is much to be desired that we should have 
 further information in the shape of carefully reported cases, hospital 
 surgeons will agree that if Mr. Barker succeeds in proving his point, 
 he will have done more for the surgery of hip-joint disease than almost 
 any other surgeon. I have quoted the passage, owing to its absorbing 
 interest, in extenso. " Except for the drain-openings, such wounds 
 heal, in my experience, as a rule, by first intention. The fluid, more- 
 over, after the first day or so, which comes from the drain-tube, is 
 little more than thick, odorless serum. It exudes in very small 
 quantity, and ought never to become truly purulent. This is the 
 reason why the opening, although anterior, is perfectly adequate for 
 the drainage of the cavity left by the operation. I have often been 
 asked, ' Do you find this anterior incision gives sufficient drainage 
 for discharges? ' My answer always is, ' Certainly, for there are no 
 discharges worth mentioning after the first oozing of blood and serum 
 immediately following operation.' Those who ask this question have, 
 doubtless, in their eye, the older experiences of excision of the hip, 
 when the operation was usually undertaken in an advanced stage of 
 the disease, when suppuration had already set in freely, with rami- 
 fying sinuses. I am not alluding to such cases, .believing, as I do, 
 that experience shows, and especially Mr. jMarsh's figures alluded to 
 already, that, beyond aseptic drainage, they are best left to Nature, 
 and are unsuitable for excision. But in relatively earl_y cases treated 
 carefully, as just described, we have vmally, and ought abrnijs to have, 
 healing without any suppuration at all, properly so called. I could 
 produce a series of cases, illustrating this fact, from my own practice 
 and from that of my colleague, Mr. Bilton Pollard, who operates on 
 exactly the same lines at the Children's Hosjjital, and I believe other 
 surgeons have found the same thing. It must not be forgotten that 
 when an excision is performed early, and all tuberculized tissue is 
 removed, a clean-walled cavity is left, most of which is quite capable 
 of healing by first intention, when its different surfaces are brought 
 into contact by firm pressure. And in these cases, the head of the 
 bone being removed, and the acetabulum quite clean, the cut surface 
 of the neck of the femur can be brought close up to the latter, so that, 
 although there is potentially a large space in the field of operation, 
 there ought to be actually little or no cavity left, if pressure have been 
 properly applied from the first. There is no need, then, in such 
 cases, after the first day or two, for extensive drainage if the wound 
 
EXCISION OP THE HIP. 865 
 
 be kept aseptic. If it is not so, of course the case is totally different, 
 and drainage is absolutely necessary. For my own part, I intend to 
 try whether some of these early excisions cannot be left to heal abso- 
 lutely by first intention, without any drainage at all, just as in many 
 cases tubes, can be dispensed with altogether in analogous cases of 
 operation on the knee." 
 
 As I have said before, this question can alone be settled after a 
 large number of cases have been published. Surgeons will, no doubt, 
 follow Mr. Barker, and test this method widely. Most will, I think, 
 begin by draining the deepest cavity of the wound by a tube brought 
 out by counter-puncture on the outer aspect of the thigh, in the event 
 of their cases not running so smooth a course as Mr. Barker's. Two 
 expressions in the above most interesting remarks require attention — 
 first, where Mr. Barker says, " when an excision is performed early 
 and all tuberculized tissue is removed ; " the second, " in these cases, 
 the head of the bone being removed, and the acetabulum quite clean." 
 I fear these most desirable conditions will be found most difficult to 
 secure absolutely, even if early excision is resorted to, but I would 
 not in this put a mere opinion before Mr. Barker's experience. We 
 must wait for that light which carefully reported cases alone give. 
 
 Operation. — The patient being on his back, with the limb ex- 
 tended, and the parts duly cleansed, the surgeon standing, in the 
 case of either limb, on the right side, makes an incision 3 to 4 inches 
 long, starting immediately below the anterior superior spine down- 
 wards, and shghtly inwards, between the tensor vagina3 and glutei 
 externally and the sartorius internally. The upper part of this 
 incision should pass down to the capsule at once, the lower third 
 should divide skin only. A second incision in the upper part of the 
 first should certainly open the capsule. An aseptic finger now ex- 
 amines the condition of the joint. The wound being opened by 
 retractors, a narrow-bladed saw is introduced in the upper part, and 
 the neck of the bone is divided from above downwards, in situ, and 
 with as little damage to the soft parts as possible. The head of the 
 femur is now extracted and the acetabulum treated by the means 
 given at p. 862. The remaining steps should be carried out after Mr. 
 Barker's directions.* " Every trace of diseased synovial tissue dis- 
 coverable is now removed with scissors, knife, and sharp spoon, 
 special care being also taken to clear out any caseating abscesses 
 communicating with the joint. All this should be done with as little 
 violence to the tissues around as possible, so that none of the tuber- 
 cular debris shall be forced into its fresh-cut surfaces. When every 
 portion of the diseased tissue has been thoroughly removed, the 
 
 * K.C.8. hect; Brit. Med. Journ., p. 1326. 
 55 
 
866 OPERATIONS ON THE LOWER EXTREMITY. 
 
 cavity is freely flushed with some germicide solution until all loose 
 particles have been washed away. It is then sponged dry from the 
 bottom, and is immediately dusted with iodoform, which may be 
 carried further into the ramifications of the cavity on the end of the 
 finger. It is well, I think, after this, again to introduce a small 
 sponge for the purpose, not only of drying the part, but also for 
 wiping away any excess of iodoform which may be about. This 
 sponge should be left in until the sutures which close the wound are 
 in position and are ready to be tied. It is then removed and the 
 threads are knotted, a medium-sized drainage-tube being carried 
 down as far as the acetabulum." 
 Usual Causes of Failure after Excision of the Hip. 
 
 1. Persistent pelvic disease. 
 
 2. Chronic osteo-myelitis of sawn end of femur. 
 
 3. Suppuration and hectic. 
 
 4. Lardaceous disease. 
 
 5. Tubercular conditions elsewhere. General outbreak of tuber- 
 culosis. 
 
 6. Disease of the opposite femur. 
 
 CHAPTER II. 
 
 OPERATIONS ON THE THIGH. 
 
 LIGATURE OF THE COMMON FEMORAL —LIGATURE 
 OF THE SUPERFICIAL FEMORAL IN SCARPA'S TRI- 
 ANGLE.-LIGATURE OF THE SUPERFICIAL FEMO- 
 RAL IN HUNTER'S CANAL.— PUNCTURED AND STAB 
 WOUND IN MID-THIGH. -AMPUTATION THROUGH 
 THE THIGH. -AMPUTATION IMMEDIATELY ABOVE 
 THE KNEE - JOINT. — REMOVAL OF EXOSTOSIS 
 FROM NEAR THE ADDUCTOR TUBERCLE. — UN- 
 UNITED FRACTURE OF THE FEMUR. 
 
 LIGATURE OF THE COMMON FEMORAL. 
 
 Though this operation is not regarded with much favor, especiallj'' 
 for aneurism, it will be described here, as the question of tying it arises 
 from time to time, and as it should always be performed for the sake 
 of practice, on the dead body. 
 
 Indications. 
 
 1. A\^ounds. — These are rare here compared with those affecting the 
 vessels lower down. The wound must always be explored and the 
 
LIGATURE OP THE COMMON FEMORAL. §67 
 
 Weeding-point sought, for two reasons— (a) Ligature of the external 
 iliac will usually fail to arrest bleeding from the common femoral. 
 (b) The source of the bleeding may easily be mistaken here ; thus, Mr. 
 Liston,* in a case of iDistol-shot wound of the groin, tied the external 
 iliac for what was proved, post mortem, to have been a wound of " one 
 of the superficial branches of the common femoral, about i inch below 
 Poupart's ligament." 
 
 After ligature for gun-shot injuries, whether for direct, or for con- 
 secutive bleeding unattended by primary injury to the vessel, the 
 mortality in the American warf seems to have been high— over 70 per 
 cent. 
 
 The very important subject of ligature of the femoral artery or vein, 
 or both, in cases of wounds, will be referred to here, though briefly. 
 Such cases will arise most frequently in removal of growths— e.^., epi- 
 theliomata, lymphomata, sarcomata, less often in cases of stabs. 
 Much interesting information on these subjects will be found in papers 
 by M. Kirmisson;|: and Dr. L. Pilchcr.g 
 
 2. Removal of Growths from Scarpa's Triangle and Injury to Fem- 
 oral Vessels. M. Kirmisson has lately drawn attention to the following 
 points: In the course of the deeper dissection the pulsation of the 
 femoral artery should be frequently felt for with the finger. As this 
 vessel may have been displaced it is not enough to trust to anatomical 
 knowledge alone. After separating the structures on either side of the 
 tumor, this should be left adherent where in connection with the 
 sheath, and especial care devoted to this spot. Where the adhesions 
 are very firm, and where a large tumor surrounds the sheath, it is 
 useful to divide the tumor and to remove large parts of it, only pre- 
 serving that part in intimate connection with the vessels, this being 
 finally separated most carefully. In the case of growths in intimate 
 connection with the sheath the vein is particularly in danger, because 
 (a) the vein-walls are much more quickly invaded than the arterial, 
 and (6) the vein is in closer connection with the glands. Two con- 
 ditions are likely to be met with by the surgeon; 1. Denudation of 
 the vessels. Here the adhesions are sufficiently loose to be separated, 
 and the sheath is either left intact or opened. Every effort must be 
 
 * Med.-Chir. Trans., vol. xxix. p. 107. The flow of blood here is said to have been 
 ■'most impetuous and profuse." In Mr. Liston's words: "The division of even a small 
 branch close to the principal vessel, it is well known, pours out blood furiously, as 
 much ao, in fact, as if an opening in the coats of the artery itself were, so to say, 
 punched out, corresponding in size to the area of the branch." 
 
 f Otis, Medical and Surr/iml History of the War of the Rebellion, pai-t iii. pp. 1'", 43, 49. 
 
 X Rev. de Chir., May 10, 1886. I am indebted for my knowledge of this paper to an 
 abstract by Mr. T. Jones, of Mnnchester (Med. Chron., September, 1886, p. ol4). 
 
 § Annals of Surgery, February, 188ti. 
 
868 OPERATIONS ON THE LOWER EXTREIIITY. 
 
 taken to keep the wound here aseptic. 2. Resection and ligature of 
 one or other of the femoral vessels. If the vein alone has been injured 
 in an operation or by a stab it should be secured if possible by a later- 
 ally applied ligature, or by the application of Spencer Wells's forceps 
 left in situ for two or three days* These being impossible, or failing, 
 the femora] vein must be hgatured. Dr. Pilcher, quoting from a paper 
 of Braun's,t shows that of eighteen cases in which ligature of the 
 femoral vein alone was practiced at the level of Poupart's ligament, 
 thirteen occurred as the result of wounds inflicted during the removal 
 of tumors. In none of these tumor-extirpation cases did gangrene 
 ensue. J 
 
 The question has been raised lately whether, when ligature of the 
 common femoral vein has been foimd needful, the common femoral 
 artery should not be tied also, in order to diminish the risk of gan- 
 grene. Dr. Pilcher, while quoting the cases of Roux, Linhart, and 
 Langenbeck, in which this step was successful, shows that the practice 
 of ligature of the common femoral artery as a prophylactic step after 
 wound of the common femoral vein high up, whether in the removal 
 of tumor or in injuries, e.g., stabs, is to be discouraged,| 
 
 Dr. Pilcher suggests Hoc. supra cit., p. 119) that where the femoral 
 vein has been suddenly and completely occluded high up it will be 
 wiser to tie not the common but the superficial femoral artery, as 
 likely to materially diminish the current to the limb, while the 
 amount provided will be quite sufficient for its nutrition. 
 
 In cases where both vein and artery are wounded these must be 
 secured in situ. The risk of gangrene is now enormously increased, 
 though the risk will vary somewhat accordingly as the simultaneous 
 ligature is made above or lielow the deep femoral. 
 
 A few other points bearing upon the removal of tumors here may 
 be alluded to. The internal saphena vein should be carefully pre- 
 
 * A case in which I thus treated a wound of the internal jugnlar has been recorded 
 at p. 410. Pilcher mentions a case of Knester's, in wliich a wound in the vein wag 
 secured with lipemostatic forceps; tlie removal of these after onlv twenty-fours hours 
 was followed by renewed bleeding, ligature of the femoral artery, and fatal gangrene. 
 
 t Arch.f. Klin. Chii:, Bd. xxviii. Heft 3, S. 610. 
 
 i Dr. Pilcher points out that this is due to the gradual enlargement of the collateral 
 venous circulation which takes place during thegrowth of the tumor. This constitutes 
 a most important diflereuce between wounds of the vein during operation and by a 
 stab. Thus, in five cases in which as the result of acute injuries the femoral vein was 
 tied high up, recovery without disturbance took place in only one. In two, death took 
 place from septictcmia and pya?mia; in the remaining two, gangrene rapidly super- 
 vened. 
 
 ^ In support of this, Dr. Pilcher writes : "To diminish, to an extreme degree, the 
 arterial snjiply to a part whose nutrition is already seriously compromised by general 
 venous stasis, would certainly tend to precipitate and aggravate the threatened necrosis.'' 
 
LIQATUEE OF THE COMMON FEMORAL. 869 
 
 served intact, and where it is really needful to divide it, this should be 
 done as far from the main femoral trunk as possible, otherwise most 
 troublesome oedema may subsequently develop * 
 
 In operating close to Poupart's ligament, and especially on the inner 
 side, the presence of the peritoneum,t and the possible existence of a 
 femoral hernia must be remembered. 
 
 3. Aneurism.— There has been much difference of opinion as to 
 whether it is wiser, when dealing with an aneurism on the superficial 
 femoral high up, to tie the common femoral or the external iliac. 
 EngHsh surgeons have rejected ligature of the common femoral for 
 these reasons: (1) The risk of gangrene a? the ligature is placed 
 above both the great nutrient arteries of the limb. (2) The probability 
 of firm clotting taking place after the ligature is rendered doubtful, 
 owing to the number of small vessels given off here — viz., the super- 
 ficial epigastric, and circumflex iliac, the superior and inferior ex- 
 ternal pudic, and very commonly one of the circumflex arteries, and 
 also by the proximity of the profunda. (3) The uncertainty of the 
 origin of the profunda, and thus of the length of the common femoral. 
 (4) I would add to the above that ligature of the common femoral for 
 aneurism approximates the treatment to that of Anel rather than to 
 that of Hunter. ErichsenJ goes so far as to say, " It may be laid 
 down as a rule in surgerj-, that in all those cases of aneurism which 
 are situated above the middle of the thigh, in which compression has 
 failed and sufficient space does not intervene between the origin of 
 the deep femoral and the upper part of the sac for the application 
 of a ligature to the superficial femoral, the external iliac should be 
 tied." 
 
 Mr. Holmes, § while adducing facts to show that the operation on 
 the common femoral is not in itself by any means so fatal as has been 
 represented, and that no just cause whatever has been shown for 
 banishing it from surgical practice, allows that he should be in favor 
 of ligature of the external iliac for femoral aneurism high up, under 
 ordinary circumstances, and reserve that on the common femoral for 
 cases where the belly is extremely fat. 
 
 The opposite opinion has been held by some of the Irish surgeons 
 — viz., the two Porters, Mr. Smyly, Mr. Butcher, and Dr. Macnamara. 
 
 * Dr. Pilcher [loe. supra eii., p. 114) mentions a case where, after ligature of tlie 
 saphena vein close to the comiuon femoral, the tendency to ojilema was so great that 
 the patient, nnfitted for work, begged for removal of the limb. 
 
 t M. Kermisson mentions a case in which the peritoneum was wounded and 
 sutured, the patient recovering. 
 
 X Surgery, vol. ii. p. 244. 
 
 I Hunt. Lect., Lancet, 1874, vol. ii. p. 300. 
 
870 OPERATIONS ON THE LOWER EXTREMITY. 
 
 The last-mentioned surgeon has published* eight cases, of which six 
 were successful, two dying of hemorrhage. 
 
 It is probable, however, that, for the reasons given above, ligature 
 of the external iliac will be preferred, especially as nowadays anti- 
 septic precaution and improved ligatures will have rendered this 
 operation increasingly safe. 
 
 4. Ulceration of the Artery by Growth.— From the frequency of 
 growths here this indication will occasionally arise. I have met with 
 one case. A man was admitted under my care who had been operated 
 on elsewhere for the removal of sarcomatous glands in the groin. 
 The apphcation of zinc chloride paste had led to detachment of 
 sloughs and exposure of the common femoral, which gave way, lead- 
 ing to profuse hsmorrhage. I tied the common femoral immediately 
 above the bleeding-point ; this was slowdy followed by typical dry 
 gangrene, necessitating amputation through the lower third of the 
 thigh. 
 
 .5. As a Preparatory Step to Amputation at the Hip-joint.— The 
 need of this has been largely done away with by the Furneaux Jor- 
 dan method. Where this is not available, one of the other means 
 tiiven at p. 845 will, I think, be found preferable. 
 
 Line and Guide.— From a point midway between the anterior su- 
 perior spine of the ilium and symphysis puljisto the adductor tuber- 
 cle, or the inner margiii of the internal condyle. 
 
 Another line is sometimes taken from the centre of Poupart's Uga- 
 ment (or a point midway between the two spines) to the inner margin 
 of the patella or the front of the internal condyle, but that above given 
 is the more correct. 
 
 Relations : In Front. 
 
 Skin ; fascite ; lymphatic glands. 
 Sheath. 
 Outside. Inside. 
 
 Anterior crural. Septum of sheath. 
 
 Common femoral. Femoral vein. 
 
 Behind. 
 Sheath. 
 Psoas. 
 
 It is important to note that the common femoral is usually only IJ 
 inch long, and that from it come off not only the superficial epigastric, 
 
 * Brit. Med. Journ., October 5, 1867. Mr. G. H. Porter {Dub. Journ. Med. Sci., vol. 
 XXX. N.S. 1860, p. 302) reports three cases, and alludes to two under his father's care. 
 All were successful, tliough secondary haeiuorrhage occurred in two. 
 
LIGATURE OP FEMORAL IN SCARPA'S TRIANGLE. 871 
 
 circumflex iliac, and superior and inferior external pudic, but occa- 
 sionally one of the circumflex arteries as well. 
 
 Collateral Circulation. 
 
 Above. Below. 
 
 Glutajal and sciatic, with Superior perforating and cir- 
 
 cumflex arteries. 
 
 Superficial circumflex iliac, with Ascending branch of exter- 
 nal circumflex. 
 
 Obutrator, with Internal circumflex. 
 
 Comes nervi ischiadici, with Perforating of profunda and 
 
 articular of popliteal. 
 
 Operation. — The groin being shaved and cleansed, the hip and 
 knee semiflexed, and the limb adducted and rotated somewhat 
 outwards, an incision about 2 J inches long is made in the line of the 
 artery, commencing just above Poupart's ligament. The skin and 
 8ui3erficial fascia being divided, and any overlying glands displaced 
 or removed, any veins which may be met with descending to join the 
 internal saphena are either drawn aside or tied between double liga- 
 tures of chromic gut. The fascia lata being opened just below Pou- 
 part's ligament, the artery or its pulsation is felt for, the vessel exposed 
 here, and the needle passed from within outwards, care being taken 
 to avoid the crural branch of the genito-crural, which lies superficial 
 to the artery. The neighborhood of any branch is, if possible, 
 avoided. A horse-hair drain is then inserted, and the wound care- 
 fully closed. 
 
 By another method the artery is found by an incision parallel. with 
 the centre of Poupart's ligament and about i inch below it. This is 
 recommended by Mr. Porter and Dr. Macnamara (loc. supra cit). Of 
 the two, the first in the line of the vessel is to be preferred. 
 
 LIGATURE OF THE SUPERFICIAL FEMORAL IN 
 SCARPA'S TRIANGLE (Fig. 154). 
 
 Indications. 
 
 1. Certain Cases of Aneurism of the Popliteal Artery or the Femo- 
 ral low down.— Thus the ligature will probably be indicated— (a) 
 where a popliteal aneurism is rapidly growing, especially when (b) it 
 is on the anterior aspect of the artery instead of behind or at one side 
 of it, as in the former case the knee-joint may become involved after 
 very obscure symptoms ; (c) when the aneurism is fusiform rather 
 than saccular; (d) when it has very thin walls ; («) when it threatens 
 to burst, or when this has already happened, unless other symptoms 
 —e.g., gangrene— call for amputation ; (/) if visceral disease— cardiac, 
 
872 OPERATIONS ON THE LOWER EXTREMITY. 
 
 renal, hepatic— or an atheromatous condition of the vessels is present, 
 the surgeon must weigh carefully the question of operative interfer- 
 ence ; I should prefer in most cases a trial of the ligature as likel^v, 
 with the aid of antiseptic precautions, a modern ligature and primary 
 union, to entail less taxing of the patient's powers : (g) where a trial 
 of pressure has failed, or is certain to fail from the irritability of the 
 patient. 
 
 2. Wounds. — Nothing need he added here to what has been said on 
 the subject at pp. 875, 876. 
 
 3. For Ha-morrhage low down — c.gr., after amputation in the middle 
 of the thigh, when other means fail and the wound is nearly united 
 (p. 876). Two other instances are given by Mr. Bryant* One was 
 " a case of Mr. Bransby Cooper's, in which a compound fracture of 
 the leg was complicated with a laceration of the femoral artery. The 
 artery was secured at the seat of injurjr, and repair went on well in 
 all respects. Mr. Bransb}^ Cooper has also recorded in his Surgical 
 Essays a case of fracture of the femur in which the femoral artery 
 was ligatured for a ruptured popliteal artery, and in which recovery 
 took place in six weeks." Each of such cases must be considered on 
 its own merits, but the 'above shows what ligature of the femoral artery 
 will do in appropriate cases. 
 
 4. For Elephantiasis. — Cases in which the superficial femoral has 
 been tied will be found in the Lancet for 1879, vol. i. p. 44 ; and Rank- 
 ing's Abstract for 1860, vol. ii. p. 193. The subject of ligature of the 
 main artery of a limb for this affection has been considered at p. 531. 
 
 5. Acute Inflammation of the Knee-joint. — Mr. Maunder brought a 
 case before the Clinical Society {Trans., vol. ii. p. 37), in which, at his 
 suggestion, Mr. Little had tied the femoral artery for acute inflamma- 
 tion of the knee-joint, ten days after a lacerated wound. The pain 
 and other acute symptoms were at once relieved, and the patient 
 made a good recovery. The antiseptic treatment of wounds of joints 
 aided by free incisions will, nowadays, do away with the need of the 
 above treatment. 
 
 Line. — That above given, p. 870. 
 
 Guide. — The above line and the inner border of the sartorius at 
 the apex of the triangle. 
 
 Relations ; 
 
 In Front. 
 Skin; superficial fascia; glands; crural 
 branch of genito crural nerve ; middle 
 cutaneous and branch of internal cu- 
 taneous ; fascia lata ; sartorius. 
 
 * Surgery, vol. ii. p. 417 
 
LIGATURE OF FEMORAL IN SCARPA'S TRIANGLE. 
 
 873 
 
 Outside. 
 Femoral vein (below). Ante- 
 rior crural nerve, and some 
 of its branches — viz., nerve 
 to vastus internus, and Ions; 
 saphenous nerve. 
 
 Behind. 
 Psoas ; pectineus ; adductor longus ; femoral 
 vein (below); profunda vein; nerves to 
 pectineus. 
 
 Inside. 
 Femoral vein (above). 
 
 Collateral Circulation. 
 
 Above. 
 Perforating of profunda, 
 
 External circumflex 
 
 profunda, 
 Comes nervi ischiadic!. 
 
 of 
 
 with 
 
 with 
 with 
 
 Below. 
 Lower muscular of femoral, 
 articular of popliteal, and 
 anterior tibial recurrent. 
 
 Ditto ditto. 
 
 Perforating of profunda, 
 and articular of popliteal. 
 
 Operation (Fig. 154).— The parts being shaved and cleansed, the 
 knee and hip slightly flexed, the thigh abducted and somewhat 
 everted, and the leg resting on a pillow, the surgeon, seated or stand- 
 ing to the right of the affected limb, makes an incision 3 inches long 
 in the line of the artery (p. 870). This should begin about 21 inches 
 below Poupart's ligament, and run down to, and somewhat below, 
 the apex of Scarpa's triangle, which lies usually 4 to 5 inches below 
 Poupart's ligament. The skin and superficial fascia being divided, 
 any small vessels are secured, and branches of the saphena vein 
 drawn aside with a strabismus hook or secured with double chromic- 
 gut ligatures. The deep fascia is now slit up for the whole length of 
 the wound, and the inner margin of the sartorius, which crosses the 
 lower part of the incision, identified. This is then turned outwards, 
 and so held with a blunt hook or retractor, while the artery or its 
 pulsation is felt for. The wound being now well opened out with re- 
 tractors and carefully wiped out, the sheath is opened to the outside, 
 care being taken to avoid the nerves in contact with it — viz., the long 
 saphenous, or the nerve to the vastus internus. The artery being 
 cleaned, thoroughly but most carefully, on either side and behind, 
 the needle is passed from within outwards, being kept very close to 
 the vessel so as to avoid the vein which lies behind and internally.* 
 
 * The vein is so frequently damaged here, especially on the dead subject, that a few 
 precautions may be given as to the best way of avoiding it. First, the sheath must 
 be identified exactly, and sufficiently opened at its outer part. It will be found of 
 
874 
 
 OPERATIONS ON THE LOWER EXTREMITY, 
 
 The artery being tied, the ligature is cut short, drainage provided by 
 horsehair or a small tube, according to the amount of disturbance of 
 
 Fig. 154. 
 
 Fig. 155. 
 
 Ligature of the superficial femoral at the 
 apex of Scarpa's triangle, and in Hunter's 
 canal. Above, the sartorius (the only struc- 
 ture which happened to be met with) is drawn 
 outwards. Below, it is drawn inwards. The 
 long saphenous nerve lies on the outer side of 
 the artery, here. 
 
 Incised wound of the thigh explored and 
 found to involve the femoral artery. An Es- 
 march's bandage should have been shown in 
 situ above. 
 
 ranch help in cleaning the vessel if one edge of the cut sheath is held by an assistant, 
 while the surgeon has hold of the other ; the opening in the sheath is tluis made sure 
 of and retained. There must be no needless disturbance, or lifting np of the vessel 
 upon the needle, which, with the director, must be used with the utmost carefulness. 
 As soon as the eye (and this should be at the very end of the needle) is seen to have 
 passed round the vessel, the ligature should be at once seized and the needle with- 
 drawn. 
 
LIGATURE OF FEMORAL IN HUNTER's CANAL. 875 
 
 the parts, etc., and the wound closed. The precautions given at p. 
 535 for the prevention of gangrene must be taken. 
 DiflBculties and Mistakes. 
 
 1. Wounding the Saphena Vein.— Tliis may occur if the incision 
 is made too internal It is ahvays to be avoided if possible, owing 
 to the troublesome oedema which may follow. 
 
 2. A very broad Sartorius. 
 
 3. Injury to the Femoral Vein.— This may easily take place if force 
 is used in pushing the needle round an imperfectly cleaned artery, or 
 if the needle is not kept close to the vessel. If the accident occur, 
 the surgeon must not persist in his attempt to tie the artery at this 
 spot, a course which will only end in his inflicting more injury on 
 the vein, but, finger-pressure being made in the lower angle of the 
 wound, the artery is tied either above or below the spot where the 
 vein has been injured. As soon as the artery is secured, no further 
 hajmorrhage will take place, but pressure may be kept up by means 
 of a carbolized sponge over the ivound for a day or two.* The patient 
 will do well to wear a Martin's bandage or an elastic stocking for 
 some time after getting up. 
 
 4. Including one of the nerves. 
 
 5. A matted condition of the parts due to a previous trial of com- 
 pression. 
 
 Abnormalities of the Femoral Artery. 
 
 1. A double superficial femoral, the two trunks uniting below to 
 form the popliteal. More than one case of this kind is recorded. 
 The persistence of pulsation in the aneurism after the first ligature 
 would lead to a suspicion of this condition. 
 
 2. The vessel may run down at the back of the limb. 
 
 LIGATURE OF FEMORAL ARTERY IN HUNTER'S 
 CANAL (Fig. 154). — TREATMENT OP STAB IN MID- 
 THIGH (Fig. 155). 
 
 Indications for Ligature of the Femoral Artery in Hunter's 
 Canal. 
 
 1. Wounds. — These may be, (a) incised; (6) punctured. 
 
 (a) Here, if immediate death from hgemorrhage has been arrested, 
 the wounded vessel must be secured. The artery above being com- 
 pressed by an Esmarch's bandage or the hands of an assistant, the 
 wound is enlarged, clots sponged away, and the artery tied above and 
 below the wound in it (Fig. 155). If the vein is found injured too 
 
 * If venous heemorrhage persist, the opening in the vessel shonH he secured with 
 a chromic-gut ligature, or a pair of Spencer Wells's forceps left in situ (p. 868). 
 
876 OPERATIONS ON THE LOWER EXTREMITY, 
 
 severely for a laterally applied ligature, and requires ligature in the 
 ordinary way, the patient or the friends must be prepared for the 
 imminent need of amputation. 
 
 (6) If a punctured wound lies in the line of the artery (p. 870), 
 and if much blood has been lost, the main trunk is probably injured, 
 and the question will arise, if the bleeding has ceased, whether to cut 
 down upon the artery or to trust to pressure. Mr. Cripps (Z>irt. o/ 
 Surg., vol. i. p. 525) advises that if the wound be in the upper part of 
 the thigh, " the surgeon may enlarge the wound with a good prospect 
 of finding the wounded vessel without an extensive or prolonged 
 operation. If the wound be in the lower half of the thigh, owing to 
 the greater depth of the artery, and the possibility of its being the 
 popliteal which is wounded, the search is rendered far more severe 
 and hazardous, and it should not be undertaken until a thorough 
 trial of pressure has proved ineffectual." 
 
 The following mode of applying pressure is taken from Mr. Cripps 
 (foe. supra cit.')* I would also refer my readers to the account of 
 punctured wound of the palm given at p. 36 of this work. 
 
 The main vessel being controlled above the foot and leg should be 
 carefully strapped from the toes to the knee, and a bandage then car- 
 ried from the toes up to the wound, and then, avoiding this, up to the 
 groin, where it is secured, spica fashion, over a pad on the main 
 artery. The limb is then laid on a long back splint with a foot-piece 
 and secured to this in an elevated position. The wound being cleansed 
 and dusted with iodoform, a graduated compress (p. 36) is then 
 fastened over it. Two rectal bougies are then applied in the course 
 of the artery, above and below the wound, outside the bandage which 
 surrounds the limb, so as to keep these segments of vessel empty. 
 Two well padded lateral splints are then secured with straps and 
 buckles to the thigh. Morphia must be given as freely as is judi- 
 cious.f 
 
 2. HEemorrhage from Stump after Amputation in Lower Third of 
 Thigh or Knee. — If clearing away the clots and disinfecting the 
 stump, followed by well adjusted pressure, and, this failing, trying to 
 
 * Mr. Cripps's account will be found under the heading of the treatment of second- 
 ary haemorrhage from the femoral. He draws attention to the instructiveness of the 
 literature of this subject, as it proves not only that many cases have been successfully 
 treated by pressure from the first, but that both life and limb have been saved by 
 pressure after the surgeon has failed to find the artery in the wound, or after tying the 
 iliac in vain. 
 
 t Mr. Cripps advises that the limb should be slightly raised on a pillow, and partly 
 bent at the knee and thigh. The toes should be left exposed that their condition may 
 be watched. 
 
LIGATURE OF FEMORAL IN HUNTEr's CANAL. 877 
 
 find the bleeding point in the flaps, do not suffice, the artery must be 
 tied above.* 
 
 Line and Guide (p. 870). 
 Relations: In Front. 
 
 Saphena vein. 
 Skin; fascite; sartorius; aponeurosis between 
 
 vastus internus and adductors. 
 Outside. Inside. 
 
 Vastus internus ; vein (slightly). Adductor longus and magnus. 
 
 Femoral artery in Hunter's canal. 
 
 Behind. 
 Femoral vein (especially above). 
 _ Operation (Fig. 154).— The knee and hip being flexed, and the 
 limb abducted and rotated outwards, the surgeon, seated comfortably 
 on the inner side of the limb, makes an incision 3} inches long in line 
 of the artery in the middle third of the thigh.f The skin, superficial 
 and deep fascite, being divided, and the saphena vein drawn to one side 
 with a strabismus hook, and any of its branches divided between 
 double chromic-gut ligatures, the sartorius is identified by the direction 
 of its fibres and drawn to the inner side. The canal is next opened by 
 dividing the aponeurotic roof, and the artery or its pulsation felt for. 
 This vessel will be found closely connected with its vein, which lies 
 behind it, while the saphenous nerve crosses it from without inwards. 
 The artery being most carefully cleansed all round, the ligature may 
 be passed from either side, as is found most convenient. J 
 
 Causes of Failure after Ligature of the Femoral. 
 
 1. Gangrene. 
 
 * I would again refer my readers to Jlr. Cripps's article {loc.supra cit, p. 526). He 
 points out that a decision between opening the flaps or ligaturing the main vessel high 
 up must depend on the amount of union, and that if the flaps must be opened and 
 the vessel sought for before there is much firm union, as in the first fortnight, a director 
 should be used rather than a knife, and that if the vessel is found, its .soft condition 
 will require very gentle tying. 
 
 t This incision must not be made too low down. Its centre should correspond to the 
 centre of the thigh. 
 
 X Much difliculty will be met with in tying the femoral artery in Hunter's canal un- 
 less the line of the artery (p. 870) is strictly followed. A common mistake is to make 
 the incision too far out, thus exposing the fibres of the vastus internus, which run 
 downwards and outwards, instead of those of the sartorius, which run downwards and 
 inwards (Smith and Walsham, Man. of Oper. Surg., p. 83). Erichsen (Surgery, vol. ii. 
 p. 250), who gives as the line of the artery, one drawn from a, point exactly midway 
 between the anterior superior spine and symphysis pubis to the most prominent part of 
 the internal condyle, insists on the need of making the incision a finger's breadth in- 
 ternal to this. The line given above (p. 870) will be found sufiiciently internal. 
 
878 OPERATIONS ON THE LOWER EXTREMITY. 
 
 2. Secondary Hfemorrhage.— If pressure fail, an attempt must be 
 made to re-tie the vessel, and, this not succeeding, the limb must be 
 amputated. 
 
 3. "Suppuration of the Sac of an Aneurism.— This is very rare. 
 
 4. Recurrent Pulsation in the Aneurism. The premature softening 
 of catgut, especially in a septic wound, must always be remembered 
 as a possible cause of this. Pressure failing, the artery may be tied 
 lower down. 
 
 5. A very rare complication is the formation of an aneurism at the 
 seat of ligature. 
 
 AMPUTATION THROUGH THE THIGH. 
 
 Practical Points in Amputation of the Thigh. — As the soft 
 parts behind are more bulky than those in front, and as it is desirable 
 to place the bone as near as j)0ssible in the centre of the soft i:)arts,the 
 back of the thigh, in the case of a bulky limb, may be supported by 
 the hand of an assistant during the first introduction of the knife to 
 form the anterior flap (Skey). Amputation should alwa^'S be per- 
 formed as low down as possible, not only to avoid shock and to secure 
 as long a stump as possible for the artificial limb, but also to secure as 
 much as possible of the rectus femoris. This muscle is the sole agent 
 by which the thigh is put forward in stepping. Its division does not 
 preclude the retention of its office, as it acquires a sufficient adhesion 
 to the material of the stump to answer every useful purpose as an agent 
 in the flexion of the thigh on the pelvis, though that of extension of 
 the leg be destroyed (Skej^, Oper. Surg., p. 391). 
 
 Different Methods.— The following five, which will give ample 
 choice, will alone be described here ; the first is especially recom- 
 mended : 
 
 I. Mixed Antero-posterior Flaps and Circular Division 
 
 of the Muscles. 
 II. Antero-posterior Flaps by Transfixion. 
 
 III. The Circular Method. 
 
 IV. Rectangular Flaps. 
 V. Lateral Flaps. 
 
 I. Mixed Antero-posterior Flaps and Circular Division of 
 the Muscles. — By the term mixed is meant an anterior flap of skin 
 and fascite raised from without, and a posterior one made by transfixion. 
 The anterior is, wherever practicable, made the longer of the two. 
 
 This method has the following great advantages: (1) The longer 
 anterior flap falls well over the bone and thus keeps the scar behind ; 
 (2) Being raised from without inwards, it can be taken from the neigh- 
 borhood of the knee-joint and patella; (3) It is a most expeditious 
 
AMPUTATION THROUGH THE THIGH. 879 
 
 method * almost as quick as that by double transfixion flaps • f4) It 
 IS suited to all cases, save perhaps those of very muscular thighs', where 
 the surgeon should be careful to take only part of the muscl..s behind 
 as he transfixes, or else should raise his posterior flap also from with- 
 out mwards ; (5) It gives good drainage. 
 
 Operation— The femoral artery being controlled with an Esmarch's 
 bandage,t the limb being brought over the edge of the table and sup- 
 ported by an assistant, who has bandaged the damaged or diseased part 
 to give his hands a firmer grip, and to prevent their becoming septic; 
 
 Fig. 156. 
 
 I 
 \ 
 
 \ 
 \ 
 
 I \ *- ■-, I, nil 
 
 I' 
 
 The knife should have been inserted here from the inner side. 
 
 the opposite ankle being tied to the table, and the parts duly cleansed, 
 the surgeon, standing to the right side of the limb to be removed, places 
 his left index and thumb on either side of the limb, at the level where 
 he intends to saw the bone,J and sinking the point of his knife through 
 the skin just below the former and rather below the centre of the outer 
 or inner aspect of the limb as the case may be, carries it rapidly down 
 for about 4i inches, and then sweeps it across the limb with a broad, 
 not pointed, convexity, and carries it up along the side nearest to him 
 as far as his thumb. This flap is then quickly dissected up of skin 
 and fasciae, and the knife, being sent across the limb, behind the bone, 
 cuts a posterior flap almost as long as the anterior, the knife being used 
 with a rapid sawing movement, and driven at first straight down paral- 
 lel with the bone, and then sharply brought out through the skin. 
 
 * As in railway and otiier accidents. 
 
 f If tlie snrgeon is amputating very high up, the method given in the account of 
 amputation at the hip-joint (pp. 845-6) may be used. 
 
 X The finger and thumb should not be shifted (ill the anterior flap is marked out. 
 
880 OPERATIONS ON THE LOWER EXTREMITY. 
 
 The flaps being held out of the way with the surgeon's left hand,* 
 the soft parts around the femur are next severed with a circular sweep,t 
 the knife being used as at p. 100, till the bone is exposed, when one 
 more firm sweep divides the periosteum.J 
 
 The saw is now placed with its heel on the bone and drawn towards 
 the operator once or twice with firm pressure so as to make one groove 
 and one only. With a few sharp sweeps the bone is next severed, care 
 being taken to use the saw lightly for fear of splintering the linea as- 
 pera, and to use the whole length of the instrument. At this time 
 the limb must be kept steady and straight, the assistant neither raising 
 it, which will lock the saw, nor depressing it, which will splinter the 
 femur when this is partly divided. 
 
 If the surgeon decide to make his posterior flap also of skin and 
 fascia', he must have the limb raised, and first looking over and then 
 stooping down, marks out a skin flap about f the length of the anterior ; 
 this is then dissected up, and the operation completed as before. 
 
 In addition to the femoral vessels, the anastomotica, and descending 
 branch of the external circumflex, some muscular branches will require 
 attention ; and one of these last may give some trouble from its posi- 
 tion close to the bone in contact with the linea aspera.§ 
 
 In amputations of the thigh accomiDanied by grave shock, no need- 
 less time should be lost in looking for vessels, save the femoral and 
 any other large branch which can be seen. Firm bandaging and rais- 
 ing the stump will suffice. It is well to partially relieve the tightness 
 of the bandaging in a few hours by nicking them. Very few sutures 
 should be used in these cases of shock, or in those where the soft parts 
 are sinus-riddled. 
 
 II. Transfixion Flaps. — Advantage. — Great rapidity. Disadvan- 
 tages. — Those given at p. 61, on a large scale. This method may be 
 used where great speed is needed, as in a double amputation after a 
 railway accident, or where many wounded require attention, as after 
 a great battle. It is also adapted to the wasted muscles of a patient 
 
 * And also pressed firmlv upwards, so as to enable the saw to be applied as high up 
 as i)ossible. If the limb is bulky an assistant must help here. 
 
 f Ibis requires really forcible use of the knife, the muscles behind the bone tending 
 to be pushed before the knile rather than divided by it. 
 
 J This final cut should be a little above the base of the fJaps, in order that tlie sawn 
 femur may lie well buried in soft parts. 
 
 § The following points deserve attention in tying the femoral vessels: (1) Not to 
 include the saphenous nerve; (2) the tendency of the vessels to slip up if the point o^ 
 their division passes through Hunter's canal ; (3) if the vessels are atheromatous they 
 must not be tied too tightly. A carbolized silk ligature, not too fine, should be em- 
 j)loyed now, and care should be taken to include a little of the soft parts to prevent 
 the ligature cutting through. 
 
AMPUTATION THROUGH THE THIGH. 
 
 n 
 
 who has long suffered from some chronic disease of knee or Ic^, but 
 even here it is inferior to the mixed method. 
 
 Operation.— The prehminary steps given at p. 879 being taken, 
 the surgeon, standing to the right side of either limb, with his left 
 index and thumb marking the site of his intended bone-section, raises 
 
 Fig. 157. 
 
 ( Fergusson ) 
 
 with his hand the soft parts on the front and sides of the thigh, and 
 sends his knife across the limb in front of the femur. The knife 
 should be entered well below, so as to get as large an anterior flap as 
 possible, and, at its entry, should be pushed a little upwards so as to 
 go easily over the bone. An anterior flap is then cut 4 to 4= inches 
 long, with a broadly curving almost square extremity, and not too 
 thin at its edg-e. This being raised by the surgeon or an assistant, 
 the knife is now passed behind the bone and a posterior flap cut of 
 the same length as the anterior, the making of this flap being some- 
 what facilitated liy drawing the soft parts on the back of the limb 
 away from the bone. 
 
 If the limb be very Indky the knife should be kept well away from 
 the bone, especially behind it, and not as at p. 880; thus the more 
 superficial muscles only will be included in the posterior flap. 
 
 Both flaps being retracted, the remaining soft parts are severed with 
 circular sweeps, and the rest of the operation completed, as at p. 880, 
 but with this difference, that here there will be more need of trim- 
 ming some of the soft parts clean and square.* 
 
 * While dresser to the late Mr. Poland, I once saw the femoral vessels split for 
 about 3J inches by his rapid hands. This amputation of the thigh was his last opera- 
 tion at Guy's Hospital. He was even llien facing with quiet bravery the bronchitis 
 which, a very few days later, ended his life. 
 
 50 
 
882 OPERATIONS ON THE LOWER EXTREMITY. 
 
 III. The Circular Method.— I may here state briefly why this 
 method is, nowadays, considered inferior, both -in the thigli and else- 
 wlierc, to tliat liy tiaps. In saying this, it is not denied that in many 
 
 Fig. 15S. 
 
 Circular Hinputalion of the tliigli to show the greater retraction of the muscles beliind. 
 
 oases stumps by the circular method are fully equal to those by flaps; 
 indeed, in many it is impossible to tell, in later years, which method 
 lias been employed. On the whole, however, the flap-method has the 
 following advanttigcs : (1) It is most generally applicable — e.g., in 
 parts not circular and at the joints.* ' 2j By it the surgeon can better 
 adapt his skin covering to his needs — e.g., when the skin is less 
 available on one asjiect of the limb than on another. (3) There is 
 less risk of a conical stump; and (4) of a cicatrix adherent to the 
 bone. The great tidvantage of the circular method — viz., that the 
 vessels an'd nerves are cut square, and that, thus, the former retracting 
 more easily, fewer need securing, while there is less risk of bulbous 
 vnAa forming on the latter, is attained l)y the mixed method (.)f skin 
 flaps and circular division of the muscles as at p. 879. f 
 
 The circular mctliod is only to be adoi>ted here in the case of the 
 lower third of wasted thiglis, or in those of voung subjects. Even 
 here the gn-Lter tendency of tlie posterior muscles to retract must be 
 nict by cutting them aljout 3 inch longer than those in front. 
 
 While this operation is for tlie above reasons not recommended in 
 practice, it may be nuide use of in the lower third of the thigh, in the 
 cases mentioned a))ovc. On the deod subject the student who has 
 not had a chance of performing it u])on the arm, may make use of 
 it here. 
 
 Operation. — As this method has beini described in detail at p. 
 
 * T(i these it may be added lliat the rircnhir iiielliod is not adapted to a case where 
 the skin is matted to the sidijacent muscles. 
 
 t One more advantage of the ilap metliod is the greater rapidity, especially when 
 t]ansfixion is employed, though this, in these day.s of anaesthetics, is only of importance 
 in a few cases. 
 
5 
 
 AMPUTATIOJ^ THROUGH THE THIGH. §83 
 
 100,'*= it will be only briefly given here. The preliminaries are those 
 already given. The surgeon standing to the right of the limb the 
 assistant who stands on the opposite side to liim, but nearer the trunk 
 draws up the skin with both hands. The surgeon, stoopin- a little 
 passes his knife first under the limb, then above, across, and so around 
 It till by dropping the knife vertically the back of the instrument looks 
 towards him, while its heel rests on that side nearest to him. He then 
 makes a circular sweep around the thigh, this being aided by the 
 assistant who has charge of the limb rotating it so as to make the soft 
 parts meet the knife. The surgeon then taking hold of the edge of the 
 incision dissects up a cuff-like flap, aljout Ai inches in length, cutting 
 it of even thickness all round the limb. This flap is then folded back, 
 and the remaining soft parts divided with circular sweeps of the knife' 
 In doing this, the greater contraction of the hamstring muscles must 
 be remembered, and these muscles cut rather longer than those in 
 front. Care must be taken, if it is thought needful, after making the 
 circular sweeps, to free the bone higher up, and so to secure its being 
 well buried in the soft parts, and not to prick the already divided 
 femoral vessels which lie in close proximity to the femur in the lower 
 third. 
 
 IV. Rectangular Flaps of Mr. Teale.— This method is fully 
 described below. It is not recommended here as it is expensive, 
 involving division of the bone nearer to the trunk than other methods. 
 (1) Owing to the bulkiness of the long anterior flap, it is, here, especi- 
 ally difficult to fold and adjust it at the conclusion of the operation, 
 and still more so to keep it adjusted if primary union fails. (3) Its 
 chief advantage, that of keeping the end of the bone well buried, and 
 of cutting the vessels and nerves clean and square, are also sufficiently 
 attained by the other flap methods already given, especially the mixed 
 method (p. 880). 
 
 V. Lateral Flaps. — This method has certain grave objections here. 
 (1) The sawn femur, tilted upwards by the ilio-psoas, is very liable to 
 press against the upper angle of the flaps, and to come through at this 
 spot and necrose. (2) If this does not take place, the bone often 
 adheres to the cicatrix here, while the flaps hang down and away from it. 
 
 It should only be made use of when no other method is available, as 
 in a case where, owing to the condition of the soft parts, flaps can 
 only be got by making one long external and a short internal, or vice 
 
 versa. 
 
 * If it be objected that the plan here given of turning up a cuff-like flap is likely to 
 lead to sloughing, I would reply that this is not so in these days of anliseptic surgery. 
 If sloughing is dreaded, a little more time should be taken in dissecting up a thin layer 
 of muscle, so as to secure the deep fascia, and thus a belter vascular supply. 
 
884 OPERATIONS ON THE LOWER EXTREMITY. 
 
 Operation.— This and its modification of antero-external and 
 postero-internal flaps are fully described at p. 879. 
 
 AMPUTATIONS IMMEDIATELY ABOVE THE KNEE- 
 JOINT (Figs. 159-165). 
 
 Methods. 
 
 i. Garden's (Figs. 159, 160, 161). 
 ii. Gritti's Trans-condyloid (Figs. 162, 164). 
 iii. Stokes's Supra-condyloid, an important modification of the 
 
 above (Figs. 163, 165). 
 
 All the above, but especially the two latter, possess the following 
 advantages (which they share with amputation through the knee- 
 joint) over amputation through the thigh, viz. : 
 
 1. The patient can bear his weight in walking on the face of his 
 stump, thus, he is not compelled to take his bearing from the tube- 
 rosity of the ischium, or to walk as if he had an ankyksed hip-joint 
 (Stokes), as is the case after amputation of the thigh, where the stump 
 is ever liable to be fretted by the slightest pressure on it. 
 
 2. Very good power of adduction over the artificial limb remains. 
 Every operating surgeon must have noticed how badly off a patient is 
 in this respect after an ordinary amputation through the thigh. By 
 these methods the adductors are left almost intact, even to part of the 
 strong vertical tendon of the adductor magnus, the result being that 
 the balance between the adductors and abductors of the thigh remains 
 practically undisturbed, and the patient when walking has none of 
 
 Fig. 159. 
 
 (Garden). 
 
 that difficulty (which is seen after thigh amputations) of bringing the 
 limb which he has swung forwards, in again under the centre of 
 gravity.* 
 
 3. The medullary canal is not opened ; on this account there is less 
 risk of necrosis and osteo-myelitis if the stump becomes septic. 
 
 4. There is less shock, because (a) the limb is removed farther from 
 
 * The importance of the preservation of the quadriceps extensor, given by the 
 Stokes-Gritti metho 1, need only be alluded to. 
 
AMPUTATIONS IMMEDIATELY ABOVE THE KNEE-JOINT. 885 
 
 the trunk, (6) the muscles are divided not through their vascular bel- 
 lies, but through their tendons. 
 
 i. Garden's Amputation (Figs. 159, 160, 161). 
 
 Advantages. — This valuable amputation has some points in common 
 with Svme's amputation at the ankle-joint. In both the bone-section 
 
 Fig. 160. 
 
 (Garden). 
 
 is made not through a medullary canal, but through vascular quickly 
 healing cancellous tissue ; in both, the skin reserved for the face of the 
 stump has been used to pressure, though not equally so, for the skin 
 preserved in the ankle amputation is thick and callous, in the other 
 thinner and more sensitive. 
 
 Sir J. Lister* thus recommends this amputation : " This operation, 
 when contrasted with amputation in the lower third of the thigh, pre- 
 sents a remarkable combination of advantages. It is less serious in 
 its immediate effects upon the system, because a considerably smaller 
 quantity of the body is removed, and also because the limb, being 
 divided where it consists of little else than skin, bone, and tendons, 
 fewer bloodvessels are cut than when the knife is carried through the 
 highly vascular muscles of the thigh ; the popliteal and one or two 
 articular branches being, as a general rule, all that require attention, 
 so that loss of blood is much diminished. In the further progress of 
 the case the tendency to protrusion of the bone, which often causes 
 inconvenience in an amputation through the thigh, is rendered com- 
 paratively slight by the ample extent of the covering provided, and 
 also by the circumstance that the divided hamstrings slip up in their 
 sheaths, so that the posterior muscles have comparatively little power 
 to' produce retraction. The superiority of the operation is equally 
 conspicuous as regards the ultimate usefulness of the stump, which, 
 from its great length, has full command of the artificial limb, while its 
 extremity is well calculated for sustaining pressure, both on account 
 of the breadth of the cut surface of the bone divided through the con- 
 dyles, and from the character of the skin habituated to similar treat- 
 
 *■ System of Surgery, vol. iii. p. 705, 
 
OPERATIONS ON THE LOWER EXTREMITY. 
 
 ment in kneeling. Considering, therefore, that this procedure can be 
 substituted for amputation of the thigh in the great majority of cases 
 both of injury and disease formerly supposed to demand it, ' Garden s 
 operation ' must be regarded as a great advance in surgery."* 
 
 Disadvantages.— The chief of these is the sloughing of the long ante- 
 rior flap which may occur, " in spite of faultless operating," especially 
 if the skin, of which it chiefly consists, has been damaged by injury 
 or disease, or if the patient be old or weakly, thus leading to an 
 adherent, tender scar, and a useless stump. 
 
 Operation. — According to its introducer this amputation consists 
 in removing a rounded flap from the front of the joint (Figs. 159, 160, 
 161), dividing everything else straight down to the bone, and sawing 
 this slightly above the plane of the muscles. 
 
 The operator standing on the right side of the limb, seizes it, between 
 his left forefinger and thumb, at the spot selected for the base of the 
 flapt and enters the point of his knife close to his finger, bringing it 
 
 Fig 161. 
 
 Fig. 102. 
 
 Gritti's trans-condyloid section of the femur, leaving 
 a surface mucli too large for the sawn patella to fit. 
 
 round through the skin and fat below the patella to the spot pressed 
 by his thumb, then turning the edge downwards at a right angle with 
 the line of the limb, he passes it through to the spot where it first 
 entered, cutting outwards through everything behind the bone. The 
 flap is then reflected, and the remainder of the soft parts divided 
 
 * Other advantages given by Mr. Garden are, the favorable position of the stump 
 for dressing and drainage ; its painlessness, the chief nerves being cut high up out of 
 reach of pressure ; and the cicatrix being drawn clear of the point of the bone, and 
 out of reach of pressure. 
 
 t This corresponds with the upper border of the patella, the limb being extended. 
 The lower margin comes down to the tubercle of the tibia, as in Fig. 159. See also 
 Bnt. Med Journ , 1864, vol. i. p. 416. 
 
AMPUTATIONS IMMEDIATELY ABOVE THE KNEE-JOINT. 887 
 
 straight down to the bone; the muscles are then slightly cleared up- 
 wards, and the saw applied " through the base of the condyles." The 
 projecting part of the femur may be rounded off. Where there is any 
 doubt about the vitality of the large anterior flap, a short posterior 
 one should be made, the anterior one thus not needing to be so long 
 (Fig. 161). 
 
 ii. Gritti's Trans-condyloid. iii. Stokes's Supra-condyloid 
 Amputation (Figs. 162, 163, 164, 165). 
 
 For fuller information on the above amputations I would refer my 
 readers to a paper I contributed to the Gwy's Hosp. Rejiorts, vol. xxiii. 
 p. 211, 1878. The objections to amputation through the knee-joint, 
 whether by a long anterior, or long posterior flap are given at p. 891. 
 Amputation through the knee-joint by lateral flaps gives excellent 
 results, but in this method the incisions are carried into the leg below 
 the tibial tubercle ; in the two amputations mentioned above this 
 point is not trenched upon, and every surgeon knows that after a 
 severe compound fracture of the le^;, an inch or two more or less of 
 damage to the soft parts in the upper third of the leg makes a most 
 important difference as to where he can amputate. 
 
 The two methods are often confu.^ed. Between them there is this 
 all-important difference: in Gritti's, the section of the femur is made 
 
 Fig. 163. 
 
 Fia. 164. 
 
 '.JS*-- ' 
 
 .A..^^ *u: •na. 
 
 ntttb. 
 
 Stokes's supra-condyloid section of tlie femur, Tlie flaps in Gritti's trans-condyloid amputation, 
 leaving a surface mucli more easily fitted by the showing tlie patella hitched and requirnig force to 
 
 adapt it to the femur, which is now too long as well 
 as too broad. 
 
 sawn patella. 
 
 through the condyles ; in Stokes's, at least J inch aboveiham. In other 
 words, the one operation is trans-, the other supra-condyloid. 
 
 On this point great stress has been laid, and very rightly, by Sir W. 
 Stokes, and a comparison of the two operations will convince every 
 one that he is correct. If the section of the femur be made through 
 the condyles (Figs. 162, 164) the sawn patella will not fit down into 
 place. It will either be drawn up altogether on to the front of the 
 
OPERATIONS ON THE LOWER EXTREMITY. 
 
 femur, or else will project forwards, somewhat like the half-ojien lid 
 of a box, at an angle to the broad sawn surface, which is also too large 
 for it to cover, and across, and off which it is liable to be shifted by 
 the contraction of the quadriceps, if it has been found possible to get 
 it into place. To effect this, an amount of force will be required which 
 is almost certain to result in bruising of the cut periosteum on the 
 edge of the femur, and consequent necrosis. If, on the other hand, 
 the saw is made to pass i inch above the condyles (Fig. 163), the patella 
 will fall readily into place, it will cover more completely the now 
 smaller sawn surface of the femur, and will remain easily in situ here, 
 the flaps when brought together presenting the ajjpearance shown in 
 Fig. 166. 
 
 Operation. — An Esmarch's bandage being applied, the limb 
 brought over the edge of the table and supported, and the opposite 
 one secured out of the way the surgeon standing to the right of the 
 limb, with his left index and thumb marking the base of his flap, 
 makes an incision commencing (on the left side) an inch above and 
 rather behind the external condyle, carried vertically downwards to a 
 point opposite to the tibial tubercle, then broadly curved across the leg 
 and carried upwards to a point opposite to that from which it started. 
 This flap, having been dissected upwards, together with the patella 
 
 Fig. 165. 
 
 
 Appearance of the stump in a Stokes-Gritti's amputation. The patella has 
 come easily into place. 
 
 (after severing the ligamentum patella?) a posterior flap is cut nearly 
 as long as the anterior. This may be effected in one of two ways, 
 either by the surgeon looking over and then stooping a little (the limb 
 being now raised), next drawing the knife from without inwards 
 across the popliteal space, thus marking out and then dissecting up a 
 skin flap, or by transfixing and cutting the flap from within outwards. 
 Of the two I prefer the first; the latter is the speedier, but less suited 
 to bulky limbs. The flaps being retracted, the soft parts are cut 
 through with a circular sweep ■> inch above the articular surface of the 
 femur, the bone is then sawn through here, and the limb removed. 
 
REMOVAL OP EXOSTOSIS FROM NEAR ABDUCTOR TUBERCLE. 
 
 889 
 
 The posterior surface of the patella is next removed with a metacarpal- 
 or small butcher's-saw. This last step is the only difficult one in the 
 operation, owing to the mobility of the bone: it will be facilitated by 
 an assistant with both his hands everting and projecting the under 
 surface of the anterior flap, so as to make the patella stand out 
 from it. 
 
 The vessels— popliteal, one or two articular and the anastomotic— 
 having been secured, drainage is provided, and the flaps are brought 
 together with numerous points of suture, save at the angles (Fig. 165). 
 
 Where the flaps are cut of proper length and the femur is sawn at 
 the proper height, it is quite exceptional for the patella not to ride 
 easily in situ. If there seem any doubt on this point, or if the patient 
 is very muscular, additional security may be given— (a) By passing 
 sutures of chromic gut or carbolized silk between the tissues on the 
 under surface of the anterior flap, at the edges of the patella, and the 
 soft parts in the posterior flap (avoiding the vicinity of the large ves- 
 sels) ; (6) by wiring or pegging the bones; (/;) by dividing the rectus 
 muscle on the under surface of the anterior flap. Of these, wiring or 
 pegging is the best ; the pegs must be scrupulously clean. An ordinary 
 bradawl, also rendered aseptic, will be found quite as efficient as a drill. 
 
 REMOVAL OF AN EXOSTOSIS FROM NEAR THE 
 ADDUCTOR TUBERCLE* 
 
 As these growths are by no means uncommon in adolescents, this 
 operation will be briefly described here. Aseptic excision has now 
 replaced any other operation such as subcutaneous fracture. 
 
 Operation. — The parts being thoroughly cleansed, the knee is 
 flexed so as to bring down the synovial membrane, and the limb 
 placed on its outer side. A free incision, about Si inches long, is made 
 over the growth down to the vastus internus, and any superficial ves- 
 sels attended to. The muscular fibres are then cleanly cut through,! 
 and the bluish-gray cartilage which caps the swelling now comes into 
 view.J Any muscular branches being now carefully secured, and the 
 wound sponged dry, the cut vastus is pulled aside by retractors, and 
 the growth being thoroughly exposed it is shaved off with an osteotome 
 or chisel, leaving exposed cancellous tissue. A little iodoform is dusted 
 in, and drainage provided by a tube or large horsehair drain, passed 
 from the wound to the most dependent spot on the inner side, the 
 
 * This account will serve for the removal of other exostoses — e.g., that met with at 
 the deltoid insertion. 
 
 f This is more likely to conduce to primary union than tearing them through with 
 a director. 
 
 X Any synovia-like fluid now escaping comes probably from a bursa over the growth, 
 not from the joint. 
 
890 OPERATIONS ON THE LOWER EXTREMITY. 
 
 dressing-forceps passing under the muscle and being cut down upon by 
 counter-puncture, where they project under the skin. The muscular 
 fibres are then united with chromic gut, cut short, and the wound 
 closed with separate sutures. Strict aseptic precautions are taken 
 throughout to secure primary union. The limb should be kept abso- 
 lutely quiet on a back splint, and a Martin's bandage worn, later, for 
 a short time. 
 
 UNUNITED FRACTURE OP THE FEMUR. 
 
 The large number of failures after operations for this condition are 
 well known. The difficulties which may be present during and after 
 these operations are very considerable ; amongst them sufficient ex- 
 posure of the fragments, and keeping the wound aseptic, are most 
 prominent. 
 
 Operation. — On the whole, the introduction of pegs having been 
 less successful, sub-periosteal resection of the fragments is indicated 
 here.* This is especially so in long-standing cases, where other 
 methods have failed, where there is very little attempt at repair, where 
 an artificial joint exists, or where, after a severe injury, necrosis, atrophy 
 of the fragments, and fibrous union have followed. 
 
 The operation of resection should always be performed with strict 
 aseptic precautions, otherwise the risks of suppuration, erysipelas, 
 osteo-myelitis, and pvfemia, owing to the very free incision required, 
 the exposure of cancellous tissue and, perhaps, of the medullary canal, 
 are considerable. 
 
 The limb having been rendered bloodless, if practicable, with 
 Esmarch's bandages, the fracture is exposed by a free incision, 5 to 6 
 inches long, on the outer side of, and going down to, the bone. The 
 periosteum is next most carefully detached from the ends of the frag- 
 ments, and a thin layer of bone, about a } inch in thickness, removed 
 from each. To facilitate the resection, the fragments may be thrust 
 out of the wound, or, after the removal of the periosteum, dragged out 
 and steadied with sequestrum-forceps before the saw is applied. The 
 soft parts must be protected with spatulas and retractors while the 
 ends of the bone are removed with a narrow-bladed saw. The frag- 
 ments are now brought into exact apposition, and to facilitate this it 
 may be necessary to divide adhesions or to remove any intervening 
 fibrous or fibro-cartilaginous material, or a sequestrum. The ends are 
 now to be drilled, the drill being entered on the superficial surface of 
 
 " Sir J. Lister has recorded {Brit. Med. Journ., August 26, 1871) the case of an 
 ununited extra-capsular fracture of the femur in a man aged forty-five, where, eighteen 
 months after tlie injury, lie cut down on the fragments, with antiseptic precautions, and 
 gouged them, the fracture being then finally put up. Recovery was complete, the man 
 walking well. 
 
AMPUTATION THROUGH THE KNEE JOINT. 891 
 
 each fragment, and then made to project in the centre of the medullary 
 canal. They are next held too-ether by passing very stout* silver wire 
 through the drill-holes and twisting this up. If the wire is to be removed 
 three or four half-twists or two complete twists shomld be sufTicient- 
 If the surgeon prefer he may hammer it down, (V,. siiu, ha-ving made 
 three half-twists and cut the ends short. See the remarks, p. 79. 
 Sutures are best dispensed with so as to allow of free drainaga The 
 after-treatment is that of a compound fracture. 
 
 CHAPTER III. 
 
 OPERATIONS INVOLVING THE KNEE-JOINT. 
 
 AMPUTATION THROUGH THE KNEE-JOINT. — EXCI- 
 SION OP THE KNEE-JOINT.— ARTHREOTOMY OF 
 THE KNEE-JOINT.— WIRING THE PATELLA. — RE- 
 MOVAL OF LOOSE CARTILAGES FROM THE KNEE- 
 JOINT. 
 
 AMPUTATION THROUGH THE KNEE-JOINT, 
 
 Chief Methods. 
 
 I. By Lateral Flaps. II. By Long Anterior and Short 
 Posterior Flaps. Of these the first is far the superior. The great 
 objection to the second is, that in order to get sufficient covering to 
 fall readily over the large condyles, a long anterior flap must be cut ; 
 as this must reach 2 inches below the tibial tubercle, a good deal of 
 its blood-supply comes from below— e.g., the recurrent tibial must be 
 cut off, and the flap is thus Hable to slough. This risk is much 
 diminished, and the blood-supply better equalized, by the method of 
 lateral flaps. 
 
 I. Amputation by Lateral Flaps.— This, the method of Dr. 
 Stephen Smith,t was brought before English surgeons by Mr. Bryant.t 
 The femoral being controlled, the limb supported over the edge of the 
 table, and slightly flexed, the surgeon standing on the right side of 
 either limb marks out two broad lateral flaps as follows: His left 
 index finger and thumb being placed, the former over the centre of 
 the head of the tibia, the latter at the corresponding point behind. 
 
 * About tV inch in thickness, so as to withstand the strain of the muscles of an 
 adult thigh. 
 
 t New York Journ. »/ Med., September, 18')2; Amer. Juurn. Med. Set., January, 
 
 1870. 
 I Med.-Chir. Trans., vol. Ixix. p. 163. 
 
892- 
 
 OPEKATIO-XS ON THE LOWKR EXTREMITY. 
 
 opposite the centre of the joint, he marks out (in the case of the right 
 limb) an inner flap by an inci&ion which, commencing close to the 
 thumb, is carried down along the back of the limb for about Si 
 inches, and then curves upwards- and forwards across the inner aspect 
 of the leg, till it ends in front ju-st below the index finger.* The knife 
 not being taken off, a similar ffap is then shaped from the outer 
 side, but in the reverse directioii.. Dr. S.. Smith calls attention to the 
 following points :. In. making these flaps, they should be ent broad 
 
 Fig.. 166. 
 
 Amputation through knee-joint by lateral flaps. (Bryant. >■ 
 
 enough to secure ample covering for the condyles, and the inner one 
 should be made additionally full as th« internal condyle is longer 
 than the external. The flaps should be at least 3? inches long, if of 
 equal length. They consist of skin and fascite. Wlien they have 
 been raised as far as- the lime of the articulation the ligamentum pa- 
 tellae is then severed, allowing the patella to- go upwards. The soft 
 parts around the joints are then cut through with a circular sweep, 
 and the leg removed. In doing this, the limb being flexed to relax 
 the parts aiud facilitate opening the joint,, the semilunar cartilages 
 will very likely be found closely encircling the condyles of the femur. 
 Mr. Bryant, in the paper already quoted,, and Dr.. Brinton,t as long 
 ago as 1872, have strongly advised that the semilunar cartilages 
 should be left in situ, by severing the coronary ligaments which tie 
 tliem to the tibia. They tlius, in Dr. Brinton's words, form " a cap, 
 fitted on the end of the femur, which preserves aU. the fascial rela- 
 
 * Dr. S. Smith begins. his incision about 1 inch below the tubercle of the tibia, and 
 carries it np rather higher beliind — viz.,. to the centre of the articnlation. It will be 
 found easier tiOopen tlie joint and todetacli the seniLLunar cai'Lilagss irota the tibia by 
 making the incision as recuniniendedi above.. 
 
 f. Pliiladi. Mnl. Times, December 28, 1872. 
 
EXCISION OF THE KNEE-JOINT. 893 
 
 tions, eventually prevents retraction, and guards against the projection 
 of the condyles." 
 
 Mr. Pick's* modification of the above operation is twofold— viz., 
 (1) He begins his incision higher up— i.e., at the upper border of the 
 patella; and (.2) he removes the patella. This last would appear 
 likely to run the risk of damaging the blood-supply. 
 
 II. By a Long Anterior and a Short Posterior Flap.- The 
 position of the patient and the surgeon being as at p. 891, the latter 
 with his left index and thumb on either side .of the intej-val between 
 the femur and tibia, enters his knife (in the case of the right limb) 
 just below the finger and internal condyle, carries it straight down 
 along the inner side of the leg till it .reaches a spot 2 inches below the 
 tibial tubercle,t then squarely across the leg till it reaches a corre- 
 sponding point well back upon the outer side, and thence up to a 
 point just below his thumb, or to the external condyle. This flap is 
 then dissected up, containing the patella, as thickly as possible, and 
 almost rectangular in shape, anything like pointing of its lower end 
 being most carefully avoided, as certain to lead to sloughing. 
 
 This flap being raised, a posterior flap is made abont two-thirds the 
 length of the first, as at p. 888, either by dissection from without 
 inwards, or by transfixion after ■disajticulation. 
 
 EXOISIONi OF THE KNEE-JOINT. 
 
 Indications. — A. For Disease. B. Injury. 
 
 A. (i.) Pulpy. Tubercular knee. 
 
 This condition being the most frequent indication for excision of 
 the knee, calls for most careful consideration of the following points : 
 
 (1) Safety and Amount of Risk. — Sir J. Lister's treatment, by re- 
 moving sepsis, has rendered excision of the knee absolutely safe in 
 properly selected cases. No surgeon who is familiar with careful 
 antiseptic treatment and excision of the knee will say that the above 
 is too strong a statement.§ Excision here contrasts very sharply 
 
 * Med Soc.Proc, vol. vil. 1884, p. 134. 
 
 f Mr. Pollock {Med.-C'hir. Trans., vol. liii. p. 20) advises that the anterior flap 
 should reach '' quite 5 indies below the patella," It is difficult to see how sloughing 
 can be avoided here, so much of the blood to this very long flap coming from below 
 and being of necessity cut ofl^. 
 
 % This operation is contrasted with arthrectomy of the knee at p. 909. 
 
 I I may perhaps say here that I have exci.'ied the knee fifty-seven times. Of these 
 three died of eflfects of the oiieration, one (mentioned below) from shock, another (also 
 mentioned below) from threatening gangrene, and another from surgical scarlet fever. 
 This child was moved, during my absence from town, into an empty, chilly ward; the 
 eruption became dusky and then suppressed ; coma, followed by death, ensued. Four 
 have been submitted to amputation, making good recoveries. This number would 
 
894 OPERATIONS ON THE LOWER EXTREMITY. 
 
 with the same operatioa at the hip, from the much greater facilities 
 for getting away all the disease at the time, and for getting at and 
 examining the wound later, together with the greater ease with which 
 the wound here is kept aseptic. 
 
 (2) Age.— Here the operation has to be considered— (a) as a substi- 
 tute for amputation;, {b) as a substitute for the expectant treatment. 
 While excision may be successfully employed at any age up to thirty, 
 and even occasionally in older* patients, I consider the most favora- 
 able years to. be from, about fifteen to twenty. Before fifteen, and 
 particularly before ten, we have especially to consider the effect of 
 the operation on the growth of the bone; after twenty we have more 
 and more to consider the condition of the patient, the state of the 
 viscera,, general vitality, etc. I would ask my reader's careful atten- 
 tion to these points— (1) that the chief growth of the femur takes 
 place at its lower end (p._858) ;. (2) that by fifteen, and still more by 
 seventeen, the growth of the bone is largely completed. It follows 
 from the above remarks that in young subjects especially before ten, 
 as little of the bones as possible should be removed,! that repeated 
 slices, rather than one small one,. should lie made, and that gouging 
 may largely replace the saw (p. 905). 
 
 (3) Rank of Life. — Excision of the knee being almost unknown in 
 private practice, it is needless to remark that this account of the 
 operation refers almost entirely to hospital patients. Let me briefly, 
 though imperfectly, depict the usual £ite of these patients with pulpy 
 knee if not excised early ^ Bandied about from one out-patient room to 
 another, treated more or less imperfectly with splints and strapping, 
 frequently recommended for admission that they may obtain that 
 '■ rest " which can nowhere else be carried out, at last " the dresser for 
 the week," or surgeon, takes pity on the case and it is admitted. 
 With what result? As soon as the inflammation has subsided and 
 the pain has ceased, the child is thought to be occupying a bed which 
 can be better employed for clinical teaching, and after a few weeks' 
 rest in bed,, is turned out again, perhaps in plaster-of-Paris or a 
 Thomas's splint. A little later, in the rough-and-tumble life of the 
 courts and alleys of our large towns, the joint is wrenched, and the good 
 gained is alL undone. Suppuration now sets in at one or more points 
 of the pulpy tissue, sinuses form, the ends of the bone become carious, 
 and the condition of the joint from the now advanced stage of the 
 disease, and its probably septic condition, is rendered far less favor- 
 probably liave been five, as a patient, aged fiftv-tliree-, wliose knee bad been excised 
 I'or disorganization after osteo-artbrjtis and wboni I had advised to submit to ampu- 
 tation, went out able to walk a little with a stick, but witli two sinuses. 
 
 * See the remarks on osteoarthritis. 
 t See the foot-note, p. 905. 
 
EXCISION OF THE KNEE. 895 
 
 able for any operation than it was at an earlier stage. Speaking 
 iDriefly, believing, as I do, that in this rank (if hfe excision will be 
 needed in nine cases out of ten, 1 am of opinion, most distinctly, 
 that, as soon as a pulpy condition is declared, excision or erasion (or 
 rather both, combined, p. 899) should be performed while the state 
 of the joint and the general cDudition of the patient are, alike, 
 favorable. 
 
 (4) Value of the Limh. — Tliis qufestio vexata of thirty years ago is 
 now largely settled. Very few will, nowadays, be found to dispute 
 which is most serviceable, a limb though much shortened with a, 
 natural foot, or an artificial leg, especially of the kind supplied to 
 hospital patients after amputation of the thigh. On this subject sornr 
 remarks of Mr. Holmes {Surf/. Dis. of Children, p. 497), may be quoted. 
 "Even if we allowed that a patient, after successful excision of the 
 knee, could only walk as fast and as far as some with a good artificial 
 limb after amputation, this would still leave the operation of excision, 
 in my mind, far the superior one, since the former patient can do by 
 his own force, without an}^ preparation and without any expense, 
 what the latter can only do by the aid of the instrument-maker. I 
 need hardly say, however, that this is a gross understating of the 
 case. A patient after excision of the knee can often walk nearly as 
 fast and nearly as far as he could before. The patient after amputa- 
 tion of the thigh, however well the case may have done, can rarely 
 bear the fatigue of carrying the artificial limb many miles together, 
 nor can there be any reasonable comijarison of the agility of the two 
 — at least in those cases where the foot, after excision, comes nearly 
 onto the ground, and is in good position." As to those cases where 
 the limb is flail-like, and its growth seriously arrested, I would point 
 out that they should hardly ever occur, with the improved treatment 
 of wounds, the greater facilities with which a stifl' apparatus of a 
 simple kind can nowadays be supplied, our more exact knowledge of 
 the epiphyses, and the substitutes for the saw which are to our hands 
 in the shape of sharp spoons (p. 898). I may also refer my readers 
 to Sir. W. Fergusson's Hunterian Lectures, Lecture VL, and his argu- 
 ments in favor of a much-sliortened limb over any artificial one. 
 
 (5) Condition of the Patient.— I may refer my readers to the remarks 
 on this point on excision of the hip, p. 859. There is the same need 
 here for examining for any evidence of lardaceous disease, or tuber- 
 cular mischief, elsewhere, and to remember how latent and insidious 
 these may be. Bone mischief elsewhere is not necessarily prohibi- 
 tive. Three out of my fifty-seven cases (p. 893) had had spinal dis- 
 ease, well-marked bosses remaining in all. Each of them made an 
 excellent recovery. Strumous disease of the tarsus existed in two 
 others, and was cured by the time the knee was well. In two, disease 
 
896 OPERATIONS ON THE LOM^ER EXTREMITY. 
 
 of the hip coexisted on the same side ; in one the limb had eventu- 
 ally to be removed by a Furneaux Jordan's amputation, the child re- 
 covering ; in the other (the disease being on the opposite side) the 
 knee after a trans-patellar exrdsion did excellently, the hip-disease 
 being cured by rest. 
 
 (6) Stage of the Disease.— I have already shown (p. 894) that I am 
 a strong advocate for early excision in hospital cases, believing that, 
 with the usual treatment, short of this, pulpy disease goes on, as a 
 rule, inveterately from bad to worse. But in early life excellent re- 
 sults may be obtained in advanced cases, with sinuses and caries, if 
 only all the diseased and septic material is got away. 
 
 (ii) Threatening disorganization of the knee, with caries, after pye- 
 mia, rheumatic fever, etc. 
 
 (iii) Osteo-arthritis. — Where one joint only is affected, and the 
 patient is not past middle life, excision gives good results. The sur- 
 geon must be prepared for sawing very dense bones. 
 
 (iv) Ankylosis. — I think excision should be abandoned here for the 
 far better operation of dividing, with aseptic precautions, the union, 
 with an osteotome introduced first on one side and then on the other, 
 and worked forwards under the patella, and skin, and backwards as 
 far as the popliteal artery- allows. If this fail, a double osteotomy of 
 the femur and tibia should be performed rather than excision, an 
 operation which, in the case of true bone ankylosis, is liable to be 
 severe, prolonged, and to leave a large wound, and, in the- case of 
 young subjects, to lead to further shortening of a limb already 
 atrophied and weakened from disease. As I shall not have space again 
 to refer to this matter of ankylosis of the knee, I would strongly urge 
 caution in rapidly and completely straightening a knee-joint which 
 has long been the seat of a bon}' ankylosis in a bad position. ]My 
 attention was draAvn to this matter in a painful way about five years 
 ago. A girl of nineteen had been admitted under my care with bony 
 ankylosis of the knee at a right angle, dating to disease seventeen years 
 before. Finding that I was unable to materially improve the position 
 by subcutaneously sawing through the bony union, I excised the joint 
 and straightened it completely. The foot and leg remaining cold, an 
 ansesthetic was given next day, and the limb put up flexed. The 
 mischief was, however, done. The coldness remained, all pulsation 
 in the tibials stopped, and gangrene evidently threatening, the thigh 
 was amputated, the patient sinking afterwards.* 
 
 '■ Just after this anotlier London surgeon published a very similar case. Suffi- 
 cient attention has not been drawn to this matter. It would have been much wiser on 
 ray part, with such dense and old-standing ankylosis, not to have attempted complete 
 straightening at once, but to have straightened partly with an osteotome at first, and 
 then to have completely rectified the position later. I have adopted this mode suc- 
 cessfully since, ou a much older patient, witli almost as much contraction. 
 
EXCISION OF THE KNEE. 897 
 
 Post-mortem, a layer of ostcoi)hytes was found on the posterior 
 border of tlie tibia projecting backwards, and it was evident that over 
 these, when the limb was straightened, the popliteal vein, a very 
 small one, had been stretched and closed. Another most serious risk 
 of at once straightening a contracted knee is tetanus, from stretching 
 of the contracted popliteal fascia and the popliteal nerves. 
 
 (v) Old, Neglected Infantile Paralysis.— Excision of the knee seems 
 to me to be perfectly justifiable here, with a view of giving a firm 
 support in the case of a limb useless from its flail-like, distorted 
 state. I speak here of hospital cases, which furnish those miserably 
 crippled lives which arc still seen from time to time going the rounds 
 of the hospitals. I have tried it in one case, whore the result is good, 
 the knee having healed with one dressing, but the child is still 
 under treatment for the paralytic talipes of the ankle, and paralysis 
 of one upper extremity. I followed in this my old friend G. A. 
 Wright, of Manchester, who in the abstract of cases treated in the 
 Pendlebury Hospital, 1S84, records* the result of a case — a girl, aged 
 fourteen — in which he had successfully excised the knee and ankle in 
 such a case. 
 
 B. In.tury. — Here such injuries as those from gunshot and those 
 fi'om a lacerated wound or a compound fracture, must be considered 
 separately. 
 
 1. Gunshot. — "The results of the excisions of the knee-joint, per- 
 formed during the late civil war, whether the operations were primary, 
 intermediary, or secondarj^, were not very encouraging, forty-four of the 
 fifty-four cases in which the issues were ascertained having terminated 
 fatally, a mortality of SI. 4 per cent, exceeding the mortality of the am- 
 putations of the thigh (53.8) by 27.6 per cent." (Otis).t Sir T. Long- 
 raorej lays down these definite rules : " From all the experience which 
 has been gained regarding gunshot wounds in which the knee-joint has 
 been opened, especially if the surfaces of the bone have escaped damage, 
 as may occasionally happen with modern narrow rifle-bullets, and even 
 in other cases where one of the bones has been fissured, or partial fract- 
 
 * The knee excised in 1883 was, a year and a half later, sound, straight, and well. 
 The ankle, remaining very weak, was excised, December, 1884, by a transverse inci- 
 sion. The bones were soft and fatty, and could be cut with a knife. The tibia and 
 astragalus were joined with stout silver wire, the ends being twisted and knocked down ; 
 the tendons were sutured wilh catgut. The wound was healed in less than a month. 
 Measurement on January 12, 1885, showed 2{ inches shortening as the result of the 
 two excisions; the ankle excision did not appear to have percpjitibly shortened the 
 limb, while there is 1} inch less shortening than before the excision of the knee. No 
 doubt the limb had grown with the increased power and use in it. February, 188.5 : 
 The child could now walk across the room upon the leg. 
 
 f Loc. svpra cit., p. 419. 
 
 + Syst. of Surg., vol. i- p. 565. 
 
 57 
 
898 OPERATIONS ON THE LOWER EXTREMITY. 
 
 ure has occurred, provided early immobilization of the injured parts 
 can be secured, antiseptic treatment carried out, and the general sur- 
 roundings are sufficiently hygienic, it may now be laid down as a 
 rule that conservative treatment ought to be adopted. When, however, 
 the circumstances under which the wounds have been inflicted are 
 such that the precautionary measures and modes of treatment men- 
 tioned cannot be put into practice, when the patients are liable to be 
 moved frequently or to long distances hurriedly and without adequate 
 protection, or when the joint is not only penetrated, but the surround- 
 ing coverings are much lacerated, or the bones are comminuted and 
 the fragments completely detached, the sacrifice of the limb by am- 
 putation above the joint is the only measure calculated to afford a fair 
 promise of safety of life to the patient." 
 
 2. Injuries other than Gunshot.— Excision is rarely practicable here. 
 A very careful consideration of the local and general conditions 
 present is needful. Amongst the former, damage limited to the artic- 
 ular surfaces, but little splintering of the shafts of the bones, an intact 
 condition of the soft parts behind the joint are absolutely essential. 
 No less important is it to weigh the more general points connected 
 with the patient— viz., his age not reckoned by years only, the condi- 
 tion of his viscera, and his habits ; all these points are attended to in 
 the account of "The Treatment of Compound Fractures," given 
 later on. 
 
 Operation.* — The more I perform this operation, the more do I 
 feel the truth of the words of Prof. Bruns, of Tubingen, that, while 
 formerly its chief object was to remove all dead bone, it should now 
 be considered of chief importance to remove all the granulation- 
 material that can possibly be got away, and that the surgeon should 
 not content himself with snipping away all he can, leaving the rest 
 to caseate or become scar-tissue if it will, but pursue it with the same 
 earnest aim of extermination as he would in the case of malignant 
 disease. I would not by the above seem to speak slightingly of the 
 value of securing healthy and correctly sawn surfaces of bone, as 
 on these largely depends firm ankylosis and a sound and useful 
 limb, but I would insist on the fact that such surfaces are secured in 
 vain if pulpy material is allowed to remain, and that it is not as yet 
 sufficiently recognized that other instruments — e.g., sharp spoons and 
 scissors curved on the flat — are, to the full, as useful as the saw. 
 
 Before the time of the excision, any flexion of the knee should be 
 corrected as far as possible by careful weight extension. A knee 
 should never be excised while flexed. Such a step will not only be 
 
 * Kefore and tlirongliout an excision of the knee the operator shonld bear in mind 
 the foUowing points: (1) To remove every atom of the disease; (2) to secure good 
 drainage; (3) to'leave the bones in good position; (4) to ensure absobite immobility 
 afterwards; (5) to watch for and at once attack any relapse. 
 
EXCISION OF THE KNEE. 899 
 
 liable to lead to removing bone needlessly in order to straighten it, 
 but stretching the contracted deep fascia and nerves may lead to 
 tetanus (p. 896). The risk of gangrene has also been already men- 
 tioned (p. 896). 
 
 The parts being duly cleansed, and an Esmarch's bandage* applied 
 &i mid-thigh, the limbf is brought over the edge of the table, flexed, 
 and held by an assistant as in Fig. 169. 
 
 From the moment of commencing the operation to its very close 
 the surgeon mu.st bear in mind the inveteracy of tubercular pulpy 
 material (malignancy would prol>ably not be too strong a word), and 
 in his endeavors to extirpate the disease completely, both in the soft 
 parts and in the bones, his operation must combine the operations of 
 erasion and excision. J 
 
 The following modes of exposing the joint will be given here : 
 
 A. Transverse, Removing the Patella, 
 
 B. Transverse, through the Patella. 
 
 C. The Semi-lunar Flap (lately recommended by Mr. Barker, 
 and attributed by him to Moreau). 
 
 A. Transverse, Removing the Patella (Fig. 167).— This, the 
 older method, is still resorted to by those surgeons who, like Mr. 
 Howse, believe that, if the patella is retained a most serious risk is 
 run of leaving behind pulpy material which will require removal 
 later on under less favorable circumstances, and, this failing, may 
 lead to amputation. 
 
 The surgeon, standing on the left§ side of the diseased knee (the 
 opposite limb being tied to the table), makes an incision right across 
 the joint from the back of one condyle to that of the other.|| This 
 
 * Some object to the bandage as needless and as likely to lead to troublesome ooz- 
 ing after the operation. This may be met by firm pressure and even bandaging on 
 of the dressings, so as to distribute any oozing evenly throughout them. If an 
 Esmarch's bandage is not applied, the bleeding during the operation interferes with tlie 
 removal of diseased tissues, requires constant pressure to arrest it, and taxes the 
 j)atient's resources considerably. Its use meets another risk, which is possibly hypo- 
 thetical, and that is, it renders impossible the general diffusion of tubercular material 
 by the cut veins and lymphatics. Two Esmarch's bandages must not be applied if 
 there is any risk of rupturing a pulpy capsule, or where the capsule has given way 
 and septic sinuses exist. 
 
 t Before the operation the area of incision should be thoroughly cleansed ; the foot 
 and lower leg should be well wrapped up in cotton wool, a heel-stirrup being applied 
 if there is likely to be a sore heel. 
 
 X If operations for pulpy knee are resorted to at an earlier stage in hospital patients 
 the bones will less and less need interfering with. 
 
 ? This position renders it much easier for him to saw the femur and tibia. 
 
 II Beyond this spot the incision should not go, for fear of wounding the internal 
 saphena vein. This would lead to troublesome oedema of the foot and leg, and, if the 
 wound should become septic, might bring about septic phlebitis and pysemia. 
 
900 
 
 OPERATIONS ON THE I.OWEE EXTREMITY. 
 
 incision passes over the lower part of the patella and divides the 
 lateral ligaments at once. The soft parts being then dissected up for 
 2 inches above the patella, so as to expose the supra-patellar pouch, 
 deep incisions are made above and below the patella, which is then 
 removed and the joint opened* 
 
 If the patella is ankylosed to the condyles, it must be removed by. 
 a blunt elevator, aided by a narrow saw, or, better, by an osteotome 
 and mallet. No violence should be used in opening a joint partially 
 ankylosed, for the epiphyses may easily be separated from the shaft, 
 especially in a child. 
 
 B. Transverse, through the Patella (Fig. 168).— This method, 
 by preserving the patella and the insertion of the quadriceps, coun- 
 
 FiG. 167 
 
 Fig. 168. 
 
 Trans-patellar excision. 
 
 terbalances the flexing action of the hamstringsf at the same time. 
 It was brought before the notice of English surgeons by Mr. Golding 
 Bird in a case which he brought before the Clinical Society (Clin. Soc. 
 
 * I invariably, when raising tlie Hap of soft parts in an excision of the Icnee, how- 
 ever perfurintd, slit tliem np bv ii ve''tical incision, going to the npper limit of the 
 snpra-patellar ponch, so as to expose fnlly all its folds and recesses. Unless tliis is 
 done, pulpy material is very easily left behind, and, later on, breaking down, leads to 
 redema, persistent sinuses, giving way of the pouch and escape of pulpy snppnration 
 amongst the adductors and into the vicinity of the femoral, and jierforating vessels, 
 where it is impossible to eradicate it, amputation being eventually called for. 
 
 t F. 908. 
 
EXCISION OP THE KNEE. 901 
 
 Trans., vol. xiv. p. 82). In the nine cases in which I have employed 
 it, it has given excellent results, though I have not sought to ohtain 
 the movable joint which Mr. Golding Bird hopes may follow on this 
 method. 
 
 The transverse incision is made here much as in the first method, 
 only across the middle of the patella ; this is sawn through or divided 
 with a stout knife, the fragments turned up and down,* and the joint 
 freely opened (Fig. 168). To facilitate thorough cleaning out of the 
 supra-patellar pouch, I always slit this up, as in the first case, by a 
 vertical incision. 
 
 C. Semi-lunar Flap (Moreau, Barker).— Here a large U-shaped 
 flap is raised by a semi-lunar incision,t starting above one condyle, 
 descending to the level of the tibial tubercle, crossing the leg here 
 and running up to a corresponding point on the other side. In rais- 
 ing this flap, which includes all the soft parts down to the bone, either 
 the ligamentum patelLc should be severed (suturing of this being re- 
 sorted to later), or the tuberosity, attached to the ligament, is removed 
 with a chisel, and subsequently wired down (Barker). 
 
 The joint being opened by one of the above incisions, the surgeon 
 begins by snipping away, with blunt-pointed scissors, aided by mouse- 
 tooth forceps, every atom of pulpy tissue around the patella and liga- 
 mentum patelhe, going as close to the bone as possible, removing com- 
 pletely the altered ligamentum mucosum and alaria. Then the supra- 
 patellar pouch is in every case slit up:|: with a sharp bistoury to its upper 
 limits (readily reached by a finger) so as to lay bare every crevice and 
 remove every atom of altered tissue. The vasti fibres will now be bared, 
 and while working downwards on the inner side the proximity of the 
 femoral vessels must be remembered. In order to deal as systematically 
 as possible with the diseased synovial tissue, the lateral and crucial 
 ligaiBcnts are next examined, and every particle of diseased tissue 
 removed, onty bright, glistening, clearly healthy ligamentous tissue 
 being left.§ But as naked-eye examination in ijarts perhaps not 
 absolutely bloodless may easily be fallacious, it is much better in 
 doubtful cases to remove these completely than to run any risk what- 
 ever. The assistant who is in charge of the limb now brings the 
 
 * They may be held out of the way by a sharp hook, or by the aseptic finger of 
 an assistant. 
 
 t The incision should begin sufficiently high up to open freely the supra-patellar 
 pouch. 
 
 t I look on this as one of the most cardinal points of the operation. 
 
 ? Prof. Oilier (loc.infra cit., and Bev. de C'hir., 1882) drew attention to preserving the 
 lateral ligament.^, if possible, together with all healthy periosteum and cupsule— i.e., 
 those tissues which will keep the bones in place and which will tend to produce ossify- 
 ing material. This will not interfere, if carefully carried out, with extirpating dis- 
 eased parts, while it will go far to prevent progressive flexion of the joint. 
 
902 
 
 OPEEATIONS ON THE LOWER EXTREMITY. 
 
 head of the tibia well into view by pulling the calf of the leg well 
 forward with one hand while he further dislocates the bone by push- 
 ing up the leg (Fig. 169). 
 
 Fig. 169. 
 
 The condition of the semilunar cartilages is next examined, and if 
 they are much invaded by pulpy tissue, or if it is intended to perform 
 a complete excision, they must be cut away completely. 
 
 The back of the joint is next taken in hand. This region can be far 
 more effectually dealt with after removal of the ends of the bones. If, 
 owing to the case being an early one, with little or no caries, the sur- 
 geon decides to remain content with an erasion, he must still deal 
 
EXCISION OF THE KNEE. 
 
 903 
 
 thoroughly with the posterior ligamentf= and deeper parts of the sides 
 of the joint, with all recesses and folds of the synovial membrane To 
 expose these parts thoroughly is a matter of some difficulty The 
 assistant should manipulate the limb as above directed at one time, 
 at another flex the leg back towards the table, while occasionally a 
 hnger m the popliteal space will keep within reach some altered tissue 
 that It IS desired to deal with. Every pains must be taken to use the 
 scissors systematically and thoroughly here as elsewhere, until healthy 
 tissues are reached, and not to dread the pophteal artery too much. 
 These points should be enforced for two reasons. If any diseased 
 tissues are left here they will be shut in, after the Umb is extended, 
 and found impossible to deal with, save by a fresh and probably un- 
 successful operation. Again, there is always a risk, especially in a 
 surgeon's earlier operations, of his not deahng with disease here with 
 sufficient thoroughness from dread of injuring the popliteal artery. 
 This vessel may be avoided by (1) not dipping the points of the 
 scissors deeply, but using the blades as far as possible parallel with 
 the course of the vessel; (2) by remembering that even after the 
 posterior crucial ligament has been entirely snipped away (a matter 
 often imperfectly done) there is still a considerable thickness of struct 
 ures in front of the artery. (3) In a case where it is necessary to go 
 very deeply to remove all doubtful patches, the Esmarch should be 
 slackened and the pulsation felt for. But this is most rarely needed. 
 After all the diseased tissues at the back have been thoroughly 
 eradicated, the deeper aspects of the sides of the joint must be exam- 
 ined. In one case I was unable to satisfy myself that the limits of the 
 diseased tissues were reached till the tendons of the semi-tendinosus 
 and semi-membranosus came into view ; and in another, that of the 
 sartorius, caseating foci having spread down beneath the skin on the 
 inner side of the joint. If an erasion is thought sufficient, the surgeon, 
 having gone over the synovial membrane systematically and in detail, 
 now attends to the bones. With a stout, sharp scalpel he scrapes or 
 pares off from the cartilaginous surfaces of femur and tibia any adhe- 
 rent pulpy material, removing thin shavings of the cartilage where 
 needful. This must be carried out to the very back of the condyles 
 and throughout the inter-condyloid notch, and around the posterior 
 aspect of the head of the tibia, if diseased. 
 
 It now remains to describe the removal of the bones in case erasion 
 is not sufficient. Thus, excision will in future be probably called for 
 only in cases of long standing, where caries is present, and in those 
 with sinuses and suppuration. Where excision is evidently needed, 
 the bones should be sawn after the supra-patellar pouch is cleared 
 
 * This and the posterior parts of the semilunar fibro-cartilages are liable to be 
 ineflSciently treated. 
 
904 
 
 OPERATIONS ON THE LOWER EXTREMITY. 
 
 out, and before the posterior aspect of the joint is taken in hand, as 
 this step Avill be much facilitated thereby. 
 
 The femur, held as steady as possible, is taken first. A groove for 
 the saw is first so marked out with the scalpel as to remove about 
 one-third of the condyles. In severer cases or where the above section 
 
 Fig. 170. 
 
 Fig. 171. 
 
 will clearly be insufficient, half, or even two-thirds, of the articular 
 surface may be removed, but no section should be made further back 
 than this, or the epiphj'sis will be trenched upon with serious after- 
 results.* The section of the femur should be made from above down- 
 wards, and slightljr from behind forwards so as to be parallel with the 
 articular cartilage and at right angles with the shaft. 
 
 The tibia is taken next and a groove marked out with the knife 
 about i inch below the articular cartilage. A Butcher's saw, set hori- 
 zontally, is used from behind forwards, and on a perfectly level plane. 
 Neither here nor in sawing the femur must the slightest wobbling of 
 the saw be permitted. 
 
 About i inch only of the tibia should be removed, just enough in 
 
 * Dr. Hoffa, of Wnrzbiirg (Arch. f. Klin.Ukir., Bd. xxxii. Heft iv. 1885; Aunals of 
 Surgery, March, 18S6), brings forward cases to show that removal of both epiphyses 
 led, at the end of ten years, to shortening, amounting to 23.} cm. (1 cm. = -^ inch), 
 while in another case it amoimted in two years to 10 cm. Loss of the femoral epi- 
 physis alone showed 17 cm. of shortening in six years, and 7 cm. in a year and a half. 
 Two cases of the like duration affecting the tibial line showed respectively 1.5} and 6 
 cm. It is, however, well known that considerable shortening may occur in cases treated 
 expectantly. Dr. Hoffa found in one case that at the end of twelve years the shorten- 
 ing amounted to 18 cm. with ankylosis at an angle; in nine other such cases, ranging 
 in duration from one to eight ye;us, the shortening varied from 1 to ISJ cm., with 
 angular contraction in most cases, and with atrophy and trophic disturbances very 
 marked. 
 
EXCISION OF THE KNEE. 905 
 
 fact to expose healthy cancellous tissue and no more. Of the femur 
 no more than li inches should be removed if possible.* Any soft 
 yellow, cheesy, fatty patches, any cancellous tissue into which pulpy 
 tissue has dipped after perforating the cartilage, should be carefully 
 removed with a gouge. Where, however, there is much caries or the 
 above patches are numerous, breaking down readily under the finger- 
 nail, more than one slice of bone had better be removed. 
 
 The whole wound is now finally most carefully scrutinized, every 
 outlying angle and recess lieing examined for pul])y tissue left behind. 
 
 The Esmarch's bandage is now removed, and while lint wrung out 
 of 1 in 20 carbolic acid is held firmly over the sawn tibia, any bleed- 
 ing points in the upper half of the wound are attended to. The safest 
 way of arresting the bleeding is by underrunning with chromic gut 
 and fine needles all the vessels which spirt, as practiced by Mr. Howse. 
 Pressure will suffice for oozing. Bleeding from the cancellous tissue 
 will be arrested by placing the bones in contact.f 
 
 The patella, if sawn, is now drilled and wired, or united with stout 
 silk or chroniic gut. I prefer the first, the wire being left long and 
 removed in about a fortnight. 
 
 The question now arises whether the tibia and femur should be 
 united by wiring or pegging.^ I am of opinion that if the bones have 
 been so sawn as to bring their faces squarely together, with sufficiently 
 exact closeness to prevent more tlian a finger-nail being inserted be- 
 tween them, and if they are put up with the security whicli is given 
 by Mr. Howse's method, the above aids are not needed. § Failure of 
 excision is due not to deficiency of repair in the bones, but, as a rule, 
 to persistencj' of pulpy, tubercular material. 
 
 Mr. Barker (Hunt. Lect., supra cit.) does not remove the Esmarch 
 
 * Very much larger amounts may be removed if needful, especially in children and 
 young adults, with good reparative power. If the surgeon is obliged to trench upon 
 the epiphysis it should be with the gouge, and not with the saw, if possible. In one 
 case of a boy, aged seven, the bones being carious, soft, and fatty, a large patch of 
 cheesy, fatty bone presented Itself in the head of the tibia after the firstslice had been 
 removed. On removing this, the gouge entered the medullary canal, which was ex- 
 posed, gaping on the sawn surface. I was doubtful how far union would take place 
 here, but three years later the boy had a most useful limb, probably from a ring of 
 epiphysial tissue being left. 
 
 t The following vessels will be found to give the chief trouble after a combined 
 erasion and excision ; One or two running down in the periosteum over the femur, 
 one or two in the cut periosteum surrounding the sawn margin of the tibia, and one 
 from the azj'gos-articiilar in the posterior ligament. 
 
 X The bones have been united with different forms of pegs or nails, or by wire, stout 
 carbolized silk, or chromic gut. 
 
 J I may be speaking with insufficient knowledge, but I am under a strong impression 
 that the advocates of these aids have not made trial of the absolute fixity ensured by a 
 well-applied Howse's splint (vide infra). 
 
906 OPERATIONS ON THE LOWER EXTREMITY. 
 
 till the wound is dressed and bandaged. Any vessels that can be seen 
 are secured before the wound is closed, but the chief means of meet- 
 ing bleeding are by firm, even bandaging over antiseptic dressings, 
 and by keeping the limb in an almost perpendicular position for the 
 first few days. It is not stated how this is done, nor whether this 
 position is followed by troublesome oozing reaching to the end of the 
 splint. Having seen in one case almost fatal hfemorrhage follow on 
 excision of the knee put up carefully in the box splint of seventeen 
 years ago— the blood running through the bed on to the floor— I much 
 prefer to follow Mr. Howse's method of underrunning the chief 
 bleeding-points. 
 
 The amount of drainage needed will vary. I usually, even in the 
 least severe cases, insert one drainage-tube projecting above from the 
 remains of the supra-patellar pouch, and below (by a counter-puncture) 
 low down on the outer aspect of the popliteal space. Where there has 
 been much pulpy mischief to clear out, or much oozing, the above 
 should never be dispensed with, and another tube should be similarly 
 placed on the inner side. Two or three sutures may be made use of 
 in the middle of the incision, the sides being always left open. Before 
 closing the wound I dust a little iodoform, finely powdered, over the 
 different surfaces, and dry these scrupulously, when the sutures are 
 in place. Mr. Howse's splint is now applied. To those who are not 
 familiar with the most excellent method devised by my colleague, the 
 following brief account* may not be unwelcome. The arrangement 
 will be found most simple, and equally efficient in admitting of anti- 
 septic dressing and maintaining the parts in absolute rest. The splint 
 consists of two interrupted tinned-iron troughs for the thigh and leg 
 joined by a posterior bar. This is from 4 to 6 inches long, according 
 to the age of the patient; it is convex from side to side to avoid cut- 
 ting into the popliteal space, and can be lengthened or shortened if 
 any alterations in the interruption are required. At the end of the 
 splint is an adjustable foot piece. 
 
 The limb being laid in the splint, attention must be paid to the 
 posterior bar being in the centre of the popliteal space, the foot must 
 be well down on the foot-piece ; if the splint grips the thigh or leg 
 too tightly or rides too loosely, it must be bent out or in with iron 
 " crows." The dressings are now applied, preferable, I think, those 
 of dry sal alembroth or iodoform gauze. Great care must be taken 
 to bandaging from below upwards and from within outwards, the 
 bandage being laid on evenly and firmly so as to distribute the dis- 
 charges, evenly, right through the dressings, and to prevent their 
 coming through at one or two spots. The splint is next secured to 
 
 * Ouy's Hosp. Reports, 1877, vol. xxii. p. 503, and the accompanying plate. 
 
EXCISION OF THE KNEE. 907 
 
 the limb with " waxed bandages," prepared by passing them through 
 a mixture of ordinary yellow wax and ohve oil, in proportions suffi- 
 cient to make the wax soft and workable. After they are applied 
 to the leg and thigh they are painted over with a little hot wax 
 mixture, so as to make them weld into one mass* The limb, thus 
 secured, is slung with cord and pulley to a Howse's cradle. This 
 occupies the lower part of the bed- the patient lies on a half 
 water-bed. 
 
 The chief points here are (1) to ensure as absolute immobility as 
 possible; (2) to employ as infrequentf dressings as practicable; (3) 
 to watch for every sign of relapse, and to attack it as soon as noticed.;!: 
 
 After-treatment. — Morphia or laudanum should be used freely 
 at first, if needful. If the temperature keep down, the dressings 
 should be left undisturbed for two weeks, when an anaesthetic should 
 be given to remove the wire if the excision has been a trans-patellar 
 one, take out any drainage tubes, and also to make sure that there 
 are no persistent sinuses pointing to residual pulpy material. These, 
 
 * The splint is usually lined with lint wrui^ o it of the ab:)ye mixture. But the 
 popliteal bar and any of the splint close to the wound must be metal only, uncovered, 
 to favor asepsis. If any spaces are found to exist between the limb and the splint they 
 may be filled in with cotton-wool, soaked in some of tlie hot wax mixture. 
 
 t Infrequency of dres-iing-s has been strongly insisted on by Prof. Oilier (Rev. de 
 Chir, August, 1887; Annals o/Swrgcr!/, November, 1887, p. 424). This most important 
 economy — of pain to the patient, and time to the surgeon — is only to be secured by — 
 (1) Removing ev«ry atom of the disease that ean be got at. (2) Providing drainage. 
 The more thoroughly the disease is extirpated, the less need is there to drain; but 
 however completely the disease is removed, many sutures should not be employed, 
 especially at the endsof the wound. (3) Usingdry dressings. Of these sal alembroth 
 or iodoform gauze (either being used with iodoform) is the best, the first being the one 
 I prefer, from its efficiency, its softness, its cheapness, and the fact that the parts not 
 discolored by the discharges can be used again. Excellent pioneering work as car- 
 bolic oil gauiedid.it had the great disadvantage of being moist. Unless most carefully 
 wrung out— a thing difficult to secure in a surgical ward, where a large number of 
 dressings have to be provided together— within twenty-four hours, it was difficulty to 
 say how much of the discharge was oily and how much serous; the surgeon knowing 
 that he should not have a chance of seeing the case— perhaps an imporlant one-for 
 another twenty-four hours, had the dressings changed, very often, I think, needlessly. 
 Of course, in many eases this infrequency of dressings is impossible to secure- e.jf., 
 where all the disease cannot have been removed at the first operation, and the tem- 
 perature keeps up, probably accompanied with pain; {2) where sinuses have been 
 present, and the joint is probably septic. In such cases if needful, the dressings must 
 be changed dailv, to enable the surgeon at onee to decide a.s to the need of again 
 attacking any relapse (vide infra). Infrequency of dressings will not interfere with 
 the use of drainage-tubes. 
 
 X It is especially, I think, to neglect of this last detail, that the fact arises that 
 almost as many cases are lost from mistakes in the after-treatment as from want of 
 skill in the operation. 
 
908 OPEEATIOSS ON THE LOWER EXTREMITY. 
 
 if found, must be slit up with a sharp-pointed curved bistoury, and 
 scraped out with a sharp spoon. While this may be repeated every 
 ten days, on five or six occasions successfully, the more deliberately 
 the surgeon endeavors to extirpate the disease, both in the soft parts 
 and in the bones, the more he treats it as if malignant at first, the 
 less, often will he have to interfere with the rest of the parts after- 
 wards. 
 
 In about three months Mr. Howse's splint may be left off and a 
 leather splint fitted on, carrying a metal bar to resist the tendency to 
 flexion. Some such fixed apparatus should be worn, in children, for 
 three or more yeare.* 
 
 Causes of Failure and Death after Excision of the Knee. 
 
 1. Inveterate persistence of pulpy materiiil leading to (a) giving way 
 of the supra-patellar pouch, and the results mentioned at p. 900; (,S) 
 to formation of caseating foci, especially at the back of the joint 
 (p. 902), and only to be removed by re-excision or ami)utatiou. 
 
 ± An unhealthy condition of the bone-ends, with caries and chronic 
 osteo-myelitis. 
 
 3. Deficient reparative power, leading to bed sores, emaciation, irri- 
 tative fever, hectic. 
 
 4. Coexistence or subsequent development of such visceral diseases 
 as phthisis, etc. 
 
 5. Surgical scarlet fever. 
 
 6. Septic Conditions. — For these the surgeon will, nowadays, be, as 
 a rule, entirely to blame. 
 
 7. Tetanus (p. 897). 
 
 8. Secondary Hajmorrhage. — Another very rare condition (p. 906). 
 
 9. Fat Embolism. — This is a still rarer condition, but one which, on 
 account of the interest it excited some years ago, and because it has 
 once, at least, proved fatal, deserves mention here. The case was that 
 of a child, aged twelve, submitted to excision for pulpy disease by 
 Vogt, of G-riefswald.t The bones were so fatty as to cut with a knife. 
 Though but little chloroform had been given, and the loss of blood 
 
 * In early life callus-liUe material is tlirown out quickly, and often somevvhat irreg- 
 ularly, between tlie bont-s, but it is extremely slow in really ossifying. As the 
 quadriceps extensor wastes mncli more quickly than the hamstrings, even when the 
 patella is retained, the latter muscles keep np their action on the tibia for months, and 
 even for years, ontil the union is firm. Tenotomy has been advised, and even resection 
 of all the hamstring tend()ns(I>r. Phelps, NewYwk 3Ied. Reeoril, July 21, 1886 : Annals 
 of Surgerji, Ocln\ier, 1886, p. 3(jl). I think, however, that retaining the bones immo- 
 bile and in good position, securing eiu-ly healing of the wound, wearing a stiff appa- 
 ratus, and, wherever practicable, using the transpalellar method, will best ensure a 
 limb soundly ankylo«ed in good [jositlon. 
 
 t Cent. f. Cliir., 18S;5, p. 2t. 
 
EXCISION OP THE KNEE. QO^ 
 
 had been slight, the patient died twenty-four hours later with shallow 
 respirations, feeble pulse, and low temperature. Fat embolism of the 
 lungs, extensively diffused, was found post mortem, 
 
 Vogt considered that this case predisposed to fat-embolism. Thus 
 cut vessels were exposed on the sawn surfaces with plenty of free oily 
 matter close by, and unable to escape, owing to the bone-ends being 
 in close contact (two wire sutures were used). A similar case, after 
 resection of the hip, by Prof. Liicke, is mentioned. Prof. Vogt thought 
 that he would amputate in another case if, after excision of the knee, 
 the limb could not be straightened without close apposition of the 
 sawn fatty bone-ends. 
 
 10. Shock. — This, though very rare, must be borne in mind. Eleven 
 years ago I lost a case from this cause. The patient was a delicate 
 boy, aged seven, with a large pulpy knee. As there was no suppura- 
 tion, no sinuses,nor evidence of much mischief in the bones, I, unwisely 
 as it proved, tried to save the limb. The child sank a few hours after- 
 wards. Volkmann (Ccntr.f. CMr., Bd. xii. Heft 9, Feb. 28, 1885; Ann. 
 of Surg., May, 1885, p. 486) draws attention to the need of taking care 
 in children that too much blood is not lost, and that deep narcosis is 
 not too prolonged. 
 
 Erasion of the Knee compared with Excision.— I must 
 confess to looking upon erasion alone with much suspicion. Excision 
 combined with erasion gives such good results that I have been dis- 
 inclined to substitute any operation for it, and thus have only per- 
 formed erasion alone on two occasions ; one of these was most entirely 
 successful, the other required excision, and the child did well a;fter- 
 wards. 
 
 The advantages claimed for erasion over excision are mainly two. 
 (1) That there is no removal of bone and, still less, any risk of inter- 
 ference with the epiphyses. (2) That the joint may retain mobility. 
 
 (1) This is certainly correct. In one of my cases the child not only 
 had no shortening, but repeated careful measurements showed that 
 the limb on which erasion of the knee had been performed was actu- 
 ally i inch longer than its fellow. But though absence of shortenmg 
 may be often secured, I think that this, like other advantages, maybe 
 secured at too great a risk. Erasion alone will need to be done with 
 exceeding care if pulpy disease is not to be left behind. It may be 
 asked how removal of the bone-ends facilitates removal of the pulpy 
 material, if care has been taken to open the joint thoroughly m the 
 course of the erasion. I would reply that it does so m two ways, and 
 in two very cardinal places. Firstly, the removal of a slice of the femur 
 makes it very much easier to get at the posterior crucial and the pos- 
 terior ligaments, and any pulpy tissue in the intercondylmd notch. 
 In the second place, after removing the articular surface of the tibia. 
 
910 OPERATIONS ON THE LOWER EXTREMITY. 
 
 the condition of the posterior part of the semilunar cartilages can be 
 much more thoroughly investigated. 
 
 (2) With regard to the retention of mobility I have not the shadow 
 of a doubt that a large number of erasions will show that movement 
 is often accompanied by a degree of permanent flexion. I should 
 strongly dissuade from any attempt to secure mobility in the case of 
 the knee and ankle. 
 
 I trust that the account of the operation of combined erasion and 
 excision will be fo^und to contain sufficient information to help those 
 who wish to make trial of erasion only. Those interested in the sub- 
 ject should refer to the papers in which my old friend G. A. Wright, 
 of Manchester,. brought this subject before the profession.* Two points 
 require a word from me. It will be seen that he advises that the cru- 
 cial ligaments be scraped but carefully preserved. I doubt the wisdom 
 of this in any case, especially those where erasion has been attempted 
 in cases of pulpy disease at all advanced. The other is the statement 
 that erasion, if it fails, leaves the limb, little, if at all, in worse condi- 
 tion for excision afterwards. This may be misleading if not carefully 
 read. It is true of the limb but not of the joint. In the case of mine 
 which required excision, I found that the previous erasion had entireh' 
 obliterated the usual landmarks, and that much difficulty was experi- 
 enced and much care needed in dealing with such parts as the remains 
 of the posterior ligament, 
 
 * Lancet, 1881^ vol. ii. p 99!2r Med. Ou-on^-Tnly, 18i).>. See also a paper by Mr. 
 Shield {Ann. of Sury , Feb., 1888). Tlie foljowinj; are Mr. Wright's conclusions: "In 
 those that have done well the common factors appear to be : (1) absence or verv small 
 amount of suppuration ; (2j superficial or,, at least, not widespread bone di.sease; (3) 
 absence of general tubeiculos-is. In short, fairly early disease in a not hopelessly 
 tuberculous child. This pretty well corresponds to the cases generally considered 
 suitable for excision. 1 have not yet tried the operation in adnlts. Jt is clear that 
 extensive disease of bone and much suppuration will not allow good results to be ob- 
 tained by erasion ; neither, as a general rule, will they by excision, though I am quite 
 sure that the knee may be successfully excised in cases where erasion is out of the 
 question, as shown by excision succeeding where erasion has failed. Although in one 
 case a freely movable joint resulted, I do not advise the attempt to obtain mobility by 
 early passive movement, except in a few instances where the wound has healed at once, 
 and there is no obstacle in the way such as dense and lowly vitalized cicatricial tissue. 
 Erasion, if it fails, leaves the limb little, if at all, in worse condition for excision 
 afterwards. In those cases where amputation became necessary, either the local or 
 constitutional condition forbade hope of successful excision Where it sncceed.s, erasion 
 leaves as sound a limb as excision, without shortening. In some cases there may be 
 mobility, though I think in most it will be found that there is not enough mobility to 
 be useful; here the limb is very liable to become flexed after healing of the wound, 
 but the same is true of excision in children. I think, then, that in suitable cases era- 
 sion is in disease of the knee, better surgery than excision, but its application is 
 strictly limited. In all cases I have employed strictly Listerian antiseptics.'' 
 
WIRING FRACTURES OF PATELLA. 911 
 
 WIRING UNUNITED FRACTURES OF PATELLA.* 
 
 This operation, brought before the profession by Sir J. Lister in 
 1883, seems lately to have dropped out of notice. This is perhaps due 
 to two facts ; (a) In the majority of cases a quite sufficiently good 
 result is obtained by non-operative means. (6) In spite of the vastly 
 increased familiarity with antiseptic details, and their simplification, 
 much of the old dread of opening the knee-joint still survives. The 
 question was, however, sufficiently thrashed out to make it clear that 
 the operation is justifiable under certain conditions. The indications 
 may be stated somewhat thus : 
 
 1. In Sir J. Lister's words (loc. svpra cit.), "no man is justified in 
 performing such an operation unless he can say with a clear conscience 
 that he considers himself morally certain of avoiding the entrance of 
 any septic mischief into the wound." 
 
 2. Certain Cases of Old Fracture of the Patella. — This important 
 matter must be taken somewhat in detail. The chief points here jus- 
 tifying resort to wiring are — (a) Failure of previous treatment, espe- 
 cially is hospital patients. (6) A useless limb, especially in a man 
 whose occupation entails much walking or standing, where the gait 
 is helpless and requires much attention, or where many falls have fol- 
 lowed involving serious risk of fracture on the opposite side, (c) 
 Where both patellae are fractured, (d) Where the patient is young 
 and has many years of active life before him. (e) Where, if not young, 
 the patient is sufficiently healthy. (/) Where enough is known of 
 the patient's habits to ensure his being amenable. 
 
 3. Recent Fractures. — These must be considered separately, accord- 
 ing as they are — (a) simple; or (6) compound. In the former case the 
 general opinion of the profession has appeared to be against operation, 
 owing to the good result which usually follows on non-operative 
 measures. Prof. Lister'sf five cases of wiring in recent fractures prove 
 how safe this method is in skilled hands. (6) In compound fractures 
 the matter seems to be different. Here a wound already exists, and if 
 the patient's condition is good no harm can be done by wiring, with 
 
 * Mr. Ogier Ward {Lancet, November 1, 1884), in some interesting remarks on three 
 cases -of which one was treated withont, and the other two by, wiring— shows that in 
 the first the total time lost before resuming worls was twenty-seven weeks, and in the 
 two wired, thirteen and eight weeks respectively; that the first case could not kneel 
 before nine months, while the other two could do so six and five weeks after (he oper- 
 ation. It will be seen that the loss of time was reduced by more than one-half. 
 
 t Sir Joseph goes so far as to consiiler {Lancet, November 3, 1883) that "the unu- 
 nited case is in every respect worse as a subject of operation than the recent." This is 
 chiefly owing to tlie wasting of fragments and their greater separation. Again, in 
 recent cases, there is no need to pare the fragments, for after sponging away of clots 
 the surfaces are ready for coaptation. 
 
912 OPERATIONS ON THE LOWER EXTREMITY. 
 
 antiseptic precautions, any fragments which appear to be widely sep- 
 arated. Furthermore, such a step may be easily combined with the 
 needful examination and irrigation of the joint with dilute solution of 
 mercury perchloride or carbolic acid, and the insufflation of iodoform * 
 Operation.— The parts being thoroughly cleansed, an incision is 
 made, with the strictest antiseptic precautions, including the spray, 
 about 31 inches long, either vertically or transversely. The former is 
 adopted by Sir J. Lister. The latter is the more convenient, and 
 admits more readily of getting at the lateral aspectsof the joint, if the 
 aponeurosis above requires division at these points.f It is said to have 
 the disadvantage of being more likely to give way and expose the joint 
 if a refracture should take place later. I used it in the two cases men- 
 tioned hclow, and think it well to make it. rather above or below the 
 interval between the fragments, so that this and the wound shall not 
 lie opposite to each other. J The fragments when exposed§ are generally 
 found embedded in fibrous tissue, thickened synovial membrane, 
 and old decolorized coagulum. This must be snipped or cut away, 
 and any spirting vessels in the thickened synovial membrane niustbe 
 secured. A very thin section from each fragment is then removed with 
 a narrow-bladed saw, this needing much caution in the case of the 
 lower one, which is the smaller of the two. If the fragments can now 
 be pressed into close apposition, nothing remains save to wire them, 
 but the case is by no means so simple where the bones are widely 
 apart. Tlius, in one of my cases, after paring the fragments, these 
 were quite 22- inches from each other, and after most forcible traction, 
 the upper could only be made to descend f inch. Malgaigne's hooks 
 were now applied and tightly screwed uj), but with no result on the 
 desired approximation. The lateral expansions of the quadriceps 
 were next still more fully divided (cut muscular fibres l_ieing seen on 
 the inner side), but the fragments were almost as far apart as ever. 
 As the only alternative to excising the joint (in order to substitute a 
 firm support for the flail-like limb), I now divided partially the rectus 
 tendon, but it was not till the upper fragment was only held by a 
 
 * Dr. G. K. Fowler, of New York (Amutls of Suryery, September, 1SS5, p. 248), 
 calls iitieiilion to the great importance of makinfi; these cases aseptic at the first. In his 
 case the bone was split into three fragments. The two lower ones were first wired 
 together, and tlieir ujiper margins were ne.xt siitnred to the npper fragment by two 
 sutures, one for each lower fragment. 
 
 f It wonld also be probablv more convenient in a componnd fracture. 
 
 X \n Esmarch's bandage is not needed, and wonld have the objections of causing 
 oozing afterwards into the joint cavity, and also of preventing that bringing down of the 
 extensors of the thigh which may be rerjiiired in cases of wide separation. 
 
 Jin one case, the skin being dimpled, puckered down, and adherent between the frag- 
 ments, I had to cut away a piece abcait J inch in diameter. 
 
WJEING FRACTURES Or PATELLA. 91 3 
 
 narrow stout band at its upper and inner parts that it could be 
 brought in apposition with the lower one. The result was excellent- 
 
 In these difficult cases it must be remembered that it is not abso- 
 lutely necessary to get the fragments into exact apposition. If after 
 wiring they come within i inch of each other, the limb will be a most 
 useful one, though of course exact apposition is to be desired.* When, 
 in spite of all the above, approximation of the fragments is still im- 
 possible—though it is difficult to imagine such a contingency— the 
 knee should be excised either now, or on another occasion, so as to 
 give a firm support. 
 
 The fragments being sufficiently approximated, they are now drilled. 
 This may be easily effected by an ordinary clean bradawl. The bones 
 should be drilled obliquely, the instrument entering each fragment a 
 full 2 inch from the fracture on the upper surface, and emerging above 
 the cartilaginous surface below.f Where the lower fragment is too 
 small to hold a wire,J this may be passed through the ligamentum 
 patella;, as has been done by Sir J. Lister {loc. supra cit.) and Mr. 
 Teale.§ One wire would appear to be sufficient : though this unites 
 the centre of the fragments exactly, a very slight interval remains at 
 the edges, but does not interfere with an excellent result. 
 
 When the wire is twisted, two half twists, or one complete one, will 
 be sufficient, and it should be noted at the time in which direction 
 the twist is made, in case the wire is removed. This raises the ques- 
 tion as to the best way of dealing with the wire, whether to cut 
 it short and embed the ends by gently hammering them into the 
 fibrous tissue over the upper fragment, or to leave the wire long 
 
 * In a case of Mr. Wheelhouse's ( i?)-j(. Med. Journ., June 9, 1883) the fragments, 
 originally IJ inch apart, could only be bronglit within J inch of each other; an excellent 
 limb resnlted. 
 
 f While it is well to take this last precaution, it probably does hot matter much 
 (supposing, of course, that strict antiseptic precautions are taken) if the wire is passed 
 witliin the joint. Sir J. Lister gives the following aid to making tlie two drill-holes 
 exactly correspond : "iSupposing that on one side the instrument should have come 
 too far down, it may be into the cartilage ; we do not regard that at first, bnt pass the 
 wire through the two drill-holes, and then on that side on which the liole has come 
 too far down, by means of the bradawl we simply chip away a little of the material 
 that is above the wire, until the wire comes to be in a position exactly opposite to 
 the hole on the other side." If, in another case, there is difficulty in making the 
 drill emerge upon the fractured surface, Sir Joseph would advise to withdraw the drill 
 and substitute the blunt end of a needle, and then with a gouge or bradawl to excavate 
 an opening upon the fractured surface, opposite to the other drill-hole, until the needle 
 is exposed ; the wire can then be easily passed. 
 
 J The most diffloult fragment s-hould be taken first. The wire is liable to hitch at 
 two points — one in hitting off the drilled orifice in the second fragment; the other, as 
 it comes up through the fibrous tissue covering this fragment. 
 
 I Bril. Med. Journ., June 9, 1883. 
 
 58 
 
914 OPERATIONS ON THE LOWER EXTREMITY. 
 
 enough to admit of its being removed later. I have alluded to this 
 question at p. 78. Sir J. Lister advocates the former course. I shall 
 not, I trust, be thought wanting in proper respect if I suggest that in 
 the knee, at least in women who have much kneeling, removal of the 
 wire will be more satisfactory. Thus, in one of my cases, in which I 
 had hammered down the wire, the woman returned nearly a year 
 later to have the wire removed. She had not been able to kneel, the 
 suture could be felt, and at one spot the skin was ulcerating over it. 
 I ought to state that the patient was a very thin one, and that I had 
 made three or four half turns instead of two (p. 903).* 
 
 Before the wire is twisted or hammered down, if this course is 
 decided upon, the surgeon must decide as to drainage of the joint. 
 When the operation has been difficult, involving much separation 
 of adhesions, and interference with ihe parts, drainage should be 
 employed either by inserting a tube or horsehair drain into each 
 angle of the wound if a transverse one has been made, or, more effici- 
 ently, by passing a narrow-bladed dressing-forceps through the wound 
 to the most dependent part of the joint at the outer side (Lister), 
 thrusting the instrument here through the joint and soft parts, cutting 
 upon it and drawing a drain through. f The wound is then united 
 and dressed. As soon os the deeper part of the wound is healed, 
 every pains must be taken, by massage, etc., to improve the atrophy 
 of the quadriceps. Healing should be complete in three weeks. If 
 it be decided to remove the wire, this may be done six or eight weeks 
 after the operation, by making a small incision through the scar. 
 The number of half-twists and the direction in which they have been 
 made must be recollected at this time. The wire is first untwisted 
 and straightened, one end is next cut off short, and the other grasped 
 in dressing-forceps, and wound round the tips of these. It is then 
 extracted without jerking. 
 
 The question of passive movement now arises. Usually, about 
 six or eight weeks after the operation, the patient may get up and 
 begin to use the limb (with the aid of two sticks at first), flexion and 
 extension being diligently practiced. Unless the joint is very stiff, 
 massage, friction, and gentle persevering movement, aided by time 
 
 * Dr. Macewen {loc. infra cit.) mentions a case which came under observation three 
 months after suture of tlie patella, with acute suppurative artliritis of the joint and 
 ulceration of the cartilage. A probe passed through a sinus detected the wife sur- 
 rounded by carious bone. The twist was still intact, but the loop was loose, the bone 
 having become inflamed, softened, and ulcerated. Excision of the joint was required. 
 This shows that occasionally the wire may excite irritation and thus lead to serious 
 results. 
 
 t Dr. G. K. Fowler {loc. supra cil.) used large rubber drainage-tubes, which were no 
 removed till the end of fourteen days. 
 
WIRING FRACTURES OF PATELLA. 915 
 
 and patience, will be sufScient, If an anaesthetic is given, move- 
 ments must be made cautiously, as the patella has been refractured 
 on this occasion more than once* 
 DiflBculties in Wiring the Patella. 
 
 1. Atrophied surfaces of the fragments, making it difficult to refresh 
 them satisfactorily. 
 
 2. A very small lower fragment. 
 
 3. Fragments embedded in very firm fibrous tissue, fascial, peri- 
 osteal, and synovial, or old coagulum. This condition will' prevent 
 satisfactory apposition unless the intervening tissue be all removed. 
 
 In a very interesting case recorded by Mr. 0. Ward {Lancet, Nov. 1, 
 1884) it was found, on exploring the fragments, that the capsular tissues 
 torn off the lower fragment remained attached above, and hung like a 
 flap between the fractured surfaces, effectually preventing their appo- 
 sition. It is suggested that some such complication may, in many 
 cases which have been treated in the usual way, cause the fragments 
 to fall apart as time goes on. This is supported by Dr. Macewen 
 {Ann. of Surg., March, 1887, p. 178), who has collected thirteen cases of 
 transverse fracture of the patella, in which portions of soft tissue inter- 
 vened between the fragments in such a manner as to render osseous 
 union an impossibility. 
 
 4. A contracted, rigid quadriceps, 
 
 5. Indipping skin, p. 912. 
 
 6. Multiple fragments. This may cause much difficulty, especially 
 if it is the lower and usually smaller fragment, which is comminuted. 
 If the lowest fragment is large enough to bear wiring, a smaller one 
 may be removed ; or the wire may be passed through the ligamentum 
 patellte. If a case seemed to require it I should not hesitate to wire 
 smaller fragments with finer wire, and to pass one stout one from the 
 highest to the lowest fragment (or ligamentum patellse), this wire 
 lying in the joint, and passing under and over one of the smaller ones. 
 To give a firm support excision could be resorted to as a last resort, 
 either at the time or later. 
 
 Causes of Failure.— These are mainly ; 
 
 1. Inability to bring the Fragments together.— Mr. Turner (Clin. 
 Soc. Trans., vol. xvii. p. 41) mentions a case in which the operation 
 was abandoned, as it was found impossible to get the fragments 
 
 * In one of Sir J. Lister's cases [he. mpra cit.), passive movement being employed 
 with " considerable force " four weeks after the wiring, tlie rigid quadriceps not yield- 
 ing, the wire gave way, and the cicatrix (a long longitudinal one), which had healed 
 save where tlie wire projected, opened. The joint was at once washed out antisepti- 
 cally, and, six days later, some coagula were removed and the old wire retwisted. An 
 excellent limb was the result. 
 
916 OPERATIONS ON THE LOWER EXTREMITY. 
 
 togetiier after wiring them. The patient was " no-better and no worse " 
 eventually. 
 
 2. Septic conditions.. 
 
 3. Necrosis of a Fragment. — This is a complication rather than a 
 cause of failure. It is especially likely to occur after severe com- 
 pound fractures, in which the periosteunx was much injured at the 
 time of the accident. This happened with the ujjper fragment in Dr. 
 G. R. Fowler's case already quoted. About three months after the 
 wiring, this fragment, about the size of a walnut, was removed. It 
 was now found that " the joint was perfectly closed by a thick fibrous 
 capsule underlying the necrosed portion, connected to the upper 
 margins of the now firmly united two lower fragments, and forming 
 a strong bond of union between the quadriceps above and what 
 remained of the patella below." The resulting limb was useful, with 
 considerable movement at the knee-joint. 
 
 REMOVAL OF LOOSE BODIES* FROM KNEE-JOINT. 
 
 This is another instance of an operation rendered safe and simple 
 by the antiseptic treatment of Sir J. Lister. Removal by direct 
 incision will therefore be alone described here. 
 
 Operation. — The parts having been kept at rest for some days 
 before and scrupulously cleansed, the foreign body is found,! if pos- 
 sible, and retained in a superficial part of the capsule. If it be very 
 movable, it should be harpooned with a sharp needle at the beginning 
 of the operation. The joint is then deliberately and sufficiently 
 opened. In the traumatic case I have mentioned, the body could 
 not be felt at the time of the operation ; on cutting freely into the 
 
 * The following classification may be useful to a surgeon about to operate for one of 
 these bodies :. (1) A thickened or indurated synovial fringe which has become pedun- 
 culated and perhaps detached ; (2) a fibro-enchondroma originating in those cartilage 
 cells which are naturally found in the synovial fringes; (3) a portion of articular car- 
 tilage detached by injury (two years ago I removed one of these loose bodies from the 
 knee-joint of a railway porter who came to nie for synovitis, with the history that the 
 attacks dated from the time when a cask which he was moving had slipped and struck 
 the inner side of his right knee-joint) ; (4) a bitof cartiLage may, after injury, gradually 
 become detached by a process of quiet necrosis (Paget) ; (5) blood efliised into a synovial 
 fringe; (0) a, mass of fibrine ; (7) a detached osteophyte; (8) Mr. H Marsh (Dis. of 
 Jomis, p. 182) mentions a case of Mr. Shaw's,,in which a loose body on removal was 
 found to contain the point of a needle. 
 
 t The patient is often clever at this. Mr. H. March (loc. supra cit.) suggests that 
 it may save disappointment if fixing the body luis been practiced beforehand by the 
 assistant to whom this office is to be intrusted. In those rare cases where the body 
 cannot be fonnd, no surgeon familiar with antiseptic details would hesitate to freely 
 cut into the joint if the history and the crippling of the patient justified this. In 
 other cases, as occasionally happens in lithotomy, the body is known to be present, 
 but cannot be felt when the patient is on the table. 
 
IjIGature of the popliteal artery. 917 
 
 joint I came down on a tiny pedunculated body attached to the de- 
 formed internal condyle; as this was evidently too small to be the 
 offending body, I had, after removing it, to make a prolonged search 
 with the finger before the loose cartilage was found at the extreme 
 upper end of the supra-pateller pouch. In any such case where the 
 body can be felt, but not brought down, a second incision should be 
 made over it. Any bleeding is now finally arrested, and the wound 
 closed by sutures which carefully take up the capsule. If the opera- 
 tion has been a simple one, no drainage will be required, effusion 
 being prevented by aseptic precautions and firm, even bandaging. 
 When the search has been prolonged, the parts much interfered with, 
 or many bodies removed, a horsehair drain or a small tube must be 
 employed, either coming through the wound, or through this and a 
 counter-puncture at the most dependent part of the joint (p. 914). 
 
 Iodoform having been dusted on, dry antiseptic dressings are ap- 
 plied, and the limb put ujj on a back splint. 
 
 CHAPTER IV. 
 OPERATIONS ON THE POPLITEAL SPACE. 
 
 LIGATURE OF THE POPLITEAL ARTERY. 
 
 Indications. — Extremely few. 
 
 1. Stab or Punctured Wound.— Here ^the surgeon would only resort 
 to ligature, (1) if pressure was unavailing ; (2) if the patient insisted 
 on running the risk of gangrene ; (3) it would be well, if possible, 
 to get leave for immediate amputation if the vein was found injured 
 also. 
 
 2. In some cases of ruptured popliteal artery it will be right to ex- 
 plore and see if any other complication exists beyoad the rupture 
 of the artery.* If there is no injury to the vein, nerves, or the joint 
 (a very unlikely contingency), the rupture may be treated by double 
 ligatures as elsewhere. The surgeon must afterwards be prepared to 
 amputate through the lower third of the thigh on the first sign of 
 gangrene appearing. The operation of ligature of the popliteal 
 artery is extremely difficult here, owing to the depth of the vessel, 
 the strong fascia, the amount of coagulated blood, and the infiltrated, 
 obscured condition of the parts. Primary amputation will, as a rule, 
 be required in cases of ruptured popliteal artery, especially where 
 skilled assistance and facilities for antiseptic treatment aj-e not at 
 
 * Poland, Guys Ho$p. BepoHs, third series, vol. vi. p. 294, 
 
&18 OPEKATIONS ON THE LOWER EXTREMITY. 
 
 band. A free incision will enable the surgeon to investigate the 
 amount of injury, and at the same time will relieve tension if an 
 attempt is made to relieve the limb.. This incision may form part of 
 the ampufation (p. 891). 
 
 3. The artery has been wounded in the course o-f an osteotomy of 
 the lower end of the femur. In such a case the vessel should be 
 reached by the incision given at p. 920. 
 
 4. " Possibly in a small traumatic aneurism- " (Sir W. MacCormac, 
 Ligature of Arteries^ p. 109). If any surgeon is inclined to perform 
 the old operation for, a ruptured popliteal aneurism, he should first 
 consult a cMnical lecture on a case of this kind by Mr. Holmes. The 
 difficulties which may be expected are graphically described, and the 
 wisdom of amputation shown. 
 
 Extent.— From the adductor openirug to the lower harder of the 
 popliteus. 
 
 Guides. — Behind: A line drawn from just inside the inner ham- 
 strings above to the centre of the lower part of the popliteal space. In 
 Front: The tendon of the adductor magnus. 
 
 Relations (in the paj)liteal space) : 
 
 In Front. 
 Skin ; fascise ; small sciatic nerve above ; short saphena vein 
 
 and extenal saphena nerve below. 
 Fat; glands. 
 Semi-membranosus above ; gastrocnemius, plantaris, soleus, 
 
 below. 
 Internal popliteal nerve ;. popliteal vein, outside above, inside 
 
 below, exactly over the artery in the centre of the space. 
 Branch of obturator above. 
 
 Outside. Inside. 
 
 Keeps, above ;■ gastrocnemius, Semi-membranosus, above ; 
 
 and plantaris,. below. gastrocnemius, below. 
 
 Popli'teaf artery. 
 
 BeHINDv 
 
 Femur. 
 
 Posterior ligament. 
 
 Popliteus^ 
 
 Collateral Circulation. 
 
 Above. Below. 
 Anastomotica magna, superior Inferior articular, and re- 
 articular, descending branch with current from anterior 
 of external circumflex. tibial. 
 
LIGATURE OF THE POPLITEAL ARTERY. 
 
 919 
 
 Operations (Figs. 172, 173).-The artery may be tied in three 
 places. A. At tiie upper part of the popliteal space. B. At the lower 
 part of the popliteal space. C. Prom the front, at the inner side of the 
 limb. For the sake of experience, all should be practiced on the 
 dead body. 
 
 A. At the Upper Part of the Popliteal Space (Fig. 172).— The 
 patient being rolled two-thirds on to his face, and the limb at first ex- 
 
 FiG. 172. 
 
 Fig. 173. 
 
 The artery lie-s embeded in fat. Above it are some of tlie 
 fibres of the adductor magnus. In the upper angle of the 
 wound the sartorius has been drawn down. 
 
 Above, the artery is shown under 
 cover of the semi-membranOBUs. 
 The small sciatic has been drawn 
 aside with a blunt hook. Below, 
 the vessel is exposed just above 
 the heads of the gastrocnemius. 
 The internal popliteal nerve is seen 
 below outside the artery just be- 
 fore it crosses to the inner side. 
 
 tended, an incision 3^ inches long is made, in the line of the vessel, 
 along the outer margin of the semi-membranosus, and then down- 
 wards and outwards to the centre of the space. The small sciatic 
 nerve, if seen, should be drawn to one side ; the deep fascia is then 
 freely opened up, and the pulsation or the artery felt for at the inner 
 margin of the semi-membranosus. The nerve is generally seen first, 
 and this and the vein are to be drawn to either side with blunt hooks. 
 The needle should be passed from the vein. A good deal of loose fat 
 is usually in close contact with the vessels, and is liable to be a source 
 
920 OPERATIONS ON THE LOWER EXTREMITY. 
 
 of trouble wherever the artery is ligatured, especially in the dead 
 subject. 
 
 B. At the Lower Part of the Popliteal Space cFig. 173).— 1 he 
 limb being in the same position, an incision 3^- inches long is made, 
 in the line of the artery, from the centre of the popliteal space to the 
 junction of the upper and middle thirds of the back of the leg. 
 The external saphena vein and its nerve being avoided, the deep 
 fascia is freely opened and the limb flexed. The exact interval 
 between the heads of the gastrocnemius is next sought for. The fol- 
 lowing structures may now be met with overlying the artery, and 
 must be drawn aside— viz., the plantaris, the sural arteries which run 
 down on the vessel, and the posterior tibial nerve, which is often 
 given off as high as this. The popliteal vein now lies to the inner 
 side, together with the popliteal nerve, which is superficial to it, if this 
 has not given off its branches. These structures should be drawn to 
 either side, and the needle passed as is convenient. 
 
 C. From the Front, at the Inner Side (Fig. 173).— This opera- 
 tion might be useful in cases where haemorrhage recurs after oste- 
 otomy at the lower end of the femur. 
 
 The following account is taken from Sir W. MacCormac (Ligature of 
 Arteries, p. 110) : " Flex the knee and place the limb on the outer side. 
 Make an incision 3 inches long immediately behind and parallel to 
 the tendon of the adductor magnus downwards from the junction of 
 the middle and lower thirds of the thigh. Divide the skin, superficial 
 and deep fascife, avoid the long saphenous nerve, seek the tendon of 
 the adductor magnus, draw it forwards and the hamstring tendons 
 backwards. The artery will then be found surrounded by fatty 
 areolar tissue. The nerve and vein do not necessarily come into view, 
 being on the external aspect of the vessel." 
 
 CHAPTER V. 
 
 OPERATIONS ON THE LEG. 
 
 LIGATURE OP POSTERIOR TIBIAL ARTERY. - LIGA- 
 TURE OF ANTERIOR TIBIAL ARTERY.— LIGATURE 
 OF PERONEAL ARTERY.— AMPUTATION OF LEG.— 
 OPERATION FOR NECROSIS.— TREATMENT OF COM- 
 POUND FRACTURE. 
 
 LIGATURE OF THE POSTERIOR TIBIAL ARTERY. 
 
 Indications. — Very rare. 
 
 i. Chiefly Wounds. — Mr. Cripps,* in a very interesting paper, 
 
 * St. Barthol. Hasp. Reports, vol. xi. p. 94 ; Diet, of Surg., vol. ii. p. 626. 
 
LIGATURE OF THE POSTERIOR TIBIAL. 
 
 921 
 
 divides up the sources of hasmorrhage from the upper two-thirds of 
 the posterior tibial into (1) hemorrhage after amputation ; (2) hemor- 
 rhage from injury to the vessels in continuity. 
 
 1. Hemorrhage after Amputation.— This is usually due to a dis- 
 eased condition of the vessels, and to the fact that the vessels, lying 
 between the bones, are now especially difficult to take up. If from 
 their constantly breaking away it is found impossible to deal with 
 them, the limb should at once be amputated above the knee. If the 
 hemorrhage occurs later on, well adjusted pressure (p. 877) should 
 be carefully tried, aided or followed by ligature of the femoral or by 
 amputation higher up. 
 
 2. Hemorrhage from Wounds of the Tibials in Continuity.— Three 
 chief causes may lead to this: (a) Incised wounds. (6) Punctured 
 wounds, (c) Wounds other than punctured or incised. Four methods 
 of treatment are open to the surgeon— viz., (a) Pressure and band- 
 aging. (6) Ligature of both ends of the vessel, (a) Ligature of the 
 femoral, (d) Amputation. 
 
 (a) Incised Wound— If this is seen soon after its infliction the bleed- 
 ing-point should be sought for and tied, the wound being enlarged, 
 
 Fig. 174. 
 
 Ligature of the posterior tibial artery at tlie inner ankle. The irjcisions In amputation of the 
 great toe at the metatarso-phalangeal and the inter-phalangeal joints are also shown. 
 
 if needful. If sloughing and extravasation of blood have taken 
 place, amputation will probably be the wiser course, though if the 
 patient decide to run the risk, an attempt may be made to save his 
 limb by making free incisions, providing drainage, plugging the 
 wound (rendered as far as may be aseptic with irrigation and iodo- 
 form) with dry gauze, bandaging evenly and firmly, and tying the 
 femoral in Hunter's canal. 
 
922 OPERATIONS ON THE LOWER EXTREMITY. 
 
 (6) Punctured Wound— It this is deep, and the vessel injured un- 
 certain, the question of treatment is a verj' serious one * Mr. Cripps 
 shows that, in the majority of instances, pressure deserves a fair and 
 thorough triaL If it is useless or prejudicial to other treatment, 
 either the femoral must be tied or the wound enlarged to secure the 
 wounded vessel. Between these operations the features of the par- 
 ticular case must decide. If pressure is made use of it should be 
 applied methodically and with intelligent purpose (p. 877), and so 
 that it needs no alteration or repetition. 
 
 (c) Wounds other than Punctured or Incised— viz., Injury to the Vessel 
 from Fracture or Gunshot Wound. — In many cases conditions will be 
 present which will call for amputation— viz., the severity of the 
 crush; the extent of the comminution; injury to the nerves or to 
 both arteries, as evidenced by the condition of the foot; and the age or 
 the health of the patient. In most of these cases, as an attempt to find 
 the vessel involves great difficulty and danger, and the probabilities of 
 success diminish as the interval between the infliction and treatment 
 of the injury increases, ligature of the femoral would be less hazardous 
 than any interference with the wound. But amputation will frequently 
 be needed. The above remarks apply to compound fractures; an 
 instance of successful ligature of a lacerated femoral coexisting with 
 a simple fracture of the leg is given at p. 872. 
 
 ii. Small traumatic aneurisms. 
 
 iii. The posterior tibial may be tied low down, together with the 
 dorsalis pedis, for certain wounds of the sole or for some vascular 
 growths of the foot. 
 
 Line and Guide. — A line drawn from a point at the lower part of 
 the centre of the popliteal spacef to one midway between the tendo- 
 Achillis and the internal malleolus. 
 
 Relations. — These differ according as the vessel is tied — (A) in 
 the middle of the leg, (B) in the lower third of the leg, (C) at the 
 inner ankle. 
 
 A. Relations in the Middle of the Leg : 
 
 Superficial. 
 
 Skin ; fasciae ; branches of saphense veins and nerves. 
 Gastrocnemius ; soleus ; plantaris. 
 
 * Where the wound lias passed obliquely, Diipuytren's words should be remem- 
 bered. They refer to hasmorrhage from the calf caused by a pistol-bullet. "Should a 
 ligature be placed on the ends of the divided vessel ? But what were those vessels? 
 Was it the anterior or posterior tibial, or the peroneal or the popliteal ? Was it 
 several of them at the same time ? Should they be attacked before or behind ? " 
 
 t This point, representing the lower border of the popliteus, would be about 2J 
 inches below the knee-joint. 
 
LIGATURE OF THE POSTERIOR TIBIAL. 
 
 923 
 
 Special fascias ; transverse branches of vena comites ; 
 tendinous origin — arcii of soleus (above). 
 
 Outside. 
 
 Vena conies. 
 
 Posterior tibial nerve 
 which has crossed 
 above from the 
 inner side. 
 
 Posterior tibial. 
 
 Beneath. 
 
 Inside. 
 
 Vena comes. 
 Posterior tibial nerve 
 (above). 
 
 Flexor longus digitorum. 
 Tibialis posticus. 
 
 B. Relations in Lower Third of Leg: 
 
 Superficial. 
 Skin ; fasciae ; superficial veins and nerves. 
 
 Outside. Inside. 
 
 Vena comes. Vena comes. 
 
 Posterior tibial nerve. 
 Tendo-Achillis. 
 
 Posterior tibial. 
 
 Beneath. 
 
 Flexor longus digitorum. 
 Tibia. 
 
 C. Relations at Inner Ankle : 
 
 Superficial. 
 
 Skin ; fascias ; branches of internal saphena vein 
 
 and nerve. 
 Internal annular ligament. 
 
 Outside. 
 
 Vena comes. 
 
 Flexor longus poUicis. 
 
 Posterior tibial nerve. 
 
 Posterior tibial. 
 
 Inside. 
 
 Vena comes. 
 Flexor longus digi- 
 torum. 
 
 Beneath. 
 Internal lateral ligament. 
 
924 
 
 OPERATIONS ON THE LOWEE EXTREMITV. 
 
 Fia. 175. 
 
 llil^'!^(^!!^.^ 
 
 Operation in Middle of Leg (Fig. 175). 
 
 The parts being cleansed, the knee flexed, and the limb supported 
 on its outer side, the surgeon, standing or sitting on the inner side, 
 makes an incision 3i inches long, parallel with the centre of the 
 inner border of the tibia; and J or J inch behind it, according to the 
 size of the limb. This incision divides skin and fasciae. If the in- 
 ternal saphenous vein is met with, it must be drawn aside with a 
 strabismus hook; any of its branches may be divided between two 
 chromic-gut ligatures. The deep fascia is then freely slit up, and the 
 
 inner edge of the gastrocnemius defined 
 and drawn backwards. This will expose 
 the soleus, the tibial attachment of which 
 is to be cut through, any sural artery 
 being at once secured. The incision 
 through the soleus should be 3 inches 
 long and quite J inch from the tibia ; as 
 the fibres are divided the central mem- 
 branous tendon will come into view, and 
 must not be confused with the special 
 deep fascia or intermuscular septum over 
 the deep flexors. Usually, before this 
 comes into view, some additional fibres 
 have to be divided. When this is done 
 the above special fascia must be iden- 
 tified stretching between the bones. The 
 wound must be carefully dried, and well 
 opened out with retractors, and exposed 
 with a good light at this stage. The deep 
 fascia being opened carefully, the nerve 
 usually comes into view first, the artery 
 The position of the incision is shown lying a little deeper and more internal. 
 
 on the figure to the left. That to the rni -i i i i i 
 
 right shows the parts on a larger scale. ^ ^c vena3 comites should be Separated as 
 The inner border of the gastrocnemius far as possible, but rather than puncture 
 
 is seen to the right beneath the cut fat. .1 1 v i j. j.i • 
 
 one of the edges of the cut soleus is ^hem and cause hemorrhage at this 
 shown retracted. One of the vense stage, Or waste time, the surgeon should 
 
 comites is shown internal to the artery, ^^g ^^^^^^ J^^ Tj^^ ^^^^^j^ should be 
 the nerve lying to its outer side. 
 
 passed from the nerve. To facilitate 
 this the knee should be well flexed, and the foot also flexed down- 
 wards so as to relax the muscles thoroughly. The ligature will lie 
 below the peroneal artery. 
 
 Operation in Lower Third of Leg.— The limb and the operator 
 being in the same position as at p. 924, an incision, 2J inches long, 
 is made through skin and fascia^, parallel with the inner border of the 
 
LIGATURE OP THE ANTERIOR TIBIAL. 925 
 
 tibia, and midway between it and the tendo-Achillis ; after the deep 
 fascia has been opened, another layer, tying down the deep flexor 
 tendons, will require division. The artery here lies between the flexor 
 longus digitorum and pollicis, surrounded by vena; comites. The 
 needle should be passed from the nerve, which lies external. If the 
 incision is made too high, some of the lowest fibres of the soleus will 
 require detaching from the tibia, if too low the internal annular liga- 
 ment would be opened. The sheaths of the flexors (their synovial 
 investment commences about 1* inch above the internal malleolus) 
 should not be interfered with. 
 
 Operation at the Inner Ankle (Fig. 174). — The limb and 
 operator being placed as before, a curved incision, 2 inches long, is 
 made, i inch behind the internal malleolus. Skin and fascise being 
 divided, and any branches of the internal saphena vein tied, the in- 
 ternal annular ligament is divided and the artery found, closely sur- 
 rounded with its veins. The nerve lies externally, and the needle 
 should be passed from it. The artery is so superficial here, that the 
 veins can be easily separated. The nerve has occasionally ))ifurcated 
 higher up. 
 
 LIGATURE OF THE ANTERIOR TIBIAL. 
 
 Indications. — These are very few, and resemble so closely those 
 already given for the posterior tibial — viz., wounds and traumatic 
 aneurism— that there is no need to go into them again here. 
 
 In the course of 1887, I had occasion to tie the anterior tibial in its 
 lower third for profuse haemorrhage from a compound fracture not 
 arrested by pressure. There was a compound comminuted fracture 
 of the right leg in the lower third from a fall of 4 cwt. upon the limb. 
 The upper end of the artery was found with some difiiculty, owing to 
 the pulped-up condition of the soft parts. Having failed to find the 
 lower end, I was about to expose the dorsalis pedis, and, trusting to 
 antiseptic' precautions, trace this up to the anterior tibial, when, an 
 urgent strangulated hernia being admitted I plugged the wound, all 
 the undermined parts being previously laid freely open. No recur- 
 rence of bleeding took place, and the man (aged forty-four) made an 
 excellent recovery, aided by his temperate life and patient ways, the 
 freedom with which the wound was laid open, this preventmg all 
 retention of discharges, the use of dry gauze dressings only changed 
 at rare intervals, and, not least, the fact that iodoform was thoroughly 
 
 dusted in. n^ ■ 
 
 Dr Shepherd, of Montreal (Annals of Surgery, No. 1, p. 7), gives 
 another, but more difficult, case in which the compound fracture was 
 
926 OPERATIONS ON THE LOWER EXTREMITY. 
 
 about the junction of the middle with the upper third of the leg. The 
 bleeding was first arrested by pressure, on the fourth day a traumatic 
 aneurism appeared. The artery was exposed with difficulty* and 
 found partly divided, two ligatures were applied, and the patient made 
 a good recovery. 
 
 Line and Guide. — From a point midway between the head of the 
 fibula and the outer tuberosity of the tibia to the centre of the front 
 of the ankle-joint. The outer edge of the tibialis anticus. 
 
 Relations : 
 
 Superficial. 
 
 Skin ; fasciae ; cutaneous branches of saphenous veins 
 and nerves, and (below) musculo-cutaneous nerve. 
 
 Tibialis anticus and extensor longus digitorum (above), 
 overlapping. 
 
 Tibialis anticus and extensor longus pollicis (below), 
 overlapping. 
 
 Outside. Anterior tibial artery. InsiDE. 
 
 Extensor longus digitorum (above). Tibialis anticus. 
 
 Extensor longus pollicis (below). Vein. 
 
 Anterior tibial nerve. 
 Vein. 
 
 Beneath. 
 
 Interosseus membrane. 
 
 Operation at the Junction of the Upper and Middle Third 
 of Leg. — The knee being flexed and the limb supported upon its 
 inner side, the surgeon having defined if possible the outer edge of the 
 tibialis anticusf sits or stands on the outer side of the patient, and 
 
 * Dr. Shepherd points ont that, the injury to the vessel being just in front of the 
 place where it pierces the interosseous membrane, if the artery had been completely 
 torn through, it would have retracted through the opening, and ligature would 
 have been impossible. Mr. Page (i(race(, 1887, vol. i. p. 522) gives a case of a traumatic 
 aneurism of ten weeks' duraticm, after a stab, at the junction of the middle and 
 lower third of the leg. The swelling had been poulticed and opened, with the 
 result of haemorrhage. Mr. Page, on clearing ont the clots and opening up the 
 swelling, was unable to find the anterior tibial artery. Hsemorrhage recurring, the 
 leg was amputated. The patient recovered. 
 
 + The patient may put this into action just before taking the aneesthetic. 
 
LIGATURE OF THE ANTERIOR TIBIAL. 
 
 927 
 
 m- 
 should 
 
 Fio. 176. 
 
 makes an moision about 4 inches long in the line of the artery beg 
 nmg about 2 inches below the head of the tibia. This incision 'shoi 
 lie (if the edge of the muscle has not been marked 
 out) f to 1 inch— according to the size of the leg— 
 from the crest of the tibia, and should expose the 
 deep fascia carefully so that the white line which 
 marks the desired inter-muscular septum may be 
 looked for. This line is often whitish-yellow, and 
 varies much in distinctness. If there is any diffi- 
 culty in finding it, any bleeding points must be 
 secured, and the deep fascia slit up over the line 
 of the artery, and the finger-tip inserted to feel for 
 the sulcus between the muscles. A third aid is 
 almost constant, and that is a small muscular 
 artery* which comes up between the tibiahs and the 
 extensor longus digitorum. The sulcus being found 
 between the muscles (without tearing them), they 
 are separated with the handle of a scalpel or a 
 steel director, and retractors inserted, the outer one 
 being hooked over the fibula. If the limb is a very 
 muscular one the deep fascia should be nicked 
 transversely at the upper and lower extremities of 
 the wound, and the parts more relaxed by bending 
 the knee more and pressing the foot upwards. The 
 finger now directed toward the interosseus space 
 feels for the artery deep down in the bottom of the 
 wound. The nerve should be drawn to the outer 
 side. If much trouble is met with in separating 
 the vense comites they may be included. 
 
 Drainage being provided, and all haemorrhage pVa°e/TMaiis 
 stopped, the wound is slightly dusted with iodo 
 form, the muscles united with one or two chromic- i^r branch is shown, but 
 gut sutures, and the wound closed and the limb kept rather too large. 
 raised and flexed. 
 
 Operation at the Junction of the Lower and Middle Third 
 of Leg. — An incision about 2i! inches long is made in the line of the 
 artery, in the upjDer part ; this incision will be about 1 inch from the 
 tibia. The white line and the interval between the tibialis anticus 
 and the extensor proprius pollicis are both looked and felt for. The 
 deep fascia being divided and the muscles relaxed and retracted, the 
 
 The anterior tibial is 
 seen with one of its veins 
 lying between the dis- 
 anticus 
 and extensor longus 
 digitorum. The muscu- 
 
 * This is pointed out by Mr. C. Heath {Oper. Surg., p. 47). I have found the 
 same thing most lielpfid in the ligature of the ulnar in the middle third (p. 56). 
 
928 OPERATIONS ON THE LOWER EXTREMITY. 
 
 artery is found surrounded by its vense comites. The needle must be 
 passed from without inwards. 
 
 LIGATURE OP THE PERONEAL ARTERY. 
 
 Indications. — As these are extremely few, and as in the case of a 
 wound of the vessel (which is very rarely met with) the best course 
 would be to enlarge the wound, any formal operation for its ligature 
 need only be very briefly described. 
 
 Relations. — The peroneal artery comes off from the posterior tibial 
 about 1 inch below the popliteus, descends at first parallel with this 
 artery but sei^arated from it by the posterior tibial nerve; it then 
 passes outwards towards the fibula and runs down between this bone 
 and the flexor longus pollicis. In the upper part of its course it lies 
 upon the tibialis posticus, and is covered by the soleus. 
 
 Operation. — To tie the artery when no wound is present to guide 
 the surgeon, an incision, 3 inches long, should be made along the 
 posterior border of the fibula with its centre at the junction of the 
 upper and middle thirds of the legs. The gastrocnemius being drawn 
 aside, and the soleus separated from its attachment to the fibula, the 
 special deep fascia is slit up and the artery sought for close to the 
 fibula. 
 
 AMPUTATION OF THE LEG. 
 
 Different Methods. 
 
 1. Lateral Flaps (Fig. 177). 
 
 2. Teale's Rectangular Flaps (Figs. 178, 179, 180). 
 
 3. Antero-posterior Flaps of Skin. 
 
 4. Antero-posterior Flaps, Anterior of Skin, Posterior by 
 
 Transfixion of Muscle. 
 
 5. Circular. 
 
 I shall only describe the first two, as they will be found adapted to 
 all emergencies, and to be devoid of the disadvantages of the others. 
 
 1. Lateral Skin Flaps, witK Circular Division of the 
 Muscles, etc.— This is, I believe, a method not well known beyond 
 Guy's and those who have been taught there. It will not only be 
 found most convenient at the time, but it also gives very satisfactory 
 results afterwards. The blood-supply is well and equally distributed 
 to the lateral flaps, one can be conveniently cut longer than the other, 
 and they are more easily shaped and dissected up than antero-posterior 
 skin flaps, while no mass of muscle is left to drag away from and ex- 
 pose the bones, as in the antero-posterior flaps, with the anterior of 
 skin and the posterior by transfixion. 
 
AMPUTATION OF THE LEG. 
 
 929 
 
 i:iarts 
 
 Fig. 177. 
 
 Operation (Fig. 177).-The femoral artery being commanded, 
 the leg brought over the table, and the damaged or diseased 
 wrapped in carbolized lint so as to give 
 the assistant a firm hold and also to pre- 
 vent his soiling the flaps later on, the 
 opposite ankle is tied to the table. The 
 surgeon standing to the right of the limb 
 places his left index on the crest about an 
 inch below the tubercle, and his thumb at 
 a corresponding point behind in the centre 
 of the limb. Looking over he inserts his 
 knife close to the thumb and cuts on tlie 
 side of the limb farthest from him a lateral 
 flap broadly oval in shape and 3 inches 
 long, ending at the index finger, from 
 which point, without removing the knife, 
 a similar flap is marked out ending on the 
 back where the first began. The flaps are 
 now dissected up of skin and fascise, and 
 the muscles all cut through with a circular 
 sweep of the knife at the intended point 
 of bone-section, this sweep being repeated 
 two or three times till the soft parts are all 
 clearly severed. The interosseous mem- 
 brane is next divided, so that it shall not 
 be frayed by the saw, and with one final, 
 firmly drawn, circular sweep the perios- 
 teum is grooved for the saw.* This is then applied witli the follow- 
 ing precautions. The position of the fibula behind the tibia and its 
 much smaller size must be remembered lest it be splijitered. This 
 may be avoided by rolling the leg well over on to the inner or outer 
 side as the case may be, and placing the heel of the saw well down 
 on the outer side so as to start the .'section of the bones simultaneously, 
 and thus ensure complete division of the fibula before the tibia. This 
 object may also be effected, if the leg is held in the ordinary position, 
 by applying the saw to the tibia, and remembering, when this bone 
 has been sawn half through, to depress the handle, and thus complete 
 the section of the bones simultaneously. In either ease the saw 
 should be used lightly and quickly, with the whole length of the 
 blade, and without jamming. As the sharp projecting angle of the 
 
 * Nowadays, with antiseptic precautions, the old need of j>eriosteal flaps — viz., to 
 keep pus, etc, out of the diphie and medullary canal — is no longer present. Further- 
 more, these flaps are very difficult to raise, unless inflamed, especially in the thin 
 periosteum of adults. 
 
930 OPERATIONS ON THE LOWER EXTREMITY. 
 
 crest tends to come through to the anterior angle of the flaps, this 
 should be sawn off oljliquely either after the bones are sawn, or 
 by starting the saw first obliquely about li inch above the place 
 where the bones are to be sawn transversely. 
 
 Teale's Amputation by Rectangular Flaps (Figs. 178, 179, 
 180). 
 
 Advantages.— 1. The covering for the bones is ample, and the flaps 
 come together without tension.* 2. The way in which flaps are united 
 
 Fig. 178. 
 
 fTeale.) 
 
 favors drainage during healing, and provides a scar well out of the 
 way of pressure. 3. The stump bears pressure well. 
 
 Disadvantages. — 1. It is an expensive method, involving a high sec- 
 tion of the bones. 2. The long anterior flap may slough. 3. If per- 
 formed with the accuracy of its introducer, it involves more time than 
 that by lateral flaps (p. 928), and is, thus, not suited to cases of 
 shock. 
 
 Operation. — The preparatory steps, and the position of the opera- 
 tor and patient, are as at p. 929. The surgeon having measured the 
 circumference of the limb at the spot where he intends to saw the 
 bones, and placing here his left index and thumb on the tibia and 
 fibula, traces out a long rectangular, anterior flap which is to be, both 
 in its length and breadth, equal to half the above circumference.f In 
 tracing this flap the incision starts from the index finger, runs down 
 along the bone farthest from the surgeon for -ii inches (if the circum- 
 ference at the site of bone section is 9 inches), then crosses the limb, 
 
 * Save when infiltrated; the difficulty of getting the anterior flap into position is 
 then often considerable. 
 
 f In the lower third, where the leg tapers cfuickly, «kre mnst be taken to keep this 
 flap of the same width below as it is above. 
 
AMPUTATION OF THE LEG. 
 
 931 
 
 cutting all the structures down to the bones— this end of the flap 
 being also 4i inches wide— and then travels up along the opposite 
 bone to the surgeon's thumb. The anterior flap is then dissected up, 
 partly with the knife— e.£^., on the inner side, where the scanty cover- 
 
 FiG. 179. 
 
 ings must be raised as thick as possible and without scoring, partly 
 with the knife and partly with the finger on the outer aspect, where 
 the extensors, anterior tibial vessels and nerves must be stripped up, 
 uninjured, from the interosseous membrane. The posterior flap, 
 
 Fig. 180. 
 
 (Teale.) 
 
 which has been previously marked out fully i in length of the ante- 
 rior, is now cut by the surgeon looking over the limb and passing 
 his knife beneath it, and cutting everything down to the bones. It is 
 next raised as high as the point where the bones are to be sawn. The 
 
932 OPERATIONS ON THE LOWER EXTREMITY. 
 
 interosseous membrane and the bones are then attended to with the 
 precautions given at p. 929. 
 
 The vessels being secured and drainage provided, the anterior flap 
 is folded over the bones (care being taken not to double it too sharply), 
 its cut end stitched to the cut end of the posterior flap, and the por- 
 tion folded below the bones stitched to that folded above them (Fig. 
 
 180). 
 
 SEQUESTROTOMY. 
 
 As the removal of necrosed bone is most frequently required in the 
 leg, the above operation will be described here. 
 
 Indications. — The question will often arise as to whether the case 
 is ripe for operation. The chief points bearing upon this, and the 
 looseness of the sequestrum, are (1) The time that has elapsed since 
 the beginning of the illness ; thus, two to three months will probably 
 be required in the case of the tibia, but more likely six in that of the 
 femur ; (2) the age and general health* of the patient. The younger 
 the patient, and the more vigorous his vitality, the more rapidly will 
 the sequestrum become detached; (3) the size of the sequestrum. 
 The larger and more total the sequestrum, the slower will be the pro- 
 cess ; (4) the feel of the sequestrum. When steel probes announce this 
 to be dry, hard, and ringing, exploration is justified, especially if the 
 sequestrum can be felt to be loose or depressed by the probe ; (5) 
 the size and amount of the new shell of bone. The more distinct 
 this is, the more probable is it that the process of separation is com- 
 plete. 
 
 Operation. t — This should be always conducted antiseptically, 
 with the spray, when practicable, or with careful irrigation with a 
 solution of mercury perchloride (1 in 2000), and for these reasons — 
 (a) to prevent any risk of setting up septic osteo-myelitis ; (6) to 
 diminish the amount of suppuration, and so the risk of necrosis after 
 the interference with the periosteum which is entailed by the operation. 
 
 The limb being rendered evascular by vertical elevation as the pa- 
 tient is taking the anaesthetic, and the application of Esmarch's band- 
 age, is firmly supported on sand bags, steel probes are placed in the 
 cloacae which mark the limit of the disease, and with a strong-backed 
 scalpel the surgeon makes an incision between them on the inner sur- 
 face of the tibia down to the bone. If only one sinus is present, this 
 will probably be taken as the centre of the incision. The soft parts 
 being reflected, with every care of the periosteum, partly with the 
 finger, partly with a blunt dissector, the new sheath of bone, spongy 
 and vascular, is thoroughly exposed with a chisel and mallet. This 
 
 * Freedom from syphilis and phthisis will be noted. 
 
 f It is supposed here that the sequestrum is one of considerable size. 
 
SEQUESTROTOMY. 933 
 
 is then cut into and sufficiently removed so as to expose its cavity 
 completely from end to end* The sequestrum is now removed with 
 sequestrum-forceps, or prised out with an elevator. If too large, it 
 must be divided with cutting-forceps. The bed of ill-formed granula- 
 tion-tissue in which the sequestrum lay is then carefully examined 
 for any small bit which may be concealed, and this tissue is all scraped 
 away with a sharp spoon. When the surgeon is satisfied that all the 
 mischief has been removed, he plugs the resulting cavity carefully 
 with strips of dry gauze, dusted with iodoform, bandages these dress- 
 ings firmly on while the limb is elevated, and not till then removes the 
 Esmarch's bandage. If the bandage is removed before the dressings 
 are applied, such free venous oozing takes place that the plugs are at 
 once loosened and rendered inefficient, and the wound has to be re- 
 dressed shortly. The limb is kept raised on a back splint and an in- 
 jection of morphia given. 
 
 Two questions with regard to sequestrotomy require to be 
 alluded to— viz., that of performing early sub-periosteal re-sec- 
 tion— /.e., as soon as the bone is dead, and before any shell of new bone 
 has formed around it, and that of amputation. 
 
 Early Sub-periosteal Resection.— Mr. Holmesf has discussed 
 this question, and given the following advantages and disadvantages : 
 " The advantages of sub-periosteal resection of the shaft of the bone 
 over the expectant treatment are : (1) That it takes away what is a 
 source of very acute and dangerous constitutional irritation, and (2) 
 that it avoids the embarrassment of future operations, and the tedious- 
 ness of the convalescence which follows on the invagination of a large 
 sequestrum. The drawbacks are chiefly two : the almost certainty of 
 more or less sliortening, and the great probability of abscess sjoreading 
 into the nearest joint." 
 
 Antiseptic treatment will probably remove this second drawback — 
 i.e., after the operation there will be no acute suppuration to make its 
 way into a joint. The certainty of shortening which takes place here, 
 although the fibula is present to act as a stay, and to prevent any ap- 
 proximation of the ankle to the knee, is a much more serious draw- 
 back, and when coupled with the fact that the patients who would be 
 submitted to early sub-periosteal resection are often only just recovered 
 from a very prostrating illness seems to me to be strongly against it. 
 
 * Mr. Howse {Brit. Med. Jovm., J874, vol. i. p. 476) lays great stress on the need of 
 this. The new bone should be removed as far as a probe can be passed upwards or 
 downwards inside it, so as to make the whole easily granulate up from the bottom. 
 Otherwise, the part that is not laid open will very likely persist with a sinus. Further- 
 more, laying the whole cavity open not only ensures its granulating up from the bottom, 
 but also allows of the removal of all ill-formed granulation material. 
 
 f Surgical Treatment of Children's Diseases, p. 386. 
 
934 OPERATIONS ON THE LOWER EXTREMITY. 
 
 Question of Amputation.— The following are some of the condi- 
 tions which will call for this operation : (1) When the patient's vitality 
 is so low as to be unable to repair the wound of an early sub-periosteal 
 resection, or to stand the tax upon it of the expectant treatment; (2) 
 When the epiphyses are perforated, and the knee or ankle (especially 
 if both are affected) are involved ; (3) If a condition of chronic sep- 
 ticffimia is present ; (4) If the general health, from the presence of 
 phthisis, lardaceous disease, or syphilis, is much impaired. 
 
 TREATMENT OF COMPOUND FRACTURES.* 
 
 The following special points for consideration arise here— viz., 
 (1) The reduction of protruding fragments and the treatment of 
 splinters; (2) The best mode of dressing the wound ; (3) Complica- 
 tions ; (4) The question of amputation. 
 
 (i.) Protrusion of Fragments. — It is usually the upper one which pro- 
 trudes. The difficulty of reduction is in proportion to the size of the 
 wound, the length of the protruding bone, and the amount of spasm. 
 If reduction cannot be effected by moderate extension and dexterous 
 manoeuvring, the wound must be enlarged, and if this is not sufficient, 
 part of the bone must be removed with a narrow-bladed saw (Adams' 
 osteotomy saw will be found very useful), care being taken to separate 
 the periosteum first, and to protect the soft parts with a blunt dissector 
 passed under the bone and by retractors. If the bone is splintered, 
 some judgment is required as to what pieces to remove. Those which 
 are still adherent by their periosteum should be left. Those completely 
 torn away must be removed, whether they carry their periosteum or 
 not. As to a third set partly adherent, partly not, these, as a rule, 
 partially die in proportion to the injury to their periosteum, and keep 
 up for a long time irritation, and delayed union with, perhaps, sup- 
 puration, erysipelas, etc. They must, therefore, as far as practicable, 
 be removed, counter-openings being made for the purpose, when they 
 cannot be reached through the wound. 
 
 (ii.) In dressing the icound the one great object is to convert the fracture 
 as soon as possible into a simple one. In less severe cases, sealing a 
 small clean cut wound at once with dry gauze, and collodion and iodo- 
 form, or tinct. benz. co., will be sufficient. But in those cases, common 
 enough in large hospital practice, where the wound is extensive and 
 lacerated, and accompanied by much contusion of the soft parts, with 
 abundant blood extravasation, with much comminution of fragments 
 and injury to the periosteum, or where the fracture is complicated with 
 
 * From the frequency with wliich these occur in the leg this subject will be treated 
 here. The account is taken largely from the article " Fractures," Syst. of Surg., vol. i. 
 p. 421, which I rewrote in 1882. 
 
TREATMENT OF COMPOUND FRACTURES. 935 
 
 a dislocation, the antiseptic method will be found to give the best re- 
 sults in the largest number of cases. 
 
 While an anesthetic is given, the limb is cleansed with lint, and 1 
 in 40 carbolic lotion. An Esmarch's bandage being applied, and the 
 wound enlarged, the bone which requires it (vide supra) is removed, 
 any vessels secured,* and a 1 in 30 solution of carbolic acid is injected 
 into all the recesses of the wound by means of a syringe with a gum- 
 elastic catheter attached by tubing. Prof Lister has sliown that this 
 must not be done too vigorously, as extensive injection of the cellular 
 interspaces may set up serious irritation and sloughing. Tor this rea- 
 son he advises that the outlet of the wound should not be held closed 
 around the catheter, but left freely open during the syringing. If the 
 spray or irrigation with mercury perchloride and glycerine are em- 
 ployed, and one or other should always be made use of, I would 
 strongly advise slitting up any very undermined parts, and making 
 free counter-openings for drainage. All hamorrhage being arrested, 
 and any torn nerves pared and sutured, the recesses of the wound are 
 dried with sponges in holders, powdered iodoform f with boracic acid 
 are then dusted in, and dressings of dry sal-alembroth or iodoform 
 gauze, and the limb put up either in a back and two side splints, or, 
 according to Mr. Croft's directions, in plaster-of-Paris. Of the two I 
 prefer the former in severe cases for the first week; infrequent dress- 
 ings, wherever practicable, are most essential. 
 
 * See the case at p. 925. 
 
 f This most yahiable drug is not sufficiently used in these cases. I may brietiy 
 mention three cases in which limbs were, I think, saved by it. One was a very severe 
 compound fracture of the femur in a man, aged forty-six, who fell twenty-two feet on 
 to the bank of the Thames, striking a stone buttress as he went down. I saw him about 
 an hour after the accident. The fragments were much displaced and overlapping, the 
 lower one being also split vertically, but not as far as the knee-joint. The ends of both 
 were bare, and the vastus externus and hamstrings were lacerated, the injury having 
 been made greater by the patient having been lifted off the mud on to which he fell 
 into a boat, and then into a cab. Ether having been given, the external wound, through 
 which the vastus externus protruded, was freely enlarged, and its recesses well washed 
 out with 1 in 30 carbolic-acid solution, as advised above. About 3j of iodoform was 
 then carried down right between the fragments by means of the finger and a narrow 
 spatula, and two large drainage-tubes inserted. An aseptic result was secured from 
 the first and maintained throughout by the dresser (Mr. J. H. Lister), the man making 
 an excellent recovery. The second case was that of a compound comminuted fracture 
 of the leg, with wound of the anterior tibial artery (mentioned at p. 925). The third 
 occurred in a boy with compound separation of the lower epiphysis of the tibia, in 
 which two inches of the protruding diaphysis were removed. The case did so well 
 after the introduction of iodoform and the other precautions already given, that the 
 first dressings (dry sal-alembroth gauze) were not removed till the eighth day, and the 
 lad recovered with an excellent limb. 
 
936 OPERATIONS ON THE LOWER EXTREMITY. 
 
 (iii.) Complications.— My space will only allow me to enumerate these. 
 They are local and general. The former include pruritus, vesicles, 
 ecchymosis, suppuration, oedema, phlebitis, gangrene, ostitis, caries, 
 necrosis, muscular spasms, dislocations, and implication of a neigh- 
 boring joint. The general complications are such as are common to 
 all injuries — viz., traumatic fever, delirium, erysipelas, septicffiniia, 
 pyajmia, hectic, tetanus, jaundice, and retention of urine; in older 
 patients a tendency to hyprostatic congestion and broncho-pneumonia, 
 and finally, in a few cases, pulmonary fat-embolism. 
 
 (iv.) Quedions of Amputation. — The following are amongst the condi- 
 tions requiring primary amputation : (1) When a limb is torn off by a 
 cannon l.)all, aportio-n of shell, or by machinery. (2) When the division 
 of the soft parts is nearly complete, exceiJt in the case of a clean cut 
 across the phalanges, metacarpus, or metatarsus; even the forearm 
 may occasionally be saved under similar circumstances. (3) When 
 there is much actual loss of soft parts, as when one side of a limb is 
 torn away, or the skin is extensively peeled off. (4) ^^'hen, with or 
 without great comminution of the bones, there is much bruising and 
 laceration of the soft parts, with protrusion of muscular bellies, and 
 extensive tearing up of deep planes of areolar tissue. (5) In some 
 cases when the principal artery and nerves of the limb are both 
 divided ; thus, in the case of the lower limb, primary amputation will 
 usually be required. (6) In certain cases of severe lucmorrhage, jjri- 
 mary or secondary. On this subject I must refer my readers to the 
 remarks already made at p. 924. (7) Some cases of compound frac- 
 ture of large joints — viz., when one bone is shattered or more than one 
 is broken : when there is much laceration of the ligaments ; when, in 
 addition to comminution of the bones, there is much contusion of the 
 soft parts, especially if complicated with division of an artery; when 
 the foreign body which has caused the fracture remains in the joint, 
 or, projecting into it from its bed in the bone, cannot easily be removed, 
 or when there is much damage to- the articular surfaces. It will be 
 understood that all these forms of injury are most fatal when affecting 
 the knee or hip ; in dealing with other joints much greater latitude 
 may be allowed. 
 
 Finally, before deciding on amputation, the surgeon must take into 
 consideration, in addition to the above points which concern the frac- 
 ture itself, any general information to be gained about the patient 
 himself. Thus, the age, constitution, habits, any sign of visceral 
 disease, and the appearance of the patient, are all points of material 
 importance in coming to a decision between amputation and an attempt 
 to save the limlx Thus, to make my meaning clearer, there are no 
 more anxious cases than severe compound fractures in dwellers in 
 
TREATMENT OF COMPOUND PRACTLTEES. 937 
 
 large towns, who are past middle life, flabbily fat, with dilated venules 
 about the cheeks and nose, whose conjunctivte are slightly jaundiced, 
 the urine of low specific gravity and perhaps albuminous* The sur- 
 geon must here bear in mind that saving the patient's life is, after all, 
 of more importance than the preservation of his limb. 
 
 In performing amputation in these cases of compound fracture it is 
 always to be remembered that the injury is not so localized as would 
 appear from the surface; thus, in compound fracture of the leg there 
 is often extensive loosening of the skin from the deep fascia, and 
 extravasation of blood into the deep planes of connective tissue for 
 some distance above, the knee joint being perhaps full of blood, and 
 its cartilages bruised. In such cases if amputation be performed just 
 above the injury, sloughing and separation of the flaps will inevitably 
 follow. On the other hand, in cases of severe compound fracture of 
 the thigh, where amputation is required high up, it will be found 
 better practice to ami^utate, in part at least, through injured tissues.f 
 
 If, in addition to the fracture, there are serious injuries to other 
 organs, immediate amputation is useless or injurious. The only 
 chance of recovery here is afibrded by secondary amputation, after the 
 early dangers are past. 
 
 Secondary amputation may be required for profuse suppuration 
 with hectic, for gangrene, or uncontrollable haemorrhage. The decision 
 must here be made according to the needs of each case. The surgeon 
 must, if possible, wait till the traumatic fever and constitutional dis- 
 turbance are subsiding, till the temperature has begun to fall, and till 
 all redness, erysipelas, and sloughing have ceased. On the other hand, 
 if the operation be deferred till the powers of the patient are running 
 down from profuse suppuration and hectic, and till confirmed asthenia 
 has set in, the period of performing it will, very probably, have passed 
 away. 
 
 At a still later period the operation may be desired by the patient 
 if, in consequence of non-union, incurable deformity, or tedious bone 
 disease, the limb has become an incumbrance to him. Some of these 
 conditions may, of course, be treated by resection, osteotomy, etc. 
 
 * Note will also be taken of the occupation, as in brewers, draymen, and commer- 
 cial travellers. 
 
 t Thus, in the case of a young railway porter, whose thigh was smashed by a railway 
 accident at Epsom, I performed amputation at the level of the lesser trochanter, in 
 preference to the hip-joint. The damaged flaps sloughed, as I expected, but the 
 patient made a good recovery, after the removal of some dead bone. The precautions 
 alreadv given against shock (p. 848) will, of course, be taken in these cases. 
 
938 OPKRATIONS ON THE LOWER EXTREMITY. 
 
 CHAPTER VI. 
 
 OPERATIONS ON THE FOOT. 
 
 LIGATURE OF THE DORSALIS PEDIS.— SYME'S AM- 
 PUTATION.— ROUX'S AMPUTATION. -PIROGOFF'S 
 AMPUTATION. — SUB-ASTRAGALOID AMPUTA- 
 TION. -EXCISION OF THE ANKLE.-EXOISION OP 
 BONES AND JOINTS OF THE TARSUS.— EXCIS- 
 ION OF ASTRAGALUS.— EXCISION OF OS CALCIS. 
 -MORE COMPLETE TARSECTOMY FOR CARIES.— 
 REMOVAL OF WEDGE OF BONE FOR TALIPES. 
 — CHOPART'S AMPUTATION. — AMPUTATION AT 
 METATARSO - PHALANGEAL JOINT. — AMPUTA- 
 TION OF THE TOES. 
 
 LIGATURE OF THE DORSALIS PEDIS (Fig. 181). 
 
 Indications. — Very rare. (1) Wounds. (2) Together with the 
 posterior tibial in the lower third, for hfemorrhage from punctured 
 wounds of the sole resisting other treatment. (3) For some vascular 
 tumors of the foot. 
 
 Line. — From the centre of the ankle-joint to the upper part of the 
 first interosseous space. 
 
 Guide.— The above line and the adjacent tendons of the great and 
 second toe. 
 
 Relations : 
 
 In Front. 
 
 Skin, fascise; branches of saphense veins, and of 
 musculo-cutaneous and anterior tibial nerves. 
 
 A special deep fascia continuous with the sheaths 
 of the adjacent tendons. 
 
 Extensor brevis (innermost tendon). 
 
 Outside. Inside. 
 
 Vein. Vein. 
 
 Anterior tibial nerve. Extensor longus pollicis. 
 
 Extensor longus digitorum. 
 
 Dorsalis pedis artery. 
 
 Behind. 
 Astragalus; scaphoid; internal cuneiform. 
 Operation (Fig. 181).— The foot being cleansed, an incision about 
 U inch long is made in the line of the artery, in the lower part of its 
 
syme's amputation. 
 
 939 
 
 course, commencing about li inch below the ankle-joint. Skin and 
 fascuce being cut through, and any superficial veins tied with chromic 
 gut or drawn aside, one of the long extensors is found (its sheath is 
 not to be opened), and the strong fescia given off from them opened 
 it the extensor brevis cross the artery at this spot it must be drawn 
 aside. The ligature should be passed from without inwards. 
 
 SYME'S AMPUTATION (Pigs. 182, 185, 189). 
 
 An amputation at the ankle-joint by a heel-flap, with removal of 
 the malleoli. 
 
 Operation.— Hemorrhage being controlled, any sinuses present 
 scraped out, the foot bandaged,* and held at right angles to the leg, 
 
 Fig. 181. 
 
 Fig 182. 
 
 Y ; 
 
 • 
 
 The dorsalis pedis (too much 
 of the artery is shown clean) is 
 seen lying between the extensor 
 longus pollicis and digitorum, 
 and crossed by the innermost 
 tendon of the short extensor. 
 
 The parts in a Syme's am- 
 putation before the heel-flap 
 is adjusted (left side). The 
 bones are shown above with 
 the extensor tendons and the 
 anterior tibial vessels, and, 
 below, the tendo-Achillis. On 
 the inner side the flexor ten- 
 dons and the plantar arteries 
 are shown cut ; on the outer 
 side, the perontei. This Fig. 
 should be contrasted with Fig. 
 187. 
 
 the surgeon, standing a little to the right, but so as easily to face the 
 sole, makes, with a short, strong knife, an incision (in the case of the 
 left foot) from the tip of the external malleolus to a point i inch 
 
 * So as to j^ive a grip, and also to prevent the assistant's hands from being septic 
 when he holds the stump a little later. 
 
940 OPEEATIONS ON THE LOWER EXTREMITY. 
 
 below* the internal one, this incision not going straight across the 
 sole as in Pirogoff's amputation, but pointing a little backwards to- 
 wards the heel.f The horns of this incision are then joined by one 
 passing straight across the joint,! and severing everything at once 
 down to the ankle-joint. -The foot being now strongly bent down- 
 wards, the lateral ligaments are severed, and the joint thus fully 
 opened. The foot being slightly twisted from side to side, the soft 
 parts on either side are carefully divided, especial precautions being 
 taken on the inner side to cut the posterior tibial artery as long as 
 possible (to ensure getting below the internal calcanean) and not 
 to prick it afterwards. 
 
 The foot being still more depressed, the upper non-articular surface 
 of the OS calcis comes into reach, and then the tendo-Achillis. This 
 is severed, and the heel-flap next dissected off the os calcis from above 
 downwards, especial care being taken to cut this flap as thick as pos- 
 sible, not to score or puncture it, but rather to peel it off the bone with 
 the left thumb-nail kept in front of the knife, aided by touches of 
 this.§ 
 
 The foot having been removed, the soft parts are carefully cleared off 
 the malleoli, and a slice of the tibia sufficiently thick to include these 
 prominences removed. The slice should in any case, to avoid shorten- 
 ing, be the thinnest possible. Prof. Macleod|| has recommended to 
 remove only the malleoli, leaving the cartilage on the under surface 
 of the tibia. I have followed his advice in my last two cases — one a 
 private patient of sixty-three ; here I had not the carrying out of the 
 after-treatment, and the cartilage exfoliated. The other was a much 
 younger patient, who, in addition to the disease of the tarsus, had 
 active secondary syphilis ; in spite of pulpy sinuses which required 
 
 * The directions usually given are to go behind this point as well as below it, bnt 
 by following the above course the posterior tibial is more likely to escape section be- 
 fore its time, and the flap will be found sufficiently symmetrical. 
 
 f If the foot is small, and still more if the parts on the dors\im are damaged, the 
 plantar incision should run straight across. On the other hand, the more prominent 
 the lieel, the more should the flap point backwards. This will facilitate turning the 
 flap over the heel. 
 
 t Or with a very slight convexity. If anything of a flap is made here, the operator ■ 
 is liable to get away from the joint and cut into the neck of the astragalus. Moreover, 
 the parts are not well nourished, especially if sinus-riddled or undermined. 
 
 J If, in a young subject, the epiphysis comes away in the heel-flap, it mav remain 
 there if the parts are healthy. The same course may be followed with the periosteum, 
 if it is found loose and peels easily away. Mr. Johnson Smith, when amputating both 
 feet for frost-bite, left the periosteum on one side. On the other no attempt was made 
 to save it. The first stump was much larger than the other, harder, and more rounded ; 
 more like that of a Pirogoff's amputation. 
 
 11 Brit. Med. Journ., 1869, vol. ii. p. 239. 
 
syme's amputatiox. 
 
 941 
 
 repeated scraping out (Fig. 185), no exfoliation took place. If the 
 stump can be kept aseptic, Prof. Macleod's advice seems to me well 
 worth a further trial, as it entails less shortening of the Hmb and does 
 away with the risk of septic phlebitis, which may be brought about 
 by opening the cancellous tissue. If, on the other hand, the lower 
 end of the tibia is diseased, it must be removed and the sawn surface 
 gouged or treated with a sharp spoon. If the cartilage is only slightly 
 
 Fig. 183. 
 
 Roux's amputation at the ankle-joint by an internal flap. Below is shown a foot 
 upon which the operation has been performed. (Smith and Walsham.) 
 
 diseased, it may be sliced off with the knife, and here and there 
 treated with a gouge. 
 
 Tendons are now cut short, sinuses laid open or thoroughly scraped 
 out, and the vessels secured. Free oozing is often present in chronic 
 pulpy cases, or where the periosteum has been left in the heel-flap. 
 It is best treated by firm pressure with dry dressings, and elevation 
 of the stump. Drainage being provided, the sutures are inserted ; 
 where many sinuses have been present along* the line of the incision, 
 it is no good uniting the wound too closely. 
 
 * Sinuses which have been scraped out will give good drainage if enlarged If any 
 puncture has been made in the heel-flap, it should be utilized for the sanae purpose. 
 
942 
 
 OPERATIONS ON THE LOWER EXTREMITY. 
 
 Roux's Modification of Syme's Amputation— In cases 
 where a satisfactory heel-flap cannot be obtained, an efficient substi- 
 tute can be got by a large internal flap. 
 
 The incision is commenced at the apex of the outer malleolus and 
 carried half across the front of the ankle-joint, from whence it should 
 run inwards in an oblique direction over the astragalo scaphoid 
 ioint, then pass, in a curved manner, downwards and backwards to 
 the middle Hue of the sole of the foot, and, running along the under 
 surface of the heel, must ascend the posterior aspect of that part, and 
 
 Fig. 184. 
 
 Eoux's amputation. The incisions shown from the outer and the inner side. 
 (Stimson.) 
 
 terminate at the outer malleolus, where it commenced. The ankle- 
 joint should be opened at its upper and outer part, the calcis dissected 
 from its connections, the malleoli and a slice from the articular sur- 
 face of the tibia removed, and the' operation will be complete. The 
 shape of the flap will be gathered from the appearance of a foot 
 operated upon (Fig. 183). 
 
 Causes of Failure after Symes Amputation.— (1) Sloughing 
 of the heel-flap. This is nearly always due to faulty operating, to 
 scoring or " button-holing " the flap, or to dividing the posterior tibial 
 high up.* 
 
 (2) Persistence of sinuses and pulpy disease. If, in spite of repeated 
 scraping out (Fig. 185) with the aid of anesthetics, this condition 
 
 Where a diseased foot has been long on a back splint, the skin over the tendo-Achillis 
 may be so thinned that it is advisable to make a counter-puncture heEe and insert a 
 tube. 
 
 * If possible, the cut ends of the two plantar arteries should always be seen, and 
 not the single mouth of the posterior tibial. In the former case the surgeon is certain 
 that the main vessel is divided below the internal calcanean branch. 
 
pirogoff's amputation. 
 
 943 
 
 recurs mveterately and spreads along the sheaths, the limb must be 
 amputated higher up. This will, however, be rarely called for with 
 perseverance on the part of the patient and surgeon, and a determi- 
 nation on the part of the latter to treat this condition as a kind of 
 malignant disease. If one or two sinuses remain, and look likely to 
 persist, scraping out should be resorted to at once. 
 (3) Recurrence of caries in the tibia. 
 
 PIROGOFF'S AMPUTATION (Figs. 186, 187, 188, 189). 
 
 An amputation at the ankle-joint, in which the posterior part of the 
 OS calcis is retained and united to the sawn surface of the tibia. 
 
 Question of the Value of this Operation especially as com- 
 pared with Syme's Ampu.ta,tion.~Dimdva7itages .- These have 
 
 Fig. 185. 
 
 Fig. 186. 
 
 Fig, 185. — A Syme's stump soundly healed after scraping out of sinuses had been resorted to. 
 The patient was sent to me by Dr. Fraser, of Romford, and had active secondary syphilis as 
 well as extensive caries of the tarsus. 
 
 been put prominently forward by Scotch surgeons. 1. The amputa- 
 tion is not suited for cases of disease, except of distinctly traumatic 
 origin in young healthy subjects. 2. Occasionally the sawn os calcis 
 fails to unite, causing either a kind of movable joint or necrosis. 3. 
 It is said by some that the stump is more difficult to fit with an arti- 
 ficial foot.* The first two objections are undoubted, but I think that 
 they are quite outweighed by the Advantages : 1. No dissection of the 
 
 * Prof. Macleod thinks that the presence of the heel is here " a great drawback, and 
 that the back of the heel, not the firm plantar pad, is what comes in contact with the 
 ground." 
 
944 
 
 OPERATIONS ON THE LOWER EXTREMITY. 
 
 heel-flap is needed. 2. The blood-supply is less interfered with. 3. 
 The stump is firmer and more solid. 4. The stump is longer by 1 or 
 1 J inch, often more.* 5. The stump does not go on wasting, as is the 
 case after a Syme's amputation.f 6. Dr. Hewson (Amer. Jourii. Med. 
 Sci, 1864, pp. 121, 129) has pointed out that, in a Pirogoff, the origin 
 and insertion of the gastrocnemius being both intact, the combined 
 movements of the knee and ankle are preserved, as in running, etc. 
 
 Operation.— The position of the patient's foot and the surgeon 
 being as at p. 939, an incision is made, straight across the sole, from 
 the tip of the external malleolus to a point i inch below the internal 
 one.J This incision goes right down to the bone. Its horns are then 
 joined by a transverse cut across the front of the ankle. The lateral 
 ligaments are now severed, care being taken to cut inside the malleoli 
 and to divide the posterior tibial artery as long as possible — i.e., below 
 
 Fig. 187. 
 
 Fig. 188. 
 
 Fig. 188.— PirogofiPs amputation as modified by Dr. E. Watson. (Smith and Walshiam.) 
 
 its origin into the two plantar — and not to prick it after it is divided. 
 With a few touches of the knife at either side of the astragalus, aided 
 by twisting of the foot from side to side and forcible bending of it 
 downwards, the non-articular part of the upper surface of the os calcis 
 comes into view (Fig. 186). A groove is now cut through the fatty 
 tissue and the periosteum, and the saw applied just in front of the 
 
 * Dr. Hewson (loc. infra cit.) gives the shortening after a Pirogoff as from 1 .to 2 
 inches; that after a Syme as 2J to 3 inches. 
 
 t The continuance of tliis wasting is shown by the hospital patient being for soine 
 time obliged to stuff the socket of his elephant-boot with a sock. It ih^ not intended 
 by this to depreciate the value of a Syme's stump. Every surgeon knows how mnch 
 good, life-long work the heel-flap is capable of however ranch it shrinks, as long as it 
 has healed. 
 
 % I.e., not pointing backwards. 
 
pieogoff's amputation. 945 
 
 tendo-Achillis, obliquely downwards and forwards, care being taken 
 to bring It out through the incision in the heel. The foot bein«- 
 removed, the soft parts around the bones of the leg are carefully 
 cleared to a level just above the tibial articular surface and the 
 malleoli. The saw is next applied in the reverse direction to that 
 just given— viz., from below upwards and backwards, and slightly 
 obliquely. 
 
 The vessels, the tibials, anterior peroneal, and perhaps one or both 
 malleolars, having been secured, the tendons cut square, the bony sur- 
 faces are placed in contact, and, if needful, drilled with a clean bradawl 
 and united with wire or stout chromic gut.* 
 
 If it is found advisable to convert the Pirogoff into a Syme, all that 
 is needed is to divide the tendo-Achillis and to dissect out the part of 
 the OS calcis, keeping the knife close to the bone. 
 
 Modifications of Pirogoff's Amputation.— One of the chief of 
 these is that introduced by Dr. E. Watson {Lancet, 1859, vol. i. p. 
 577). He claims— (1) That it is shorter and easier, the trouble of 
 disarticulation being avoided. (2) That it is less likely to damage 
 the posterior tibial artery. (3) That it does away with one of the 
 chief difficulties in a Pirogoff's amputation for injury— viz., the want 
 of purchase over the smashed parts while the os calcis is being sawn 
 through. 
 
 Operation. — The operator, standing as before, having cut across 
 the sole from the tip of one malleolus to the corresponding point (p. 
 939) down to the bone, introduces a small Butcher's saw, or one with 
 a narrow blade, into this wound, and saws off the posterior part of the 
 OS calcis by carrying his section upwards and backwards. This and 
 the heel being now retracted by an assistant, the surgeon, resuming 
 his knife, cuts upwards behind the ankle-joint between the sawn 
 bones. The ends of the first incision are now joined by one passing 
 between them, the skin being pulled up a little and the tendons and 
 vessels severed down to the tibia and fibula just above the ankle-joint. 
 Lastlj', these bones are sawn through in a slanting manner by direct- 
 ing the saw from before backwards and downwards. f While the bones 
 of the leg are being sawn the heel-flap should be held well up against 
 the back of the leg to keep it out of the way. 
 
 * If the patient is young and healthy, this step is not ab.sohitely needful. I would 
 recommend it in other cases. Thus I have made use of it in a Pirogoflf's amputation 
 for inveterate infantile paralysis, with eycellent results. If wire be used, it must be 
 left long. A little ether will probably be needed when the wire is removed. 
 
 f It will be noticed that the direction of the bone section above given by Mr. Watson 
 is contrary to that usually taught. 
 
 60 
 
946 
 
 OPERATIONS ON THE LOWER EXTREMITY. 
 
 SUB-ASTRAGALOID AMPUTATION (Fig. 189). 
 
 This amputation, very rarely practiced in England, has, I believe, 
 largely replaced that of Chopart in Prance. The following account is 
 taken from Dr. Stimson :* 
 
 " The guides to this operation are the tip of the external malleolus 
 and the head of the astragalus. The joint must be entered from in 
 front on the fibular side, and the strong interosseous ligament which 
 forms the key to the articulation must be divided, step by step, from 
 before backwards and inwards. The posterior tibial vessels must be 
 carefully avoided. 
 
 " Beginning at the outer side of the heel nearly 1 inch below the tip 
 of the external malleolus, an incision' extending through to the bone 
 is carried straight forward to the base of the fifth metatarsal bone. 
 
 Fig. 189. 
 
 v^ 
 
 1. The incisions in Pirogoflf's amputation. The dotted line sliows the direction of the plantar 
 incision in that of Syme. 2, The incisions in sub-astragaloid ; and 3, Those in Chopart's ampu- 
 tation. 
 
 thence curving forwards across the dorsum of the foot to the base of 
 the first metatarsal, thence obliquely backwards and outwards across 
 the sole of the foot and around its outer border, rejoining the first 
 horizontal part of the incision at the calcaneo-cuboid joint. The soft 
 parts must be separated from the outer surface of the calcaneum and 
 cuboid with division of the peroneal tendons, the dorsal flap dissected 
 
 * Man. of Oper. Surg., p. 133. 
 
EXCISION OF THE ANKLE. 947 
 
 back to the head of the astragalus, and on the inner side beyond the 
 tubercle of the scaphoid, thus dividing the tendon of the tibialis anticus 
 and the anterior portion of the internal laternal ligament The inter- 
 osseous hgainent can then be easily reached by depressing the toes 
 passing the knife between the astragalus and scaphoid, and cutting 
 backwards and inwards along the under surface of the former. The 
 sott parts on the inner side are then separated from the calcaneum 
 injury to the vessels being avoided by keeping close to the bone 
 between it and the tendons of the flexor communis, the foot depressed, 
 and the tendo-Achillis divided. This last is a very difficult part of 
 the operation, and great care must be taken to keep the edge of the 
 knife close to the bone so as not to cut through the skin. The poste- 
 rior tibial nerve should be dissected out and cut off as high as possible, 
 so that it shall not be pressed upon in the stump." 
 
 EXCISION OF ANKLE. 
 
 This operation is one of very disputed value, and thus rarely per- 
 formed. Objections: (1) Disease here is often associated with disease 
 of the tarsus. (2) Even if the wound heals, the foot left is often of 
 little use. (3) Syme's amputation affords not only a radical cure, but 
 a most excellent stump. This may be imperilled by a previous exci- 
 sion of the joint. 
 
 Indications. — These, which are very few, must be considered 
 separately, according as they fall under the head of A. Dimm, B. 
 Injury. 
 
 A. Disease. — (1) The patient must be young and healthy, witfi no 
 evidence of other strumous disease, or of phthisis or syphilis. (2) The 
 disease should be of traumatic origin — e.g., following a sprain — and 
 (3) limited to the bones which form the joint, the whole astragalus 
 being taken away if needful. To another class of cases in which this 
 operation has been too often performed — viz., where the patient's 
 health is reduced by discharge, pain, hospital air, etc., where other 
 tarsal bones are involved — this excision is not applicable; it is here 
 much severer than amputation, and leaves the patient most liable to 
 recurrence.* 
 
 * In Mr. Holmes's words {Sy.it. of tiurg., vol. iii. p. 766), in the first class of cases 
 "the inflammatory softening or suppuration does not usually extend far from the 
 neighborhood of the joint originally implicated, and, after the removal of the diseased 
 bone, the parts take on a healthy action and become rapidly consolidated. In strumous 
 disease, on the other hand, inflammatory softening, if not diffused suppuration, often 
 exists in the tarsal bones or bones of the leg in parts not exposed to view in the opera- 
 tion ; and, in patients laboring under general constitutional affections, the parts 
 operated on, instead of consolidating, usually soften, and iifter a long and exhaustive 
 suppuration the bones are found carious, leaving no resource except amputation, and 
 that sometimes under unfavorable circumstances." 
 
948 OPEEATIONS ON THE LOWER EXTREMITY. 
 
 The chief points in excision of the ankle-joint which have been 
 raised as objections to the operation are: (1) The difficulty office ex- 
 posure of the parts to be dealt with ; (2) The frequency with which 
 other bones are diseased. Thus, Mr. F. Jordan* strongly objected to 
 the operation on the ground that the astragalus is not a long bone 
 with an epiphysis in which the chief disease may lie, but a short bone 
 consisting of a mass of cancellous tissue throughout which the disease 
 is more or less diffused. This objection may be answered by the fact 
 that if the disease in the astragalus is found not to be limited to the 
 upper articular surface, it will in no way interfere with the results if 
 the whole bone is removed.f And this fact will meet another objection 
 to excision of the astragalus made by Prof. Syme — viz., that the fre- 
 quency with which disease of the astragalus originates on the under 
 surface of this bone (i.e., between it and the os calcisj) calls rather for 
 amputation than excision. (-3) The difficulties of securing afterwards 
 a splint which will combine the three following essentials, viz., (a) 
 Sufficient rest; (b) Sufficient exposure for needful change of dress- 
 ings ; (c) The possibility of antiseptic treatment. 
 
 B. Injury. — In a young, healthy patient, where the vessels and 
 nerves are mainly intact, where the mischief is limited to the ends of the 
 bones, an attempt to save the limb by excision, partial or complete, is 
 abundantly justified. The steps given at p. 934 for the antiseptic 
 treatment of compound fractures should be carefully attended to, as 
 to the preservation of periosteum, the due providing of drainage, etc. 
 As to gunshot injuries, Dr. Otis§ thought that " the substitution of 
 exctsion of the ankle-joint for amputation effected no saving of life," 
 formal excisions being rarely successful. 
 
 Operation. — This may be either bj' two lateral incisions, or by a 
 transverse one, dividing the extensor tendons, which are sutured 
 afterwards. 
 
 Excision by Lateral Incisions. — An Esmarch's bandage being 
 applied above, and the parts rendered evascular as well, the foot is 
 
 * Lancet, 1867, vol. i. p. 729. 
 
 t Mr. Holmes, whose experience of this operation is a large one, advises (Brit. Med. 
 Journ., 1878, vol. ii. p. 875) that the whole of the astragalus should always be removed, 
 for these reasons — (1) As it is often softened to a considerable depth, mere removal of 
 its articular surface will often leave disease behind ; (2) in patients low in health, or 
 of strumous constitution, the violence done by the saw may prove the starting-point 
 of renewed caries; (3) the bones of the leg unite quite as Brmly to the exposed carti- 
 laginous surfaces of the os calcis and scaphoid as they do to the sawn surface of the 
 astragalus; (4) the shortening is not appreciably increased ; (5) the difficulty of the 
 operation is lessened (p. 949). 
 
 X Instances of extensive removal of the bones of the tarsus are given at pp. 954 
 955, 956. 
 
 J Med. and Surg Hist, of the War of the Rebellion, pt. iii. p. 610. 
 
EXCISION OF THE ANKLE. 949 
 
 laid upon its inner side firmly supported on a sand-bag. An incision 
 is made along the lower 2^ inches of the posterior border of the fibula 
 and then, when it has reached the tip of the malloolus, it is carried 
 downwards and forwards at an angle to within an inch of the base of 
 the fifth metatarsal bone. A slight flap is now sufl^iciently dissected 
 forwards to expose the bone and to clear the peronei ; these being 
 drawn aside, the bone is divided with a narrow saw or cutting-forceps 
 about 2 inches above the malleolus, and removed after division of the 
 external lateral ligament. This wound is now covered with carbolized 
 lint and the foot turned over, and a similar angular incision made 
 along the lower 2 inches of the inner margin of the tibia, and then 
 forwards and downwards as far as the projection of the internal 
 cuneiform bone.* A flap being dissected slightly inwards, the tendons 
 of the tibialis and flexors are exposed and retracted,t the knife being 
 kept close to the bone so as to avoid the posterior tibial vessels. 
 
 The internal lateral ligament is now cut through close to the tibia, 
 and on displacing the foot outwards the tibia and astragalus present 
 in part at the inner wound. A metacarpal saw being next passed from 
 the inner to the outer wound, the lower end of the tibia is sawn off 
 sufficiently high up to secure a healthy section of bone and no more. 
 The astragalus is next treated similarly,^ all the articular cartilage 
 being removed. Any soft patches of bone are next gouged, and pulpy 
 material snipped away from the synovial sheaths of the tendons, etc. 
 All sinuses are next scraped out or laid open. The only vessels which 
 will require tying are some branches of the peroneal and the malle- 
 olar, none of any importance being divided. Very few, if any, sutures 
 should be used, so as to allow of very free drainage. 
 
 Excision by Transverse Incision. — The parts being rendered 
 evascular, an incision is made transverselj' across the front of the 
 ankle-joint from the tip of one malleolus to the other. The extensor 
 tendons being divided, the anterior and lateral ligaments severed, the 
 end of the tibia is exposed, a way cleared for the saw just above the 
 malleoli, and a slice removed. The upper articular surface of the 
 astragalus is then treated in the same way, the peroneal and flexor 
 
 * The lower extremities of these incisions need not go down to the bones. 
 
 t Unless these tendons are sufficiently freed from their connection with the lower 
 end of the tibia, difficulty will be met in everting the foot sufficiently to bring the tibia 
 out of the wound (Hancock, Lancet, 1867, vol. i. p. 731). 
 
 X If the disease here is at all extensive, this bone should be entirely removed (p. 
 948). If a section only of the astragalus is taken, much difficulty will be met in re- 
 moving the upper articular surface. Thus, unless the saw be directed properly, the 
 astragalo-scaphoid or astragalo-calcanean joints may be opened. To meet the difficulty 
 of fixing the foot the heel should be held in the left hand, and the upper surface of 
 the astragalus is pressed against the cut end of the tibia, while an assistant holds the 
 leg firmly on, and a little over, the edge of the table (Porter, Brit. Med. Journ., 18"8, 
 vol. ii. p. 792). 
 
950 OPERATIONS ON THE LOWER EXTREMITY. 
 
 tendons being drawn aside while the bones are sawn. Any dead bone 
 is gouged away and pulpy tissue removed, as mentioned above. 
 Hemorrhage being arrested, several of the divided tendons — e.g., the 
 tibialis anticus, two or three of the extensor tendons — are sutured 
 with chromic gut or carbolized silk. 
 
 In either of the above operations ever}' care must be taken to pre- 
 serve the periosteum, especially where this is softened and loosened. 
 A suitable splint is always a difficulty in these cases. On the 
 whole, a back splint and foot-piece, and two side splints, all being 
 padded with gauze, will be found most suitable for the first ten or 
 fourteen days ; the side splints, being secured with straps and buckles, 
 readily admit of removal so as to change the dressings. If all the 
 disease lias been taken away, and due drainage provided, the dress- 
 ings will need changing very infrequently. After the first fortnight 
 the limb may be put in Mr. Croft's method of plaster-of- Paris, or with 
 plaster-of-Paris and a Nathan Smith's metal bar shaped to the leg 
 and inste25, with two windows at the sides or one anteriorly. Another 
 arrangement which answers well with a quiet patient is to put up the 
 limb on its outer side, with the knee flexed, on an outside angular 
 splint interrupted opposite the wound, the splint being duly sup- 
 ported with pillows. If the external wound is left freely open, this 
 method gives good drainage. 
 
 EXCISIONS OP BONES AND JOINTS OF TARSUS. 
 
 Before considering these separately, I would invite attention to the 
 following practical points : 
 
 i. Those cases are the least hopeful in which there is no history of 
 injury, in which there is evidence of a strumous constitution, or per- 
 haps of disease dating to an exanthem and coupled with the above 
 constitution; cases in which the patient is wan and sickly with long 
 lasting pain and sleeplessness ; cases in which the parts are much 
 swollen, dusky red, and glossy, with sinuses numerous or excavated, 
 giving vent to watery, ill-smelling discharge— all points denoting a 
 disease that is not limited to one joint or to few bones. 
 
 ii. Mere laying open, and, still more, injection, of sinuses where 
 there is disease of the tarsus is absolutely useless in most cases. 
 
 iii. When a patient is under care for caries of the foot, his lungs 
 should always be carefully examined before operative treatment is 
 undertaken. 
 
 iv. When the amount of disease present is being estimated, it must 
 be remembered that patients, especially children, will often use their 
 feet with much freedom, limping, even bearing their weight on their 
 toes with the aid of a crutch, though all the time extensive disease is 
 present. 
 
EXCISION OP THE ASTRAGALUS.. 951 
 
 V. That before an operation the parts should always be rendered 
 absolutely avascular by the use of Esmarch's bandage8,=i= and that 
 thus the hmit of the disease should be defined as accurately as 
 possible. 
 
 vi. Sub-periosteal excision is only advisable in the case of single 
 bones where the periosteum is already thickened and loosened, and 
 that in other cases it is not of such great advantage as to justify any 
 considerable prolongation of an operation. 
 
 yii. Strict antiseptic precautions should be made use of wherever 
 this is possible, because— (a) Prolonged suppuration will exhaust a 
 patient, whose powers are already sufficiently handicapped by dis- 
 ease and operation; (b) suppuration will cause destruction of the 
 periosteum, and thus fresh caries and necrosis; (c) interference with 
 inflamed bones may, if sepsis result, easily cause osteo-myelitis and 
 pyasmia. 
 
 viii. When the question arises between excision and amputation, 
 when the powers of repair have been duly considered, the question of 
 time and the ranli of Hfe should also be remembered. Thus, after an 
 extensive excision, six months will probably be required before the 
 toot can be used, but only three months after an amputation. The 
 time in the first case may after all be wasted, a point of much impor- 
 tance when the questions of schooling, learning a trade, etc., have to be 
 considered. 
 
 ix. No use of a foot can be permitted after an operation till firm 
 consolidation is obtained. 
 
 X. If pulpy mischief persist after an operation, the shnrp spoon 
 must be freely used, together with laying open sinuses, snipping away 
 of undermined skin, etc. If all carious bone has been removed, the 
 above steps may be repeated again and again here, as in the knee, 
 with ultimate success. 
 
 EXCISION OP THE ASTRAGALUS.f 
 
 Indications — These will be for A. Disease, B. Injury. Both are 
 rare. 
 A. Disease. — (1) Caries of the bone, especially when comparatively 
 
 * This is disputed by some. I strongly advise it. Tiie free oozing after this 
 mettiod may be met by tying any vessels which are seen in the absolutely dry wound, 
 and then plugging this with strips of sal-alembroth or iodoform gauze, around a 
 drainage-tube, bandaging firmly over well-applied dressings before the Esmarch's 
 bandage is removed, and giving sufficient morphia in the first twelve hours. This 
 dressing will seldom require removal for several days, when the strips must be 
 thoroughly soaked before removal. 
 
 f A good instance of the occasional value of this operation has been given by my 
 old friend Oeorge Wright (Pendkbury Abstracts, 1884, p. 124). The case was one of 
 
952 OPERATIONS ON THE LOWER EXTREMITY. 
 
 recent and of traumatic origin in a young and healthy patient, and 
 when the disease is found to be limited to the upper surface. (2) In 
 disease of the astragalo-calcanean joint, where it is thought, from the 
 position of the sinuses, etc., to be more advisable to expose this joint 
 by removing the astragalus than the os calcis. (3) Talipes : excision 
 of the astragalus for these affections has been mainly replaced by 
 removal of wedges of bone (p. 956). 
 
 B. Injury. — (1) Primarily, (a) In simple dislocation of the astrag- 
 alus not reducible with the aid of anaesthetics and tenotomy of the 
 tendo-Achillis and the tibials or extensors, if it seem certain that the 
 skin will slough, (h) In compound dislocation of the astragalus 
 when the bone is too far displaced or comminuted to admit of re- 
 placement, and when the condition of the soft parts, vessels, and 
 tendons does not call for amputation. Secondarily, when the foot is 
 useless and painful. In these cases, especially, strict antiseptic pre- 
 cautions must be taken and free drainage provided. 
 
 Operation. — This may be performed by two lateral or a transverse 
 incision, with suture of the tendons. On account of the freer exposure 
 given, I prefer the latter. The parts being rendered evascular, the 
 bone is exposed by an incision crossing the dorsum between the 
 malleoli, as in Syme's amputation ; the tendons are cleanly cut, and 
 the astragalus exposed. At this stage all that may be required is to 
 remove a sequestrum from the upper surface of the neck of the bone. 
 The ligaments must be divided by carefully keeping the knife close 
 to the bone* while this is twisted out in the grasp of lion-forceps, 
 aided, if needful, by the levering movements of an elevator. f If the 
 astragalo-calcanean joint is found diseased, this must be now attended 
 to with chisel, gouge, and sharp spoon. The scaphoid is next ex- 
 amined. All jiulpy material being removed, hemorrhage is arrested, J 
 the chief tendons sutured, and the centre of the wound closed, the 
 sides being left open for drainage. 
 
 severe talipes valgus, due to infantile paralysis of a ye:\r's standing. The reaction of 
 the muscles to Faradism was extremely poor. ''The deformity clearly depended on a 
 partial sub-astrag.aloid dislocation." The bone was removed by an incision along the 
 inner border of the tibialis anticus, and a shorter one meeting this between the tibialis 
 anticus and posticus. No tendons were cut; one small vessel required twisting. The 
 foot could be inverted into good position after removal of the bone. Twelve months 
 later the child could walk painlessly and much more freely, without eversion, and 
 with a good arch. 
 
 * Especially at the back and on the inner side. 
 
 t Care must be taken in using this not to bruise any soft bone which is used as a 
 fulcrum. 
 
 X The dorsalis pedis should be secured, and oozing met by plugging the wound 
 with strips of sal-alembroth gauze and iodoform, the ends of the strips being brought 
 out at the sides. 
 
EXCISION OF THE OS CALCIS. 953 
 
 Mr. Barker {Man. of Surg. Oper., p. 175) recommends an incision 
 running from just above the tip of the external malleolus forwards 
 and a little inwards, curving towards the dorsum of the foot. This 
 will cross a space between the perona3i tendons, in which no struc- 
 tures of much importance are found, and may go straight down to 
 the bone at once. If the foot is now turned well inwards and ex- 
 tended, the astragalus is easilj^ exposed and removed. 
 
 EXCISION OF THE OS GALOIS. 
 
 Practical Remarks.— Disease here is not infrequent, and often 
 remains limited to this bone for a long time. It may commence in 
 one of three sites — viz., (a) the posterior epiphysis, which, not appear- 
 ing until the tenth year, does not unite till between the fifteenth and 
 nineteenth years ; (ft) the body of the bone ; (c) the calcaneo-astraga- 
 loid joint, either de novo, or as an extension of the last. The diagnosis 
 of primary disease in this joint is often difficult; thus the swelling 
 and position of the sinuses recall disease of the ankle-joint. The pain 
 is usually greater than in ordinary disease of the os calcis itself, and 
 the foot is sooner disabled. With an anaesthetic, the ankle-joint is 
 found free, and probes introduced by sinuses may pass towards the 
 level of the upper surface of the os calcis (known by the tubercle for 
 the extensor brevis). 
 
 Operation. — The parts being rendered evascular and the foot 
 firmly supported on its inner side at the edge of the table, an in- 
 cision* is made with a strong-backed scalpel, commencing at the 
 inner edge of the tendo-Achillis, and passing along the upper border 
 of the os calcis (vide supra) along the outer border of the foot as far 
 as the calcaneo-cuboid joint, which lies midway between the outer 
 malleolus and the fifth metatarsal bone. This incision should go 
 down at once upon the bone, so that the tendon should be felt to 
 snap as the incision is commenced. Another incision is then to be 
 drawn vertically across the sole, commencing near the anterior end of 
 the first and terminating just short of the inner surface of the os 
 calcis, beyond which it should not extend for fear of wounding the 
 posterior tibial vessels. The bone being now exposed by throwing 
 back the flap, the calcaneo-cuboid joint is first found and opened. 
 The peronasi must be dissected outf and drawn aside with a blunt 
 hook. The astragalo-calcanean joint is next attacked, and the close 
 
 * The above incision is taken from Mr. Holmes's article, Syst. of Surg., vol. lii. 
 
 p. 771. 
 
 t Mr. Holmes (loc. supra cit ) says that he has always divided these without ill 
 effect. Care must be taken in drawing them aside, for, if this is done too vigorously, 
 one may slough, as happened to me in one of my cases. 
 
954 OPERATIONS ON THE LOWER EXTREMITY. 
 
 connection between the bones at this point constitutes the principal 
 difficulty of the operation, unless the joints have been destroyed by 
 disease. This difficulty can best be met by grasping the bone firmly 
 with lion-forceps, and wrenching it backwards and outwards, aided 
 by levering movements of an elevator, and a knife-point kept very 
 close to the bone. Especial care must be taken on the inner side to 
 avoid the vessels. The bone being removed, any vessels which can 
 be seen are secured, a drainage-tube is inserted, and the gap around 
 it plugged with gauze. 
 
 The question of preserving the periosteum has already been re- 
 ferred to, p. 951. Some good cases of excisions of tarsal bones are 
 recorded by Mr. Holmes, Syst. of Sarg., vol. iii. p. 769 et seq., and Surg. 
 Treat, of Children's Bis., chap. xxiv. 
 
 OPERATIONS FOR MORE COMPLETE TARSEGTOMY. 
 
 It is scarcely worth while to give directions for the removal of other 
 single bones — e.g., the scaphoid and cuboid — as these are rarely dis- 
 eased alone, and, if this should be so, their removal is easy. 
 
 The operations of Mickulicz and of Dr. P. H. Watson will be 
 described to meet those cases where more extensive disease is present, 
 and where the patient's age and condition justify a trial of these 
 severe operations instead of amputation. 
 
 Operation of Mickulicz.*— The object of this operation is to 
 procure an artificial pes equinus, and to preserve the toes and meta- 
 tarsals, these being brought into a straight line with the leg and the 
 toes bent at a right angle, so that the patient walks on the ends of the 
 metatarsal bones covered by the thick pads of tissue, which invest them ; 
 a broader surface of support is provided than after Syme's or Piro- 
 goff 's amputations, and there is some elasticity of the foot left. It is 
 especially indicated in cases where the bones of the heel and the soft 
 parts covering them are extensively diseased. 
 
 Sir W. MacCormac's patient was aged fifteen, and the disease dated 
 to a sprain of the ankle. On the lad's admission the swelling and 
 sinuses pointed to disease of the os calcis; later on, the ankle-joint 
 became involved. Amputation being refused. Sir W. MacCormac 
 operated thus: "The patient was placed in the prone position. If 
 it be the right foot, the knife is introduced on the inner border of 
 the foot, just in front of the scaphoid tubercle, and a transverse in- 
 cision, extending to the bone, is made across the sole to a point a 
 little behind the tuberosity of the fifth metatarsal. On the left foot 
 
 * The account of this is taken from a paper of Sir W. MacCormac (Lancet, May 5, 
 1888), four figures accompanying this. Miclculicz's paper will be found in Langen- 
 beck's Arch., 1881, Bd. xxvi. S. 191. 
 
TAESECTOMY. ggg 
 
 the direction of this incision will be reversed. From the inner ■nid 
 outer extremities of the wound incisions are prolonged upwards and 
 backwards over the corresponding malleolus, and their extremities 
 united by a transverse cut across the back of the leg, down to the 
 bone, at the level at which it is to be sawn, usualfy immediately 
 above the joint surface of the tibia. In cases where a larger removal 
 ot the tibia and fibula is required, the lateral incision must be more 
 oblique, and the posterior transverse cut made at a higher level. The 
 ankle-joint is now opened from behind, the disarticulation completed 
 and, after flexing the foot, the soft parts are carefully separated in 
 front until the medio-tarsal joint is reached, through which disarticu- 
 lation IS effected as in Chopart's amputation. The heel portion of the 
 foot, consisting of the astragalus, calcis, and the soft parts covering 
 them, is thus removed. The articular surfaces of the tibia and fibula, 
 with the malleoli, are now sawn off, as well as those of the cuboid and 
 scaphoid. The anterior portion of the foot remains connected with a 
 bridge of soft parts. The blood-supply appears to be ample, for 
 almost directly after the amputation blood issues freely from the distal 
 ends of the divided plantar arteries. All hemorrhage having been 
 arrested, the foot was brought into straight line with the leg, and the 
 cut surfaces of the bone were sutured together with kangaroo tendon. 
 The attempt to discover and unite the divided ends of the posterior 
 tibial nerve failed, on account of the sodden condition of the soft 
 parts. Suitable dressings and a plaster-of-Paris splint were applied, 
 the toes being brought into a position of complete dorsal flexion." 
 
 The boy made an excellent recovery. Firm bony union took place. 
 In about a month sensibility began to return in the sole and grad- 
 ually became more complete. The toes were mobile.* 
 
 Operation of Watson. — This is adapted to cases where the medio- 
 tarsal articulation is involved, the importance of which, from the 
 number of bones and the complicated synovial membrane, is well 
 known (p. 960). In other words, the disease should be situated be- 
 tween the bases of the metatarsal bones in front and the os calcis and 
 the astragalus behind. The parts being rendered evascular, incisions 3 
 to 4 inches long are made, on the outer side, from the centre of the os 
 calcis to the middle of the fifth metatarsal bone, and on the inner from 
 the arch of the astragalus to the middle of the first metatarsal. The 
 soft parts are carefully dissected off from the dorsal and plantar 
 aspects of the foot by means of these incisions, the left thumb being 
 kept between the point of the knife and the bones. With a curved 
 
 * Tlie patient was shown to the Medical Society more than a year after the opera- 
 tion. " He walked np and down the room, both with and without his boot, with freat 
 ease and evident satisfaction to himself. The union is quite solid, and he now 
 attends to his daily work without any inconvenience." 
 
956 OPERATIONS OX THE LOWER EXTREMITY. 
 
 probe-pointed bistoury the joints between the astragalus and scaphoid, 
 and OS calcis and cuboid, are opened up, and, a saw being passed be- 
 tween the plantar soft parts and the metatarsal bones, these are cut 
 through from below upwards. The diseased bones being removed, 
 the wound is firmly plugged and pressure applied with gauze pads and 
 bandages before the tourniquet is removed. That this operation, 
 though little known, is an excellent one in Dr. "Watson's hands is 
 shown by the fact that five out of bis six cases did well. It must be 
 remembered that it is an operation in the dark, and one that may 
 involve a good deal of damage to so-ft parts, owing to the amount of 
 disease which has to^ be removed by somewhat limited incisions. 
 
 REMOVAL OF TARSAL BONES FOR INVETERATE 
 
 TALIPES. 
 
 The removal of single bones — e.g., the cuboid as performed by Mr. 
 Solly, or the astragalas by Mr. Lund — has now been replaced by the 
 resection of a wedge oi bone from, the outer side, an operation for 
 which we are indebted to Mr. Davies-Colley and Mr. Davy. 
 
 Indications — Cases which deserve the above epithet of invete- 
 rate, in which tenotomy and manipulation have been thoroughly 
 tried ; cases in which there is evidently confirmed alteration in the 
 shape of the bones — e.g., in talipes equino-varus — such rigidity that 
 the position of the foot cannot be possibly altered, the astragalus pro- 
 jecting outwards on the dorsum, and the scaphoid so displaced that 
 it almost touches the internal malleolus ; where the patient walks on 
 the outer border of his foot, and large Ijurste have formed over the 
 cuboid \ and where the patient is prevented from earning his liveli- 
 hood. Finally, the surgeon must feel assured as to his power of 
 conducting the case antiseptically. 
 
 Operation. — The parts, being rendered evascular with Esmarch's 
 bandages, are duly cleansed and supported on a sand-bag. A T-shaped 
 incision is then made with the horizontal limb along the outer side 
 of the foot over the os calcis and the cuboid, and the longitudinal 
 one at a right angle to this passing across the dorsum and ending 
 over the scaphoid. The flaps thus marked out are turned aside. 
 With a periosteal elevator the tendons and vessels in the dorsum are 
 now raised so that sufficient room is given for the saw to pass between 
 them and the bones. With a retractor on the other side the peronsei 
 tendons are held out of the way, due care being taken of their sheaths 
 to avoid the risk of sloughing. With a narrow-bladed saw or a 
 chisel, a wedge of bone is then removed by two cuts, one above and 
 one below, meeting at the scaphoid. The upper of these will pass 
 through the os calcis to the scaphoid, the lower through the cuboid, 
 through the joint between this and the fifth metatarsal, or through 
 
chopart's amputation. 957 
 
 the base of this bone, according to the severity of the case. While 
 these sections are made, a blunt dissector may'be pushed under the 
 bones very cose to their plantar surfaces, so as to protect the soft 
 parts beneath. The wedge of bone is then removed with a lion- 
 orceps, or by levering it out with an elevator, care being taken not 
 to damage any parts used as a fulcrum. As it is twisted out, a few 
 attachments to the structures in the sole may require division or peel- 
 ing ofi. If the position of the foot cannot be rectified, the gap must 
 be widened by removing more bone either with a saw or with a chisel 
 and mallet ; it is especially towards the apex that this must be done * 
 When the foot can be brought into good position any tendons that 
 have been divided are united with earbolized silk or chromic gut. 
 Any vessels which can be seen are then secured, a drainage-tube is 
 inserted, and the wound partly closed with one or two wire sutures. 
 Dressings of dry gauze are then firmly ba:ndaged on before the Es- 
 march's bandage is removed. The foot is put up with a back and two 
 side splints, or on an external splint with an interruption, the bone 
 being flexed and the limb resting on its outer side. Mr. Davy has 
 devised a special splint to secure eversion. Morphia should be given 
 freely at first if required. In six or eight weeks the union should be 
 firm. 
 
 Great care must be taken during the after-treatment to keep the 
 parts aseptic. Mr. Davy lost one case, two weeks after the operation, 
 from septicemia (^Brit. Med. Journ^ 1879, vol. i. p. 221). Occasionally 
 complete closure of the wound is delayed by the coming away of a 
 scale of bone; the ill-vitalized corns ajid bursal tissues may show 
 some signs of sloughing.f 
 
 CHOPART'S AMPUTATION (Figs. 190, 191, 192). 
 
 In this medio-tarsal amputation only the astragalus and the os 
 calcis are retained, disarticulation being effected through the joints 
 between the alxive bones and the scaphoid and the cuboid. 
 
 Value of the Operation. — This has been a good deal disputed. 
 The following objections have been raised to it: 
 
 1. That the tendo-Achillis, no longer counterbalanced b3^ the 
 extensor muscles which have now lost their attachment, draws up the 
 heel, tilting down the scar, which now becomes tender and irritable. 
 
 2. In the normal foot the weight of the bodj is transmitted through 
 
 * Some contracted tendons m-ay now require diviiaon before the inversion can be 
 completely overcome. The tendo-Achillis may be divided now or later. 
 
 t In a case of Mr. Bennett's (CTin. Soc. Trans., vol. sv. p. 83) erysipelas attacked 
 the sinus, which was all that remained of the wound, and all the union between the 
 bones, which had been very firm, gave way. The case ultimately did well. 
 
958 
 
 OPERATIONS ON THE LOWER EXTREMITY. 
 
 the astragalus to the other bones of the tarsus and metatarsus. When, 
 as in this amputation, these bones have been removed, the weight of 
 the body tends to thrufvt forward the astragalus, no longer supported 
 by the elastic bones in front, against the scar, and thus renders this 
 tender and crippling. 
 
 The above objections apply to the operation performed for injury 
 or disease, the next to amputation for the latter only. 
 
 3. If the operation be made use of in caries, this disease is likely to 
 recur in the two bones left. 
 
 In answer to the first two of the above objections it may be said 
 that this tendency to tilting upwards of the heel and downwards of 
 the scar may be met: (a) By stitching the anterior tendons— e.g'., 
 tibiahs anticus, extensor proprius pollicis, and some of the tendons 
 of the extensor communis— into the tissues of the sole-flap with stout 
 earbolized silk or chromic gut, so as to give them a fixed point by 
 which they may counterbalance the tendo-Achillis ;* (b) by cutting 
 the plantar flap sufiiciently long, and securing firm primary union ; 
 (c) by division of the tendo-Achillis. This, however, is only of 
 fugitive value. 
 
 The third objection is answered by never performing the operation 
 
 Fig. 190. 
 
 Incisions in Chopart's amputation. (Fergusson.) 
 
 for caries, unless of distinctly traumatic origin, and in a healthy 
 patient. 
 
 Operation (Figs. 190, 191\ — An Esmareh being applied round the 
 leg, and the foot supported at a right angle over the edge of the table, 
 the surgeon, standing to the right side of the foot, and so that he can 
 easily face the sole, places (e.g., on the right side) his left index and 
 thumb nnmediately behind the tubercle of the scaphoid and the cor- 
 
 * We owe this ingenious precaution to Mr. Delagarde, of Exeter. Till it is more 
 frequently made use of, and a larger number of cases are collected, the value of this 
 operation must remain somewhat undecided. In two eases of Chopart's amputation 
 of mine — one a severe crush, and the other for the results of perforating ulcer — in 
 which this precaution was taken, the slumps prwved sound and nsefnl. 
 
chopart's amputation. 959 
 
 responding point on the outer side— viz., the calcaneo-cuboid joint, 
 which lies midway between the external malleolus and the base of 
 the fifth metatarsal bone. He then joins these points by a slightly 
 curved incision crossing the tarsus, and dividing everything down to 
 the bones. The foot being flexed upwards, a plantar flap is then 
 marked out by an incision running from the outer extremity of the 
 
 Fig. 191. Fig. 192. 
 
 y 
 
 stump after Chopart's amputation. (Fergusson.) 
 
 first up the outer side of the little toe, then across the sole, along the 
 roots of the toes, and then down the inner side of the great toe to join 
 the inner extremity of the first. The flap thus marked out is raised 
 with the same precautions given at p. 961. It is then held out of the 
 way, and the anterior half of the foot being strongly depressed, dis- 
 articulation is effected by passing the knife behind the tubercle of the 
 scaphoid between this bone and the astragalus, and then between the 
 OS calcis and cuboid. In effecting this the position of the joints and 
 the shape of the astragalus must be remembered, and Mr. Skey's words 
 borne in mind : " The joints should be opened with tact and not by 
 force : if the knife be applied to the right surface, it will pass without 
 effort into the articulation ; if in the wrong direction, no force will 
 effect it." 
 
 The anterior tibial and plantar arteries are then secured, and, on 
 removal of the Esmarch's bandage, any other vessels which require it. 
 The flap is then folded up over the bones, but without any forcible 
 bending, which might interfere with the blood-supply. While it is 
 held in this position, before any sutures are inserted, the extensor 
 tendons (vide mpra) should be carefully stitched into the fibrous 
 tissues, which abound in the heel-flap, care being taken in so doing 
 not to puncture the external plantar vessels. 
 
960 OPERATIONS ON THE LOWER EXTREMITY. 
 
 AMPUTATION THROUGH TARSO-METATARSAL 
 JOINTS (Fig. 193). 
 
 This, though usually spoken of as Hey's or Lisfranc's amputation, 
 includes, accurately speaking, the following operations : 
 
 1. Lisfranc's.— Amputation by disarticulation through all the 
 joints. 
 
 2. Hey's. — This is usually described as amputation here by sawing 
 through the bases of the metatarsals. In reality. Hey seems to have 
 disarticulated through the outer four joints, and sawn off the project- 
 ing internal cuneiform.* 
 
 3. Skey's.t — Disarticulation through the outer three and the first 
 joints, the base of the second metatarsal being sawn off. 
 
 Indications. — Few. (1) Limited crushes in which the sole is 
 sound. (2) Disease limited to the front of the foot. (3) Inveterate 
 bunion, with pereistfent sinuses and recurrent attacks of cellulitis. 
 (4) Perhaps perforating ulcer. (5) Some cases of frost-bite. 
 
 Owing to the complexity of the synovial membrane here, any dis- 
 ease which has invaded the synovial membrane between the second 
 and third metatarsals and the second and third cuneiforms, has also 
 spread to that between the scaphoid and three cuneiforms. This, 
 though of small moment in cases of injury, should put this amputa- 
 tion aside in most cases of disease. 
 
 Lisfranc's Amputation (Fig. 193). — The preliminaries are the 
 same as in Chopart's amputation. The surgeon, standing to the right 
 side of either foot, and so as easily to face the sole, places his left 
 index and thumb in the bases of the little and great toe metatarsals 
 respectively. The first of these can always be found by pressure, even 
 if swelhng is present ; if there be any difficulty with the latter, it will 
 be found a full inch in front of the readily detected tubercle of the 
 scaphoid. These two points thus marked out are joined by a slightly 
 curved incision with its convexity forwards. As a rule, if the tissues 
 in the sole are sound, no dorsal flap should be made, the above in- 
 cision being kept close to the line of the joints through which 
 disarticulation is to be performed. 
 
 The foot being now flexed upwards, the surgeon, looking towards 
 the sole, marks out a plantar flap by an incision running from the 
 outer extremity of the first cut (for the left fioot) up the outer side of 
 the foot, then across the heads of the metatarsals, and down the inner 
 side, so as to join the inner extremity of the dorsal incision. This 
 flap should be made a little longer on the inner than on the outer 
 
 * Observations in Surgery, 3d edition, p. 552. 
 t Oper. Surg., p. 406. 
 
AMPUTATION THROUGH THE METATARSAL JOINTS. 961 
 
 side of the foot, so as to cover the additionally projecting bones on 
 this side. Its cut edge being taken firmly between the finger and 
 thumb, the flap is then dissected up as thickly as possible— i.e., con- 
 taining all the tissues possible in the sole. In keeping the knife'close 
 
 Fig. 193. 
 
 
 6"-' ^- 
 
 Disarticulation of the second metatarsal in Lisfranc's amputation. Tlie linife is being 
 used as described below, to separate the second from the first metatai-sal bone. 
 
 to the bones some of the metatarso-phalangeal joints will probably be 
 opened. Below these the flap, if steadily pulled upon, will, with light 
 touches of the knife, readily separate from the metatarsal bones. The 
 flap should be raised. evenly, and without scoring or any bufton-holes. 
 The prominent bases of the first and fifth metatarsals being laid bare, 
 a few strong touches of the point of the knife may be required to 
 separate part of the tibialis anticus and peronseus longus from the 
 base of the former. The anterior part of the foot is now strongly 
 depressed so as to stretch the dorsal ligaments, and the knife, having 
 been thoroughly carried round the base of the fifth metatarsal, is 
 drawn obliquely forwards and inwards so as to open the joints of the 
 outer three metatarsals with the cuboid and the external cuneiform. 
 The joint between the first metatarsal and the internal cuneiform is 
 next opened', and, lastly, the second metatarsal is next freed as fol- 
 lows : The knife being held firmly in the fist, its point is inserted 
 between the first two metatarsal bones, and the knife carried back- 
 wards and forwards in an antero-posterior direction in the long axis 
 of the foot (Fig. 193). The same is then done between the second and 
 third metatarsals, and, the lateral ligaments being thus divided, the 
 joint between the second metatarsal and the middle cuneiform is then 
 
 61 
 
962 
 
 OPERATIONS ON THE LOWER EXTREMITY. 
 
 found and opened * this being facilitated by strongly depressing the 
 
 foot, care being taken not to do this so violently as to separate the 
 
 second metatarsal from its upper epiphysis.! A few remaining touches 
 
 ^ ,„, of the knife, aided by a twisting 
 
 Fig. 194. ■■,■,.-, m i. 
 
 movement, will then sutnce to 
 
 se]3arate the foot. 
 
 This method of cutting the 
 plantar flap before any attempt 
 is made to disarticulate is 
 strongly recommended in prefer- 
 ence to disarticulating immedi- 
 ately after making the dorsal 
 incision by passing the knife be- 
 hind the bones and cutting the 
 flap from within outwards. In 
 th us disarticulating before making 
 the plantar flap, it is quite possi- 
 ble to puncture the tissues in the sole, and perhaps to wound the 
 external plantar artery. Again, passing the knife behind the meta- 
 tarsal bones often leads to a hitch, especially with the projecting fifth. 
 The dorsalis pedis and the external plantar artery are now secured, 
 with any smaller vessels which need it. Tendons are cut square, 
 drainage provided, and the plantar flap then brought up and secured 
 in accurate position. 
 
 Owing to the thickness of the heel-flap and its tendency at first to 
 unfold itself downwards, numerous points of suture, of sufficiently 
 stout wire or carbolized silk, must be made use of, or one or two hare- 
 lip pins may be employed. 
 
 AMPUTATION OF TOES. 
 
 Practical Points. — (1) Any plantar scar is to be avoided. (2) 
 The line of the metatarso-phalangeal joints lies a full inch farther 
 
 Slump after Lisfrauc's amputation. 
 (Fergusson.) 
 
 * The position of this joint must be remembered and the way in which the base of 
 the second metatarsal bone is locked in between its fellows and the cuneiform bones. 
 Its base projects upwards between J and ^ inch above the others. Prof. Syme gave 
 this rule to guide the surgeon in disarticulating the outer three metatarsals; "Having 
 once entered the joint of the fifth, the knife must be drawn along in the direction of a 
 line drawn towards the distal end of the first metatarsal ; for the fourth, the direction 
 must be changed for the middle of the same bone; and to open the third it will be 
 necessary to come across the dorsum of the foot, as if intending to reach the proximal 
 end." 
 
 f While the surgeon is disarticulating the metatarsal bones the plantar flap must be 
 held well out of the way to prevent its being punctured. 
 
AMPUTATION OF THE GREAT TOE. 963 
 
 back than the inter-digital folds of the skin* (Holden). (3) Partial 
 amputations (save in the case of the great toe) are very seldom advis- 
 able, the stumps left being of little use, and inconvenient, owing to 
 their liability to stick upwards. 
 
 AMPUTATION THROUGH PHALANGES OR INTER- 
 PHALANGEAL JOINTS. 
 
 These operations are not recommended, for the reasons just given. 
 If a patient insist on having one performed, the directions already 
 given for the fingers (p. 20) will be found sufficient. 
 
 AMPUTATION OF ANY OF THE FOUR SMALLER TOES 
 AT THE METATARSO-PHALANGEAL JOINTS. 
 
 This amputation is performed much as in the case of the fingers 
 (p. 22), but the following points must be remembered : 
 
 (1) The line of the joint lies a full inch above the web (vide supra). 
 (2) The head of the metatarsal bone is not here removed, so as to 
 leave the supporting power of the foot undiminished. (3) It is most 
 important to avoid, as far as possible, any scar in the sole. 
 
 The scar, a simple antero-posterior one, is well protected by the 
 adjacent toes. The incision should always be begun on the dorsum, 
 even in the case of the little toe, so as to avoid friction of the boots. 
 
 AMPUTATION OF GREAT TOE AT INTER-PHA- 
 LANGEAL JOINT (Fig. 195.) 
 
 This is usually performed with a palmar flap, as at p. 18. 
 
 AMPUTATION OF GREAT TOE AT METATARSO- 
 PHALANGEAL JOINT (Fig. 195). 
 
 This is performed by the oval method described at p. 28. The fol- 
 lowing points must be borne in mind : 
 
 (1) Owing to the large size of the head of the metatarsal bone, the 
 flaps are often cut of insufficient length. The incision must be begun 
 U inch above the joint, and carried well on to the phalanx, one flap 
 being cut longer than the other if needful. (2) The sesamoid bones 
 must be left in connection with the head of the metatarsal bone, as 
 any attempt to dissect them out is likely to imperil the vascularity of 
 the flap, especially after middle life. 
 
 In all other details the steps of this amputation are very similar to 
 those already given, p. 22. 
 
 * According to Erichsen, as a general rule it will be found that these articulations 
 are about the same distance above the web as the point of the toes are below it. This, 
 I think, places the line of the joints too high. 
 
964 
 
 OPEEATIOyS ON THE LOWER EXTREMITY. 
 
 Though it is recommended by some excellent surgeons to remove 
 the head of the metatarsal bone either transversely or obliquely from 
 
 Fig. 195. 
 
 Fig. 196. 
 
 Amputation of great toe and its meta- 
 tarsal bone. (Fergusson.) 
 
 Ttie foot letl by the operation. 
 (Fergusson.) 
 
 within outwards, this step, narrowing as it does the treading width of 
 the foot, is not advisable, unless the condition of the skin is such as 
 to render it impossible to obtain sufficient flaps to cover the entire 
 head. 
 
 CHAPTER VII. 
 
 OSTEOTOMY. 
 
 OSTEOTOMY OP THE FEMUR FOR ANKYLOSIS OF 
 HIP-JOINT-FOR GENU VALGUM.— OSTEOTOMY OF 
 THE TIBIA.— OSTEOTOMY FOR DISPLACEMENT OF 
 THE GREAT TOE IN BUNION. 
 
 FOR ANKYLOSIS OP HIP-JOINT. 
 
 This includes Adams's operation of division of the neck of the 
 femur and Gant's operation of division of the shaft of the femur 
 just below the trochanters. The latter being much the simpler, and 
 giving excellent results, will, I think, replace the former. These opera- 
 tions are intended to remedy cases in which the hip-joint is perma- 
 nently flexed and stiff, and the patient accordingly crippled, either from 
 old hip disease, or from ankylosis after rheumatic fever, pyemia, etc. ; 
 cases in which extension has failed, together with trials of straighten- 
 ing the limb with the aid of anajsthetics. 
 
 Adams's operation divides the neck of the femur subcutaneously 
 within the capsule. It is best suited for those cases in which the neck 
 
OSTEOTOMY FOR ANKYLOSIS OP HIP-JOIXT. 965 
 
 remains unabsorbed, as in anliylosis after rheumatic fever and, much 
 more rarely, pyaemia. A long tenotome or a straight narrow bistoury 
 is entered a little above the great trochanter, and carried straight down 
 to the neck of the femur, dividing the muscles and opening the capsule 
 freely. The knife being witlidrawn, the excellent saw which bears Mr. 
 Adams's name is passed along the wound made down to the neck of 
 the bone, which is then sawn through. After sawing for about four or 
 five minutes, the limb should become movable. If this is not the case, 
 the section has been made, not through the neck itself, but through the 
 junction of the neck and shaft. 
 
 In order to bring down the limb completely, the contracted tendons 
 of the adductor longus, sartorius, and perhaps the rectus will probably 
 require division with a tenotome. The operation should be conducted 
 with strict antiseptic precautions. 
 
 The limb is straightened at once, and put up with a long outside 
 splint— e.gf., a Desault's — and a little morphi.'o given subcutaneously. 
 There is no haemorrhage, and the wound heals quickly. 
 
 This operation gives good results, though, as I have said, I prefer 
 Gant's, owing to its greater simplicity. For there is no doubt that if 
 the bone is dense from previousinflamniation,and the section trenches 
 upon the shaft instead of going through the neck only, the sawing may 
 be very tedious. Thus I have twice seen cases in which this took over 
 half an hour. 
 
 A case is mentioned in a report from a committee of the Belgian 
 Academy of Medicine, in which a patient who had been submitted to 
 Adams's operation insisted on getting up on the twentieth day. Hffim- 
 orrhage came on from the fragments wounding the femoral vessels or 
 some large branch. The femoral was tied just below Poupart's hga- 
 ment; the hemorrhage ceased, but free incisions were required for 
 suppuration. The patient ultimately recovered. The same committee 
 reported a death from hasmorrhage, and one from purulent infiltration. 
 No bad results have, I believe, followed in England. 
 
 Gant's Operation.— Here the shaft of the femur is divided just 
 below the trochanters. Thus the operation is a simpler one than that 
 just given, as the shaft is more readily reached and divided than the 
 neck. Furthermore, it is an operation of wider apphcability, for it is 
 suited to all cases, not only those in which a neck remains, but those 
 more common cases of ankylosis after hip disease, in which repair has 
 taken place with partial displacement of the head, or what remains of 
 it. The fact that in these cases there is next to no neck left to divide, 
 makes them unsuited for Mr. Adams's operation. . ^ , . , 
 
 A lone, tenotome or, better, a sharp-pointed, narrow, straight bistoury 
 is entered just below the great trochanter, and made to divide every- 
 thing down to the bone as it is lodged upon the outer aspect of the 
 
966 OPERATIONS ON THE LOWER EXTREMITY. 
 
 anterior surface, and then drawn down over the outer surface of the 
 shaft. As it is withdrawn the wound is a little enlarged downwards. 
 The saw is then introduced along the wound well down to the bone, 
 and the outer two-thirds of this sawn through, the rest being effected 
 by snapping the bone by lateral movements. The same tendons will 
 probably require division. 
 
 In neither case is it any practical good to try and secure a false joint. 
 
 OSTEOTOMY FOR GENU VALGUM (Figs. 197, 198, 199). 
 
 Under this heading the following operations will be described : 
 I. Division of the Shaft of the Femur from the Outer 
 
 Side. 
 II. Division of the Lower End of the Femur from the 
 Inner Side, just above the Epiphysial Line (^lac- 
 ewen). 
 
 III. Division of the Internal Condyle Obliquely (Ogston). 
 
 IV. Division of the Lower End of the Femur and the 
 
 Upper End of the Tibia above and below their 
 
 respective Epiphyses (Barwell). 
 I, Division of the Shaft of the Femur from the Outer Side 
 (Figs. 197, 198, 199). — The limb being supported, with the knee flexed, 
 on a sand-bag, an incision about an inch long is made at a right angle 
 to and down to the bone on its outer side about 3 inches above the ex- 
 ternal condyle. The knife — a narrow, straight bistoury — should go 
 down to the bone deliberately, and cut firmly and strongly on it, en- 
 larging the wound slightly as it emerges, in order that the soft parts 
 may not be damaged if the heel of the saw is depressed, and that there 
 may be no lip of tissues to hinder the escape of discharges. The saw 
 or chisel is then introduced, and the bone divided for its outer two 
 thirds. As the thicker part of the bone is on the outer side, as soon 
 as this is divided the inner third usually gives way readily on carrying 
 the knee and leg from without inwards. But tlie operator should con- 
 tinue the division of the bone till he can feel certain that two thirds 
 are divided, for if, after dividing only half, he tries, especially in the 
 case of a dense bone, to fracture the rest and straighten the limb, either 
 great and prolonged force must be made use of, leading probably to 
 irritation, cellulitis, and suppuration, with, perhaps, necrosis, or the 
 saw or chisel must be re-introduced, a point to be always avoided if 
 possible, as the difficulty which is usually met with in hitting off the 
 original track will be likely to lead to the above drawbacks. 
 
 The advantages of the above method are (1) that the femur is divided 
 at a much narrower part than in the supra-condyloid operation of 
 Macewen, and that thus it is more easily and quickly done. (2) The 
 
OSTEOTOMY POK GENU VALGUM. 
 
 967 
 
 bone section is farther away from the epiphysis, and the line of the 
 synovial membrane, in case subsequent inflammation takes place (3) 
 I here are no important bloodvessels near (p. 972). 
 
 Fig. 197.* 
 
 Fig. 198.* 
 
 Fig. 199. 
 
 Fig. 199.— The transverse line on the shaft of the femur shows the site of division of the bone 
 from the outer side. Below this are shown Macewen's and Ogston's operations. Tlie arrow in- 
 dicates the direction in which the osteotome is worlied in the former. The line on the tibia 
 shows the site of division of the bone for an ordinary ricliety curve. This curve in the lower 
 third should have been shown more marked. (After Earlier.) 
 
 II. Division of the Lower End of the Femur from the Inner 
 Side, just above the Epiphysial Line (supra-condyloid of Mac- 
 ewenf) (Fig. 199). — The knee being flexed and supported firmly on a 
 sand-bag, the skin cleansed, the position of the adductor tubercle is 
 defined, and a longitudinal incision about an inch long (a little longer 
 than the breadth of the chisel to be used) is made down to the bone 
 at a point where the two following lines meet — viz., one drawn trans- 
 versely a finger's breadth above the superior tip of the external 
 
 * Double genu valgum treated by division of the shaft of the femur from the out- 
 side. A good average case, both as to its severity and the results of operation. Some 
 flat foot remains on the left side. 
 
 f Osteotomy, p. 120. 
 
968 OPERATIONS ON THE LOWER EXTREMITY. 
 
 condyle, and another drawn longitudinally about J inch anterior to 
 the adductor tubercle. The scalpel goes at once down to the bone. 
 Superficial veins may be cut, but no artery normally distributed, as 
 the incision is below and anterior to the anastomotica magna and 
 above the superior internal articular. Before withdrawing the knife, 
 the osteotome* is introduced by its side down to the bone in the same 
 way as the knife— i.e., parallel to the long axis of the limb — is then 
 turned at a right angle to it, and the inner two-thirds cut through. 
 The direction of the bone incision is most important. The surgeon must 
 cut transversely across the femur on a level with a line drawn i inch 
 above the tip of the external condyle.f Otherwise, as in a valgous 
 limb the whole internal condyle is lowered, a line drawn transversely 
 from the adductor tubercle might land the operator low down in the 
 external condyle. The osteotome must be driven at first from behind 
 forwards and to the outer side; it is then made to move forwards 
 along the inner border until it comes to the anterior surface, when it 
 is directed from before backwards and towards the outer posterior 
 angle of the femur. By keeping on these lines there is no fear of in- 
 jurying the artery. The hard exterior of the bone usually resists the 
 osteotome, especially in adults, but several strokes cause it to pene- 
 trate this superficial dense portion, | when the instrument will pass 
 easily through the cancellous bone. The surgeon will soon recognize 
 b_y touch or by hearing when the osteotome meets the hard layer on 
 the opposite side. If it be thought desirable to penetrate this outer 
 dense part, it must be done very steadily, so as to check any undue 
 impetus on the part of the osteotome. A sponge, wrung out of 1 in 
 40 carbolic lotion, is then placed over the wound ; the surgeon, grasp- 
 ing this and the limb with his left hand, and taking the limb again 
 
 * In adults asecund, or even a third, finer instrument may be used, being slipped in 
 ovpr the first as this is withdrawn. In children one instrument will suffice. 
 
 f The incision above given will avoid the epiphysis and synovial membrane. The 
 line of the former may be usually represented by one crossing the femur at the level 
 of the highest point of the femoral articulating surface, and running through or just 
 below the adductor tubercle, so that, the incision being an inch above the tubercle, the 
 epiphysis will be cleared. The only part of the synovial membrane which is as high 
 as the bone incision is that under the quadriceps, which may reach in the adult as 
 high as 2 inches above the trochlear surface. It is somewhat triangular in shape, its 
 base being at the condyles, and it gradually tapers to the middle line as it ascends. 
 There is generally a quantity of fat between it and the bone. The spot selected by 
 Dr. Macewen for his incision is posterior to this point. 
 
 X The osteotomes must be bevelled on both sides, wedge-like, and suflSciently trust- 
 worthy for hardness and toughness, points only to be secured by getting them of first- 
 rate and painstaking makers. Dr. Macewen's test is as follows: If the instrument will 
 neither turn nor chip in penetrating the thigh-bone of an ox, it is well suited for cut- 
 ting human bones. 
 
OSTEOTOMY FOR GENU VALGUM. 
 
 969 
 
 lower down with his right, gives the extended limb thus held a quick 
 jerk inwards : this is repeated if needful, or the limb may be carried 
 outwards, and thus broken or bent sufficiently. 
 
 . J"'i2!^'^'^^°^ *^® ^""^^'"''^^ Condyle Obliquely (Ogston*) 
 CJ^ig. IJJ). — This operation, though a great improvement on the 
 operation which preceded it-yiz, opening the joint and sawin^ off 
 the internal condyle-has been, practically, replaced by others-viz 
 Macewen's, and division of the shaft from the outer side. The free 
 opening of the joint, with its great risks if the wound becomes septic, 
 and the stiffness in any case, have led to this. 
 
 The limb being flexed, and supported on a sand-bag, a long teno- 
 tome is entered about an inch above the upper border of the articu- 
 lar surface of the femur exactly in the middle of the inner aspect of 
 the thigh, and with it an incision is made down to the bone, down- 
 wards and forwards, until its point is felt beneath the skin' in the 
 inter-condyloid notch.f The knife must cut down upon the bone de- 
 cidedly, and as it is withdrawn it must enlarge the opening for the 
 saw. An Adams's saw is then thrust along the knife-track, and the 
 inner condyle sawn off from before backwards. The bone must be 
 sawn almost completely through, the strokes being increasingly care- 
 ful as the back of the bone is reached. When the section is thought 
 to have nearly reached this point the saw is withdrawn, the wound 
 covered with a carbolized sponge, and the extended leg forced strongly 
 inwards. The condyle now slips up somewhat on the cut surface of 
 the femur. 
 
 IV. Division of Tibia as well as Femur.— The division of the 
 tibia (and the fibula also) as well as the femur has been advocated by 
 Mr. Barwell. It will only be required. Dr. Macewen thinks, in cases 
 of very aggravated genu valgum, for these reasons : (1) as a rule the 
 tibia is only involved to such a slight extent that osteotomy of the 
 femur is alone sufficient to straighten the limb. (2) Even when the 
 tibia is markedly involved the limb can be sufficiently straightened 
 to appear quite symmetrical when clothed. (3) The amount of 
 straightening brought about by division of the tibia is disappointing. 
 The same is the' case when the fibula is also divided. Dr. Macewen 
 explains this by the mass of muscle on the outer and bade part of 
 the limb, which tends to bind the tibia and make it inflexible. For 
 the above reasons Dr. Macewen has abandoned this operation, trust- 
 ing to division of the femur alone, combined, if needful, witli the 
 division of the biceps. 
 
 * Edin. Med. Jour., March, 1877. 
 
 f If the patella is sufficiently dislocated outwards, the point of the saw can lie felt 
 in the groove ; but if the patella is not so displaced, it must be lifted up and the point 
 of the saw passed under it. 
 
970 OPERATIONS ON THE LOWER EXTREMITY. 
 
 Operation.— An incision is made in the soft parts over the inner 
 surface of the tibia just below its tubercle, and the bone divided with 
 osteotome or saw from within outwards. The tissue on the anterior 
 part just below the tubercle is much the densest. The section of the 
 tibia should be made on the same occasion as that of the femur. Dr. 
 Macewen has never found it needful to operate on the fibula. 
 
 In extremely aggravated cases, multiple osteotomies will be required 
 on the femur and the tibia. Thus in one case of genu varum, in 
 which the limbs (when the ankles were placed togther) formed a circle. 
 Dr. Macewen performed ten osteotomies at one time (foe. supra cit., 
 Figs. 40 and 41). However an osteotomy wound is made, whether 
 with saw or chisel, no attempt should be made to close it, but a little 
 iodoform dusted on and dry-gauze dressings applied. It is very rarely 
 needful to remove these before the tenth or fourteenth day. If a stain 
 come through, it should be dusted with iodoform and a little fresh 
 dry dressing applied. 
 
 Dr. Macewen uses a splint consisting of a long outside, a short back 
 and a foot-piece.* I have usually preferred plaster-of-Pavis, applied 
 by Mr. Croft's method, for children, amongst whom my experience 
 has mainly laid. It makes even, steady pressure upon the muscles 
 around the wound, keeping them and it at rest, and it allows the 
 patient to be more easily moved, especially when both limbs have 
 been operated on. However the limb is put up, the bandages must 
 be applied firmly and evenly, but without undue tightness. The con- 
 dition of the toes, as to color and movement, must be carefully 
 watched. When the dressings are removed at the end of ten or four- 
 teen daj's I like to have an antesthetic given, and to rectify any slight 
 remaining deformity if possible. 
 
 The splint in the case of plaster-of-Paris should be continued for 
 six weeks, when the limb may be only supported with sand-l^ags if the 
 union is firm. Passive and active movement may be now allowed. 
 In about another fortnight the patient may be got up, on crutches, 
 under observation. Before the patient leaves the sugeon's eye, care 
 should be taken that he can bend his knee well. 
 
 OSTEOTOMY OF TIBIA (Fig. 199.) 
 
 This may be (A) Simple Division or (B) Cuneiform— /.f., the 
 taking out of a wedge of bone. The former of these, a very 
 simple operation, will suffice for the ordinarily curved tibiffi, where 
 the bone is bent laterally and the bend is most marked at the junction 
 
 * Dr. Macewen advises tlie use of a mattress consisting of four parts, the two centre 
 pieces corresponding to llie gliitieal region, and easily removed to admit of the intro- 
 duction of the bed-pan. 
 
OSTEOTOMY OP THE TIBIA. 971 
 
 of the middle and lower thirds. Cuneiform osteotomy will be required 
 when the bending is not only lateral, but antero-posterior as well. 
 
 A. Simple Osteotomy of the Tibia (Fig. 199).— The parts being 
 cleansed and the limb resting on its outer side on a firm sand-bag, the 
 surgeon notes, at the anterior and inner margins of the tibia, the spot 
 where the curve is sharpest. Fixing his left index over the inner 
 margin, he enters a long tenotome or narrow bistoury exactly over 
 the crest of the tibia, sends it down under the skin over the inner 
 surface of the bone till its point is felt just beneath the finger; it 
 is here pushed through the sldn to make a counter-puncture for 
 drainage. The knife, hitherto held horizontally, is now turned ver- 
 tically and cuts firmly on the bone, dividing the periosteum, thick 
 in these cases, in one line right across the inner surface of the tibia. 
 As the knife is withdrawn it is made to enlarge tlie wound of en- 
 trance slightly, to make room for the saw. This (Adams's) is now 
 introduced in the same way as the knife, carried horizontally down 
 to, but not through, the puncture througli the skin of the inner 
 border of the tibia. The left index keeping guard at this spot, the 
 saw is turned towards the bone and cuts through the inner two-thirds 
 of it. The entrance of the saw into cancellous tissue can be known 
 by the diminution of resistance and the increased bleeding which 
 often occur, but the best test of the depth to which the operator 
 has arrived is the depth of the groove in which the saw has sunk. 
 When the bone is sawn sufficiently, carbolized lint is placed on 
 the wound, and the surgeon, firmly placing his two hands, close 
 together, immediately above and below the wound, sharply carries the 
 lower fragment outwards. If the saw has been sufficiently used, the 
 tibia snaps distinctly, while the fibula* yields with a " greenstick " 
 sensation. Great care must be taken to exert the force just on the 
 sawn portion, or the ligaments of the ankle or the superior tibio-fibular 
 joint may be strained and damaged. Attention has already been 
 drawn to the need of using the saw sufficiently, otherwise the parts 
 will be bruised and damaged in the futile attempts at fracture. 
 
 A horsehair drain should be inserted, a little iodoform dusted on, 
 and the usual dry-gauze dressings applied. 
 
 B. Cuneiform Division of the Tibia— Removal of a Wedge. 
 —The parts being duly cleansed, an incision is made along the crest 
 of the tibia equal to the base of the wedge which is going to be removed. 
 It need not be longer, as the skin can be pulled up and down if need- 
 ful. The periosteum is then divided cleanly, and separated from the 
 tibia with the handle of the scalpel carbolized. This membrane being- 
 held out of the way with retractors, a wedge is next removed with an 
 
 * In many of my earlier cases I cut down upon and divided tliis bone, a step not at 
 all needful. 
 
972 OPERATIONS ON THE LOWER EXTREMITY. 
 
 osteotome or a narrow and sharp chisel but little bevelled. The gap 
 can then be enlarged by removing from either side further shavings as 
 required. Occasionally free haemorrhage takes place from the medul- 
 lary artery, but this soon stops with firm sponge pressure. The limb 
 is now straightened by bending the lower fragment upwards* so as to 
 bring the surfaces of the gap in contact. The periosteum at the upper 
 and lower angles of the wound may be closed with chromic catgut 
 sutures cut short. The skin wound is also closed above and below, 
 but left oi^en in the centre for drainage. SufSciently thick dressings 
 should be applied to meet any oozing from the bone. 
 
 OSTEOTOMY FOR DISPLACEMENT OF SMALL TOE 
 
 JN BUNION. 
 
 Mr. Barker, at the suggestion of a University College student, has 
 recommended this mode of correcting the inward deformity when very 
 troublesome in these cases. Antiseptic osteotomy of the first phalanx 
 or metacarpal bone will be found simpler, and thus preferable, to 
 division of the shortened external lateral ligament, and any tendons, 
 such as the extensor longus digitorum, which require it. In bringing 
 the line of the great toe straight after osteotomy, care must be taken 
 not to do this too rapidly, or the contracted skin on the outer side of 
 the toe may give way. 
 
 Causes of Death and. Failxire after Osteotomy. 
 
 1. Septic troubles. Such a case will be found published Clin. Soc. 
 Trans., vol. xii. p. 27. It is too probable that other operators have not 
 been so candid. 
 
 2. Carboluria. A case of rapidly fatal carbolic intoxication after 
 antiseptic osteotomy of the tibia will be found in the same Transactions, 
 vol. xiv. p. 201. 
 
 3. Haemorrhage. At least one case has occurred of haemorrhage 
 from the femoral and one from the anastomotica after division of the 
 femur. I have also heard of one in which the posterior tibial was in- 
 jured in osteotomy of the tibia. 
 
 4. Necrosis. This occurred in one of my cases of osteotomy of the 
 femur, a lad of sixteen. It was noticed that he took the anaesthetic 
 (ether) very badly, and when the effects of this had passed off he was 
 extremely restless and excited for forty minutes. To this I attribute 
 the mischief that followed. Suppuration with a very unhealthy state 
 of the wound, oadema, and cellulitis ensued, leading to necrosis. 
 Eventually the lad recovered, but required a cork sole of 2 inches. 
 The presence of a presystolic murmur perhaps accounted for the 
 effects of the anaesthetic. 
 
 * Aided by movements in the opposite direction, and from side to side if needed. 
 Tiie fibula is broken subcutaneoiislv. 
 
TENOTOMY. 973 
 
 5. Division of the tibialis anticus tendon. This occurred in an oste- 
 otomy of the tibia performed by one of my dressers, who forgot how 
 close the tendon lies to the outer side of the crest. The cut ends were 
 joined by chromic catgut, and the action of the muscle wa^ unimpaired. 
 
 CHAPTER VIII. 
 TENOTOMY. 
 
 TENOTOMY OP THE TENDONS ABOUT THE FOOT.— 
 SYNDESMOTOMY-TENOTOMY OF HAMSTRING 
 TENDONS.— TENOTOMY OP STERNO-MASTOID. 
 
 TENOTOMY OF TENDONS ABOUT THE FOOT. 
 
 Division of Tibial Tendons. 
 
 Tibialis Anticus. — This is usually divided where it is crossing the 
 ankle-joint from without inwards, a little above its insertion into the 
 internal cuneiform. It has, here, the anterior tibial vessels on its outer 
 side, but separated from it by the extensor proprius poliicis. 
 
 The surgeon usually stands on the opposite side of the leg to that 
 of the tendon, either facing the trunk or with his back towards it, as 
 is most convenient. The assistant stands opposite to him, grasping 
 the foot with one hand and the leg with the other. The position of the 
 tendon is made out by making it tense by abducting and extending the 
 foot. The surgeon then notes the position of the anterior tibial vessels, 
 defines exactly the width of the tendon, and places the tip of his index 
 finger exactly on the side of the tendon farthest from him. He then 
 inserts the tenotomy knife vertically' close to the tendon on the side 
 nearest to him ; sinks it lightly till he feels sure it is on a level lower 
 than that of the tendon ; then sends it horizontally across till he feels 
 its point just under his index finger, and, having turned its edge up- 
 wards, finally, by a series of light levering or sawing movements, cuts 
 through the "tendon. The assistant relaxes the foot^/.f., adducts and 
 bends it upwards— when the knife is first introduced, but places it on 
 the stretch at a signal from the surgeon. Finally, as soon as the com- 
 pletion of the creaking sound and the sudden snap denote the division 
 of the tendon, the foot is again relaxed. A small pad of gauze being 
 at once applied, the foot is put up in the everted position. For this 
 purpose nothing is, to my mind, so simple and efficient as a well- 
 padded splint of the proper width, with two notches at its lower end, 
 the upper end being just below the knee in infants, and the lower pro- 
 jecting 2i inches below the foot. The splint ifi applied to the outer 
 
974 OPERATIONS ON THE LOWER EXTREMITY. 
 
 side, the leg being first rolled in a flannel bandage to prevent pressure- 
 sores. 
 
 Tibialis Posticus. — It is usually recommended to divide this IJ 
 or 2 inches above the internal malleolus.* The tendon is here sepa- 
 rated from the posterior tibial vessels by the flexor longus digitorum. 
 
 The surgeon and his assistant, occupying positions as at p. 973, 
 the exact site of the tendon is defined, if possible, by abducting and 
 bending down the foot. In fat infants it is often quite impossible to 
 feel the tendon, and in these cases a spot midway between the anterior 
 and posterior l)orders of the leg will be the best guide, as denoting 
 the inner margin of the tibia. The surgeon then introduces a sharp 
 tenotome ;^o as just to touch, if possible, the inner margin of the tibia, 
 taking care to sink the blade sufficiently to open the sheath freely. 
 This being done, a blunt tenotome is introduced through the same 
 opening, and pushed under the tendon ; the edge being then turned 
 towards it, and the tibia used as a fulcrum, the tendon is severed, 
 together with that of the flexor longus digitorum. The assistant first 
 relaxes and then extends the tendon, as advised above (p. 973). 
 
 If the artery be cut, as shown by the jetting hiemorrhage and the 
 blanching of the foot, firm pressure must be applied, the foot being 
 first bandaged. No eversion must be practiced but the foot put up in 
 the faulty position for about a week. 
 
 Plantar Fascia.f — This may be divided just below its origin from 
 the OS calcis, or in advanced cases close to the transverse crease, which 
 is here found in the sole. With regard to this fascia, the surgeon 
 should not tie himself down to any fixed spot, but divide resisting 
 bands wherever they are felt. 
 
 Syndesmotomy.— This term has been introduced by Mr. R. W. 
 Parker,;!; who believes that in many cases — e.g., severe ones, cases not 
 treated in early life, and in some relapsed cases — the foot cannot be 
 rectified even by multiple tenotomy. He attributes this, not to adhe- 
 sions, but to the faulty shortness, and unyielding nature of the liga- 
 ments. Chief amongst these, in equino-varus, are the ligaments about 
 the astragalo scaphoid joint. " In these cases there is a capsule made 
 up above and internally by a blending together of the superior astra- 
 galo-scaphoid ligament with fibres from the anterior ligament, and 
 the anterior portion of the deltoid ligament below with fibres from the 
 inferior calcaneo-scaphoid ligament. To these are united fibrous 
 expansions of the tendons of the anterior and posterior tibial muscles ; 
 
 * The tendon is here rather farther from the artery, and (he surgeon will be above 
 the commencement of its .synovial sheath, in which it traverses the internal annular 
 ligament. 
 
 t Division of the palmar fascia is fully described at p. 32. 
 
 I Congenital Club-foot, p. 62 et pas&irn. 
 
TENOTOMY. 975 
 
 IS 
 
 together they form an unyielding capsule of great strength, which i. 
 attached to the several bones, not in the usual manner, but in adap 
 tation to their altered relative positions. This I would name the 
 '^ astragalo-scaphoid capsule.' " Mr. Parker gives directions for divid- 
 ing this structure which can be made to combine division of the tibial 
 tendons in a manner which I consider far more satisfactory than that 
 already given. Since reading his book I have adopted his method 
 in nine cases with good results. I much prefer it to that usually 
 followed. 
 
 The site chosen for this combined division of tendons and ligaments 
 is a little below and anterior to the tip of the internal malleolus.* 
 Other guides are the site of the astragalo-scaphoid joint, and in 
 advanced cases the transverse crease which, running down on to the 
 sole, denotes the inversion of the foot. Two tenotomes are required, 
 one of ordinary pattern, and one curved, somewhat sickle-shaped, 
 and with a cutting blade about J inch in length. 
 
 The surgeon notes the position of the tibial arteries, and the lines 
 along which the tibial tendons are curving towards the internal cunei- 
 form. Having marked at the spot above given the position of these 
 tendons, he enters a sharp-pointed tenotome, the parts being relaxed, 
 just above the posterior tibial artery, and pushes it inwards on to the 
 dorsum to a spot just short of the anterior tibial artery, the knife being 
 entered just below the skin to make a path for the next instrument, 
 which does the work. The curved tenotome is then inserted under 
 the skin, and pushed on, flat wise, till its tip can be felt over the 
 tibialis anticus ; it is then turned blade downwards, the tibialis 
 anticus is felt to give way, and, as the knife cuts on the subjacent 
 bones and cartilages, the ligaments are felt to yield to it, while, as it 
 is withdrawn, its edge divides the tibialis posticus. 
 
 The internal saphena vein would seem to lie under this incision, 
 but the haemorrhage, never marked, is usually very slight. As I have 
 stated, the results in the nine cases in which I have used this method 
 have been excellent, though in two I was unable to satisfy myself that 
 the tibialis posticus had given way; in one it was certainly notched, 
 and yielded subsequently. 
 
 As in this method the incision is made from the skin down upon 
 the tarsal bones, I have used the spray or irrigation with lotion of 
 mercury perchloride or carbolic acid. The wound is a comparatively 
 free one, but quite subcutaneous, starting from a mere puncture. 
 
 As I have stated, I prefer to put up a case of talipes varus after 
 syndesmotomy, with the foot everted at once, on a notched splint like 
 
 * Mr. Parker (loc. supra dt, p. 78) shows that Velpeau and Syrne pointed out the 
 possibility of dividing the tendon of the tibialis posticns here. 
 
976 OPERATIONS ON THE LOWER EXTREMITY. 
 
 a Dupuytren's, but applied to the outer side. If the tendo-Achillis 
 requires division, this is done in a few days, and the foot put up for 
 about a week, in good position, by Mr. Croft's method of plaster-of- 
 Paris. After this, in early life, the foot must be manipulated daily 
 by the surgeon for a while, and later by the friends, the surgeon seeing 
 it at first every other day. If these manipulations are persevered 
 with daily by the mother or nurse, and the case kept under the 
 surgeon's eye, expensive boots and other apparatus will not be needed 
 in children. 
 
 Tendo-Achillis. — This should be divided about an inch above its 
 insertion, its narrowest part. The surgeon stands inside the right, 
 outside the left, foot, with his back turned towards the body in the 
 former, and facing it in the latter case. The assistant stands opposite 
 to him, grasping the foot as before. 
 
 The foot and leg being turned well over on to the outer side, and 
 the tendon being relaxed by bending the foot downwards, the margins 
 of the tendon are accurately defined. The knife is then introduced 
 vertically close* to the inner side of the tendon till it reaches a suffi- 
 cient depth to ensure being beneath it ;t it is then pushed horizontally 
 across under the tendon till it is felt under the skin by the left index 
 finger, which accurately marks out the outer limit of the tendon ; the 
 blade is then turned towards the tendon, which, being put on the 
 stretch by bending up the foot, is divided by a series of levering 
 movements of the handle. Creaking movements, followed by a 
 sudden snap or thud, denote complete division, when the tendon is 
 to be at once relaxed and the knife brought out horizontally. 
 
 The Peronsei. — The peromeus longus et brevis occasionally require 
 division. They may be divided simultaneously by entering a teno- 
 tome between them and the bone about an inch above the external 
 malleolus. Immediately above this process they are more under 
 cover of the bone. If divided below it, their synovial sheath would 
 be opened, a result requiring greater care in cleanliness. 
 
 TENOTOMY OF THE HAMSTRINGS. 
 
 The patient being rolled two-thirds on to his face, the surgeon 
 stands on the same side as that on which lies the tendon to be 
 divided, facing or turned from the trunk as is most convenient. An 
 assistant stands opposite to him to relax and tighten the tendon. 
 
 Biceps. — The exact limits of the tendon being defined, the surgeon 
 
 * So as to avoid the posterior tibial artery. 
 
 f Young operators often do not insert the l<nife siifBcieutly deep ; tliey thus, when 
 it is pushed across, get into the tendon instead of beneath it, and so divide it incom- 
 pletely. 
 
TENOTOMY. 977 
 
 introduces a sharp knife close to the inner side of the biceps, so as to 
 get between it and the external popliteal nerve, and, having sunk it 
 sufficiently to get beneath the tendon, pushes the knife outwards, 
 horizontally, till it is felt beneath the skin under the left index| 
 which marks the outer limit of the tendon. The edge being turned 
 towards this, the tendon is extended by the assistant, and divided in 
 the usual way. When this is done, the limb is flexed and the knife 
 withdrawn horizontally. 
 
 AVhen the tendon is cut, a cord often rises up close to it. This is 
 the nerve, and the knife must on no account be re-introduced. 
 
 If, after tenotomy in long standing cases, any contracted bands of 
 fiiscia do not give way to extension, which they will generally do, it is 
 wiser to make a small open wound, antisepticaily, and divide them 
 thus, that the surgeon may be certain as to what he is dividing. The 
 wound is united afterwards with one or two horse-hair sutures. 
 
 Semi-tendinosus and Semi-membranosus.— These tendons 
 can be divided in the same way as the biceps. A contracted knee 
 can generally be straightened after division of the biceps and semi- 
 tendinosus. If it is needful to insert the knife more deeply so as to 
 divide the semi-membranosus, it would be well to use a blunt-pointed 
 tenotome.* In one case of a girl of sixteen, after I had divided the 
 biceps and semi-tendinosus, I had dipped the point of the knife a little 
 more to ensure division of the deeper and larger semi-membranosus. 
 Most profuse haemorrhage followed from the superior internal articular 
 vessels. Firm padding and bandaging were applied, and the limb 
 put up in the faulty position for four days. No recurrence of the 
 bleeding took place. 
 
 TENOTOMY OP THE STERNO-MASTOID. 
 
 The two heads are best divided from separate punctures just above 
 the clavicle. The muscle being made prominent by one assistant 
 manipulating the head and another depressing the shoulder, the sur- 
 geon, standing facing the patient on the side to be operated upon, 
 defines the limits of the inner border of the sternal tendon, opens the 
 fasciffi sufficiently freely here, and then, taking a blunt-pointed teno- 
 tome, insinuates it horizontally behind and close to the tendon till it 
 is felt just beneath his left index finger, which is placed at the outer 
 margin ; the edge is then turned towards thetendon, and divides it. 
 It is withdrawn with the usual precautions. The clavicular tendon 
 is divided in a similar way through another puncture. 
 
 Care must be taken to avoid the anterior jugular, which runs out- 
 
 * Messrs. Smith and Walsham and Mr. Barker {Mans, of Oper. Sarg.) recommend 
 this course for inner and outer hamstrings alike. 
 
 62 
 
978 OPERATIONS ON NERVES. 
 
 wards under the muscle a little above the clavicle, and the external 
 jugular, which lies at a varying level close to the outer border of the 
 clavicular head. If a sharp tenotome be dipped too deeply, the 
 internal jugular might also be wounded. 
 
 If any smart venous haemorrhage occur, a pad of dry gauze should 
 be firmly bandaged on. 
 
 Another method is given by some surgeons* of passing a director 
 beneath the heads of the muscle and dividing them on it with a narrow 
 bistoury or tenotome. 
 
 Causes of Failure after Tenotomy. 
 
 1. Septic troubles. These usually arise from the use of dirty 
 instruments which clean themselves at the patient's expense, or from 
 making an open wound. 
 
 2. Incomplete division of the tendon. 
 
 3. Division of important structures— e.5'.,, the tibial arteries, the 
 external popliteal nerve, the anterior or internal jugular veins. 
 
 4. Non-union of the tendon. 
 
 5. Mal-union of the tendon — i.e., adhesions formed by it to adjacent 
 structures, e.g., its sheath or a bone. These must both be extremely 
 rare. 
 
 6. Breaking off the point of the tenotome, usually against a bone. 
 
 CHAPTER IX. 
 OPERATIONS ON NERVES. 
 
 NERVE SUTURE.-NERVE STRETCHING. 
 
 NERVE SUTURK 
 
 This may be required as a primary or secondary operation. 
 
 The latter is accompanied with much more difficulty, owing to the 
 greater retraction of the nerve ends, their bulbous or filiform extremi- 
 ties, their being often buried in scar tissue or matted by it to neigh- 
 boring parts — e.g., tendons and fascia^ ; to which must be added other 
 unfavorable points — e.g., the atrophy and fatty change in the muscles 
 and the stiffness of the joints. 
 
 Primary Suture. — As the mode of uniting nerves will be fully 
 described under the head of secondary nerve suture, the more difficult 
 proceeding, it need not be reijoated liere. It only remains to empha- 
 size the importance of always resorting to it, and not trusting to 
 
 * Smith and Walsliam, Man. of Oper. Sarg., p. 29 ; Barker, 3Iaii. 0/ Oper. Surg., p. 74. 
 
XERVE SUTURE. 979 
 
 spontaneous cure. As an instance of what may be done in very severe 
 cases I may mention the following case :* A woman of suicidal ten- 
 dency wounded herself above both wrists. On the right side, the radial, 
 ulnar, and anterior interosseous arteries were divided, the radial and 
 median nerves completely, and the ulnar almost completely. Appar- 
 ently all the tendons were severed also. On the left side, the radial 
 and ulnar arteries were divided, the radial and ulnar nerves completely, 
 and the median nerve almost cut through. The superficial tendons 
 were quite, the deep partly, severed. The nerves and tendons were 
 sutured. Three weeks later sensation was perfectly normal and active, 
 and passive movement was begun. 
 
 Secondary Suture. — The operation on the median or ulnar will 
 be considered, as these are so commonly injured. The following steps 
 must be remembered : (1) Finding the nerve ends. (2) Freeing and 
 refreshing them. (3) Passing the sutures, and bringing the ends into 
 apposition. (4) Dressing the wound, and the after-treatment. 
 
 1. Finding the Nerve Ends. — With accurate anatomical knowledge 
 this is easy. An Esmarch's bandage does not appear to be necessary, 
 as the incision is made parallel with the vessels, and the use of one 
 leads to oozing afterwards-f If bandages are employed, the parts 
 should be made absolutely evascular ; careless application will only 
 cause most annoying oozing. An incision, 2 to 3 inches long, being 
 made over and parallel to the nerve ends, the deep fascia and any 
 scar tissue are carefully divided and the ends found, the upper bulb- 
 ous and the lower filamentous usually ,J and not always in a line with 
 each other. They are next freed from the adjacent parts. 
 
 2. Resection of the Nerve Ends.— This is best effected by sharp scissors, 
 with one stroke, and without any bruising. If the nerve is held with 
 forceps, these must hold the sheath only. In ease of primary suture, 
 jagged or frayed ends need only be pared sufficiently. In later cases 
 there is much more difficulty. Supposing the upper bulbous end to 
 be taken first, I think that before this is pared the nerve should be 
 carefully stretched,§ so that dissecting-forceps or any other means of 
 
 * Land. Med. Record, 1881, p. 152; Kraussould, Centr.f. Chir., 1880, No. 47. 
 
 t Mr. Bowlby, in his Hunterian Lectures (Lancel, July 16, 1887), thinks that the 
 parts should be rendered bloodless. If this course is adopted care must be taken to 
 provide sufficient drainage, and the upper bandage must, if possible, be applied suffi- 
 ciently far from the wound not to interfere with pressing down the parts when the 
 nerve ends are approximated. j . u • 
 
 t If the distal end be very difficult to find owing to its filiform shape and its being 
 embedded in scar tissue, the wound should be prolonged, the nerve found lower down, 
 and traced up to the distal end. . . 
 
 § An Esmarch's bandage, if applied, will be found in the way now, interfering, as 
 it usually must, with the stretching of the nerve. 
 
980 OPEEATIOXS ON NERVES. 
 
 holding the nerve may inflict any necessary damage on parts that will 
 be cut away. It is not necessary to cut away the whole of a bulb ; 
 removing the greater part will expose healthy nerve fibres. Mr. 
 Bowlby (foe. sup7'a cit.) advises that the section of the upper end should 
 be carried through the uppermost part of the bulb, close to the normal 
 trunk. Not only will numerous young fibres be found here, but, as 
 he points out, the tougher tissue of the bulb affords an excellent hold 
 for the sutures. With regard to the lower end, Mr. Bowlby thinks 
 that all that is needed is " to cut away the extreme end, which, being 
 matted with fibrous tissue and compressed by the surrounding scar, 
 is very likely to contain no nerve tubules. It is seldom necessary to 
 remove as much as i inch, and, however unhealthy the section may 
 look, no good is ever to be gained by a further sacrifice."* 
 
 3. Passing the Sutures and bringing the Nerve Ends in Apposition. — The 
 sutures should be of properly prepared carbolized silk or chromic gut. 
 There has been much dispute as to whether they should be passed 
 through the substance of the nerve itself or only through the sheath. 
 Experience has shown that the former practice is not only harmless 
 to the nerve, but is the method most generally applicable. In a few 
 cases, as in that of a large nerve, where there is but little separation, 
 and where the damage is just inflicted, it may be sufficient to pass 
 the sutures through the sheath only. But in the opposite class of 
 cases the suture should be passed through the nerve itself, and at a 
 suflicient distance from the ends— viz., at least i inch — otherwise when 
 they are tightened they will cut out. Where there is much separa- 
 tion, several sutures should be passed through part of the depth of 
 the nerve, one suture thus taking off some of the tension from its 
 fellows. Another method is to pass one suture completely through 
 the nerve trunk at least \ inch from each cut end. When the sutures 
 in the nerve itself have been tied, two or three more very flne ones 
 may be placed in the sheath, where the nerve is large enough.f 
 
 In cases of much separation, before any sutures are passed, and 
 again before they are tied, the parts should be as much relaxed as 
 possible, and the upper end brought down by pressing down the soft 
 parts. Stretching the nerve has been already advised (p. 979).J 
 
 * As the whole length of the lower end is in the same condition of degeneration or 
 regeneration throughout, manifestly no good can be done by cutting off successive 
 sections in the hope that the cut surface may look more healthy than that which is 
 seen in the iirst resection (Bowlby). 
 
 t To prevent the adhesion of the recently united ends to neighboring parts, short 
 strands of catgut may be placed beneath them, but this is not essential. 
 
 X In cases where, in spite of all precautions, much tension is evidently left on the 
 sutnrw, it might be well to niwike use of "stitches of fixation," as in tendon suture 
 (p. 39). 
 
NERVE SUTURE. 981 
 
 All hemorrhage being scrupulously arrested, and drainage provided 
 by horsehair or a fine tube according to the amount of the disturb- 
 ance of the parts, etc., dry gauze dressings are applied, and the limb 
 placed on a well-padded splint in a position which will best retain 
 the nerve ends in apposition with the least discomfort to the patient. 
 
 Amount of Nerve Tissue which may he S^iccessfully Removed. — From i 
 to 4 inch is probably an average amount. 
 
 Causes of Failure. 
 
 1. Wide separation of ends. 
 
 2. Atrophy, bulbous enlargement and sclerosis of nerve ends, so 
 marked as to require much trimming, and thus tending to wide 
 separation. 
 
 3. Unnecessarily rough handling of the nerve ends. 
 
 4. Suppuration of the wound. 
 Aids in DiflBcult Cases. 
 
 1. Previous stretching of the ends. 
 
 2. Approximation of the ends by position of the limb. 
 
 3. Using several sutures, which distribute the tension evenly. 
 
 4. Perhaps cutting splices, and so joining widely separated ends. 
 The remaining methods must be looked upon, as yet, as experi- 
 mental only. 
 
 5. Autoplastic operation with nerve-flaps. M. Leti^vant advises to 
 make a slit through the nerve with a narrow bistoury, about ^ inch 
 from the end ; the knife being then carried upwards for 1 or li inch, 
 it is made to cut to one side, so as to make a flap. The same is then 
 done with the lower end, and the two flaps, being turned towards 
 each other, are united by their raw surfaces. 
 
 6. Gluck and Vanlair advise that the nerve ends, whether united or 
 only placed as closely as possible in apposition, should be passed 
 through and left in a decalcified bone-tube, so as to keep the uniting 
 material and granulations in a straight fine. 
 
 7. Engrafting one nerve upon another. Thus, where the ulnar is 
 too widely destroyed to bring the ends together, the distal end, frayed 
 out, has been stitched to the median, the sheath and superficial fibres 
 of this having been first removed. The success seems to have been 
 slight and partial. 
 
 8 Gluck has resected H inch of the great sciatic in chickens, and 
 replaced it by a bit of a rabbit's sciatic sutured in. The birds walked 
 afterwards as well as those treated by direct suture, while nerve 
 resection without suture was followed by paralysis complete at the 
 
 end of ten weeks. 
 
 Period Required for Repair.— The following appears to be a tact not 
 sufficiently recognized. The period required for union after sec- 
 ondary nerve suture is very much longer than is usually supposed 
 
982 OPERATIONS ON NERVES. 
 
 to be necessary, owing to the peripheral end being degenerated, the 
 muscles atrophied, and the joints fixed. Complete restoration of 
 function will often require from one to two years. A patient who 
 leaves his surgeon apparently but little better for the operation may 
 return at the end of the above time with his limb practically restored 
 to its natural condition.* 
 
 It is the above condition of the muscles and joints which alone puts 
 anything like a limit on the period at which secondary suture can be 
 successfully practiced. 
 
 The longer the intervalf between the injury and the suture, the 
 more perseveringly must friction, electricity, passive and active move- 
 ment, and massage be made use of, and the more will patience be 
 required by both patient and surgeon. 
 
 NERVE STRETCHING. 
 
 This operation, introduced into England in 1880, and much used 
 in the immediately succeeding years, has lately fallen into abeyance, 
 the clinical results having failed to come up to the expectations raised 
 by the operation. 
 
 Indications. — Of the following list it is only in the first six that 
 the operation can be considered justifiable. 
 
 1. Neuralgise. In all cases where previous treatment has failed, 
 nerve stretching may be practiced before division of or removal of 
 part of a nerve. J The conditions justifying this in facial neuralgia 
 have been already given (p. 235). As, however, the results of neurec- 
 tomy for facial neuralgia are far superior to those of nerve stretching, 
 the latter is only to be recommended on the ground that, owing to 
 the inveteracy of the disease, recurrence is only too probable even 
 after neurectomy, and thus a previous nerve stretching may give a 
 further period of relief. 
 
 2. Sciatica. Nerve stretching is especially indicated here in cases 
 due to rheumatic inflammation of the nerve from exposure to cold 
 and wet.§ The more definite is the sensation of adhesions broken 
 down at the time of the operation, the better is the prognosis. 
 
 * Mr. Bowlby {loc. supracit.) writes: "If there is one fact more than another which 
 stands out in the clinical histories of patients who have been under my own observa- 
 tion, it is that after the failure of union by first intention, after trophic changes of 
 many kinds, after complete atrophy and degeneration of the paralyzed muscles, 
 recovery may yet be complete." 
 
 t The longest of these with which I am acquainted is a case of M. Tillanx's, in 
 which fourteen years had elapsed between the injury to the median and its suture. 
 
 I See a paper by Mr. Walsham {Brit. Med. Joarn., December, 1880), in which tlie 
 possible causes of relief after nerve stretching for neuralgia are discussed. 
 
 § Dr. J. P. Bramwell has published {Brit Med. Journ., June 19, 1880) five cases 
 of this kind, in which much benefit followed stretching the great sciatic. 
 
NERVE STRETCHING. 
 
 983 
 
 3^ Locomotor ataxy. One or both great sciatics have been stretched 
 with a view of improving the lightning pains, the involuntary jerkings 
 of the lower hmbs, and the gait* While improvement for a varyincr 
 period may always be expected as far as the first two are concernecf 
 the prospect of improving the ataxy is very doubtful. Furthermore 
 the slow heahng of the wound in these cases must be borne in mind 
 
 4. Spasmodic contractions of voluntary muscles. Here the operation 
 seems to have been followed by success, temporary at least, in a very 
 large number of cases. Where the spasmodic affection is of traumatic 
 origin— e.5r., where a limb, after a contusion, is at the same time 
 contracted and the seat of spasmodic movements— stretching of the 
 nerves concerned may be absolutely curative. Quite another class r,f 
 cases— viz., stretching the facial for tic convulsif— has been considered 
 at p. 237. 
 
 5. Reflex epilepsy. Prof. Horsley {Diet of Surg., vol. ii. p. 61) 
 states that, in those cases of epilepsy where the attack is preceded by 
 violent pains localized distinctly to different nerves, very marked 
 relief (amounting to cure in several instances) has been obtained by 
 stretching the nerve-trunks thus indicated. 
 
 6. Ana?sthesia of leprosy. Lawrie, of Lahore, seems to have met 
 with striking success, the fifty cases published being all successful. 
 
 In the remaining conditions nerve stretching is of more than 
 doubtful benefit 
 
 7. Tetanus. Owing to the fatality of traumatic tetanus, nerve 
 stretching may be tried here if the case is seen at a very early stage 
 of the disease. But owing to our ignorance of the pathology of the 
 disease, especially with regard to the date a.t which the spinal cord is 
 affected, and from the difficulty of making sure of stretching all the 
 nerves involved, this treatment cannot be looked upon as hopeful.f 
 
 8. Infantile paralysis. Prof Horsley (loc. supra cit.) states that in 
 1881 Dr. Bastian had the great sciatic nerve stretched to improve the 
 nutrition in a limb the seat of the above disease. The effect was to 
 markedly increase the temperature and color of the part, and ap- 
 parently improve the state of the tissues. The result, however, does 
 not seem to have been such as to find imitators. 
 
 * In a case of Dr. Bastian's (Brit. Med. Journ.., July 2, 1881), the patient, in an 
 advanced stage of ataxy, experienced so much relief from the stretching of one great 
 sciatic, that he asked for an operation on the other side. An interesting paper by 
 Dr. Cavafy, with nineteen cases collected from different sources, will be found in the 
 Brit. Med. Journ., 1881, pp. 928, 973. 
 
 f Mr. H. Morris points out (Brit. Med. J"oi«-n., January 14, 1882) that in one case 
 of acute tetanus claimed to be cured by nerve stretching, the medicinal treatment 
 adopted (Calabar bean) was too active to permit of any conclusion in favor of the 
 operation. 
 
984 OPERATIONS ON NERVES. 
 
 Operation (Fig. 95).— The following remarks refer to the great 
 sciatic only, the nerve which has been most frequently stretched. 
 
 * The parts being cleansed, an incision about 4 inches long is made 
 over the nerve in the centre of the back of the thigh, commencing 
 about U inches below the lower border of the glutajus maximus. 
 The interval between the hamstrings being hit off, retractors are in- 
 serted, and the nerve found a little to the inner side of the biceps. 
 The fatty tissue around it is then carefully incised till the white 
 epineurium itself of the nerve is exposed. The nerve, being most 
 entirely separated from adjacent parts, is now stretched. The force 
 with which this is accomplished must vary somewhat in different cases. 
 Thus, in sciatica, the index fingerf being hooked under the nerve, 
 this should be raised well out of its bed in the hope of adhesions 
 being felt to give way both at the part stretched and at a distance also. 
 
 In the case of locomotor ataxy the same amount of stretching— 
 viz., hooking up the nerve some 2 inches above the level of the skin 
 and some 4 or 5 above its bed this being repeated twice in a centri- 
 fugal and centripetal direction — has been followed by satisfactory 
 results. In other cases the pull has been more forcible, care being 
 taken to lift the limb off the table several times. In any case the 
 pull must be without jerks, steady and continuous, and kept up for 
 some three minutes. J The direction of the pull, whether downwards 
 from the trunk or upwards from the limb, has been a good deal dis- 
 puted. Mr. Marshall (Bradshaive Lecture, p. 28) thinks that in neu- 
 ralgia the stretching should be performed both waj's. In ataxy it is 
 essential to stretch down from the body. 
 
 The nerve, being found to be loose and elongated, is replaced in its 
 bed, any bleeding points are attended to, drainage provided, and the 
 wound carefully closed. Antiseptic precautions must be made use 
 of throughout, and the limb be kept quiet with a splint or sand-bags. 
 The tardy healing of the wound in cases of ataxy has been already 
 alluded to. 
 
 In cases of stretching for sciatica, gentle movements of the limb 
 should be begun as soon as possible to prevent the reformation of 
 adliesions. 
 
 * Ether slioiild be given in preference to chloroform, if possible. In some cases 
 wliere anaesthetics seemed contraindicated, the ether spray was made use of. Injec- 
 tions of cocaine might be tried. 
 
 ■f In the case of smaller nerves a bhint hook would be employed. 
 
 X Mr. Marshall (foe. suprn cit.) tliinks that a force equal to 30 lb. or 40 lb. should he 
 the limit for the sciatic. He thus gives an idea of the above force : " If I first pnll as 
 hard as I imagine I should do upon a living sciatic nerve during an operation, I find 
 (liat the force employed is about equal to 20 lb.; but if I pull very hard, it is in- 
 creased to 30 lb., and tliat, I believe, is as hard as a surgeon could well pull when 
 holding a soft nerve between his finger and thumb." 
 
PART VI. 
 
 OPERATIONS ON THE VEETEBRAL COLUMN. 
 
 SPINA B1PIDA.-TREPHINING THE VERTEBRAL 
 
 COLUMN. 
 
 SPINA BIFIDA. 
 
 ^ Indications.— I cannot do better than quote here the conclu- 
 sions arrived at by the Clinical Society's Committee appointed to 
 report on this affection : " 1. Notwithstanding many failures, the plan 
 of treatment by injection is the best with which we are acquainted, 
 and the only one which we feel justified in recommending. 2. A 
 more careful selectioit of cases than has hitherto been made is neces- 
 sary. 3. Marasmus, hydrocephalus, and intercurrent disease contra- 
 indicate the operation. 4. In cases in which the operation may 
 nevertheless be legitimately performed, we should consider the fol- 
 lowing as unfavorable circumstances : (a) Distinct evidence of the 
 cord being in the sac, as shown by umbilication or a longitudinal 
 furrow;* (/3j A very thin membranous or ulcerated sac ; (r) Previous 
 rupture of the sac ; (5) The occurrence of a distinct impulse between 
 the tumor and the anterior fontanelle, or a sac the contents of which 
 are easily returned into the spinal canal; (e) A very early age of the 
 patient. 5. The best result is to be hoped for in children who have 
 reached the age of two months, in whom there is no paralysis or 
 hydrocephalus, and when the sac is covered by healthy skin." 
 
 Operations.— 1. Injection with Morton's Fluid. 2. Simple 
 Tapping and Drainage. 3. Excision. 
 
 All the above are liable to be followed by septic meningitis aided 
 by the constant soaking away of cerebro-spinal fluid, especially where 
 the coverings of the sac are thin and unhealthy. 
 
 1. Injection with Morton's Fluid.— Owing to the large number 
 of successes which have attended the use of this method, and the fact 
 that it was recommended by the Committee of the Clinical Society, it 
 is the only one which will be given here at any length. It is impos- 
 
 * Other points which make it probable that nerve trunks or the cord, or boih, are 
 present in the sac are paralysis of the sphincters or lower extremities, a large sessile 
 tumor with a broad base, and the appearance of cord-like bands when the sac is thin 
 enough to transmit light. 
 
986 OPERATIONS ON THE VERTEBRAL COLUMN. 
 
 sible to point out too strongly to my young readers that it is only by 
 a judicious selection of cases that any success can be expected* 
 
 The sac being cleansed, a syringe which will hold about 2 drachms 
 of the iodo-glycerine solution is chosen, and a fine trocar. The calibre 
 of this must not be too fine for the thick fluidf which has to pass 
 through it. The puncture in the swelling should be made well at one 
 side, obliquely through healthy skin, and not through the membranous 
 sac-wall, the objects being to avoid wounding the cord or nerves, and 
 also to diminish tke risk of leakage of the cerebro-spinal fluid. Un- 
 less the sac is very large it is probably better not to draw off much, 
 if any, of the fluid from the sac on the first occasion. The position 
 of the child during the injection has been a good deal dwelt upon, 
 most recommending that it should be upon its back. The Clinical 
 Society's Committee advise that the child should be laid upon its side. 
 About a drachm is the quantity which they recommend. Every care 
 must be taken to prevent any escape of the cerebro-spinal fluid, now 
 and later, it being clearly understood that any leakage, which is most 
 difficult to prevent, will lead to septic meningitis and death. When 
 the needle is withdrawn the puncture should be pressed around it, 
 and immediately painted with collodion and iodoform, a dressing of 
 dry gauze being also secured with collodion (p. 803). I prefer to give 
 a little chloroform to prevent any crying and straining at the time. 
 The child should be kept as quiet as possible afterwards, on its side, 
 and an assistant should make sure, for the first hour at least, that no 
 leakage is going on. Shrinking of the cyst, setting in rapidly and 
 continuing steadily, shows that all is well. If the injection fail alto- 
 gether, or OL.ly cause partial obliteration of the sac, it should be 
 repeated at intervals of a week or ten days. 
 
 2. Simple Tapping and Drainage. — This consists of either 
 tapping with a very fine trocar and carefully sealing the opening, or 
 inserting a single piece of horsehair as a drain. I have had one suc- 
 cessful case treated by the former method, and four unsuccessful ones. 
 The use of the horsehair drain is not to be recommended, as the leakage 
 cannot be kept sweet. 
 
 3. Excision of the Sac.J — There is no doubt that this method has 
 met with a considerable amount of success, but with regard to this the 
 
 * The Clinical Society's Committee collected 71 cases treated by this method. Of 
 these, 35 recovered, 27 died,4 were relieved, and 5 unrelieved. In a letter to the Com- 
 mittee (dated May 11, 1885) Dr. Morton was able to refer to 50 cases thus treated. Of 
 these, 41 appear to have been successful, and 9 unsuccessful. 
 
 t The fluid is iodine, gr, x. ; iodide of potassium, gj ; glycerine, gj. 
 
 X The Clinical Society's Committee collected 23 cases treated by excision of the sac. 
 Of these, 16 recovered, 7 died. They point out that no mention of the contents of the 
 sac is made in 6 cases; that nerves were certainly absent in 16 eases; and that in 1, 
 which was fatal, they were certainly present (Trans., vol. xviii. p. 380). 
 
TREPHINING THE VERTEBRAL COLUMN. 987 
 
 following points must be reckoned with : (1) It is probable that many 
 cases of failure have not been reported. (2) In many of the cases it 
 is not stated with sufficient clearness whether nerves were present or 
 not. (3) The patient is exposed to the grave dangers of removal of the 
 nerves or cord. 
 
 The cases best suited to this method are those, of course, where 
 there is something of a pedicle, or where the gap in the bones is very 
 small or closed.* 
 
 Mr. Robson has recordedf four cases in which he excised the sac 
 with the aid of the eucalyptus spray, suturing the meningeal and 
 cutaneous flaps respectively. Three cases did well. Nerves do not 
 appear to have been present in the sac. Mr. Robson suggests that if 
 this complication is present, portions of the cyst-wall might be removed 
 from between the nerves, and the remains of the sac placed in the 
 opening in the bones and covered over with skin.| 
 
 Causes of Failure after the Radical Cure of Spina Bifida. 
 
 1. Leakage and septic meningitis. 
 
 2. Convulsions and rapid death. § 
 
 3. Paraplegia. The setting in of this after injection may be tem- 
 porary or permanent. 
 
 4. Hydrocephalus. This also may make its appearance after the 
 injection with iodo-glycerine. 
 
 5. No result, the swelling progressing unaltered. 
 
 TREPHINING THE VERTEBRAL COLUMN. 
 
 After Prof. Horsley's brilliantly successful operation for the removal 
 of a growth from the spinal cord, brought before the Medico-Chirurgical 
 Society this year,|| this most rare operation must be, though thus most 
 briefly, alluded to. 
 
 * Dr Sinclair {Dub. Journ. Med. Sci., 1886, vol. i. p. 199) records a case of successful 
 excision Here all communication with the spinal canal was shut ofiF by » strong 
 vascular cord. No alteration in tension had occurred when the child cried, and con- 
 tinuous pressure on the swelling had produced no head symptoms. 
 
 f Brit. Med. Jnurn., April 4, 18S5. 1„„ f.„m 
 
 t Any one attempting this method would be wise to remove portions of the sac from 
 its sides onlv, suturing the edges of the wound. f Upfn.p thp 
 
 ? Mr. Glutton, who brought a successful case of Dr. Morton's treatment before the 
 Clinical Society (Trans., vol. xvi. p. 34), mentioned another .n wh.ch h s reatm ent 
 was immediately followed by fatal convulsions. The same proved fatal in about ten 
 Lur Ta case under my care. Mr. Bennett, during the above discussion menfoned 
 a~ in which, owing to the child being indisposed at the time, he declined to 
 operate! The child died on its way home of convulsions. He remarked that if he had 
 used the iniection, this would have been credited with the convulsions. 
 
 TMed. Jourr.., 1888, vol. i. p. 191, 1273. An account of theopera ion when 
 employed for fracture-dislocation of the spine will be found in my article. Injuries of 
 the Back," System of Surgery, vol.i. p. 682. 
 
APPENDIX. 
 
 TAPPING OR INCISING THE PERICARDIUM. 
 
 Indications. 
 
 (1 ) When a pericardial effusion lias resisted previous treatment. 
 
 (2) When there is a steady increase of precordial dulness. 
 
 (3) When the heart-beat and pulse are becoming feeble. 
 
 (4) When there are cyanosis, dyspnoea, and epigastric distress. 
 
 (5) When the effusion persists, when it is accompanied by oedema, 
 rigors; and pyemia, when it occurs in a much weakened patient, as 
 part of pyaemia, the fluid is probably purulent.* 
 
 The most suitable place for puncture is, in ordinary cases, the fifthf 
 left intercostal space, about 1 inch from the edge of the sternum, so as 
 to avoid the internal mammary artery,! the instrument being a trocar 
 and cannula, with or without aspiration, according to the facility with 
 which the fluid flows.§ A pint of serum, and in many cases over a 
 pint, has been removed. The withdrawal of a much smaller amount 
 — viz., 3 or 5 oz. — has been followed by recovery. || 
 
 A preliminary puncture being made with a scalpel, the trocar — in 
 the case of serum, a hydrocele trocar will probably be sufficient — 
 
 * In Dr. West's case {Med. Chir. Trans., vol. Ixvi. p. 266), treated successfully, first by 
 tapping and then by free incision, there were no rigors or sweating, but cederna of the 
 chest-walls, most marked over the precordial region, was present. So, too, in a patient 
 of Prof. Rosenstein's, a boy aged ten, with a, large purulent pericardial effusion, the 
 temperature was hardly above normal, and there was no cedema. 
 
 t The fourth space has also been chosen in many cases. 
 
 X An(J also to avoid opening the pleura. When this is adherent to the pericardium, 
 the tapping or incision can, of course, be made farther out. But Dr. West, who chose 
 the nipple line for his puncture and opening as the spot where the heart was farthest 
 from the chest-walls, found that a long sinus formed — an argument for puncturing 
 nearer the sternum. 
 
 § In Dr. West's case the pus was very viscid, and flowed slowly; the cannula was 
 accordingly connected with the aspirator, and about 14 oz. obtained. 
 
 II With regard to the amount to be withdrawn, Dr. Stewart {Edin. Med. .Toum., 
 August, 1885, thinks that, if serous fluid is found, aspiration should be made use of, but 
 only enough withdrawn to give relief. He points out that it is a sound rule, in dealing 
 with vital organs, that only a minimum amount of interference should be had recourse 
 to, and that this is especially necessary in cases which threaten pulse-failure. The tap- 
 ping should be repeated rather than too much fluid be drawn off at once. 
 
APPENDIX. 989 
 
 scrupulously clean, should be steadily pushed, with aseptic precau- 
 tions, for If or 2 inches through the chest-wall, and at a right angle* 
 to It. The trocar should then be removed, and, if fluid does not flow 
 the point will probably be found not to move freely in a cavity. It 
 should then be pushed cautiously onwards, and its point at once 
 sheathed if it is felt to touch against a soft obstacle. 
 
 On the fluid ceasing to flow, the puncture should be closed with collo- 
 dion and iodoform. 
 
 Dr. West thinks {loc. supra cit.) that paracentesis pericardii may be 
 performed with advantage, not only in the pericardial effusions of 
 rheumatic or primary origin, but also in those which occur in the 
 later stages of general dropsy, if it should appear that the fluid in the 
 pericardium is adding to the difficulties under which the heart is 
 placed. According to the cases which he has collected, with one ex- 
 ceptionf all the patients were much relieved by the removal of even 
 a small amount of flluid, and many recovered completely who would 
 probably have died if the operation had not been performed. 
 
 The coexistence of effusion into the pleursg and peritoneal cavity in 
 many of these cases must be remembered. 
 
 If pus is present the case must be treated by free incision. An 
 anaesthetic being given,J the trocar is taken as a guiding director, and 
 a narrow sharp-pointed bistoury carefully thrust in by its side, and 
 the opening further dilated with dressing-forceps or a blunt-pointed 
 bistoury, care being taken to keep the internal opening into the peri- 
 cardial sac free. A large soft drainage-tube should then be inserted, 
 and, when all the pus§ that will come away has escaped, aseptic gauze 
 dressings should be applied. 
 
 Dr. Gussenbauer, in a patient aged fifteen, with purulent pericarditis 
 after osteo-myelitis, resected part of the fifth rib before incising the 
 pericardium, and the patient recovered. While this is an improve- 
 
 * Mr. Godlee {Did. of Surg., vol. ii. p. 164) says close to the sternum, and obliquely 
 upwards and outwards, so as to avoid wounding the heart. 
 
 f In this case, No. 51 in Dr. West's list, death took place, five minutes after the 
 puncture, from hajmorrhage into the pericardium from injury to the right ventricle. 
 But in another case, No. 29, the patient died two hours after the operation, the left 
 pleura being found to contain air and blood, the latter coming from a puncture in the 
 heart. 
 
 J Chloroform will perhaps be the wisest, especially if pleural effusion co-exists, on 
 account of the greater struggling with ethW. It was well taken in Dr. West's case. 
 Punctures for cocaine injection will be painful, and very likely futile. 
 
 ? In Dr. West's case, a boy aged sixteen, this was estimated at two quarts. If the pus 
 is foul, but not otherwise, the cavity should be syringed out with dilute carbolic acid, 
 or mercury perchloride solution. 
 
990 APPENDIX. 
 
 ment on the now abandoned method of trephining the 'sternum, it 
 cannot often be required. 
 Causes of Failure. 
 
 1. The heart fatty or dilated. These changes may come on very 
 rapidly. 
 
 2. The pericardium much thickened and adherent. 
 
 3. Coexisting effusions into the pleurae and peritoneal cavity. 
 
 4. (Edema of the lungs. Evidence of this should be most carefully 
 watched for. 
 
 5. Coexisting diseases — e.g., phthisis and renal disease. 
 
INDEX OF NAMES. 
 
 Abernethy, ligature of external iliac, 535 
 
 Adams, division of contracted palmar fascia, 32 
 
 Allixgham (H.), inRuinal culotomy, 607 
 
 Allingham (W.), excision of rectum, 828 
 
 A^tussAT's operation, 7(>3 * 
 
 Angee, "distance sutures" in uniting tendons, 39 
 
 AvBLiJSTG's method of transfusion, 84 
 
 Bakek (M.), lumbar colotomy in imperforate rectum, 606 ; removal of the tongue, 337 
 
 Ball, torsion of sac in radical cure of hernia, 587 
 
 Banks (M.), excision of shoulder for enchondroma, 128; removal of nasal polypi, 265; 
 imperative need of extensive operations in breast cancer, 508 ; radical cure of hernia, 
 578, 580, 5S2; ligature of the iirst part of the subclavian, 475 
 
 Bakker, operation for ununited clavicle, 149 ; removal of a deep growth in the neck, 
 410 ; wound of obturator artery in operations for femoral hernia, 567 ; case of gastro- 
 enterostomy, 697 : excision of hip by anterior incision, 864 ; excision of knee by a 
 semilunar flap, 901 ; method of excision of astragalus, 953 
 
 Bakwell, ligature of the first part of the subclavian, 476 ; diagnosis of aortic and in- 
 nominate aneurism, 488, 490 
 
 Baitm, operation for stretching facial nerve, 237 
 
 Bennet (W. H.), removal of wedge of bone for talipes, 957; sudden death in spina 
 bifida, 987 
 
 Beenays, curetting of cancer of stomach, 699 
 
 Billroth, date of hare-lip operations, 304 ; repetition of operation in hare-lip, 314 ; pre- 
 liminary ligature of Unguals in removal of tongue, 333 ; excision of pylorus, 694 
 
 Briggs, operative treatment of traumatic epilepsy, 187, 188 
 
 Beinton, amputation through knee-joint, 893 
 
 Browne (L.), case of removal of half the larynx, 380 
 
 Bruns, excision of knee, 899 
 
 Bryant (T.), amputation through knee-joint, 892; case of colectomy, 664; puncture 
 per rectum, 780 
 
 Bryant (New York), ligature of external carotid, 447, 450 
 
 Buchanan, restoration of lower lip, 316 
 
 BuTLiN, the value of microscopic examination of tongue ulcer, 325 ; removal of tongue 
 by Kocher's method, 339 ; mortality after laryngectomy, 372 ; malignant disease of 
 kidney, 626 ; malignant disease of pylorus, 691 
 
 Cadge, lithotomy in little children, 745 ; recto-vesical fistula after lateral lithotomy, 746 ; 
 the size of stone in lithotomy, 749 ; recurrence of stone after lithotomy and lithot- 
 rity, 761 ; lithotrity and litholopaxy, 758, 761 
 
 Callisen's operation, 590 
 
 Caeden's amputation, 885 
 
 Carnochan's operation on second division of fifth nerve, 232 
 
 Chavasse, neurectomy of fifth nerve, 232 
 
 Cheevee's method of removing tonsillar growths, 342 
 
 Chopart's amputation, 957; method of restoring lower lip, 316 
 
 CiNiSELLi, galvanic puncture in thoracic aneurism, 498 
 
 Clemot, operation for hare-lip, 308 
 
 Glutton, neurectomy of fifth nerve, 232 ; treatment of thyroid cysts, 404 
 
 Cock, perineal section, external urethrotomy without a guide, 787 
 
 Cooper (Sir A.), trephining, 166; ligature of external iliac, 533; ligature of abdominal 
 aorta, 556, 557 ■-, ,,^ i. ^ ,- c 
 
 Cripps, method of transfusion, 84; ligature of external carotid, 446; treatment ot 
 wound of thigh, 876 ; hiBmorrhage from posterior tibial artery, 912 ; removal ot 
 rectum, 828 
 
 CUELING, operation for varicocele, 813 . 
 
 Czersty, method of removing tonsillar growths, 343 ; ligature of abdominal aorta dur- 
 ing nephrectomy, 637 
 
992 I^-DEX OP NAMKS. 
 
 Davies-Colley, partial resection of head of humerus, 134 ; colotomy by two stac;es, use 
 
 of pins in, 600 ; removal of wedge of tarsal bones for inveterate talipes, 95a 
 Davy, rectal lever, 84ti ; removal of wedge of bone for inveterate talipes, 956 
 Deleoaede, suture of extensor tendons in Cliopart's amputation, 958 
 DiDOT, webbed fingers, 31 
 
 DiEFPENBACH, restoration of angle of mouth, 316 
 DiETKiCH, ligature of vertebral, 464 
 DUBKEUIL, amputation at wrist, 51 
 Dhncan (,T.), re-infusion, 89 
 DUPLAY, liypospadias, 799 
 DuPUYTREN, cerebral abscess, 163 
 DUEHAM, electrolysis of hydatids, 706 
 
 Edinbuegh Suegeoss on re-infusion, 89 
 
 Eeichses, treatment of inflamed axillary aneurism, 115; excision of shoulder, 126; 
 
 ligature of common femoral, 869; operation for varicocele, 812 
 ESMAECH, fixity of lower jaw, 302 
 
 Fengee, exploration of cerebral abscess, 183; resection of ribs, 521 
 
 Feegusson (Sir \V.), date of operation for hare-lip, 303 ; treatment of pre-maxillary bone, 
 
 311, 313; operation for hard palate, 3^2; lithotomy in little children, 745 
 FoESTEE (J. Cooper), avulsion of naso-pharyngeal polypus, 279 
 
 FoWLEK (G. R. ), operations on the fifth nerve, 231, 232; ununited fracture of patella, 912 
 FuENEAUX JOEDAN, amputation at shoulder-joint, 125; at hip-joint, 844 
 
 Galabin, transfusion, 83 ; ruptured perineum, 838 
 
 Geestee, case of unilateral laryngectomy, 331 
 
 GlEALDES, position of sigmoid in imperforate rectum, 606 
 
 GoDLEE, trephining for cerebral tumor, 216; stretching of facial nerve, 236; resection 
 of ribs, .521 ; drainage of lung cavities, 527; abdominal section for obturator hernia, 
 598 ; case of suppurjitive peritonitis treated by al)dominal section, 661 
 
 GoLDiNG BlED, removal of tonsillar growtlis, 342; jejunostomy, 699; trans-patellar ex- 
 cision of knee, 901 
 
 GooDHAHT, Margate air for empyema, 518; inflation in intussusception, 647 
 
 Gould, amputation of penis, 806 
 
 Gregory, amputation in case of hand flayed by machinery, 29 
 
 Greig Smith, nephrectomy, 631, 632 ; abdominal section for intestinal obstruction, 657; 
 removal of biliary calculi. 703 ; removal of uterine appendages, 721, 722; removal 
 of cancerous uterun, 730, 732 ; ectopia. vesicae, 796 
 
 GuNN, deferred operations for old depressed fracture of the skull, 157 
 
 GussESBAUEE, resection of rib for incision of pericardium, 9-^9 
 
 Guthrie, cut-throat wound of comumn carotid, 423 ; amputation at hip-joint, 852 
 
 Haedie, contracted palmar fascia, 35 
 
 Hare, venesection, 80 
 
 Harrison (E,), uretlirotome, 794; puncture of bladder through prostate, 731 
 
 Heath, amputation at shoulder-joint for gangrene, 114; removal of scapula together 
 with upper extremity, 144; removal of jaws, 271, 294, 295; fixity of lower jaw, 303 ; 
 control of hsemorrhage from a divided lingual, 333 
 
 Hewson, comparison of Syme's and Pirogofl"s amputLitions, 944 
 
 Hey's amputation, 960 
 
 Hill (B.), internal urethrotomy, 791, 792, 793 
 
 Hilton, fissure of anus, 826 
 
 Hofpa, mortality after bare-lip operations, 313 ; shortening met with after excision of 
 knee, 904 
 
 HoLDEN, on trephining, 166 
 
 Holl, frequency of rudimentary condition of twelfth rib, 614 
 
 Holmes, treatment of axillary aneurism, 112; value of sub-periosteal excision of 
 slioulder-joiut, 135; pus between boueand dura mater, 169; treatment of pre-max- 
 illary bone in hare-lip, 310; diagnosis of wounds of the vertebral, 461 ; ligature of 
 subclavian, 466; ligature of innominate, 478; surgical interference in thoracic 
 aneurism, 490, 493, 498 ; ilio-femoral aneurism, 528 ; ligature of the common iliac, 
 540 ; glutfeal aneurism, 5.52 ; Prof. Loreta's cases of dilatation of the stomach ori- 
 fices, 687; ligature of coramiiu femoral, 869; condition of thelimtiafter excision of 
 the knee, 895; excision of ankle, 947; of os calcis, 953 
 
 Holt, aneurism of brachial, 93 
 
 Horsley, removal of brain scar for traumatic epilepsy, ISS ; tubercular tumor of brain, 
 221 ; method of operating on the brain, 227 ; etfects of tliyroidectomy, 390 ; trephin- 
 ing vertebral canal, 987 
 
 Howse, detection of stone in nephro-lithotomy, 615 ; gastrostomy, 680 ; circumcision, 801 ; 
 varicocele, 811 ; splint for excision of knee, 906 ; sequestrotomy, 933 
 
INDEX OF NAMES. 993 
 
 HuETEB, stretcliing facial nerve, 237 
 
 WT^f^l^'f' I'f '*'on 0/ sigmoid in cases of imperforate rectum, 606 
 
 lai 'aWs,'l% '""'' ""'" °' ""'*• ''°' *^^Pl^i»i"g «"-«bi--l abscess, 184; cerebel- 
 
 ^''''n,??.^?'"'-' ^■-^'''•'"*°" °f shoulder for myeloid growi.h, 130; mode of preventing l,a;m- 
 
 ?77 ^nor^ti? f °f «tV°"'i V'^' '*'*^' "^ P"P'l "' ""^1^1 1« meningeal h^Zn^^ge 
 1<7, operative treatment of lupus, 240 ; intussusception, 649; acirte intestinal ob 
 struction, question of operative interference in, 652 mtestinai ob- 
 
 Ikish Sukgeons, ligature of common femoral, 869 
 
 KeegaNj litholapaxy in male children, 769 
 
 Keen, stretching facial nerve, 238 
 
 KlHMISSON, removal of growths from Scarpa's triande, 8S7 
 
 Kochek, excision of tongue, 327 ; myxcedema after'thvroidectomy, 390 391 
 
 K.ONIG, value of free incision in lumbar neplirectmiiy, 6.31 
 
 KoKTE, rupture of axillary artery in slioulder dislocation, 112 
 
 Lange, importance in kidney operation of a rudimentary state of the twelfth rib 614 
 IjANGEKEECK, excision of wrist, 46 ; removal of naso-pharyngeal polypus through the 
 
 nose, 2n(i ; incision for nephrectomy, 289 
 Laekey, amputation at hip-joint, 852 
 
 Lawrence (Sir W.i, removal of naso-pharyngeal polypus through the nose, 285 
 Lee (Chicago), trephining for cerebral abscess, 18:3 
 Lee (H.), operation for varicocele, 813 
 Lembekt's suture of intestine, 666 
 
 LiSEKANC. amputation at hip-joint, 8.52; amputation through tarso-nietatarsal ioints, 960 
 Lister (Sir J.), excision of wrist, 42; wiring ununited fracture of olecranon, 78; on 
 
 C'arden's amputation, 8s5 ; treatment of compound fractures, 935 
 Longmoke (Sir T.), excision of radius and nlna in military surgery, 59; excision of the 
 
 shoulder. 131 ; gunshot injuries of the knee, 897 
 LOKETA, dilatation of stomach orifices, 687 
 Lossex, neurotomy of the fifth nerve, 234 
 Lucas (E. C), excision of lower end of ulna for myeloid sarcoma, .58- radical cure of 
 
 umbilical hernia, 576; haemorrhage after nephrectomy, 034; successful nephro-lith- 
 
 otomy four months after nephrectomy, 642 
 Lucas-Championniere, cerebral localization, 215 
 Ll'CKE, neurectomy of the iifth nerve, 234 
 
 MacCormac (Sir W.), rhinoplasty by the Italian method, 261 ; removal of the thyroid 
 gland, 393, 395, 396 ; treatment of ruptured bladder, 776 ; ligature of popliteal artery 
 from the front, 920 ; case of Miekulicz's operation on the tarsus, 954 
 
 Macewen, restoration of humerus by bone grafts, 102 ; replacement of bone after tre- 
 phining, 168 ; trephining for cerebral abscess, 1f<2 ; supra-coudyloid o.st60tomy of 
 femur, 966 ; osteotomy of tibia as well as femur, 969 
 
 MACLEOD, on Syme's amputation, 939 
 
 Maisonneuve'.s and Gueein's operation for naso-pharyngeal polypus by partial re- 
 moval of the upper jaw, 287 
 
 Makixs, closure of artificial anus, 662 
 
 Marsh (H.), nephrectomy for pyelitie kidney, 630; intussusception, 650; hfemorrhage 
 after cleft-palate operations, 324 ; excision of hip, 8."i4 ; removal of loose bodies from 
 knee-joint, 916 
 
 Mears, neurectomy of fifth nerve, 235 
 
 MiCKULicz, removal of tonsil growths, 344; myxcedema after thyroidectomy, 393 ; opera- 
 tion on tarsus, 954 
 
 MiRACLT, operation for hare-lip, 309 
 
 Moore, removal of rodent ulcer, 243, 245, 246 ; causes of failure after removal of breast, 
 504 ; introduction oi wire into aneurismal sac, 496 
 
 Morris, removal of myeloid growth of radius, .57; restoration of Steno's duct, 240; 
 nephro-lithotomy, 615 ; nephrectomy, 624, 642 ; nepbrorraphy, 644 ; radical cure of 
 hydrocele, 810 
 
 MOTT, removal of clavicle, 146; ligature of innominate, 480 
 
 Nancrede, trephining, 156, 1.57; cerebral abscess, 162; cerebral localization, 213; oper- 
 ative interference in abdominal injuries, 669 
 Nelaton, naso-pharyngeal polypus, 282; hare-lip, 309; right iliac enterotomy, 659 
 Norton, webbed fingers, 31 
 
 Ogston, trephining frontal sinuses, 208 ; osteotomy for genu valgum, 969 
 
 63 
 
994 INDEX OF NAMES. 
 
 Ollier, suh-periosteal excision of shoulder, 135 ; removal of naso-pharyngeal polypus 
 through nose, 286 ; preservation of lateral ligaments in knee excision, 903 ; infre- 
 quent dressings after knee excision, 901 
 
 Otis, on gunshot injuries, excision of wrist, 47 ; radius and ulna, 59; elbow, 75; inju- 
 ries at bend of elbow, 96; humerus, 101; shoulder, 137; ligature of external iliac 
 for secondary hjemorrhage from femoral, 531; hip-joint, 859; knee, 897 
 
 Paget (Sir J.), site of stricture in femoral hernia, 560; condition of intestine in stran- 
 gulated hernia, 565 
 
 Paget (S.), growths of palate, 324 
 
 Pancoast, neurectomy of fifth nerve, 234 
 
 Paekek (Eobert), thyrotomy, 346 ; angular tracheotomy tubes, 352 ; size of tubes, 352 ; 
 suturing bladder in supra-pubic lithotomy, 754; excision of hip by anterior incision, 
 863 
 
 Paekek (Eushton), malformation of anus and rectum, 835 
 
 Paekes, operative interference in abdominal injuries, 668 
 
 Pl(:'K, amputation through kuee-joint, 893 
 
 PiLCHEE, suturing bladder in supra-pubic lithotomy, 754 ; removal of growths from 
 Scarpa's triangle, 868 
 
 Pibogoff's amputation, 943 : contrasted with Syme's, 943 
 
 Pitts, stretching inferior dental nerve, 235; tumor of bladder, 738 
 
 Poland (A.), ligature of subclavian, 467 
 
 Pollock, partial removal of scapula, 139; occasional inveteracy of hj'drocele, 810 ; 
 crushing piles, 824; amputation through knee-joint, 893 
 
 Poetek, amputation at shoulder-joint, 121 ; excision of ankle, 950 
 
 Pyb, excision of wrist for injury, 47 
 
 EoBEETS, spiculation of internal table, 158 
 
 EouGE's operation, 264, 285 
 
 EoussELL, transfusion, 86 
 
 EoiTX's amputation, 941 
 
 EOYES Bell, excision of thumb phalanx for enchondroma, 27 
 
 Savoby, hfemorrhage from malignant disease opening axillary artery, 106 
 
 Schaeee, arterial transfusion, 90 
 
 Sedillot, restoration of upper lip, 316 
 
 Seere. restoration of lower lip, 314 
 
 Sheild, excision of shoulder for unreduced dislocation, 12S 
 
 Skey', recurrent hfemorrhage from wound of palm, 37; method of rhinoplasty, 263; am- 
 putation of metatai'sus, 960 
 
 Smith (H.), clamp and cautery in piles, 823 
 
 Smith (S.), amputation through kuee-joint, 891 
 
 Smith (T.), cleft-palate, 319 ; hare-lip, 304 ; supra-pubic puncture of the bladder, 779 
 
 Spanton, radical cure of hernia, 588 
 
 Spence, amputation of shoulder-joint, 120 
 
 Stimson, treatment of ruptured axillary artery, 112 
 
 Syme, old operation for ligature of axillary artery. 111 ; common carotid, 442; glutieal, 
 554 ; rhinoplasty, 256 ; restoration of lower lip, 315 ; removal of tongue, 327 ; exter- 
 nal urethrotomy, 783 ; amputation at ankle, 936 
 
 Symosds (C. J.), removal of scapula, 143; dilatation of malignant disease of cesophagus, 
 679 ; (with Dr. jMahomed) removal of concretion from vermiform appendix, 661 ; ex- 
 panded kidney in nephro-lithotomy, 617 
 
 TAi'i' (L.), biliary calculi, 709 
 
 Tayloe (F.), inflation in intussusception, 647 
 
 Thompson (Sir H.), bladder growths classification, 736; removal. 737; litholapaxy, 758, 
 
 764 ; supra-pubic lithotomy, 750, 751 ; urethrotome, 795 
 Thoenton (K.), treatment of ureter in nephrectomy, 637; enucleation of ovarian cysts, 
 
 718 ; removal of cancerous uterus, 729, 732 ; giistrotom v, 685 
 Tiffany, suture of tendon to flaps in finger amputation, 20 
 TiLLAUX, musculo-spiral nerve embedded in callus, 105 
 
 Vogt, fat embolism after knee excision, 909 
 Volkmann, treatment of lupus, 240 
 
 Walsham, treatment of epilepsy, 185; stone in female children, 773 
 Ward (O. . united fracture of patella, 911, 915 
 Watson (E.), modification of Pirogofi"'s amputation, 945 
 Watson (P. H.), extensive removal of tarsus, 955 
 West, excision of the wrist, 45 
 
INDEX OF NAMES, 995 
 
 West (S,), tapping and incising tlie pericarclium, 988 
 
 Wheelhouse, tourniquet pressure on abdominal aorta, 528 
 
 White ( II ale), cerebral tumors, 229 ; state of cranial bones in, 222 
 
 Whitehead, removal of tongue, 327 ; operation for piles, 824 
 
 Wilde's incision, 194 
 
 Williams, drainage of lung cavities, 524 
 
 Wood, radical cure of hernia, inguinal, 587; femoral, 590; umbilical, 590 
 
 Weight (G. A.), excision of vfrist, 45 ; conditions simulating renal calculus, 613 ; exci- 
 sion of hip, 854 ; excision of knee for infantile paralysis, 900 ; erasion of knee, 910 ; 
 excision of astragalus, 952 
 
GENERAL INDEX. 
 
 Abdomen, operative interference in gunshot injuries of, 666 
 
 Abdominal incision in nephrectomy, without opening peritoneum, 639 
 
 Abdominal section for ligature of abdominal aorta, 555; ligature of internal iliac, 550 ; 
 for strangulated obturator hernia, 550 ; in nephrectomy, 635 ; acute intestinal ob- 
 struction, 651, 655; in gunshot injuries, 666 
 
 Abnormalities of brachial artery, 95 
 
 Abscess, cerebellar, from ear disease, 195, 196; trephining for, 196 
 
 Abscess, cerebral, from foreign bodies in the skull, 162; from injury, 180; from ear 
 disease, 195; treiihining for, 196 
 
 Abscess, hepatic, opening, 707 
 
 Abscess in brain from ear disease, 195 
 
 Abscess in brain or cerebellum, 195 
 
 Abscess, mastoid, 192, 193; incision of, 194; trephining for, 194 
 
 Abscess of liver, opening, 707 
 
 Acid, application of, in piles, 824; prolapsus, 827 
 
 Acute intestinal obstruction, 651 ; chief varieties of, 645; exploration in, 651, 655 
 
 Adhesions, of bowel in hernia, 564; in ovarian tumors, 714, 716 
 
 Age, influence of, in tracheotomy, 348; in empyema, 511; in excision of the hip, 858 ; 
 in excision of the knee, 894 
 
 Aids in reduction of intestine in strangulated hernia, 570; in recognizing the sac in 
 hernia operations, 561 
 
 Aids to finding the bowel in colotomy, 597 ; renal calculus, 615 
 
 Air passages, foreign bodies in, 366 
 
 Amputation, of arm, 96, different methods, 97; skin flaps, 97; transfixion flaps, 97; 
 circular, 100; mixed method, 100; Garden's, 885; Chopart's, 957 ; at elbow-joint, 
 64; practical points, 64, difi'erent methods 65, mixed, 65; circular, 07 ; lateral 
 flaps, 66 ; forearm, practical anatomical points, 60; different methods, 60; skin 
 flaps, 60; transfixion, 62; circular, 64; fingers, 17; practical points, 17, difTerent 
 methods, 18; distal phalanx, 17 ; second phalanx, 19 ; at metacarpo-phalangeal 
 joint, 22; Gritti's, 884, 887 ; at hip-joint, 844, 852; flap methods, 859; lateral 
 flaps, 852; antero-posterior flaps, 853 ; P\irneaux Jordan's method, 848 ; different 
 means of arresting hajmorrhage, 845 ; Hey's, 960; knee-joint, 891 ; lateral flaps, 
 891 ; antero-external and postero-internal flaps, 893; leg, different methods, 928: 
 lateral skin flaps, 928 ; Teale's method, 930 ; in compound fractures, 936 ; in acute 
 necrosis, 960; Lisfranc's, 960 ; of penis, 803; Pirogoff's, 943; at shonlder-joint, 
 different methods, 117 ; means of arresting haemorrhage, 117 ; by lateral flaps, 
 118; Spence's method, 120 ; by superior and inferior flaps, 122 ; by deltoid flap, 
 124; by anterior and posterior flaps, 124; Furneaux Jordan's method, 125 ; for 
 axillary aneurism, 115; for subclavian aneurism, 114; Skev's, 900; Stokes-Gritti's, 
 884, 887; Syme's, 939; contrasted with Pirogoff''s, 943; Roux's modification, 
 942; subastragaloid, 946; of thumb, phalanges, 25; at carpo-metacarpal joint, 
 25; of toes, 963; of great toe, 964; through thigh, 878; practical points, 878; 
 difierent methods, 878; mixed antero-posterior flaps, 878; by transfixion, 880 ; 
 circular, 882 ; by Teale's method, 883 ; by lateral flaps, 883 ; at wrist-joint, difl^erent 
 methods, 49 ; long palmar flap, 50 ; equal antero-posterior flaps, Dubrcuil's method, 
 51 ; circular method, 51 ; Teale's method, 52 
 
 Aneurism, of aorta and innominate, 488 ; aortic, tracheotomy in, 364; axillary, 11,0, 
 466; old operation for. Ill ; cases requiring amputation at shoulder-joiut, 114 ; 
 brachial, 92; arterio-venous, 91 ; of common carotid, 431, old operation for, 442 ; 
 of external carotid, 432, by anastomosis of branches of external carotid, 449 ; of 
 internal carotid, 433, 456; femoral, 869; gluteeal, 551, old operation for, 554; 
 ilio-femoral, iliac, femoral, inguinal, 528, 539; poplitseal, 871, ruptured 912; 
 radial and ulnar, traumatic, 53; simulated by pulsating tumors, 543 ; subclavian 
 and subclavio-axillary,>467; temporal, 419 ; vertebral, 460 
 
GENERAL INDEX. 997 
 
 Aneurism needles, 470 
 
 Ankle, excision of, 947 
 
 Anterior tibial artery, ligature of, 925, 926, 927 
 
 Antiseptic excision of hydrocele, 810: of veins in varicocele, 811 
 
 Antiseptic incision of hydrocele, 808 
 
 Antrum, epithelioma of, 269; relation of a growth to, 272; tapping, 292 
 
 Anus, artilicial, formation of, 658 ; closure of, 661 ; imperforate, 835 
 
 Aorta, abdominal ligature of, 557, 558 
 
 Appendages, uterine, removal of, 721 
 
 Arm, amputation of, 96 ; difTerent methods, 97; by skin flaps, 97; by transfixion, 98; 
 combined method, 100 ; circular, 100 
 
 Arterial transfusion, 90 
 
 Arterio-venous aneurism at bend of elbow, 91 
 
 Artery, abdominal aorta, ligature of, through the peritoneum, 557 ; behind the peri- 
 toneum, 558; anterior tibial, lig;iture of, in compound fracture, 925 ; at junction 
 of upper and middle third of leg, 926 ; at junction of lower and middle third, 927 ; 
 axillary, ligature of first part, 106; ligature of third part, 110; old operation, 
 110; rupture in dislocation of shoulder, treatment, 112; brachial, ligature of, at 
 bend of elbow, 91 ; in the middle of the arm, 92 ; carotid, common, ligature of, 
 427 ; high operation, 429 ; low, 440; temporary ligature, 441 ; old operation, 442 ; 
 question of ligature of common or external carotid, 433, 446 ; carotid, external, 
 ligature of, 446 ; above and below digastric, 453, 455 ; carotid, internal, ligature 
 of, 455 ; rareness of wounds of, 446 ; dorsnlis pedis, ligature of, 938 ; facial, ligature 
 of, 421; femoral, common, ligature o', 432; injury of, in removal of growths, 867 ; 
 question of ligature of vein, 868: femoral, superficial, ligature of, in Scarpa's tri- 
 angle, 871 ; wound of vein, 875; ligature in Hunter's canal, 875 ; wound of, in 
 raid-thigh, 875; glutseal, ligature of, 551 ; by the old operation, 654; iliac, common, 
 ligature of, 538 ; bv anterior incision, 545 ; by posterior incision, 540 ; iliac, ex- 
 ternal, ligature of, 528 ; bv Sir A. Cooper's method, 533 ; by Abernethy's, 535 ; 
 iliac, internal, ligature of, 548, 550; by laparotomy, 550; interior thyroid, see 
 Thyroid Arteries ; innominate, ligature of, 477, 480 ; internal carotid, see CarotuI ; 
 internal iliac, see Iliac, Internal ; lingual, ligature of, 424 , under the hyo-glossus, 
 425- of first part, 427 ; middle meningeal, hemorrhage from, after trephmmg, 
 177 ■' occipital, ligature of, 421, 423; palmar arches, hemorrhage from, 36 ; pero- 
 neal, ligature of, 928; po]ilitfeal, ligature of, from behind, 920; from m iront, 
 920 • posterior tibial, ligature of 920 ; in middle of leg, 924 ; in lower third 924 ; 
 at inner ankle 925; radial, ligature of, on back of wrist, 52; in forearm, 53; in 
 lower third, 54 ; in middle third, 54 ; in upper third, 55 ; subclavian, ligature ot, 
 in its second and third parts, 465, 467 ; ligature of, first part, 47o ; in thoracic 
 aneurism, 493; temporal, ligature of, 419; artenotomy of, 420; thyroid arteries, 
 ligature of, in enlarged thyroid, 400 ; of superior thyroid, 401 ; of inferior 401 
 ulnar, ligature of, in the forearm, 55; in lower third, 5b ; in middle third, ,6, 
 vertebral, ligature of, 460, 463; in epilepsy, 462 
 
 Artificial anus, formation of, 658; closure of, 661 
 
 Artificial larvnx, 383 ^_ 
 
 4siiiration of nleura, 513 ; of bladder, no . . 
 
 LtSurexcisionof,952; for disea<:e, 952 ; for infantile paralysis, 9o2 ; for injury, 
 
 95^ , ,1 ■ ■ .<■ 11=; 
 
 Ixill::^ ^HgrSXhr ;!:^:';^6;'; <^:^I;-^ art, no; oM operation, no; 
 rupture of, in reduction of shoulder dislocation, 11.. 
 
 Bag, for distending rectum in supra-pubic cystotomy, 750 
 
 Biliary calculi, removal of, 708 „ „n,= f^m 735 ■ removal of stone from, 
 
 „,pr.-pAio,7™i p.r r,ot„n,, 780; llm»«l. U™ P™"=. '»' 
 
 Bone-crowns, replacement after ti-ephiuing, 168 
 Bone-grafts, restoration of humerus by 102 
 Brachial arterv, ligature of, at bend of elbow 91 ; i 
 
 in the middle of the arm, 92 ; spon- 
 Taneous aneurTsmof,y3'; abnormalities, 95 _ . jgg 
 
 of, 216; Prof. Horsley's method of operating on, AAi 
 
998 GENERAL INDEX. 
 
 Breast cancer, question of operation in, 499 ; removal of, 499, 502 ; chief objects in 
 removal, 502; recurrence after removal of, 501; need of extensive operations 
 for, 508 
 
 Bronchi, foreign bodies in, 367 
 
 Bullets in the brain, 198 
 
 C^SAMAN section, 733 
 
 Calculus, biliary, removal, 708 ; renal, evidence of, 611 ; conditions simulating, 612 ; 
 
 removal, 614; in bladder, difficulties in finding, 741 ; difficulties in extracting, 
 
 74S ; size of, suited to lateral lithotomy, 749; to lithotrity and litholapaxy, 758; 
 
 recurrence, 761 ; detection of last fragment in litholapaxy, 766 ; treatment of, in 
 
 the female bladder, 770 
 Callus, compression of musculo- spiral nerve by, 104 
 Cancer, see different parts, e.g., for cancer of tongue, see Tongue 
 Garden's amputation, 885 
 Cardiac orifice of stomach, dilatation of, 689 
 Carotid, common ligature of, 427, 438; temporary ligature, 438; old operation, 442 ; 
 
 external, ligature of, 446, 453 ; internal, ligature of, 455, 459 
 Castration, 814, 818 ; in malignant disease, 816; in tubercular testis, 817 
 Caustic paste, zinc chloride, use of, in rodent ulcer, 214 ; after removal of eyeballs, 252 ; 
 
 after clearing out orbit, 253; after removal of upper jaw, 275, 300 
 Cautery, tracheotomy by, 355 ; in removal of tongue, 338 ; in removal of the penis, 804 
 Cerebellar abscess from ear disease, 195, 196 
 Cerebral abscess, from foreign bodies in the skull, 162; from injury, 180; from ear 
 
 disease, 195; trephining for, 196 
 Cerebral sinuses, phlebitis in ear disease, 197 
 Cerebral tumor, localization of, 209 ; condition of skull bones in, 222 ; varieties of, 222 ; 
 
 trephining for, 216, 227 
 Chest, incision of, in empyema, 516; tapping of, 511, 513; nature of fluid in, serous 
 
 or purulent, 511 
 Choice of operation in thoracic aneurism, 498 ; between lumbar and abdominal 
 
 nephrectomy, 639; in stricture-retention, 790; between excision and erasion of 
 
 the knee, 909; between Syme's and Pirogofi's amputation, 943; between excision 
 
 and amputation in disease of the tarsus, 951 
 Cholecystectomy, 713 
 Cholecystotomy, 708, 710 
 Chopart's amputation, 957 
 Circular amputation of arm, 100; through elbow-joint, 67 ; of forearm, 64 ; penis, 804; 
 
 thigh, 882; wrist, 51 
 Circumcision, 801 
 
 Clamp for resection of intestine, 662; in piles with cautery, 823 
 Clavicle, wiring ununited fracture of, 149; removal of, 146 
 Clearing out of orbit, 253 
 Cleft palate, best date for operation, 317 ; operation on soft, 319 ; on hard, 321 ; nasal 
 
 flap method, 323 
 Closure of artificial anus, 661 
 Colectomy, 663 
 
 Collateral circulation after ligature, see each artery 
 Colon, abnormalities of, 603 
 Cololomy, lumbar, 591, 597 ; choice of side in, 593, 595; aids to finding bowel in, 596; 
 
 landmarks, 591, 597; presence of mesocolon in, 603; by two stages, 600; the use 
 
 of pins in, 600; inguinal, 605; inguinal of lumbar in imperforate rectum, 606; 
 
 comparison of colotomy and excision of the rectum, 829 
 Compound depressed fracture of skull, operative interference in, 156; compound frac- 
 tures, treatment of,*934; amputation in, 936 
 Condition of limb after hip-excision, 857 ; of patient after laryngectomy, 384; after 
 
 excision of rectum, 830 
 Conical trephine, 165 
 Conservative surgery of the hand, 28 
 Contracted palmar fascia, operations on, 32 
 Cranial bones and dura mater, growths from, 152 
 Cranial bones, condition of, in cerebral tumor, 222 
 Crushing of piles, 824 
 Curetting gastric cancer, 699 
 Cystotomy, 774 
 
GENERAL INDEX. 999 
 
 Digital dilntation of stomach orifices 687 
 
 DK:;;^:[rr82 "'''"' '''^ pylon.,687. cardiac orifice, 689 
 
 DklrnM .''^''T'fi'^^''' '"P""'" "f '"''"'-'■■y ^■•te'-y during reduction, 112 
 Uistal phalanx ol finger, amputation of, 18 
 
 Distance sutures in union of tendons, 3S 
 
 Divided tendons of fingers, 38 ; nerves, 978 
 
 Division of contracted palmar fascia, 32 
 
 Dorsalis pedis, ligature of, 938 
 
 Drainage of lung cavities, 5123; value of, in hydronephresis, 607 
 
 Diiodenostomy, 698 ' 
 
 Eae disease, phlebitis of cerebral s.inn>.es in, 197; meningitis in, 197 • practical aua- 
 tomical points m, 192; mastoid abscess, 193; abscess in brain or cerebellum 195 
 
 Ecra^eur in the removal of the tongue, 337; galvanic, 338; in removal of bladder 
 growths, (39; in removal ot penis, 803 
 
 Ectopia vesicse, 796 
 
 Elbow-joint, amputation througli, different methods, 61; excision of, 67 69- arterio- 
 venous aneurism at bend of, 91 ; conservative surgery in gunshot wounds of 96 
 
 Electrolysis, in naso-pharyngeal polypus, 281; in hydatids, 706 
 
 Elephantiasis, ligature of large vessels in, 531, 872 
 
 Empyema, 514; treatment of, 515; resection of ribs for, 521 
 
 Enterectomy, 663 
 
 Enterotomy, 658 ; right iliac, 659 
 
 Epispadias, 800 
 
 Erasion of knee, 910 
 
 Excision, of ankle, 947; astragalus, 951; <>lbow, 67; hip, 854; -humerus, 101; 
 hydrocele, 810; knee-joint, 893; pylorus, 691; os calcis, 953; radius and ulna 
 for growths, 57; in military surgery, 59; rectum, S28; shoulder, 126; in unre- 
 duced dislocations, 128; tarsal bones and joints, 950; temporo-maxillary ioiut, 
 300 ; wrist-joint, 40 
 
 External carotid, ligature of, 446 
 
 External iliac, ligature of, 532 
 
 External urethrotomy, 783 
 
 Facial artery, ligature of, 421 
 
 Facial nerve, stretching of, 236 
 
 Female bladder, treatment of stone in, 770; by dilatation of urethra, 770; litholapaxy, 
 771 ; vaginal lithotomy, 771 ; supra-pubic lithotomy, 773 
 
 Femoral artery, common, ligature of, 866, 871 ; question of ligature of, in wouml of 
 femoral vein, 868; question of ligature of common femoral or external iliac, 869 
 
 Femoral artery, superficial, ligature of, in Scarpa's triangle, 871, 873 ; injury to femoral 
 vein during operation, 875; ligature ot^ in Hunter's canal, 875, 877.; wounds of, 
 875 
 
 Femora] hernia, strangulated, 559; operation without opening the sac, 560; by open- 
 ing the sac, obi ; complications, 564; wound of obturator artery, 567; radical 
 cure of, 589 
 
 Femur, ununited fracture of, 890 
 
 Fifth nerve, operations on, 230; neurotomy, 230 ; neurectomy, 231 ; stretching of, 
 232, 235 
 
 Fingers, position of joints, 17; practical points in amputation, 17; different amputa- 
 tion of phalanges, 18; theca, 18; amputation of distal phalanx, 18; of second 
 phalanx, 19; through middle phalanx, 20; at metacarpo-phalangeal joint, 22; 
 removal orsupernuraerary, 24 ; excision of, 28 ; reunion of severed, 30 ; webbed, 30 
 
 Fissure of rectum, 826 
 
 Fissure of Kolando, 209; modes of finding, 208, 211 ; practical points in application 
 of trephine to, 214 
 
 Fistula in ano, varieties, 819; in phthisical patients, 820; operation, 821 _ _ 
 
 Fixity of lower jaw, 300; operations for, 300; excision of temporo-maxillary joint, 
 301 ; Esmarch's operation, 302 
 
 Flap methods, see different operations j co -a 
 
 Fore-arm, amputation of, 60; practical anatomical points, 60; methods, 60; mixed, 
 60; transfixion, 62; circular, 64 ; bones of, excision, 57 
 
1000 GENERAL, INDEX. 
 
 Foreign bodies, in the skull, removal of, 161; in the brain, operative interference in, 
 
 198; question of expectant or operative treatment, 201, 203; in the air passages, 
 
 removal of, 366 
 Fractures, of the skull, immediate or recent, trephining in, 156, punctured, 160 ;_ of 
 
 inner wall of orbit, 160; compound, treatment of, 934; question of amputation 
 
 in, 936 
 Frontal sinuses, trephining, 208 
 
 Gall-bladder, tapping and incising, 708 ; removal of calculi from, 711, 712 ; removal 
 of, 713 
 
 Gall-stones, intestinal obstructiorv bv, 657 ; when justifying operations on the gall- 
 bladder, 708, 709 ; removal of, from gall-bladder, 711, 712 
 
 Galvanic cautery, in removal of tongue, 338, in am|)Utation of the penis, 804 
 
 Gangrene, amputation at shoulder-joint for, 114; of intestine in hernia, 565 
 
 Gflstro-enterostoniy, 697 
 
 Gastrostomy, comparison of, with tubage of oesophagus, 677, 679 ; method of Howse, 
 680 
 
 Gastrotomy, 685 
 
 Glands, enlarged axillary, question of cleaning out, 508; epitheliomatous, in tongue 
 cancer, 334 ; early enlargement of, in ca^es of growths of tonsil, 341 ; enlarged, in 
 epithelioma of the penis, question of nature, 806 
 
 Glutieal artery, ligature of, 551, 553 ; old operation, 554 
 
 Growths, enchondroma of thumb, 27 ; myeloid, of radius and ulna, 57, 58 ; malignant, 
 of axilla, opening axillary artery, 106; enchondroma and myeloid growth of upper 
 end of humerus, 128; of scapula, 138, 144; of clavicle, 146 ; of scalp, 151 ; of cra- 
 nium and dura mater, 152; of brain, 216, 222; parotid, 246; of eyeball, 250 ; of 
 orbit, 253; of jaw, 2ti7, 293; naso-pharyngeal, 278 ; of palate, 324; of tonsil, 340; 
 of larynx, 370; thyroid, 385; large deep-seated, of the neck, 407 ; of kidney, 625 ; 
 of bladder, 736 ;. of rectum, 828 ; of Scarpa's triangle, 867 ; of testicle, 814 
 
 Gunshot injuries, excision of wrist, 47; excision of radius and ulna, 59; excision of 
 elbow,75; ligature of brachial, 92; excision of humerus, 101 ; excision of .shoulder, 
 137; removal of bullets from brain, 198; of abdomen, operative interference in, 
 666; of hip, 859; of knee, 897 
 
 HiEMOERHOiDS, Operations, 822 ; ligature, 822 ; clamp and cautery, 823 ; crushing, 
 823; acid, 824; Whitehead's operation, 824 
 
 Hard palate, operation on cleft of, 321 
 
 Hare-lip, best time for operation, 303; points to inqiiire into before operating, 304; 
 single, 305; double, 310; sudden death after operations, 307; treatment of pre- 
 maxillary bone, 310; mortality after, 313; repetition of operation for, 313 
 
 Hepatic abscess, 706 
 
 Hepatotomy, 706 
 
 Hei'uia, strangulated 558 ; strangulated femoral, 559 ; operation without opening the 
 sac, 560; with opening sac, 561 ; complications of operation, 564; strangulated 
 inguinal, 568 ; aids to reduction of intestine, 570; varieties, 572 ; reduction en 
 masse, 573; simulated by retained testis, 573; strangulated umbilical, 574; prac- 
 tical points before operation, 574; question of radical cure, 576; strangulated 
 obturator, 577; radical cure, 578 ; question of truss after, 579; different operations, 
 581; Banks's, 582; Macewen's, 584 ; Barker's, 586 ; Ball's, 587 ; subcutaneous 
 methods, 587 ; Wood's, 587 ; Spanton's, 588 ; radical cure of femoral hernia, 589 ; 
 radical cure of umbilical, 590 
 
 Hey's amputation, 960 
 
 Hip-joint, amputation at, 814, 848; means of controlling hfemorrhage during, 845 ; 
 Davy's lever, 846; Fnrueaux Jordan's method, 844; flap methods, 849 ; lateral 
 flaps, 852; antero external and postero-internal, 853; excision, 854, 859 ; chief 
 questions, 854 ; condition of limb after, 857 ; for gunshot injury, 859 ; operation 
 bv posterior incision, 861 ; by anterior incision, 863 
 
 Hydatids of liver, different operations for, 702; puncture, 702 ; incision, 704; elec- 
 trolysis, 702 
 
 Hydrocele, radical cure of, 807 ; iodine injection, 807 ; antiseptic incision, 809 ; excision, 
 810; occasional inveteracy of, 811 
 
 Hydronephrosis, value of drainage, 624; aspiration, 625; nephrectomy, 625 
 
GENERAL INDEX. 1001 
 
 Iliac, common, ligature of, 538, 545 ; by anterior incision, 545 ; posterior, 546 ; com- 
 
 pari-on of the two methods, 548 
 Iliac enterotomy, right, 659 
 Iliac, external, ligature of, 528, 533, 535 
 Iliac, internal, ligature of, 548, 550; by laparotomy, 550 
 Imperforate anus, 835 ; imperfectly developed rectum, 835; inguinal or lumbar colot- 
 
 omy in, 605 
 Importance of tongue cancer, 325 
 
 Incision of Wilde, 194; of empyema, 515 ; of hydatids of liver, 704; of hydrocele, 808 
 Indian method of rhinoplasty, 257 
 Indirect transfusion, 86 
 Inflation in intussusception, 047 
 Inguinal hernia, strangulated, 568 ; reduction of intestine, 570; cau.ses of difficulty 
 
 570 ; aids, 570 ; varieties, 572; reduction en masse, 573 ; radical cure of, 578 
 Injection of hvdrocele willi iodine, 807 
 Injuries of abdomen, operative interference in, 666, 669 
 Internal iliac, sec Iliac, Internal ; internal carotid, see Carotid, Internal 
 Internal urethrotomy, 791 ; two cliief modes, 793; from without inwards, 793; from 
 
 within outwards, 794; comparison of the two, 795 
 Intestine, reduction of, in femoral hernia, 562; in inguinal, 570; difficulties and aids, 
 
 570; adhesions of, 564; different conditions of, 564; acute obstruction of, 645 ; 
 
 gunshot injuries of, 666 ; resection of, 664, 673, 674; suture of, 665 
 Intussusception, 647 ; replacement by inflation or injection, 647 ; by operation, 649 
 
 Jaw, lower, fixity of, operations for, 300; excision of temporo-maxillary joint, 301 ; 
 Esmarch's operation of removal of wedge, 302 
 
 Jaws, growths of, 267, 394; questions arising before removal of upper, 271 ; complete 
 removal of upper, 273 ; partial removal of upper, 276 ; operations on upper, par- 
 tial or complete removal, or osteoplastic resection for naso-pharyngeal polypus, 
 "87 ■ antrum, tapping, 293; removal of lower, 293; partial, 294; of half, 296 ; 
 complete removal of both upper jaws, 29S ; question of gouging or removal of jaw, 
 299 
 
 Jejunostomy, 699 
 
 KlDXEY, operations on, 610 ! nephrotomy, q.v., 610; nephro-lithotomy, q.v., 611 ; 
 nephreclomv, q.v., 623 ; nephrorraphy, q.v., 642; evidence of stone m, see Kenal 
 Calcidusand Nephrodithotomy ; importance of condition in deciding on opera- 
 tion for stone, 761 
 
 L.\NDM.\i!KS in colotomy, 597 
 Laparotomy, see Abdominal Section 
 Laryngectomy, see Larynx, Kemoval of 
 
 Larvnf 3s^t,t 365; artificial, 383; malignant disease of, 370; removal of, 370, 
 
 375 379; monalitv- after removal, 372; cures due to operation, 3; 2; complete 
 
 removal, 375; date of preliminary tracheotomy, 3,o; tampon-cannul;e, 3,6; 
 
 nartial removal, 379 ; condition of patients after removal of larynx, 384 _ 
 
 Lateral lithoto™; 740; with the curved st.nff; 744; with the straight stati, -44; in 
 
 little rliildren 745; stones suited to, 749 „ „ , > »i j nin 
 
 Leg, am .utation of, different method^, 928 : lateral A'^P^- ^^^.^ T-f ^e''^^^^ ''' 
 T hJ durition of in cancer of breast unoperated upon, 500; if operated on oui ^ 
 L^^tureo "dial on back of wrist, 52 ; in forearm, '^f V'l"" - ^^ Tis' t^iali'^l 
 nt elbow 91- in middle of arm, 92; axillary, 105 ; .temporal, 419 , iacial, 4^1, 
 at ?'V"7' 7.;, ",""',„, 4-4 . common carotid, 427; external, 446; internal, 
 457^'vertebr.l' 460^ ubd;vian,Tecond and third pkrts, 465; A-t Part 475; 
 ^ nomi::;!?47Vt'^carotid and. subclavian in t>-™^c -euri^i, 4 ; ext^na 
 iliac, 528; Common iliac, 538; -'^rnal ihac 5^8 ; gU e 1, o^,l s m^^^^^ 
 
 anterfm- tibial 925; dorsalis pedis, 938; of naso-pharyngeal pol>P"^, -82, of 
 ovS'pedi'^e, 718! of cord in castration, 817 ; of haemorrhoids, 822 
 l:;pro^^tZst?303"Sr ;^:l.?:'^h:V?Ltic operations, 314; restoration 
 of lower lip, 339; upper lip, 323 
 
1002 GENERAL INDEX. 
 
 Lisfranc's amputation, 960 
 
 Litholapaxy, 758, 762 ; contrasted with lithotrity, 767 ; in male children, 769 ; for 
 stone in the female, 770 
 
 Lithotomy, lateral, 740; siipra-pubic, 749; median, 756; in the female, 771 ; com- 
 pared with lithotrity, 758 
 
 Lithotrity, choice of this or lithotomy, 758 ; operation, 762 : contrasted with lithotomy, 
 767; recurrence of stone after, 761 
 
 Littrfe's operation, 605 ; preferred by some to Inmbar colotoray, 607 
 
 Liver, operations on, 702 
 
 Loose bodies in joints, varieties, 916; removal from knee-joint, 916 
 
 Lumbar colotomy, 591 ; nephrectomv, 629 ; choice between this and lumbar operation, 
 639 " _ 
 
 Lung cavities, drainage of, 523 
 
 Lupus, operative treatment of, 240 ; erasion, 241 ; scarification, 242 
 
 Mastoid abscess, anatomy of parts concerned in, 192 ; symptoms, 193; trephining 
 mastoid cells for, 194; abscess in brain or cerebellum from, 195 
 
 Median lithotomy, 756 
 
 Membranous laryngitis, tracheotomy in, 348 
 
 Meningeal, middle, see Middle Meningeal 
 
 Meningitis in otitis media, 197 
 
 Mesocolon, presence of, in colotomy, 603 
 
 Metacarpo-phalangeal joint, amputation through, 22 
 
 Metatarso-phalangeal joint, amputation at, 963 
 
 Middle meningeal lifemorrhage, 175 
 
 Military surgery, excision of wrist in, 48 ; of radius and ulna, 59 ; of shaft of humerus, 
 101; of shoulder, 137; removal of bullets from brain, 198; g\mshot injuries of 
 abdomen, 666; haemorrhage from neck after gunshot injuries, 436 ; excision of 
 hip, 859; excision of knee, 898 
 
 Molluscum fibrosum of scalp, 151 
 
 Motor area, 209 
 
 Mouth, restoration of angle of, 317 
 
 Movable kidney, operations for, 642 
 
 Musculo-spiral nerve, compressed by callus, 104 
 
 Myeloid growth of radius, excision of, 57; of ulna, excision, 58: of upper part of 
 humerus, removal, 130; nephrorraphy, 642; nephrectomy, 645 
 
 Myomata, uterine, 725 ; removal by abdominal section, 725 ; dilferent modes of treating 
 pedicle, 727 
 
 Myxffidema, after thyroidectomy, 390 
 
 Nasal polypi, removal of, 265 
 
 Naso-pharyngeal polypus, methods of removal, 279; avulsion, 279; ligature, 2S0 ; 
 galvanic loop, 281; electrolysis, 281; removal through mouth, 282; through 
 nose, 285; through upper jaw, 287 
 
 Nephrectomy, question of, during nephro-lithotomy, 620; for malignant diseases of 
 kidney, 625; lumbar, 629; abdominal, through the peritoneum, 635 ; Langenbeck's 
 incision at outer edge of rectus, 636 ; incision in linea alba, 637 ; abdominal, 
 without opening the peritoneum, 638; Konig's free lumbo-abdominal incision, 
 631 ; treatment of kidney pedicle, 632 
 
 Nephro-lithotomy, 611,014; evidence of renal calculus, 611 ; conditions simulating 
 renal calculus, 612; operation, 614; question of nephrectomy during nephro- 
 lithotomy, 620 
 
 Nephrorraphy, 642 
 
 Nephrotomy, 611 
 
 Nerve stretching, 982 
 
 Nerve suture, 978 
 
 Nerves, operations on, fifth, 230; neurotomy and neurectomy of first division, 231 ; opera- 
 tions on second division, 232 ; neurectomy, Carnochan's operation, 232 ; operations 
 on third division, 235; nerve stretching, 2:i5 ; intra-buccal division, 236; facial, 
 stretching, 236; suture, 978; primary, 978; secondary, 979; stretching, 9S2 
 
 Neurectomy of fifth nerve, 231, 232 
 
 Neurotomy of fifth nerve, 231, 235 < 
 
 Nose, operations on, for removal of naso-pharyngeal polypus, 285 
 
 Nose, repair of, see Rhinoplasty 
 
GENERAJj INDEX. 1003 
 
 Obstetjction", site of, in large intestine, 593; varieties of, in acute intestinal obstruc- 
 tion, 645 
 
 Obturator artery, wound of, in operation for femoral hernia, 567 
 
 Obturator hernia, strangulated, 577 
 
 Old operation for axillary aneurism and ruptured axillary, 110; carotid, 442; 
 common iliac, 542 ; glutaeal, 554 
 
 Olecranon, ununited fractures of, 165 
 
 Operative interference for foreign bodies in the brain, 198; treatment of lupus, 240; 
 of rodent ulcer, 243; of suppurative peritonitis, 660; in abdominal injuries, 
 666, 669 
 
 Orbit, fracture of inner wall cf, 160 ; clearing out of, 253 
 
 Orifices of stomach, dilatation of, 687 
 
 Os ealcis, excision of, 953 
 
 Osteotomy, for anchylosis of hip-joint, 964; Adams', through neck of femur, 964; 
 Gant's infra-trochanteric, 965 ; for genu valgum, 966 ; of femur from outer 
 side, 966 ; iNIacewen's supra-condyloid, 967 ; Ogston's division of internal 
 condyle, 969 ; of tibia as well as femur, 969 ; of tibia, 970 ; simple, 971 ; cunei- 
 form, 971 ; for displacement of great toe in bunion, 972 
 
 Ostitis, septic, of skull, and its sequels, 172 
 
 Otitis media, results of, 192, 194. See also Mastoid Abscess 
 
 Ovariotomy, questions arising before, 714; operation, 716 
 
 Palate, soft operation for closure of cleft, 319 ; hard, operations on, 321 ; growths 
 of, 324 
 
 Palmar fascia, contracted, 32 ; hemorrhage, vessels concerned, 36 ; early cases, 36 ; 
 later, 37 ; danger of inefficient pressure, 38 
 
 Papilloma of bladder, 735 
 
 Paracentesis of thorax, 511, 513; of bladder, 778 
 
 Parotid growths. 246 
 
 Partial removal of scapula, 139 ; larynx, 379; thyroid, 394 
 
 Patella, ununited fracture of, 911 . ■ , n„^ n ^u j 
 
 Penis, amputation of, 803,804; by galvanic cautery, 804; circular, 804; flap method, 
 804 ; more extensive operations, 805 
 
 Pericardium, tapping and incising, 988 
 
 Perineal section, 783 . 
 
 Perineum, ruptured, operations for, 838 ; partial rupture, 838 ; complete, 840 
 
 Peritoneum, limit on rectum, 828 . , . . r oca c „„„,.; 
 
 Peritonitis, after colotoray, 604 ; suppurative, operative treatment of, 660 ; after ovari- 
 otomy, 721 
 
 Peroneal artery, ligature of, 928 , .■ ^i. u on 
 
 Phalanx, distal, of finger, amputation of, 18 ; middle, amputation through, 20 
 
 Phimosis, neglected, results of, 801 
 
 Phlebitis of cerebral sinuses in ear disease, 197 
 
 ^:^^:^!^:i^^e,S2^; acid,824; crushing, 824 ; clamp and cautery, 
 
 823 
 Pleuritic serous effusion, 512 i ork . Warl,lor 7^6 
 
 Polvnus.naso-pharvngeal, operations for, 285; nasal, 265 ; bladder, /db 
 pSueal artery, wound of, 917 ; ligature of, in popliteal space, 919 ; from the front, 920 
 
 PoS;S':r;iS:^'loU20,922; ligature in middle of leg, 924; in lower 
 
 third, 924 ; at inner ankle, 925 _ 
 Pre-cancerous stage of tongue cancer, 32o 
 
 |r:rrfv:Ketf:irp~r hemorrhage, 36; in punctured wounds of thigh, 876; 
 
 in punctured wounds of leg, 922 
 FrorpSre'ctum,827; application of acid in, 827 ; cautery, 827; excision, 827 
 
 ^u!:^rr;r;l^m:'^r»~?^? of b'^^^-- ^^«> -^-^"^'^' ''' ■• 
 
 through prostate, 781 
 Punctured fractures of skull, 160 
 Pus between skull and dura mater, 169 
 
 glo;'urdXtatfon of, 687 ; excision of, 691, 693 ; cancer of, treatment by curette, 700 
 
1004 GENERAL INDEX. 
 
 Questions arising before removal of upper jaw, 271; removal of breast cancer, 4fl9 ; 
 ovariotomy, 713 ; exploration in aonte intestinal obstruction, 651 ; before radical 
 cure of umbilical hernia, 576 ; of partial removal of rectum, 833 
 
 Radial artery, ligature of, on back of wrist, 52 ; in forearm, 54 
 
 Eadical cure of hernia, 578 ; question of use of truss after, 579 ; different methods, 
 580; method of Banlcs, 582; Macewen's, 584; Barker's, 586 ; Ball's, by torsion 
 of the sac, 589; subcutaneous methods, 587; Wood's, 587; Spanton's, 588; injec- 
 tion of astringents, 539; of femoral hernia, 589; of umbilical, 590; of hydrocele, 
 807; injection, 807 ; incision, 809; excision, 810; occasional difficulty, 811 
 
 Eadio-ulnar (superior) joint, excision of, 77 
 
 Radius, excision of myeloid growth of, 96 ; excision in military surgery, 59 
 
 Rectal bag, 750 
 
 Recto-vesical fistula, detection of, 593 ; colotomy for. 593 
 
 Rectum, fistula, 819; pile area, 824; prolapsus, 827 ; excision, 828 ; comparison be- 
 tween excision and colotomy, 829; removal of complete circumference, 831; 
 question of partial removal, 833 ; imperfectly developed, 835 ; varieties, 835 
 
 Recurrence of cancer after breast removal, 501; of stone after lithotrity, 761 
 
 Reduction, of intestine in hernia, aids, 570; en mnsse, 573 
 
 Re-infusion, 89 
 
 Removal of scapula, 138; partial, 139; complete, 141; complete, together with upper 
 extremity, 144; of clavicle, 146; of parotid growths, 246; nasal polypi, 265; 
 upper jaw, 267; naso-pharyngeal polypus, 278 ; half of lower jaw, 296; tongue, 
 325 ; tonsil growths, 340; tube after tracheotomy, 3i7 ; thyroid gland, 335 ; deep- 
 seated growths in the neck, 407; breast, 499; biliary calculi, 710, 712; gall- 
 bladder, 713; ovarian tumor, 713; uterine appendages, 721 ; cancerous uterus, 
 by vagina, 730; by abdominal section, 730; growths of the bladder, 735; rectum, 
 828 ; loose bodies from knee-joint, 916 ; exostosis from adductor tubercle, 889 
 
 Renal calculus, evidence of, 611 ; conditions simulatinsr, 612 ; removal, 614 
 
 Repair of nose, see Rhinoplasty ; of lips, see Lips; of Perineum, see Perineum 
 
 Resection of ribs, 520 
 
 Restoration of lips, 314; of angle of mouth, 317 ; of Steno's duct, 239; of perineum, 833 
 
 Retained testis, simulating strangulated hernia, 573; castration for, 817 
 
 Re-union of severed digits, 30; tendons, 38 ; nerves, 978 
 
 Rhinoplasty, 254; complete, 255; partial, 263; Verneuil's, 255; Syme's, 256; frontal 
 or Indian, 257 ; Italian or Tagliacotian, 261 
 
 Ribs, resection of, for caries, 520 ; empyema, 520 ; rudimentary last rib, 614 
 
 Rodent ulcer, operative treatment of, 243 
 
 Rolando, fissure of, 209 
 
 Rouge's operation, 264 
 
 Rudimentary last rib, importance in kidney operations, 614 
 
 Rupture of axillary artery in shoulder dislocations, 112; intestine, 666 ; of bladder, 
 775 ; of urethra, 781 ;• of perineum, 838 
 
 Sac, hernial, aids in recognizing, 561 
 
 Saline solutions for transfusion, 88 
 
 Scalds of larynx, 365 
 
 Scalp, operations on, mode of arresting hfemorrhage, 151 ; new growths of, 151 
 
 Scapula, removal for growths, 138 ; partial removal, 139; complete, 141 ; together with 
 
 upper extremity, 144; removal for caries, 146 
 Scarification in lupus, 242 
 Sciatic artery, ligature of, 555 
 Scissors operation on tongue, 327 
 Sequestrotomy, 932 
 Serous pleuritic effusions, 512 
 Severed digits, reunion of, 30 
 
 for myeloid disease, 130; by straight incision, 131 ; by deltoid flap, 131 ; site of 
 bone section, 134 ; sub-periosteal resection, 135 ; excision in military surgery 137 
 
 Simple depressed fractures of skull, 157 
 
 Single hare-lip, 305 
 
GENEEAL INDEX. 1005 
 
 Sinuses, venous, of skull, injury to, 159 ; frontal, trephining, 208 
 
 Rkey's amputation, 960 
 
 Skull, depressed fracture, operative interference in, 156 ; septic ostitis and its seqnelfe, 
 172; punctured fractures of, 160; venous sinuses of, injury to, 159; tumors of, 
 152; spiculation of inner table, 158 ; removal of foreign bodies from, 161 ; posi- 
 tion of cbief sutures in, 21 1 ; trephining in immediate or recent fractures of, 157 ; 
 bones of, condition in cerebral tumors, 222 
 
 Soft palate, operation on, 319 
 
 Spina bifida, operations, 985 ; injection with Morton's fluid, 985 ; tapping and drain- 
 age, 986 ; excision of the sac, 986 
 
 Spinal accessory nerve, operations on, 417 
 
 Spleen, excision of, 700 
 
 Steno's duct, restoration of, 239 
 
 Stomach orifices, dilatation of, 687 
 
 Stone in the kidney, see Renal Calculus ; in the gall-bladder, see Biliary Calculi ; in 
 the bladder, see Lithotomy and Litholapaxy 
 
 Strangulated hernia, femoral, 559; inguinal, 568; umbilical, 574; obturator, 577 
 
 Stretching fifth nerve, 232, 235 ; inferior dental, 235 ; facial nerve, 236 ; great sciatic, 
 984 
 
 Stricture, of rectum, with reference to colotomy, 591 ; with reference to excision, 828 ; 
 of oesophagus, 677 ; of urethra, choice of operation in retention, 790; in relation 
 to urethrotomy, 795 
 
 Sub-astragaloid amputation, 946 
 
 Subclavian, ligature of, second and third parts, 467 ; first part, 475 
 
 Sub-periosteal excision, value of, in elbow-joint, 69; in shoulder-joint, 135; in tarsal 
 disease, 951 
 
 Superior radio-ulnar joint, excision of, 77 
 
 Supernumerary fingers, removal of, 24 
 
 Suppurative peritonitis, 658 
 
 Supra-pubic lithotomy, 749, 753 ; question of suturing the bladder, 754 
 
 Supra-pubic puncture of bladder, 779 
 
 Sutures, plaited twist silk, 404; button, 507 ; Lembert's method, 665 
 
 Syndesraotomy, 974 
 
 Tagliacotian rhinoplasty, 261 
 
 Talipes, removal of wedge from tarsus for, 956; tenotomy for, 973; syndesmotomy, 
 
 974 
 Tampon cannula, 377 
 Tarsus, practical points before operation, 950; removal of many tarsal bones, 954 ; 
 
 operation of Mickulicz, 954; of H. P. Watson, 955; excision of wedge for tahpes, 
 
 956 
 Temporary ligature of common carotid, 250 
 Temporo-inaxillary joint, excision of, 300 
 
 Tendons, divided suture of, 38 ; transplantation in, 39 ; surrounding wrist, 41 
 Tenotomy, 973 ; of tibial tendons, 973: of plantar fascia, 974; syndesmotomy, 974; ot 
 
 tendo-Achillis, 976 ; of hamstrings, 976 ; of slerno-mastoid, 977 
 Testicle, growths of, 814; tubercular, 817 ; syphilitic, 817 ; old hematocele, 817; rarer 
 
 indications for castration, 817 ; retained, simulating strangulated hernia, 573 
 Tetanus, tracheotomy in, 364 
 Theca of fingers, 18 
 
 Thompson's fluid, 751 , • • i. oc • ■•„„ „f 97 
 
 Thumb, amputation of phalanges, 25 ; at carpo-metacarpal joint, 25; excision of, 27 
 Thvroid arteries, ligature of, 400 ; superior, 401 ; inferior, 401 „. 
 
 Thvroid gland, udden suffbcalion from enlarged, 386 ; '<^TlfKf.' ""^^^^^ r' !j 
 ■ theoifes explaining myxcedema, 391 ;. removal of one-half, 394; operations on 
 isthmus, 398; ligature of thyroid arteries, 400; thyroid cysts, 402 
 
 TonCTeTancer,^mportance of pre-cancerous stage in, 325 ; microscopical examination 
 of ulcer 325; questions arising before removal, 326 ; removal by Whitehead s 
 me lod 328 • preliminary laryngotomy, 329 ; slitting the cheek, 333 ; l.gatureof 
 Te Unguals, 333; Syme's methods, 334 ; Kocher's, 335 ; toaseur, 337 ; galvanic, 
 
 Tonsif removal of growths of, 340; through the mouth, 341 ; through the neck, 342; 
 Cheevers's method, 342; Czerny's method, 343; Mickulicz's method, 344 
 
1006 GENERAL INDEX. 
 
 Tracheotomy, for membranous laryngitis, 348 ; influence of age, 348 ; right time for 
 operating and selection of cases, 349; operation, 351, 352; method of Bose, 355; 
 by thermo-cautere, 355; after-treatment, 356; removal of tube after, 357; for 
 tetanus, 364; aortic aneurism, 364; tubercular and syphilitic ulceration, 363; 
 malignant disease of larynx, 364 ; acute laryngitis, 364 ; scalds of larynx, 365 ;' 
 before excision of larynx, 375 
 
 Transfusion, direct, 82 ; Galabin's method, 83 ; Aveling's and Cripps's, 84 ; Roussel's, 86 ; 
 indirect, 86 ; solutions other than blood, 88 ; re-infusion, 89 ; arterial transfusion, 90 
 
 Transplantation of bone-grafts, 102 
 
 Traumatic epilepsy, 185; trephining for, 187 ; removal of brain scar for, 188 
 
 Trephine, conical, 165 
 
 Trephining, compound depressed fractures, 156; simple depressed fractures, 157 ; 
 fractures of inner wall of orbit, 160 ; for removal of foreign bodies from skull, 161 ; 
 operation, 163; precautions, 166; for pus between bone and dura mater, 169, 171 ; 
 for middle meningeal hajmorrhage, 175, 178 ; for exploration of traumatic cerebral 
 abscess, 180, 183; for later results of cranial injuries, epilepsy, etc., 185, 187; mas- 
 toid abscess, 192, 194; cerebral and cerebellar abscess due to otitis media, 195; 
 removal of foreign bodies from brain, 198, 201, 202; removal of cerebral tumors, 
 209, 216, 219, 221, 223, 224,225; Professor Horsley's method, 227 ; in Carnochan's 
 operation, 232; frontal sinuses, 208 ; vertebral canal, 987 
 
 Tubercular tumors of brain, 221 ; of testis, castration for, 816 
 
 UliCBB of the tongue, importance of microscopical examination, 325; of rectum, 826 
 
 Ulna, excision of myeloid growth of, 58 ; excision in gunshot injuries, 59 
 
 Ulnar artery, ligature of, 55; in lower third, 56 ; in middle third, 56 
 
 Umbilical hernia, strangulated, 574 ; question of radical cure of, 676 ; radical cure of, 
 
 590 
 Unilateral laryngectomy, 381 ; removal of thyroid gland, 393 
 Ununited fracture of olecranon, 77 ; clavicle, 149; femur, 890; patella, 911 
 Upper jaw, growths of, questions arising before removal, 271 ; complete removal, 273; 
 
 partial, 276; for removal of naso-pharyngeal polypus, 287 
 Upper lip, restoration of, 316 
 XJrethra, ruptured, 781 
 Urethrotomy, external, 783; Syme's, 783 ; Wheelhouse's, 784; Cock's, 787 ; internal, 
 
 791 ; from without inwards, 793; from within outwards, 794 
 Uterine myomata, removal of, by abdominal section, 725 ; treatment of pedicle by wire 
 
 loop, 727 ; clamp, 728 ; forcipressure, 728 ; elastic ligature, 729 
 Uterus, cancerous, removal of, by abdominal section, 729; by vagina, 730 
 
 Vaginal lithotomy, 772 
 
 Varicocele, 811 
 
 Varieties of inguinal hernia, 572; bladder growths, 735; growths of jaws, 267, 293; 
 
 loose bodies in joints, 916 
 Vein, axillary, removal of part of, 507 
 Venesection, 79 
 Vertebral canal, trephining, 987 
 
 Webbed fingers, 30 ; Norton's operation for, 31 ; Didot's, 31 
 
 Wiring ununited fractures, of olecranon, 77 ; patella, 893; bones in Pirogoff's ampu- 
 tation, 945 
 
 Wound of palm, 36 ; obturator artery, 567 ; punctured and incised, of thigh, 876 ; leg, 
 920, 921 ; see also Arteries 
 
 Wrist-joint, tendons surrounding, 42 ; excision, 40 ; Sir J. Lister's method, 42 ; West's, 
 45 ; by single dorsal incision, 45; for injury, 47 ; for gunshot injury, 47 ; amputa- 
 tion at, 49 ; diflerent methods, 49 ; palmar flap, 49; equal antero-posterior flaps, 
 51 ; Dubreuil's method, 51 ; circular, 49 ; Teale's, 49 
 
^ JUNE. 1889. 
 
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A NEW" TEXT-BOOK JUST PUBLISHED. 
 
 DISEASES OF THE SKIN. 
 
 BY T. MCCALL ANDERSON, M.D., 
 
 Professor of Clinical Medicine in the University of Glasgow. 
 ASSISTED BY 
 
 Dr.. James Christie, Sec'y London Epidemiological Society for Indian Ocean and East Africa; Mem. 
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 Illustrating one of the Diseases of the Hair {See Fi^, b,J>a^e 7). 
 
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 and local manifestations of the common diseases of the economy which are manifested 
 upon the surface, will find many appreciative readers. 
 
 Diseases of the hair receive full systematic treatment. 
 
 ■' We welcome Dr. Anderson's work not only as a friend, but as a benefactor to the profession, because the author has 
 stricken ofl: mediaeval shackles of insuperable nomenclature and made crooked ways straight in the diagnosis and treatment of 
 this hitherio but little understood class of diseases. The chapter on Eczema is, alone, worth the price of the book "—Naj!h7tillr 
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 the Honors School of Science, University of Oxford, England. Third Edition 
 revised and enlarged. 692 Illustrations. 
 
 -A BRIDGE BETWEEN PHYSIOLOGY AND PRACTICAL MEDICINE." 
 
 One Volume. Royal* Octavo. Cloth, $6.50; leather, $7.50. 
 
 Fro7?i the Prefaces to the English Edition. 
 The fact that Prof. Landois' book has passed through four large editions in the original since 1880, and 
 lat m barely six months' time a second edition of the English has been called for, shows that in some 
 pecial way it has met a want. The characteristic which has thus commended the work will be found 
 lainly to he inits eminent practicability; and it is this consideration which has induced me to undertake the 
 isk of putting It into Enghsh. Landois' work, in fact, forms a Bridge between Physiology and the Practice 
 f Medicine. It never loses sight of the fact that the student of to-day is the practicing physician of 
 >morrow. In the same way, the work offers to the busy physician in practice a ready means of refreshing 
 ismemory on the theoretical aspects of Medicine. He can pass backward from the examination of patho- 
 3gical phenomena to the normal processes, and, in the study of these, find new indications and new lights 
 or the appreciation and treatment of the cases under consideration. With this object in view, all the 
 lethods of investigation which may, to advantage, be used by the practitioner, are carefully and fully 
 .escribed. _ Many additions, and about one hundred illustrations, have been introduced into this second 
 English edition, and the whole work carefully revised. 
 
 PRESS NOTICES. 
 
 ** Most effectively aids the busy physician to trace from morbid phenomena back the course of divergence from 
 ealthy physical operations, and to gather in this way new lights and novel indications for the comprehension and treatment 
 t the maladies with which he is called upon to cope." — American Journal of Medical Sciences. 
 
 " I know of no book which is its equal in the applications to the needs of clinical medicine." — Prof. Harrison Allen., late 
 ^rofessor ef Physiology , Uiiiversity of Pennsylvania. 
 
 " We have no hesitation in saying that this is the work to which the Practitioner will turn whenever he desires light 
 irown upon the phenomena of a COMPLICATED or important case." — Ediiiburgh Medical Journal. 
 
 " So great are the advantages offered by Prof. Landois' Text-Book, from the exhaustive and eminently practical 
 lanner in which the subject is treated, that it has passed through four large editions in the same number of years, . . 
 )r. Stirling's annotations have materially added to the value of the work. Admirably adapted for the Practitioner. . . . 
 i^ith this Text-book at command, NO Student could fail in his examination." — The Lancet. 
 
 "One of the most practical works on Physiology ever written, forming a ' bridge ' between Physiology and Practical 
 ledicine. , . . Its chief merits are its completeness and conciseness. . . . The additions by the Editor are able and judicious. 
 . . Excellently clear, attractive and succinct." — British Medical Journal. 
 
 "The great subjects dealt with are treated in an admirably clear, terse, and happily illustrated manner." — Practitioner . 
 '* Unquestionably the most admirable exposition of the relations of Human Physiology to Practical Medicine ever laid 
 cfore English readers " — Students' Journal. 
 
 "As a work of reference, Landois and Stirling's Treatise ought to take the foremost place among the text- 
 Doks in the English language. The wood-cuts are noticeable for their number and beauty." — Glasgow Medical Journal. 
 
 *' Landois' Physiology is, without question, the best text-book on the subject that has ever been written." 
 'New York Medical Record. 
 
 " The chapter on the Brain and Spinal Cord will be a irost valuable one for the general reader, the translator's notes adding 
 
 >t a little to its importance. The sections on Sight and Hearmg are exhaustive. . . . The Chemistry of the Urine is thoroughly 
 
 tnsidered. ... In its present form, the value of the original has been greatly increased. . . . The text is smooth, accurate, 
 
 id unusually fiee from Germanisms ; in fact, it is good English." — New York Medical Journal. 
 
 f ** It is not for the physiological student alone that Prof. Landois' book possesses great value, for it has been addressed 
 
 Ito THE practitioner OF MEDICINE as Well, who will find here a direct application of physiological to pathological processes." 
 
 pfedical Bulletin. 
 
 P. BLAKISTON, SON & CO., Publishers, 1012 Walnut St., Philadelphia. 
 
PUBLISHED ANNUALLY. 
 
 With Many Improvements for 1889. 
 
 38th YEAR. 
 
 The Physician's Visiting List, 
 
 Almanac for 1889 and 1890, 
 
 Table of Signs to be used in keeping accounts. 
 
 Marshall Hall's Ready Method in Asphyxia. 
 
 Poisons and Antidotes. 
 
 The Metric ok French Decimal System of 
 Weights and Measures. 
 
 Dose Table, revised and rewritten for 1888, by Ho- 
 jBART AMory Hare, m. u., Dem,onstrator of Thera- 
 peutics, University of Pennsylvania. 
 
 List of New Remedies for 1888, by same author. 
 
 Aids to Diagnosis and Treatment of Diseases of 
 THE Eye, Dr. L. "Webster Fox, Clinical Asst. Eye 
 Dept. Jefferson Medical College Hospital, and G. 
 M. Gould. 
 
 Diagram Showing Eruption of Milk Teeth, Dr. 
 Leuis Starr, Prof, of Diseases of Children, Univer- 
 
 (LINDSAY & BLAKISTON'S.) 
 
 CONTENTS. 
 
 PosoLOGiCAL Table, Meadows. 
 
 Disinfectants and Disinfecting. 
 
 Examination op Urine, Dr. J. Daland, based upon 
 
 Tyson's " Practical Examination of Urine," 5th 
 Edition, 
 
 Incompatibility, Prof. S. O. L. Potter. 
 
 A New Complete Table for Calculating the 
 Period of Utero-Gestation. 
 
 Sylvester's Method for Artificial Respiration. 
 
 Diagram of the Chest. 
 
 Blank Leaves, suitably ruled, for Visiting List, 
 Monthly Memoranda; Addresses of Patients and 
 others ; Addresses of Nurses, their references, etc. ; 
 Accounts asked for ; Memoranda of Wants ; Obstet- 
 ric and Vaccination Engagements; Record of Births 
 
 sity Hospital.' Philadelphia. ' ""d Deaths ; Cash Account, etc. 
 
 A NUMBER OF IMPROVEMENTS and additions have been made to the 
 reading matter in the first part. This has been done, however, without increasing 
 the number of pages. Great care has been taken in selecting the leather for the 
 covers and in each detail of manufacture. 
 
 SIZES AND PRICES. 
 
 For 25 Patients weekly. Tucks, pockets and Pencil, $i.oo 
 
 50 " " " " ■' 1.25 
 
 75 " " " " » 1.50 
 
 100 " " " " " 2.00 
 
 2.50 
 3.00 
 
 ITION. 
 
 Interleaved, tucks and Pencil, 1.25 
 
 1.50 
 
 3.00 
 
 PERPETUAL EDITION, without Dates. 
 Can be commenced at any time, and used until full. Similar in style, con- 
 tents and arrangement to the regular edition. 
 No. 1. Containing space for over 1300 names, with blank page opposite each 
 
 Visiting List page. Bound in Red Leather cover, with Pocket and Pencil, $1.25 
 No. 2. Containing space for 2600 names, with blank page opposite each 
 
 Visiting List page. Bound like No. i, with Pocket and Pencil 1.50 
 
 These lists, without dates, are particularly useful to young physicians unable to 
 estimate the number of patients they may have during the first years of Practice, and 
 to physicians in localities where epidemics occur frequently. 
 
 " For completeness, compactness, and simplicity of arrangement it is excelled bv none in the market "—N Y, 
 Medical Record. ' 
 
 " The book is convenient in form, not too bulky, and in every respect the very best Visiting List published."— 
 C'^^^f'^^'f'^"! and Surgical Journal. 
 
 .• T !_'' , ''■''''' made, there are none superior to it." — Caillard' s Medical Journal. 
 
 ., c , °'"^°^^ Standard." Soutkern Clinic. 
 
 ,, J:'-^" . '^^ '*>' seasons comes this old hvoriu."—MicAig-an Medical News. 
 
 „ " '^ 1"'" convenient for the pocket, and possesses every desirable quMiy."— Medical Herald. 
 
 •• w 1,™° P°P."'i!'' Visiting List extant."— Sa^a/o Medical and Surgical Journal. 
 
 „ r,.^."^™."?^" It for years, and do not hesitate to pronounce it equal, if not superior, to 3.ny."—Soatimt Clinic. 
 nr h , r'siting List IS too well known to require either description or commendation from \ii."— Cincinnati 
 Medical News. 
 
 5° 
 
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 ■ July 
 
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JUST P£EAr>Y. 
 
 THE SEVENTH REVISED AND ENLARGED EDITION 
 
 OF 
 
 ROBERTS' PRACTICE. 
 
 THE THEORY AND PRACTICE OF MEDICINE. By Fred. 
 T. Roberts, m.d., f.r.c.p., Professor of Materia Medica and Therapeu- 
 tics at University Hospital, Physician to Univer->'*v College Hospital, etc. 
 Seventh .Edition. Revised and Enlarged. One vo-rrae, 8vo., with nu- 
 merous Illustrations. Cloth Binding, ^5.50; Leather, ^6.50 
 The present edition has been fully revised throughout, and in some parts rewritten or re- 
 arranged. While an endeavor has been made to bring every subject up to date in all its aspects, 
 special attention has been given to the questions of treatment, viith the view of bringing into 
 notice important therapeutic agents or methods which have been recently introduced. 
 
 The unexceptional large and rapid sale of this book, and the universal commendation it has 
 received, from the profession, seems to be a sufficient guarantee of its merit as a Text-book. The 
 publishers are in receipt of numerous letters from professors in the medical schools, speaking 
 favorably of it, and below they give a few extracts from the medical press, American and 
 English, attesting its superiority and value to buth student and practitioner. The present edi- 
 tion has been thoroughly revised and much of it re- written. 
 
 " TAe best Text-book for students in the English language. We know of no work in the 
 English language, or in any other, which competes with this one." — Edinburgh Medical Journal. 
 
 " Dr. Roberts' book is admirably fitted to supply the want of a good Handbool^ so much 
 felt by every medical student." — Student' s Journal and Hospital Gazette. 
 
 " There are great excellencies in this book, which will make it a favorite with the student." 
 — Richmond and Louisville Journal. 
 
 " We heartily recommend it to students, teachers, and practitioners." — Boston Medical and 
 Surgical Journal. 
 
 " It is unsurpassed by any work that has fallen into our hands as a compendium for students." 
 The Clinic. 
 
 " We particularly commend it to students about to enter upon the practice of their profession." 
 — St. Louis Medical and Surgical Journal. 
 
 " If there is a book in the whole of medical literature in which so much is said in so few 
 words, it has never come within our xtt^.A."— Chicago Medical Journal. 
 
 BY THE SAME AUTHOR. 
 NOTES ON MATERIA MEDICA AND PHARMACY. 
 
 ESPECIALLY ARRANGED FOR THE USE OF STUDENTS. 
 
 16mo, Cloth, $2.00. 
 
 For sale by all Booksellers ; or will be sent by mail, postpaid, on receipt of price 
 by the Publishers, 
 
 P. Blakiston, Son & Co., 1012 Walnut Street, Philadelphia. 
 
"ITSTANDS WITHOUT AN EQUAL AS THE MOST COMPLETE WORK ON PRACTICE IN 
 THE ENGLISH LANGUAGE.'"— A^^a/ York Medical Journal. 
 
 FAGGE'S PRACTICE OF MEDICINE, 
 
 Two Large Royal Octavo Volumes. Containing over 1900 Pages, 
 PRICE, HANDSOMELY BOUND IN CLOTH, S8.00. 
 
 The Principles and Practice of Medicine. 
 
 By CHARLES HILTON FAGGE, M.D., F.R.C.P., F.R.M.C.S.. 
 
 Examiner in Medicine ^ University of London : Physician to, and Lecturer on Pathology in, Guy's Hospital: 
 Senior Physician to Evelina Hospital for Sick Children, etc. 
 
 EDITED AND ARKANGED FOR THE PRESS 
 
 By P. H. Pye-Smith, M.D., F.R.C.P., 
 
 Lecturer on Medicine in Guy's Hospital ^ London, etc. ^ 
 
 WITH A SECTION ON CUTANEOUS AFFECTIONS, BY THE EDITOR, A CHAPTER ON CAR- 
 DIAC DISEASES, BY SaMUEL WILKES, M. D., F. R. S., AND TWO INDEXES, ONE OF 
 AUTHORS AND ONE OF SUBJECTS, BY ROBERT EdMUND CaRRINGTON. 
 
 Two Volumes. Royal Octavo. 1900 Pages. 
 
 Price in Cloth, $8.00. Full Leather, $10.00. Half Uorocco, $12.00. Half Russia, $12.00. 
 
 It \% based on laborious researches into the pathological and clinical records of 
 Guy's Hospital, London, during the twenty years in which the author has held office 
 there as Medical Registrar, as Pathologist, and as Physician. Familiar beyond most, 
 if not all, of his contemporaries, with modern medical literature, a diliger.'. reader of 
 French and German periodicals, Dr. Fagge, with his remarkably retentive memory and 
 methodical habits, was able to bring to his work of collection and criticism almost 
 unequaled opportunities of extensive experience in the wards and dead house. The 
 result is that which will probably be admitted to be a fuller, more original, and more 
 •elaborate text-book on .medicine than has yet appeared. It is the first of importance 
 emanating from Guy's Hospital, and the only two-volume work on the Practice of 
 Medicine that has been issued for a number of years. Several subjects, such as 
 Syphilis, that are usually omitted or but slightly spoken of in a general work of this 
 •character, receive full attention. 
 
 Dr. Walter Moxon, one of Dr. Fagge's contemporaries, and a great personal 
 friend, writes of him, in a recent number of the London Lancet : — 
 
 " Fagge ivas, to my mind, the type of true medical greatness. I believe he was capable of any kind of 
 -excellence. His greatness as a physician became evident lo observers of character very soon after his brilliant 
 student career had placed him on the staff of Guy's Hospital: he did not merely group already known facts 
 but he found new facts. Former volumes of Guy's Hospital Reports contain ample and most valuable proof of 
 his greatness as a physician. His power of observation was sustained by immense memory, and brought into 
 action by vivid and constant suggestiveness of intelligence. He was a physician by grace of nature, and being 
 gifted with a quickness of perception, a genius for clinical facts and a patience in observation, he was at once 
 ■recognized as a successful practitioner and a leading figure in the hospital and among the profession.