CORNELL UNIVERSITY LIBRARY Cornell University Library RD 32.P18 1846 A treatise on operative surgery; comprisi 3 1924 012 166 942 \^y '^j^'i' ^isJ ■ !''^^,. +(» IV/'... .1/ J-'rif I. m^^^. / "f "*»4i|«. ^^ v./ ^ /■f' ^,„ /'>y-, J DSSS^*'""'' '„.<;f*'^ .<^/? Stanc (irJ^^^ueen- Thdai/^/fhm, Fu.hlisfLf^ dy Oirfv ^- Mart V.S.DllvoI, Litk FIlUJ^ DIVISION OF PARTS WITH THE BISTOURY AND SCISSORS. 13 is sufficiently large to admit its introduction, as in the operation for hernia, that we can employ it for this purpose. Under such circumstances we glide flatwise the probe-pointed bistoury along the palmar, and at times even along the dorsal face of the fore- finger of the left hand. After the probe point has passed beyond the part to be cut, the edge of the blade is turned upwards, and the division is made partly by pressure with the end of the directing finger, and partly by a sawing motion made with the right hand. Commonly, however, we have to resort to the use of the grooved director, which is to be introduced through an existing opening, or one made with the knife, and carried below the skin, fascia, or whatever tissue is to be cut. It should be held between the thumb and middle finger of the left hand. The fore finger should be extended upon its back to direct it in its introduction, and after it has entered to the extent required, to serve by being flexed below it, to aid by pressure upward conjoined with a down- 'ward pressure of the thumb upon the outer end, in elevating the part under which the instrument is passed. The cut is then made by running a probe or sharp-pointed bistoury along the groove, in such a direction as to form with the instrument an angle of about thirty degrees. When the knife is arrested at the end of the director, it is to be brought to the vertical position so as to make the division complete. Both instruments are then removed together, so as to render it certain that all the parts raised on the director have been divided. The direction of the incision has been described as made from behind forward ; but it may be varied at will. In Plate 2, fig. 7, it is shown as made in the opposite direction from before back- ward, and which, as will be seen, necessitates a change in the relative position of the fore and middle fingers. One important consideration in regard to the use of the director, when we are operating in the vicinity of important vessels and nerves, and which will be hereafter more fully noticed, is that Of raising and carefully inspecting the parts which cover it, before applying the bistoury, so as to assure ourselves that it is covered by nothing but what it is proper to divide. INCISION WITH THE SCISSORS. (PL. II. Fig. 7, 8.) There are three forms of this instrument in common use ; the straight, curved, and angular ; all of which are to be alike held, with the thumb in the upper ring, the third finger in the lower ring, and the middle placed in front and below to render the direction steady. The little finger is to be free. The use of the fore finger varies according to the kind of section desired. If a longitudinal cut is to be made, it should be placed below the instrument and immediately in front of the middle finger, so that the two may act in opposition to the thumb. If an incision is to be made flatwise, the fore finger should rest upon the side of the joint, so as to pre- vent vacillation, as shown at fig. 7. If the parts to be cut are firm and resisting, and the use of the left hand cannot be brought in to the aid of the right, it will be found advantageous to throw the fore finger across the upper branch of the handles, and make it act in opposition with the middle, which is placed on the lower branch as shown at fig. 8. Finally, if we act upon tissues out of view and through a narrow orifice, and when there is a risk of injuring important parts, the fore finger may be introduced as a 4 guide between the blades, to press out of the way the parts that are to be spared, and to facilitate the section of those which are to be cut. The scissors, as they are ordinarily constructed, cannot be employed well except with the right hand, as the attempt to close them with the left has a tendency to separate the cutting edges from each other. PUNCTURES. A puncture is sometimes, as has already been shown, but the first step of an incision. With this exception, and apart from some particular operations, such as bleeding and vaccination, the object of a puncture is either that of exploring the nature of a tumour, or giving issue to liquid or gaseous matters. Punctures are made with three separate instruments; the bistoury, the lancet, and the trocar : these however, in a great megority of cases, may supply reciprocally the place of each other. Puncture with the bistoury. — This may be made either verti- cally or in an oblique direction. For the direct or vertical puncture, the bistoury should be held in the first or third position, and the blade entered by a sudden motion of the fingers to the requisite depth, which should be pre- viously determined by the fore finger extended upon the back for the first position, and the middle finger upon the side for the third. Direct puncture is frequently employed in the opening of small abscesses, and, for drawing blood in some forms of superficial in- flammation. Oblique puncture. — In this the bistoury is held and introduced with more or less obliquity, like a trocar. It is employed espe- cially for the evacuation of fluids which have accumulated to a considerable amount, as in empyema, and congestive or chronic abscesses. The object of making the puncture obliquely is that of preventing the introduction of air into the cavity after the eva* cuation of the fluid ; an object which is accomplished by giving the knife the oblique direction, so as to prevent the internal opening and that of the skin from becoming parallel. The bistoury is to be withdrawn as soon as the matter appears upon its side, and the left hand should be pressed gently over the walls of the abscess so as to keep up a steady flow, and leave no roomi for the^ introduc- tion of air. When the contents are sufficiently discharged, the external orifice is to be covered with a compfess, and this secured by adhesive straps or a roller bandage. If any shreds of cellula? tissue or coagulated lymph block up the passage, they are to be extracted with the forceps or put aside with the probe, without any interruption of the pressure with the left hand. Puncture with the lancet may be made precisely in the same manner as it is made with the biiStoury, and it suits in. many cases of superficial abscess equally as well. It is to be held for this purpose nearly in the same manner as directed for phlebotomy. Puncture with the- trocar.— It is important before using this in^ strument, to see that the stilet slides freely in the eanula. It is to be held so that the handle shall be embraced by the last three fingers, and the end rest against the palm, with the thumb applied at the union of the eanula and handle, and the fore finger carried forwards on the instrument so as to limit the depth to which it penetrates. In operating, it should be held at first nearly vertical till the point enters the skin, and then be gradually brought to an 14 ELEMENTARY AND oblique position, while it is at the same time pressed forwards by the palm. By this simple manceuvre I find the instrument may be carried in without shock, and with less pain than by the or- dinary method of a direct push. When we discover, from the waiit of resistance and the mobility of the point that it has entered the cavity, the stilet is to be withdrawn. After the fluid is dis- charged, the canula is also to be removed. This is effected best by direct traction, while with the fingers of the other hand pres- sure is made upon the surrounding integument to prevent the sides of the puncture being drawn out and irritated by the friction of the instrument. ir. DIVISION OF PARTS BY LIGATURE. This, which is an ancient process, consists, 1st, in the complete strangulation of parts by a ligature applied round their base, so as to arrest the circulation and produce separation by gangrene ; or, 2d, a ligature less tightly applied so as to effect a division by moderate pressure, which occasions the progressive absorption of the part enclosed in the loop. The former is employed commonly in the removal of tumours; the latter method, when we wish the ligature to act both as a means of division and as a seton, so as to excite granulation behind it in order to close up the passage that it cuts. As the ligature in the latter case becomes loose from the absorption of the part within its grasp, it will require to be tight- ened from time to time. Various materials have at different periods been employed for ligatures. Those in most common use consist of well waxed silken or hempen threads of various sizes, or leaden, or annealed iron, silver or platina wire. There are three general rules for the application of ligatures. 1st. To choose a ligature sufficiently strong for the parts to be embraced. 2d. To enclose within a single loop but a moderate thickness of tissue, as the strangulation will be better effected, when the part is large, by the consentaneous employment of two or more ligatures introduced with the needle. 3d. To divide the skin previously with the knife, so as to avoid the pain and irrita- tion which would arise from including it in the loop, except in cases where the part embraced is small or the skin itself is ulce- rated or in a state of degeneration. But in tumours springing from mucous membranes, no previous section of the covering is either allowable or required. There are three processes for the application of the ligature. 1st Process. — When there is but a slight thickness of tissue to divide, we surround it with a thread which is simply to be tied. If it be a conoid tumour, with a broad base, it must be grasped with the fingers, forceps or hook, to prevent the ligature from slip- ping. If there is but little prominence, or it is necessary to stran- gulate the part below the level of the skin, as in cases of small subcutaneous aneurismal tumour, it is necessary to elevate it pre- viously by a pair of needles or pins placed crosswise under its base. 2d Process. — If the pedicle of the tumour be too thick to be effectually strangulated by a single ligature, or we wish to remove the tumour after tying it, without a risk of the ligature slipping off, a double thread should be drawn through the pedicle and MINOR OPERATIONS, divided so as to make two ligatures, which are to be tied sepa- rately on either side. 3d Process; that of the compound ligature of Mayor.— This is applied in cases of tumours having a broad base and which it is necessary to remove in separate portions. Large needles of steel, untempered so as to admit of being bent to any curve required, slightly dulled at the point, and with an eye either near the point or heel, are employed to pass the ligature. As many of these as will be required are, according to the directions of Mayor, to be threaded with the same ligature, and placed at equal distances upon it. If we wish to strangulate a tumour in three parts, three needles only will be required. The needles are then to be care- fully passed through the base of the tumour, entering them upon the side nearest any neighbouring part that it is important to avoid, and facilitating their exit at the opposite side by pressure with the left fore finger. If the eye is at the heel, the needle must be car- ried completely through; if near the point it is only necessary to push it so far through that the thread may be seized with the hook or forceps, and drawn out so as to form a loop. The needle is then to be withdrawn. The loops when thus passed are to be cut, and we have as many double ligatures, for the purpose of strangulating separately each portion into which the tumour has been divided, as there have been needles used. The same results, however, may be arrived at by a more simple process — either by carrying a single needle threaded with a double thread the requisite number of times through the base of the tumour, or by employing several se- parate needles, each threaded with a double ligature. In cases where the operation is performed for the removal of vascular tumours, there is not usually much hemorrhage, as ves- sels of much dimension fly before the dulled points of the needles without being penetrated by them. In case, however, hemorrhage should follow, the needles may be kept temporarily in the wound, and after the tying of the separate ligatures another may be ap- plied below the ends of the needles to embrace the mass at its base. If, however, there is at the base of the tumour any large vessel or other important part that it is necessary to avoid, instead of passing below it, the needles should be made to traverse the tumour itself. Various processes are employed to tighten the ligatures for the strangulation of parts. — If the wire or metallic thread is employedj it is at first usually thrown round the tumour as a free loop. If a leaden wire be used, which is suited to some soft tumours found within the mucous cavities, the strangulation may be effected to the requisite extent by merely twisting the two ends of the wire together. The silver, iron, or platina wire, should be apphed through a canula; the double canula of Levret being the one com- monly used. The two ends of the wire doubled so as to form a loop at the middle, are to be passed through the two tubes. One end is to be secured by a few 'turns to the left arm of the instru- ment, while the other is left long to be grasped by a pair of for- ceps and drawn as tight as possible after the ligature is applied, and subsequently secured by a few turns round the other arm. The canula and wire loop are usually left to remain for twenty- four hours, when the life of the part embraced, if the strangulation has been complete, is found so completely destroyed that the tumour will fall off subsequently by sphacelation. In cases of DIVISION OF PARTS BY LIGATURE. 15 tumour with large base, it may become necessary to leave the instru- ment for a longer period, and tighten the loop from time to time as it becgmes loosened, by unwinding the end from the arm and draw- ing upon it with the forceps. Vegetable and animal ligatures may also be applied in the same manner through a double tube; and occasionally, as where a large tumour is to be embraced within a narrow cavity, as that of a uterine polypus, it is convenient, as recommended by Gooch, to have each of the canulae separate, in order to facilitate the application of the ligature,, subsequently fastening them together by means of a short sliding double tube. When the latter class of ligatures are employed, and the tumour is so situated as to be readily reached with the fingers, it suffices to tie them firmly with a common knot. If the pedicle be of much size and very resisting, it will be necessary to tighten anew or reapply the ligature after three or four days, when its hold will be found loosened by the diminution of the part embraced. In some instances the operator may be compelled to renew the liga- ture three or four times. In order to keep up the progressive con- striction of the pedicle without the necessity of changing the liga- ture, which it is sometimes difficult to do when the tumour is situated within a cavity, different serre-nceuds or knot-tiers have been invented. That, of Graefe, which has been most used, consists of a stalk of steel pierced at its extremity with a hole, through which are passed the two ends of the ligature after the loop has been applied. At the other end is a screw, which can be turned so as to move upward or downwards a mobile slide, upon which the two ends of the ligature are firmly attached. The serre-nceud of Rodrigue consists of a number of small balls of wood, bone, horn or ivory, two or three lines' in diameter, pierced in the centre and strung like a chaplet of beads on the two tails of the ligature, so as to. form a flexible tube. The two terminal. balls are, however, pierced with two holes through which go separately the ends of the ligature, so that the loop maybe preserved at one extremity and the ends knotted without the knot slipping into the orifices at the other. This would seem to be a convenient means of strangulating a tumour in an irregular or sinuous passage, as the chaplet will conform itself to the existing curves of the part. The apparatus, however, is apt to prove too flexible, and take a spiral form when we wish to render the constriction very firm. To .obviate this inconvenience, it has been modified in the follow- ing manner by M. Mayor. This surgeon employs the balls only for one-half the length necessary to the instrument, and replaces them for the other and outer half, with an inflexible metallic tube, provided at its free extremity with a sort of windlass or tourniquet, upon which are rolled the free ends of the thread, so as to render the constriction tight. The first ball, that which comes in contact with the tumour, is, also modified in shape, so as to present an acute angle in order to render the cutting action of the ligature perfect over the whole part embraced in the loop. The applica- tion of this serre-nceud may be seen in the plate displaying the operations upon the tongue. Effects of the ligatures. — If the pedicle of the tumour is not above eight or ten lines in diameter, it is easy to close the loop so tight as to immediately intercept all circulation. The tumour should be covered with charpie or lint to absorb the fluids that are discharged while its separation is going on. When the constriction is complete, all sensibility ceases in the part enclosed. The tumour, which is at first swollen afterstrangu* lation, shrivels after a time, takes a livid gangrenous hue, and comes away at length in a state of putrefaction in a period varying according to the size and firmness of the pedicle, from a few days to several weeks, leaving a wound with a raw surface. If vessels of considerable size enter through the pedicle, they are sometimes found to resist the strangulation, and require to be snipped with the scissors after the other constituents of the pedicle are detached. Their cavity is usually found obliterated under such circumstances; if such should not be the case, it would be necessary to tie before dividing them. When in the constriction of a resisting pedicle the ligature is not drawn sufficiently tight to obstruct the circula- tion in the artery, though it may occlude the veins, the tumour will swell from the accumulation of arterial blood, and be the source of severe local pain and great sympathetic disturbance. If we cannot, by drawing on the ligature, effect complete strangula- tion, it may become necessary to relax or even remove the liga- ture for a time. - If a nervous trunk be included, or the irritation be so great as to excite spasm, or involve a risk of tetanus, the removal of the ligature becomes still more obligatory. In many instances, where the point of operation could be readily reached, I have been enabled to remove these symptoms by puncturing or even excising a portion of the tumour, so as to allow some of the fluids to escape, and subsequently drawing the ligature tight. Conjoined with these local measures of relief, great advantage will be derived under such circumstances from the administration of opiates and diaphoretics. III. PHLEBOTOMY, OR BLOOD-LETTING IN GENERAL. The opening of the superficial vessels for the purpose of extract- ing blood, constitutes one of the most common operations of the practitioner. The principal results, which we effect by it, are 1st. The diminution of the mass of the blood, by which the over- loaded capillary or larger vessels of some affected part may be relieved; 2. The modification of the force and frequency of the heart's action; 3. A change in the composition of the blood, rendering it less stimulating ; the proportion of serum becoming increased after bleeding, in consequence of its being reproduced with greater facility than the other elements of the blood ; 4. The production of syncope, for the purpose of effecting a sudden gene- ral relaxation of the system ; and, 5. The derivation, or drawing as it is alleged, of the force of t'he circulation from some of the internal organs, towards the open outlet of the superficial vessel. These indications may be fulfilled by opening either a vein or an artery. To the former system of vessels it is, however, except in cases of emergency, usually restricted. Formerly it was the custom to bleed from a great number of veins, as those on the back of the hand, the temporal, the frontal, the angularis oculi, the ranina, dorsalis penis, etc. ; as well as from those of the bend of the arm, the ankle, and the neck, which are the only veins that are now usually opened. VENESECTION AT THE BEND OF THE ARM. Surgical anatomy. — The veins at the bend of the arm are situ- ated between the skin and the deep-seated brachial aponeurosis, 16 ELEMENTARY AND in the midst of the fatty cellular tissue which separates these parts. In children, females and obese adults of the male sex, the accu- mulation of adipose matter is, mainly, in front of the veins, render- ing in many cases their location obscure, and but faintly indicated to the touch, as soft elastic rolling cords. But in a majority of subjects they are obvious to the eye, and stand out in relief on the arm. There is such great variation in regard to the size, number and course of the superficial veins of this region, that we scarcely find two individuals in whom they are exactly the same. Even in the arms of the same person they are very commonly found to vary. The veins as they come up from the forearm may, however, be arranged into three classes. 1. Those from the outer side of the forearm and hand, which usually form a trunk, passing over the outer side of the elbow joint, called the superficial radial. 2. Those from the inner and back part of the forearm and hand, forming on the same side of the elbow the superficial ulnar vein. 3. Those which come up on the middle and front part of the fore- arm, and form, by their union near the middle of the bend of the arm, the superficial median, which shortly after its formation di- vides into two branches like the letter Y.* One of these branches, called the median cephalic, runs obliquely outward across the bend of the arm, to join the superficial radial, and forms with it the common trunk called the cephalic vein, which runs up along the outer side of the arm, and passing between the deltoid and great pectoral muscle, opens into the axillary vein, just below the cla- vicle. The other branch, called median basilic, crosses to the inner side of the arm and joins with the superficial ulnar, to form the proper basilic vein, which empties into the brachial at a varia- * Very frequently this median vein does not branch but runs inwards as a single trunk to join the ulnar. Occasionally it will be observed running out- wards, in the same manner to join with the radial. MINOR OPERATIONS. ble distance above the elbow. From the deep-seated radial vein which accompanies the artery of that name, there is an anasto- mosing branch (vena communicans) which traverses an opening m the deep fascia at the outer side of the tendon of the biceps muscle, and discharges into the median vein just before its bifurcation, thus increasing the amount of blood that flows through this vein. Occasionally it opens into the median basilic. There are, therefore, five superficial veins at the bend of the arm, either of which may be opened in venesection ; the radial, the ulnar, the median and the two branches of the latter— the median cephalic, and median basilic. The superficial radial and ulnar, are usually the smallest of the whole, and are so surrounded with branches of the cutaneoiis nerves, especially the ulnar, (see Plate 3,) that they should not be selected for the operation, except in cases where the other veins are either wanting, or cannot be felt. The radial under equal circumstances, though it does not bleed so freely, is to be pre- ferred to the ulnar, as the latter cannot be opened without risk of injury to the nervous filaments that cover it in front, which though not so serious an accident as formerly supposed, it is desirable to avoid. As the nerves run nearly parallel with these veins, the risk of injuring the former will be diminished by making the opening with the lancet, parallel with the course of the vessel. A slightly oblique cut is, however, usually preferred even here, as it is found to give blood in a larger stream than one exactly parallel. The median vein is occasionally opened below its place of division : while yet deeply situated in the interstice be- tween the mass of muscles of the two sides of the forearm, it is surrounded with nervous filaments, and has the brachial artery placed below it, and so. near, especially in thin subjects, that there is some risk of wounding that vessel. But when it lies on either PLATE IIL-PHLEBOTOMY— BLEEDING FROM THE AKK AND FOOT. Fig. 1. — The right arm is here represented, prepared for the operation at the bend of the elbow. The circular liga- ture (a), knotted upon the anterior and outer face of the limb, has caused a distension of the superficial veins below, which are here shown as they are found existing in the greater number of cases: (1), the median basilic; (2), the median cephalic; (3), the anterior radial or common median; (4), the posterior radial, and (5), the anterior ulnar. The thumb (5) of the left hand of the operator is applied on the common median vein, so as to keep its branches full, while the lancet is introduced as seen at (/) ; the incisions {d, e, g, h,) represent the other points for puncture, as well as the diflferent directions in which the opening may be made, with least risk to the patient. Fig. 2 and 3, exhibit the surgical anatomy of the elbow, in reference to the operation. In fig. 2, the veins, absorb- ents, nerves, and the superficial fascia with its adipose layer, are exposed by the careful removal of the skin, bringing into view the aponeurosis of the arm. In fig. 3, a portion of the aponeurosis is removed in addition, all the superficial veins with the exception of the median basilic being preserved. The bicipital aponeurosis is seen projecting a little above the lower line of section. In regard to the vein and the different points for bleed- ing, the same references apply as for fig. 1. (6), fig. 2, indicates the principal group of the absorbent vessels of the arm; (7), fig. 2 and 3, the branches of the external cutaneous nerve ; (8), the internal cutaneous nerve ; (9), a cutaneous filament of the ulnar nerve; (10), the brachial artery; (11), the satellite veins ; (12), the median nerve. BLEEDING FROM THE INTERNAL SAPHENA. Fig. 4, shows the manner of bleeding in the internal saphena vein. (1), A prominence formed by the internal saphena, which is a continuation of the external vein of the foot (2). The left thumb of the operator (b) fixes the vein on the malleolus to prevent its rolling, while with the right hand the surgeon opens the vessel. In the figure (d) below, the lancet is held in the proper position for making the puncture for blood-letting. '■'Iff -'^ F/ate 3. PHLEBOTOMY. 17 side of_ this interstice or can be carried there by pronation of the hand, or pressure with the thumb, it may be bled in with im- punity.* The two branches of the median are those commonly punctured in venesection. The median basilic is generally the largest, most superficial and most constant, and the one which we are very often compelled to open, in the absence of others of sufficient size. It is the only one, however, which requires great precaution on the part of the operator. In its oblique course to join the ulnar, it rests on the aponeurosis of the biceps tendon, which alone with some thin layers of fatty cellular tissue separates it from the bra- chial artery. The vein sometimes exactly covers the artery, sometimes is placed at the margin but parallel with it, but more usually it varies a little from the same direction so as to cross it obliquely. It is surrounded with some filaments of the internal cutaneous nerve, one or two of which pass diagonally over it, in the inner half of its course. When we bleed in this vessel, it is best to select the first or lower part of its course, since the artery, as it descends, separates from the vein to get under the muscles of the forearm. When the vein runs parallel with the artery, the hand should be strongly prbnated, so as to sink the tendon and aponeurosis of the biceps by partially winding the former round the radius, and thus increase the distance between the artery and the vein while at the same time the supinator longus muscle is brought in front of the tendon, and pushes the vein upon the inner edge of the pronator teres. If the muscles are thin, a slight flexion of the forearm will aid in producing the same effect. Across the middle of the median basilic the greater part of the absorbent vessels of this region pass. These in certain subjects are prone to inflammation, and present another objection to those already mentioned, against bleeding in the middle part of the course of this vein. At its place of junction with the ulnar vein the median basilic covers the great median nerve. The median cephalic may be opened with safety in any portion of its course, as there is not, except in cases of anomalous distri- bution of the arteries, any part of importance near it except the external cutaneous nerve, which crosses somewhere in the infe- rior half of the vein but at some little distance behind it. This vein, when of good size, is to be preferred in all cases for the operation. But it is often small or imperceptible, and sometimes deficient, and notwithstanding the objections urged, we are often compelled, as before observed, to resort to the median basilic, as the only vein at the bend of the arm, in which we can succeed in drawing blood in a full current. Operation. — The points at which the veins may be opened are seen at Plate 3, fig. 1. If at the most favourable spot for the ope- ration, the scars of several previous bleedings are observed, it has been recommended by Dionis and Boyer to make the puncture just below-, lest the vein should be found narrowed or obliterated. But this is not a result met with, except there have been twelve or fifteen or twenty punctures near the same place ; and except this obliteration has taken place so as to transform the vein into a fibrous cord, it answers perfectly well to make the incision over the old cicatrix. The apparatus required for vene- section consists of a bandage for compression an inch and a half ♦ In case of need, even, ihe cephalic vein may be opened just above the bend of the arm. 5 wide and a yard long, a thumb or spring lancet, a vessel to re- ceive the blood, and a separate bandage and compress to secure the wound. The operator should first examine on the inner side of the tendon of the biceps, for the pulsations of the brachial artery, so as to form an opinion of its direction and depth. He should also feel in the neighbourhood of the different veins, whether or not there be any anormal and superficial distribution of the ulnar or radial arteries, which sometimes occurs where the division of the main trunk has taken place high up in the arm. This should be done previous to the application of the ligature, which would stop the pulsation in the superficial artery, and ren- der it readily mistaken for a turgid vein. This caution is not use- less. In two instances I have been called to operate for false aneurism, caused in a superficial artery, by careless venesec- tion. The ligature should be placed as seen in fig. 1, suf5- ciently tight to cause the veins to fill, but not check the circula- tion of the artery. The arm is then to be allowed to hang down for a few moments till the veins are sufficiently distended. If they do not quickly fill, the fingers are to be worked, friction made upwards along the arm, or the hand immersed in hot water. Bleeding with the thumb lancet. — If the right arm is the one selected, the operator places the hand of the patient under his left arm-pit, and secures it firmly against his chest. With the palm of the hand of the same side he embraces the elbow; the thumb and the fingers appearing on the opposite sides of the joint. Some slight friction being made upwards with the little finger of the right hand, so as to distend the vein, the left thumb is to be suddenly depressed, in order to retain it in the distended state. The spear-pointed lancet held as seen at fig. d, is then passed with firmness and precision obliquely on into the vein, until we see the blood beginning to ooze by its side. The smaller the vein, the larger is the opening to be made. If the vessel be deep, it is necessary to enter the lancet more or less perpendicularly for fear of missing it altogether. By elevating the point of the lancet before drawing it out, we may enlarge the opening, as will be re- quired if we intend to bleed freely. The compression made by the left thumb is to be relaxed, and the blood allowed to flow when the bowl is properly disposed for its reception. Care is also to be observed during the flow of the blood, that the arm does not much change its position, so as to produce a want of corre- spondence between the opening in the skin and vein, causing a subcutaneous effusion of blood known as thrombus or ecchymosis, which often beocmes subsequently painful when the tumour form- ed by it is large. Sufficient blood having been drawn, the ligature is to be removed, the arm partly flexed, and the orifice carefully closed and secured with the compress, and figure of 8 ban^kge. If adipose matter protrude between the lips of the incision, it is to be pressed backwards, or if that will not suffice clipped away, so as to allow the edges of the skin to come together, in order to insure union by the first intention. If the vein has been many times bled in, and has become thinned in its walls and varicose, there is sometimes a difficulty in arresting the blood. But a more methodical compression, effected by the aid of some small gradu- ated compresses, secured with a nodose bandage reversed over the wound, will be found to answer. Tlie arm should be worn in a sling for twenty-four hours, by which time the puncture is usually closed : the compress may be removed on the third day. 18 ELEMENTARY AND MINOR OPERATIONS. Bleeding with the spring lancet. — The thumb lancet, if in pro- per order, is by far the surest, safest and neatest instrument for venesection. But in this country, and the north of Germany, the spring lancet, or phleme, is more commonly employed, in conse- quence of the greater facility with which it is kept in order, and because bleeding with it is found so easy that little skill or expe- rience, in ordinary cases, suffices for its use. In using this instru- ment the blade is to be fixed, so as to strike at such a depth, as by calculation will divide the skin, cellular tissue, and anterior wall of the vein. As there is a chance, however, that the blade may penetrate the posterior wall of the vein, and wound the parts beneath, it never should be held in the direction of the artery, or the aponeurotic expansion of the biceps ; the mere puncture of the latter being apt to give rise to the inflammatory swelling of the cellular tissue belowr it, which, when it occurs, prevents for a time the complete extension of the arm, and in cases tending to suppuration requires an operation for the division of the resisting fascia, so as to take away the painful pressure on the swollen part. The cautions above given in reference to bleeding in the median basilic are especially to be observed in the use of this instrument. VENESECTION AT THE FOOT. Next in order of frequency, is the practice of bleeding from the vena; saphenae. This is resorted to in cases where it is impracti- cable to open a vein at the bend of the arm ; or, in accordance with the opinion entertained by some practitioners, for the purpose of producing a revulsion in affections of the head and chest, especially when these have followed a suppression of menstrual or heemorrhoidal discharges. We may bleed either from the in- ternal or external saphena. The walls of these veins are thick in proportion to their calibre, and seldom bleed freely. They are accompanied by nerves of the same name. The internal saphena consists usually of a single trunk, formed by veins from the same side of the foot, runs over the middle front portion of the internal malleolus, ascends on the inner side of the knee joint, and discharges into the femoral vein near the groin. The internal saphenus nerve runs on the inner margin of this vein, and sends branches across it below the malleolus. It is therefore at the upper or middle part of the ankle bone, and on the posterior part of the vein, that we make the puncture. The foot should be immersed for a sufficient time in warm water, to cause a distension of the veins. A ligature is then to be placed two inches above the ankle, and knotted on the outer side of the leg. The foot, well dried and inclined on its outer side, is to be taken on the knee of the operator or rested on a chair, and the puncture made with the thumb lancet, the vein being well secured with the thumb of the left hand to prevent its rolling under the instrument. If the spring lancet be used, great care should be taken that the blade does not come in contact with the bone, as it might be broken, and a fragment left in the wound. When the blood ceases to flow, or a sufficient quantity is taken, the vein is to be secured in the ordinary manner. The external saphena vein is usually inferior in size to the inter- nal, and is seldom opened. It runs up behind the external mal- leolus, where it has the external saphenus nerve lodged in a distinct sheath at its posterior border, and empties into the pop- liteal vein just above the knee joint. The ligature should be placed a little higher than for the preceding operation. The foot should be rested on its internal margin, and the puncture be commenced near the outer border of the vein, and carried ob- liquely across so as to avoid the nerve. VENESECTION AT THE NECK. (PL. IV.) This is practised exclusively on the external jugular vein. This vein receives blood from the exterior portion of the cranium and face, and is connected by anastomosing branches with the sinuses of the brain. It descends in the direction of a line drawn from the angle of the jaw, to the junction of the external third with the internal two-thirds of the clavicle, where it sinks under the edge of the sterno-cleido-mastoid, and opens into the subcla- vian. The vein is covered in front by the skin and platysma- myoides muscle, and lies on the outer surface of the sterno- cleido-mastoid. At several points, but especially near its middle, it is crossed by some nervous filaments from the cervical plexus. No artery is in its neighbourhood. The place at which it is opened, is, in the adult, about three fingers' breadth above the clavicle, and over the belly of the sterno-cleido-mastoid. Operation. — The patient is to be placed in the sitting posture, with the head slightly turned backward, and to the opposite side from that in which we bleed ; the shoulder should be protected with a napkin. The vein may be made to swell up and become apparent, by pressure with the thumb of an assistant upon it a little distance above the clavicle. It answers better, however, to lay a thick, hard compress on this point, and bind it firmly down upon the vein with a broad ligature or a folded cravat, which should be knotted under the axilla of the opposite side ; or the ends of the band may be carried directly round the neck, and held tightly though at some distance apart, so as. to compress only the vein, and not interfere with the circulation in the other vessels of the neck. If the vein does not fill well, it will be found advan- tageous in this respect to cause the patient to move the jaws as in mastication, and make a few prolonged expirations. The same measures will also be found after the vein is opened to facilitate the discharge of blood. The lancet properly opened, and held as seen in PI. 3, the operator, pressing with the left thumb upon the swollen vein above the compress and with the fore finger of the same hand a little distance higher in order to steady the vessel and stretch the skin, makes a puncture between these points ob- liquely upwards and outwards, in the direction of the fibres of the sterno-cleido-mastoid, conformably to the directions o-iven for bleeding in the arm. In this case, however, the puncture must be made deeper and the orifice broader. The widening of the orifice may be effected by raising the lancet, after it has well entered the vein, and withdrawing it in a vertical position, car- rying it slightly upwards at the same time. This movement divides freely the fibres of the platysma muscle, which might otherwise contract over the orifice and prevent the free discharge of blood ; and obviates, even where the vein is most deeply situ- ated, the necessity of a previous division of the skin and muscle with a bistoury, as has been suggested by M. Magistrel. The blood seldom springs in a jet; it usually trickles down the neck, and must be conducted off by a bent card pressed against the ARTERIOTOMY. 19 skin. On removal of the compression, the flow of blood usually ceases of itself. The wound is to be closed with a strap of adhe- sive plaster, and supported with a compress and a few turns of a circular bandage moderately tghtened. If, as occasionally hap- pens, these measures do not arrest the after flow of the blood, the lips of the orifice may be closed with the hair-lip suture. VENSECTION NEAR THE PART AFFECTED. Bleeding in the frontal, or ranina veins, for affections of the brain and tongue, are not now practised. In the former it is inefficient, and in the latter there is often a difficulty in checking the flow of blood. But in local inflammation of the hand or foot from arthritic or other causes, or of the external genitals, where the trunks of the veins are kept swollen from the strong determination of blood to the part, local venesection has been recommended by M. Janson and Sir A. Cooper, and has proved in my own practice occasionally useful. BLEEDING BY INCISIONS FROM THE CEPHALIC. (PL. IV. Fio. E. F.) * When the necessity for the abstraction of blood from the gene- ral circulation is urgent, and it cannot be obtained to a sufficient amount from the sources above described, it has been suggestedhy M. Lisfranc, rather than have recourse to arteriotomy, to open the cephalic vein at the upper part of its course between the deltoid and pectoralis major muscles. An incision of an inch in extent is to be made with a scalpel through the integuments and super- ficial fasciae covering the groove between these muscles, and the vein, exposed to view by a slight separation of the muscles, is to be punctured with the lancet. The operation is attended with some little difficulty, and opposite the upper third of the deltoid the vein is in company with the deltoid branch of the superior thoracic artery, which would incur some risk of being wounded. It has been proposed by M. Bourgery, (PI. IV. fig. F.) as easier and safer to open the vein below the insertion of the deltoid, following the plan above given. IV. ARTERIOTOMY. Blood-letting for therapeutic effect, is practised only on the su- perficial arteries, and is but seldom resorted to. The superficial temporal artery, the facial where it crosses the base of the jaw, the occipital above the attachment of the complexus muscle, the radial near the hand, and the anterior tibial on the dorsum of the foot, are sufficiently superficial to be opened with safety if required in a case of urgent necessity, and lie near enough to the bone to admit of the requisite degree of compression afterwards. It is to the first, however, or superficial temporal, that the operation is almost exclusively restricted. Surgical anatomy. — The main trunk of the superficial tem- poral arlery passes over the zygomatic process of the temporal bone, about a quarter of an inch in front of the auditory meatus, where it may be felt pulsating. As it passes upward it divides, at the distance usually of an inch and a quarter from the middle of the zygomatic arch, into, an anterior and posterior branch. The posterior is distributed to the hairy Scalp ovet the parietal bone. The anterior or frontal branch passes in the direction of the forehead; its position is variable, but it is obvious to the touch, and may often be seen pulsating under the skin. Blood may be drawn from the frontal branch, which is covered only by the integument and a thin layer of fascia: or if this be not of suflS- cient size, from the main trunk in any point between the zygoma and its place of division. In this part of its course it rests upon the aponeurosis, covering the temporal muscle. On its outer side is a strong layer of superficial fascia as well as integument. The latter is dense and thick, and the artery is invariably found deeper than the sensation given to the finger by its pulsation would seem to indicate. It is accompanied by some nervous filaments from the facial and inferior maxillary nerves. The vein which attends it is small and unimportant. Bleeding in the main trunk should not be undertaken without due consideration, as it has been followed by aneurism, and, in some instances, in order to stop the hemorrhage, it has been necessary to twist or tie the vessel. The best place for the operation on the trunk, is three- fourths of an inch above the zygoma, and an inch and a quarter from the auditory meatus. Operation. — Whether the frontal branch or the trunk before its subdivision is opened, the processes to be followed are much the same. A bistoury is to be preferred to the lancet for opening the resisting skin. The face is to be turned toward the opposite side, supported by an assistant, or inclined upon a pillow if the patient is in a horizontal position. 1. Process of the author. — A fold of skin about half an inch broad is to be raised above the vessel, and divided by a straight sharp-pointed bistoury, passed through its base in a direction somewhat oblique to the artery. If no other instrument be gt hand, the section may be made with the thumb lancet. The lips of the wound are to be separated with the thumb and fore-finger of the left hand ; the artery is to be laid bare with a few strokes of the point of the instrument, and punctured obliquely like a vein. The requisite amount of blood having been taken, the artery should be compressed with the finger below the wound and divided completely across. The retraction which follows usually stops the hemorrhage. The wound is then to be closed with two or three narrow adhesive strips, and secured with a double com- press and roller. If the discharge is not immediately arrested, a compress should be placed above as well as below the section, in order to prevent the return of blood by the anastomosing vessels. If the artery be large, a ligature for greater security may be placed upon it, or, which will usually suffice to stop the blood, the wound may be closed with a stout hare-lip suture. 2. Usual process. — The position of the artery being marked with ink, and the skin made tense above it with the thumb and index finger of the left hand, the artery is divided completely across with the convex-pointed scalpel, which should be pressed downwards directly upon it with the fore-finger upon its back till it meets the bone, and then drawn slightly towards the operator. 3. Process of M. Magistrel. — The artery being steadied with the middle finger of the left hand, a quarter of an inch above the place at which it is to be divided, a straight sharp-pointed bistoury, with the edge upward, is passed directly-down to the temporal aponeurosis, upon one side of the artery, and glided obliquely 20 ELEMENTARY AND MINOR OPERATIONS. under it by lowering the handle. The instrument is then to be raised to the vertical position, dividing the vessel across, and en- larffinn; to the extent of six or eight lines the orifice in the skin as it is withdrawn. The track of the wound should lie rather obliquely across the course of the artery. The operation is as rapidly done as venesection at the arm. If there is difficulty in arresting the bleeding, or the patient through delirium tears away the dressings, the diagonal direction of the wound permits of the application of a suture with a curved needle which shall enclose the two ends of the vessel and effectually stop the blood. The only objection to this and the precedingprocess is, that the retraction of the divided vessel will often check the discharge before the requisite amount of blood is obtained. V. CAUTERIZATION. Cauterization consists in the application to the living tissue, of agents capable of disorganizing the parts with which they come in contact. They are divided into two classes, distinguished by the names of potential and actual cauteries. The potential cau- teries have received their names because they possess inherently this property of disorganizing the tissues ; while in the actual, it is owing solely to the caloric with which they are charged for the occasion, so as to render the effect instantaneous, or actual, in the acceptation of this word by the older writers, from whom this classification is derived. 1. Of potential cauteries. — The articles of this class are very numerous, and are found in the solid, soft, or liquid state. Solid. — These comprise crystallized potash and soda, nitrate of silver, dento-chloride or butter of antimony, minium, calcined alum, white or deutoxide of arsenic, deutoxide of copper, deuto- chloride and red oxide of mercury, powdered savin leaves, etc. Soft. — These consist of the solid caustics pulverized and diluted with cerate, honey, alcohol, or water, so as to form a soft paste that may be spread upon the diseased parts. Of this description is the ammoniacal ointment of Gondret ; the paste of chloride of zinc employed by Canquoin, the arsenical paste of Dupuytren and Rousselot, that of oxalate of potash prepared from the leaves of the wood sorrel, etc. etc. Liquid. — These are very numerous, consisting, as they do, of all the concentrated acids, especially of the nitric, sulphuric, and hydrochloric; the saturated solution of the solid caustics, such as the acid nitrate of mercury, butter of antimony, chloride of zinc, corrosive chloride of mercury, sulphate of copper, etc. etc.; and finally the lately devised caustic of M. Recamler, which consists of a solution of the chloride of gold in aqua regia, in the proper- PLATE IV.— ARTERIOTOMY— BLEEDING FROM THE JUGULAR MJ) CEPHALIC VEINS. BLEEDING FROM THE TEMPORAL ARTERY. (A.) Bleeding from the frontal branch of the temporal artery according to the old process described by Boyer. — An inci- sion with the straight bistoury is represented as made directly across the course of the vessel so as to divide it. Two small graduated compresses are placed across parallel with the lips of the wound, to show the manner ill which compression Is to be made, after a sufficient amount of blood has been taken. A roller bandage is then applied over these compresses. (B.) Incision of the trunk of the temporal artery above the zygomatic arch. — If the cut is made transversely from a point above the zygomatic arch and In front of the concha and antltragus, the artery may be always neatly divided across. As there is a solid bony surface below, the hemorrhage may be arrested at will with a compress and knotted bandage, unless It Is preferred to close the wound with a hare-lip suture, or tie the vessel as mentioned in the text. (C.) Bleeding from the artery by the process of M. Magistrel. — The knife shown raised towards the vertex as in the last stage of the operation. (D.) BLEEDING FROM THE EXTERNAL JUGULAR VEIN. A graduated compress (a) Is placed in the fossa above the clavicle ; a band (&) Is laid with its middle over the compress and the ends passed diagonally under the armpit of the opposite side. The finger of one hand is seen com- pressing the vessel so as to cause It to fill up, while it Is opened with the instrument in the other. The mode of compression, as advised In the text, will however be found preferable. (E. F.) BLEEDING FROM THE CEPHALIC VEIN OF THE ARM. (E.) represents the place for the previous Incision to expose the vein, as advised by LIsfranc, in cases where blood cannot be got from the bend of the arm, the back of the hand, the foot, or the jugular. (F.) Bleeding from the cephalic below the tendon of the deltoid, as recommended by Bourgery. It is made in the groove, found in front of the triceps and brachialis anticus, and behind the external portion of the biceps. A compress and band (c) is applied to fill the vein and prevent the introduction of air. l'I{('h' '/ CAUTERIZATION. 21 tion of six grains of the salt to an ounce of the mixture of nitric and hydrochloric acids.* Application. — Most of these caustics are employed according to special indications, which, from the limits of this work, can only be partially noticed. The nitrate of silver or lunar caustic is employed particularly for the purpose of limiting the spread of erysipelas, repressing fungous granulations, exciting action in old wounds or ulcers, cauterizing the surface of diseased mucous membranes, for destroying the nature of primary chancres, &c. Caustic potash is resorted to for the purpose of forming issues, opening abscesses, and for the rapid destruction of tissue when this measure becomes necessary in scrofulous, and some other- analogous affections. The arsenical paste is principally employed for the cure of superficial and corroding ulcerations ; chloride of zinc in cases of deeper seated cancerous affections ; chloride of antimony for the purpose of cauterizing poisonous wounds ; pow- dered savin leaves, alone or combined with the deutoxide of cop- per, for the removal of syphilitic vegetations. Application of the liquid caustics. If the liquid caustics are used, and especially the acid nitrate of mercury, (which enjoys a high reputation in ulcerous affections of the as tinea, and where of course it is only to be applied through a speculum,) they must be laid on with a small brush, or a pledget of lint dipped in the solution and pressed on the diseased surface. If the part to be removed is of considerable thickness, several applications may be required at one sitting, carefully removing at each time the substance destroyed by the previous touch, so as to lay bare a new surface ; — the operation done, the caustic is to be wiped or washed away from the part. The action of these caustics is rapid — almost instantaneous; and a principal objection to their use is the difficulty of limiting their action to the affected part ; this in some superficial situations may, however, be readily accomplished by forming a little bank round the diseased structure with basili- con, or any other adhesive ointment. The colour of the eschar formed by nitric acid is yellow; by sulphuric acid, black; hydrochloric, greenish. The butter of antimony forms at the instant of its contact with the tissues, a thin, dry, flocculent, flaky and shining eschar, which may if necessary be removed im- mediately in order to renew the application. The acid nitrate of mercury also forms a dry solid eschar, which is of a yellowish or brownish colour. A great advantage attending the use of this caustic, shared to a certain extent by the arsenical paste, is the promptness with which it is followed with cicatrization. The acid solution of the chloride of gold used by Recamier, if experience .should confirm the allegations in its favour, ought to obtain the preference over all other forms of liquid caustics. It forms a neat, well-circumscribed eschar, which comes away at the end of three or four days, and unlike the two last mentioned, does not appear to have ever been followed by absorption, so as to make a poison- ous impression on the general system. Application of some of the soft caustics. — The ammoniacal ointment of Gondret consists of equal parts of lard and concen- trated ammonig. It is very volatile, and should, therefore, be pre- pared instanter. It is spread upon linen in a layer half a line thick. In a few minutes it will produce vesication ; at the end of * For the formula for the preparation of most of these articles, see Wood & Bache's Dispensatory, and Dunglison's New Remedies. 6 a quarter of an hour, or a little more, a superficial eschar is formed, though in some instances, in order to produce this effect, it is necessary to renew the layer. It is more commonly, however, employed as a rapid epispastic than as a caustic, and its place may then be supplied by the simple concentrated ammonia con- fined under a pill box or something similar, or by the antidynous lotion of Granville, of which ammonia is the chief constituent. Arsenical paste. — This has long been employed by the profes- sion, and with empirics is a favourite [remedy for all cancerous affec- tions. There are several forms of the paste well known, which differ from each other only in the proportion of the arsenious acid which they contain. That of Frere Come and of Rousselot consists of two parts of arsenious acid, thirty-two of the sulphuret of mer- cury, and sixteen of dragon's blood. The caustic^omjnade of Hell- mund contains three-quarters of a grain of the acid in ten drachms and a half of the excipient. The following, however, will be found one of the most safe and convenient forms for common use: Take of the arsenious acid from four to six grains finely commi- nuted, one drachm and a half of calomel, and three drachms of powdered gum Arabic : triturate these well together, and add as much distilled water as will form a soft paste. After preparing the surface of the diseased part — by removing any crust that may cover it, or excising the top — wait till the bleeding is checked, and while the surface is still humid, apply a layer of the latter mix- ture from a third to half a line thick. The paste should extend a little beyond the bounds of the disease, and be covered either with some scraped lint, or with spider's web, and the whole well secured with a bandage. A sharp burning pain, and some oedematous swelling follow. In six or eight days the paste separates sponta- neously, and the slough comes away in about as many more. From four to six applications of this description will suflice usually in effecting the desired organic changes in the part. Many super- ficial cancerous affections, and it is alleged even bleeding (not medullary) fungus, may be ctired by the employment of this formula. It produces a livid coriaceous eschar, excites actively the surrounding vessels, deterinines a peculiar alterative effect in the subjacent textures, and is followed by the singular phenomenon of a more or less copious effusion of coagulable lymph after each application. Over an extensive surface the application of this caustic paste would be attended with danger ; it has been followed under such circumstances with symptoms of poisoning. In many cases of long standing and deeply corroding lupus ulceration, M, Cazenave has recently strongly recommended the following for- mula for the arsenical paste: White oxide of arsenic, two parts; sulphate of mercury, one part; animal charcoal in powder, two parts. A small quantity of this is made into a paste with a few drops of water, and applied upon the denuded surface. The surface covered should never, however, exceed in extent that of a franc piece, for fear the arsenic might be absorbed to such an extent as to give rise to serious constitutional symptoms. The application is attended with pain and some erysipelatous swelling. A hard, brown crust is formed, which often adheres for nearly a month before it is detached. Phagedenic paste of Canquoin. (Chloride of Zinc.) This is an energetic and unfailing caustic, the application of which is attend- ed with severe pain, persisting with great intensity for the first seven or eight hours, It is free from all risk of absorption, 22 ELEMENTARY AND MINOR OPERATIONS. seldom gives rise to much surrounding inflammation or swelling, except it be applied where there is much loose cellular tissue, acts to a depth which may be calculated with considerable precision in advance, and is said to be valuable in most instances where the surgeon's hand can reach. It was introduced into practice by M. Canquoin, and has been pretty extensively used by many indi- viduals, for cancerous and other malignant diseases. In order that the caustic may act with efiicacy, it must be employed in a concentrated state. In solution it merely acts as an irritant. From its extreme deliquescency it is necessary to mix it with some substance of a counteracting tendency. M. Canquoin em- ployed wheat flour. Dr. Ure has lately suggested the use of anhydrous gypsum instead of flour, as it does not, like the latter, form a glutinous dough which has a tendency to blunt the action of the acid, but a porous medium through which all the particles of the deliquescent chloride may arrive upon the diseased sur- face.* The same writer believes that the chloride of zinc acts in virtue of its powerful afiinity for albumen, which in a state of tiiftvelopment forms the principal bulk of cancer. The proportion in which the caustic is mixed with its excipient has been much varied. M. Bureaud employs an equal portion of the two sub- stances. Velpeau doubles the proportion of the chloride. But the proportions of Canquoin are usually considered the most advan- tageous; these are found in the following formulae. Paste JVo. 1: — Chloride of zinc, one part by weight; wheat flour, two parts. * London Med. Gazette, vol. iviii. This employed in the form of a paste four lines thick, is capable, if applied during ten days, of producing an eschar an inch and a half in depth. If three lines thick, it will cause during the same period, an eschar one inch in depth. If but two lines thick, it gives an eschar half an inch in depth. A layer of one line in thickness yields in twenty-four hours, an eschar of three lines ; and one of half a line thick, in the same space of time, will pro- duce an eschar of at least a line. Paste Mo. 2 : — This consists of chloride of zinc, one part ; wheat flour, three parts ; and is em- ployed usually in painful cancerous affections. The depth to which it will act in -a given time may be readily calculated, from what has been observed in regard to the action of Paste No. 1. Paste JVo. 3 : — This comprises one part of the chloride, and four of the flour ; and is used only in very delicate and irritable sub- jects. Paste JYo. 4: — This is formed of one part of the chloride of zinc, half a part of the chloride of antimony, and two and a half parts of wheat flour. It is to be moulded into a crayon shape; it preserves always the consistence of soft wax, and a suitable thick- ness may be given to it so as to adapt it to uneven and nodulated surfaces. In preparing the phagedenic paste, thirty or forty drops of water are to be added for each ounce of the chloride. The salt is to be reduced to a fine powder, and mixed as quickly as pos- sible with the given quantity of flour. One-half of the mixture is at first to receive its given proportion of water, and worked up with a spatula, gradually adding the other half, till it forms a tena- PLATE v.— OPERATIONS UPON THE BLOOD-VESSELS. c. i. Fig. e. VARICOSE VEINS. Fig. 1. (a, b, c.) — Compression of the principal veins above the varices. — a. A needle and twisted suture applied according to the process of M. Davat, upon a branch of the internal saphena vein. b. Modification of Velpeau, by the vertical rolling of two threads upon the sides of the needle, next the two places of puncture. Compression with the forceps or double plates of Sanson ; the closure of the plates being effected with the screw. Longitudinal incision of a mass of enlarged veins, according to the process of Richerand. 2. — d. Ligature with excision of a portion of the vein. Temporary ligature with a slip knot after the manner of Wise. y. Suture or seton : Process of Fricke. g, g, g. Operation upon the vein by a series of separate incisions. Fig. 3. — Process of Davat more distinctly shown. Fig. 4. — Modification of this process, by making circular instead of figure of oo turns, to which the author gives the preference. A number of these sutures are usually required, so as to obstruct the enlarged veins at several points. CLOSURE OF THE MOUTHS OF ARTERIES DIVIDED BY A TRANSVERSE CUT. f Fig.h. — The end of the artery is seen drawn out with the tenaculum, and the ligature knotted above. Several loose ligatures are placed on the tenaculum, for the purpose of tying the vessels in succession without loss of time ; a method, however, but little practised. Fig. 6. — Ligature of the artery upon a foreign body introduced into its cavity. -F%- 7.— Process of Amussat {par refoulement) . The artery is compressed firmly with one pair of forceps, and its two inner coats doubled backwards or stuffed into its cavity with another pair, narrow and rounded near the point. Figs. 8, 9, 10. — Torsion of the arteries, by different processes. Fig. 11.— Strip of kid skin passed as a seton through the artery. — Process of Jameson. Fig. 12.— Closure of the mouth of the artery by the process of Stilling. Plate S ''mm. CAUTERIZATION. 23 cious paste capable of being rolled out into cakes or wafers from half a line to four lines in thickness. If the integuments are sound, it is necessary, before applying the paste, to remove them the day previous with a blister, caustic ammonia, or hydrate of potash. M. Canquoin, in cases of tumours, makes one, two, or three applications of the Vienna caustic paste, at intervals of twenty- four hours, placing the zinc paste over the last eschar formed. When time has been allowed for the operation of the zinc paste to be complete, it is taken off, and the part covered with emollient poultices until the eschar separates, which usually takes place, as has been already observed, from the eighth to the twelfth day. The application of the caustic is in this way to be repeated again and again, till the whole morbid structure is removed. When frequent repetition is required, M. Canquoin alternates with it the use of the Vienna caustic. The bichloride of mercury or corrosive sublimate, which like the chloride of zinc has a strong affinity for albumen, has in some instances been likewise employed in the form of paste ; but from its poisonous nature its application should be limited to small sur- faces only, for fear that the poison might enter' the circulation. The preparation used at times by Graefe for the destruction of erectile tumours, consisted of two drachms of the sublimate, with two scruples of powdered gum Arabic, and as much water ; the eschar which it leaves is soft, white and thin, and separates in two or three days. A weaker paste formed of two parts of gum Arabic to one of the sublimate, has been found in some instances to pro- mote the cure of herpetic or carcinomatous ulceration attacking the eyelids. By making a longitudinal cut in the skin, and rubbing into the fissure some of the dry pulverized sublimate, a small issue may be very neatly formed. In the state of strong solution, — a scruple to an ounce of water, M. Ricord has advised its iise over the blistered surface of a recent bubo, following chancre in order to render abortive the specific inflammation of the gland. But the practice does not in such cases, as it appears to me, merit the encomium he has bestowed upon it. In the troches of minium, — little conical masses used for the purpose of dilating and at the same time stimulating a fistulous opening, — it forms the chief active ingredient. Application of some of the solid caustics. Caustic potash or hydrate of potash. — This should be carefully preserved in close- stopped vials, as it absorbs moisture and carbonic acid from the atmosphere so as to be weakened ^in its effects. It acts by its powerful affinity for the moisture in the animal tissue, which it absorbs so as to produce a rapid softening and decomposition re- sulting in a slough. It is employed as a crayon, when we wish to effect the speedy removal of a callous or indolent structure, with stimulation of the parts beyond to healthy action. It may be rubbed upon a surface, or insinuated for a moment into the orifices of sluggish or scrofulous abscesses. Application, of solid caustics to the surface for the purpose of forming an issue, opening an abscess, or for the removal of ncevi materni. — A piece of adhesive plaster, pierced at its centre with a hole one third of the dimensions desired for .the issue, is to be fastened on the surface. In the orifice is to be placed a piece of the crystallized potash, the size of a hemp seed, which will pro- duce an eschar six or eight lines in diameter. If it is desirable to render the eschar an inch across, it is better to augment the breadth of the piece of caustic, than increase its thickness ; for a layer of two lines is quite adequate to destroy the substance of the skin down to the subjacent cellular tissue. Over the orifice which has received the caustic, another piece of adhesive plaster is applied to keep the latter in -place, and the whole should be con- fined with a compress and roller to prevent the risk of its disturb- ance. An itching and burning heat soon follows. At the end of six hours the effect is complete, and the apparatus may be re- moved. A black eschar is formed, from which all the uncombined, caustic should be removed by ablution. The eschar may then be split by the bistoury, and left to be detached by suppuration under the use of emollient poultices. If it appears disposed after a few days to dry up, rather than become detached, its removal may be facilitated by the application of small blisters over it. Hydrate of soda, though not so commonly used, is an efficient escharotic, and adapted to the same purposes as the caustic potash; being less deliquescent, it is even more manageable than the latter. Caustic or quick lime is also occasionally employed mixed with an equal portion of dry soap in the state of powder, and acts by virtue of the same properties as the two preceding alkalies, though less powerfully. Canquoin's formula was three parts of the lime with two parts of the soap, diluted with a little alcohol so as to give it the consistence of pap. It is more frequently used, how- ever, in the following combination. Caustic potash and quick lime. (Vienna caustic paste.) This is composed of five parts of the potash gradually mixed in a mortar with six parts of the powdered lime, which at the moment of using, is to be converted into a paste, with a few drops of alcohol. It is to be laid with precision upon the part, in a layer of two lines thick, and watched with attention, as it acts promptly: In about six minutes the whole thickness of the skin will be destroyed, which effect is indicated by the appearance of a circular gray line at the circumference of the paste. The caustic is then to be re- moved, and the wound washed with vinegar and water in order to neutralize the remaining particles of the paste. If we wish to act deeper with the caustic than the whole substance of the skin, as in the case of removing a tumour, it may be left applied fifteen or twenty minutes, but not longer. The sensation produced by this caustic is, like that of all the rest, a burning heat, but the attending pain is infinitely less, and more like that of a blister. Mixed with a little powdered opium and soap, it is still more endurable, though the time of action will be a little prolonged. For the formation of an issue, the removal of a small erectile, or cancerous tumour, I have found it in my own practice to realize all the advantages, with few or none of the inconveniences which attend the use of the common caustic potash. The opinion, how- ever, is commonly entertained, with what positive truth it is yet difficult to say, that in cases of malignant degeneration, it does not to the same degree as the arsenical or zinc paste, take from the part the tendency to reproduce the disease. CAUTERIZATION WITH THE METALLIC OR ACTUAL CAUTERY, OR SURGICAL PYROTECHNICS. (PL. VL Fig. 12 to 17.) Metallic cauteries are usually made of steel, set in a movable handle of wood or ebony, forming the largest bulk at the caute- rizing end, which is bent at an angle with the shaft. M, Grondret 24 ELEMENTARY AND MINOR OPERATIONS. proposed, some years since, to use copper in place of steel in the manufacture of these instruments, alleging that, from the capacity of the former for caloric and its great conducting properties, it would convert into an eschar the surfaces with which it was brought in contact, in one-fifth of the time required by the com- mon cautery heated to the same temperature. As yet, however, the use of copper has been by no means general. There are eight principal forms of the cautery, or searing iron described ; distinguished as the cylindrical, the conical, the flat round, the button-shaped, or nummulary, the three-sided prism, the halhert-shaped, the annular, and the octagonal. The two latter, however, are useless, as their place may be always well supplied with one of the preceding forms. The head of the cylindiical iron is two inches long, and half an inch in diameter; these dimensions, however, may be varied at will, without altering the proportions of the instrument. Some employ it without being bent at an angle with the shaft. From its great size, it retains caloric for a long time, and is the form chosen, where the parts to be cauterized are thick, humid, or extensive. The head of the conical iron is an inch long, and eight lines in diameter at its base ; it is only applied at the point. The flat round or olive- shaped, is small, for the purpose of being insinuated into small round cavities, as those of cysts. A modification of the flat round, called reed-shaped (cauiere en roseau, fig. 14), is occasionally used for the same purpose as the three-sided prism. The button-shaped or nummulary is an inch in diameter, and a quarter of an inch long. The three- sided prismatic iron, much employed by Rust, is an inch and a quarter long, and each side three-quarters of an inch broad, the edges being truncated, and one of them directed up- wards. The halbert or hatchet-shaped, is employed for the purpose of simple linear, or transcurrent cauterization. For minute surfaces, the stilet of a trochar, or a knitting or large sewing needle may be employed, and at need in place of the larger instruments, the surgeon may lay hold of any piece of iron or copper within his immediate reach. The iron is to be raised to the temperature desired, by the fire of a brazier or charcoal chafing dish, which should be blown by bellows, and brought to the surgeon at the time of operation, so that the iron may not cool by being carried through the air. The healthy parts near the site of the operation, should be protected with a pledget wetted with cold water ; after the operation no other dressing will be required than a simple linen compress similarly soaked. If inflammatory symptoms arise it will be necessary to employ antiphlogistics ; and to facilitate the detachment of the slough, it will be advantageous on the second or third day, to resort to the use of emollient poultices or the warm water dressing. In employing the caustic, it is neces- sary to have it raised to the white heat, as it destroys the tissues much more rapidly at this pitch of temperature, and with infinitely less pain, than at the gray or red heat. The iron, as soon as it begins to cool, which is shown by the alteration of colour, should be changed for another ; the surgeon taking care under all circum- stances that it shall not cool by resting on the eschar for fear the latter should become adherent to, and be detached with the iron, causing great pain, and risk of hemorrhage. As a general rule, the slough produced by the iron does not extend beyond the site of its application. The resulting inflammation and suppuration are usually of a healthy character, and their effect in rousing the vitality of the neighbouring textures, and removing their tendency to degeneration, is far greater than that following the use of the caustic potash. In flaps, raised in plastic operations for the pur- pose of filling the breach left after the extirpation of cutaneous cancer, Dieffenbach does not hesitate to sear the under surface immediately before their adjustment, if he has reason to suspect that they share in the least degree the tendency to degenerate. In stercoraceous abscess by the side of the rectum, malignant pustule, gangrenous rupia, and other analogous affections, I have found it one of the most efficient and rapid means of cure. From the powerful afl!lux of blood it occasions to the spot on which it is applied, and the depth to which its influence is felt, it has been much employed, especially by the surgeons of the European con- tinent, as a counter-irritant in scrofulous affections of the bones and joints, as it is believed to bring back in this manner, the red blood into the parts previously gorged only with serous fluids, so as to determine a deposit of fibrin susceptible of serving as the basis of healthy consolidation. It is also resorted to in poisonous wounds, paralysis and rheumatism, and especially, in consequence of the dry, firm, compact eschar it produces, for arresting hemor- rhage, when other means fail or from particular circumstances are inadmissible. Larrey, it is alleged, has obtained remarkable success from it, in cases of phlebitis of the stump after amputa- tion; and others, by applying it at points, have been equally for- tunate, after the phlebitis was manifested in the veins of the limb, and under circumstances nearly hopeless. Through warts and in ranula, and in erectile tumours seated in parts that forbid the use of the knife, it has been directed to pass heated needles; but the practice, according to the author's experience, is, in all these affections, inferior to the means of treatment more commonly em- ployed. In opening large chronic abscesses, in which the integu- ment has become thin and livid, it has been advised by Larrey to use the heated trocar stilet. There are three different modes or processes of applying the cautery : — 1. The radiant or objective. — In this the heated button-shaped iron is held at the distance of six inches in order to throw the radiant heat upon the part, and is gradually approximated to the surface as the iron cools. This mode is but little used. It red- dens and swells the tissues, and was formerly employed in cases of erysipelas, atonic ulcers and scrofulous tumours. A live piece of anthracite coal might be used with the same advantage. 2. Transcurrent cauterization. — This consists in running one angle of the prismatic or the edge of the halbert-shaped cautery heated to a white heat, lightly over the surface of the skin, so as to make a number of parallel lines, or rays of fire as they are called, from two to six inches long and from one and a half to three inches apart, involving only the substance of the skin. It is some- times resorted to in cases where it is desired to produce a powerful irritation of the skin with little loss of substance, as in cases of fungus articuli and hip-joint disease. The number and length of the rays are to be proportioned to the effect we wish to produce. The tracts should be traced previously with ink, over which the iron should be passed lightly, one, two or more times. The eschar which follows is of a golden colour, and seems at first a mere line, but when it comes away it will be found to have in^ volved the whole substance of the skin. Cicatrization follows SUTURES. 25 promptly, and is attended with an obvious narrowing or diminu- tion of the surface of the skin. Dry flannel or warm linen cloth should be at first applied about the limb to keep up the stimula- tion ; and emollient poultices subsequently resorted to, when the eliminatory inflammation becomes developed. 3. -Inherent or proper cauterization. — In this the action of the cautery is sustained for a time in contact with the' tissues. It is the method in by far the most common use, as it is employed whenever we wish to destroy tissue deeply or over a broad sur- face. Any of the various forms of the cauteries may be -used, though those of large size are usually to be preferred. It is ne- cessary to have the surface before using the iron as dry as possi- ble, for the moisture of the part almost immediately cools the iron, so as to diminish its cauterizing power while it increases the. pain. If the parts are freshly incised, as in the operation for caries, it will be necessary to wait till the bleeding has in a great degree ceased, and to have several heated irons at hand so that they may be used in turn. VI. REUNION BY SUTURE. The union of divided parts is always directly accomplished by the organic or instinctive action of the vessels on the sides of the section. The aid which the surgeon affords consists merely in properly retaining them in permanent apposition, without unne- cessary tension, and'giving the parts involved such a position as shall more or less relax the surrounding muscles.- Reunion may take place in two modes, which have received the names of Jirst and second intention. In that by first intention, there is a direct adhesion of the divided parts without finy previous formation of pus. In that by second intention, suppuration, attended by a growth of granulations, is the means of cure; the granulations, which form upon the sides and at the bottom of the opening, ulti- mately uniting together so as to become the medium of adhesion. There is a sort of union intermediate between the two, called im- mediate secondary union, which is occasionally resorted to with considerable advantage in practice. In this the sides of the wound are not closely approximated till after they are covered with lymph forming a layer of incipient granulations;- they are then brought together, and union takes place with very little or no subsequent suppuration. The means by which the parts are held in apposition, consist of sutures, adhesive straps, and bandages. Of the first, more than twenty different kinds were employed by the older surgeons; but since the adhesive plaster, which may be cut into any convenient shape for application, has been brought to its present degree of perfection, the following kinds are the only ones commonly em- ployed in practice, viz : the interrupted, the glover^s, the quilled, and the hare-lip suture. Other forms are still occasionally used in particular cases of injury, as in wounds of the intestine, and will be hereafter noticed. RULKS FOR THE APPLICATION OF SUTURES IN GENERAL. I. To clean the lips of the wound of all foreign bodies and coagulated blood, withbut interfering with the thin coat of fibrin that in a few hours forms a glazing over the raw surface. 7 2. To enter the needle at an anglfe of about 45°, so as to get a sufficient hold in order to unite the lips by a broad edge, and at a distance from the margin, proportioned to the length of the wound, and its tendency to open. 3. Whether the needle enters from without inwards, or from within outwards, the points of perforation should be opposite, so as to close the parts without wrinkling, and make the thickness of the substance embraced as nearly equal as possible on both margins of the wound. It is usually, proper to pass the needle merely through the skin and subcutaneous cellular tissue ; but in cases of deep cuts involving the muscles, or in wounds following resection or amputation, they may sometimes be passed with advantage through a portion of the divided muscle. 4. If the wound involve a free margin like the lip, or detach an angular flap, the first suture should be applied upon the pro- jecting angle in order to bring the parts into their proper relations, with each other. In a long incision over a flat surface, it should for the same reason be applied near the middle of the wound. 5. The distance between the points of application should be nearly equal. The two terminal ones should, however, be one- half nearer the angles of the wound than to the adjoining sutures. If reliance is solely placed on the sutures for closing the wound, a sufficient number must be applied to make the line of union complete, without the intervention of gaping orifices. In general, however, it will be found better, excepting in cases of plastic operation, to employ a fewer number of sutures, and adjust the parts between them with adhesive straps. It will rarely be found necessary to employ more than three,or four points of suture ; and to insure an exact apposition of the edges of the wound, it is best not to begin to tie them till after all are applied. 6. The knots of the ligature should be made upon the side, not over the line of the wound, and as much as possible on the opposite margin to that over which the discharges may be ex- pected to flow. They are to be tied only with a moderate degree of tightness, — just sufficient to bring the lips together, for if more firmly drawn they give rise to strangulation and ulceration of the substance inclosed. If the parts are thick, or are strongly dis- posed to separate from muscular action or other causes, so as to draw tight on the sutures, resort must in all cases be had to aux- iliary means of support by adhesive straps, which act over a large surface, or of graduated compresses laid along the edges and re- tained by a suitable bandage. The limb must also be so placed as to relax the muscles concerned. 7. The use of sutures is to facilitate adhesion. They are, however, irritating of themselves, and should therefore be removed as soon as they cease to be absolutely necessary to keep the lips of the wound in contact. If too long retained they either convert the track through which they have passed into a seton, or cut out so as to leave deformity. The time necessary for reunian by the first intention varies from three to eight days, according to the state of the part and the character of its organization. On the eyelids, where the skin is thin, it is customary to rem.ove the sutures in a much less period even than three days, in order to avoid the oedematous inflammation to which they are there apt to give rise, if too long retained in situ. In removing the sutmres it is necessary in most cases to moisten and cleanse the thread befofe cutting the knots. If the adhesion should not appear strongs ai part 26 ELEMENTARY AND MINOR OPERATIONS. of them only is to be removed at a time, and a strip of adhesive plas- ter applied in place of the suture that has been taken away. The material commonly employed in sutures is a waxed silk or hempen thread which may be used either single or double, twisted in the form of a cord or flattened like a ribbon. In some delicate plastic operations, a woolen thread may be used with advantage, as it seems less disposed to cut the parts. INDIVIDUAL SUTURES. (PL. VL) 1. Of the interrupted suture, (fig. 10, a.) — This is made with a curved semicircular needle, held, with the thumb placed in the curve and the index finger on its back. Whether it be passed from without inwards or in the opposite direction, the point should be entered perpendicularly and the needle brought round with a sweep. The loops are commonly at least an inch apart. If se- parate ligatures are used, they may be armed with the needle at one or both ends. In many cases it is more expeditious to follow the practice of Lafaye ; to employ one long ligature armed with a single needle, and carry it successively through at the different points, dividing the thread afterwards so as to form separate liga- tures. After the T or star incision a single suture through the separate angles sufBces to bring them together. An assistant in cases of large or deep wounds, should bring the edges together while the surgeon closes the knots. 2. Glover^s suture, (fig. 10, c.) — This is but little used, except in post-mortem examinations, and in some wounds of the intes- tines. It is a continuous stitch passed obliquely from right to left, at equal intervals, across both edges of the wound. The loops are all tightened at once by drawing on the two ends of the thread. The tendency of this suture to strangle the parts which it em- braces in its spiral turns, has caused its nearly total exclusion from practice. 3. Quilled suture, (fig. 11, e.) — This differs only from the inter- rupted suture, in having the separate threads passed double through the eye of the needle, so as to leave a loop at the exit of the needle on one side of the wound, and the ends at its place of entry on the other. When the loops are all placed, the barrel of a quill, or a piece of stick or bougie, is inserted within the loops on one side, and another between the tails of the ligatures on the other side of the wound. The tails are then to be drawn tight and knotted. This suture was in great favour with the older sur- geons, and is probably too little used at the present day. It is of course only applicable in straight wounds. It serves admirably PLATE VL— SETON— MOXA— ACUPFICTURE NEEDLES-^SUTURES— CAUTERIES. Figures 1, 2, 3, 4. — Application of a seton to the back of the neck. Fig. 1. — A fold of skin, through the base of which a bistoury has fteen passed. The bistoury is showii just as it is about to be withdrawn so as to prolong the incision. Fig. 2. — Mesh or seton tape, passed with the eyed probe — the fold of skin subsequently relaxed. Fig. 3. — Boyer's seton needle, threaded with the mesh. Fig. 4. — A convenient seton needle : less used, however, than the former. Figures 5, 6, 7, 8. — Moxas, and instruments for applying them. Fig. 5. — Common moxa in a state of combustion held upon the skin with a pair of forceps. The burning is accelerated by blowing on it through the pipe. Commonly, the mouth of a small pair of bellows are used instead of the pipe. Fig. 6. — A small moxa, of the form preferred by M. Sarlandiere. Fig. 7. — Port-moxa of Larrey. A convenient instrument, but not absolutely necessary. F^g. 8. — Blow-pipe of Larrey. Fig- 9- — Three acupuncture needles, of the size commonly used in practice, having separately a round, an annular, and a movable head. Figures 10, 11. — Sutures. a. Interrupted suture. 6. Twisted or hare-lip suture. c. Glover's" or continuous suture. d. Another form of continuous suture, but little used. e. Quilled suture. Figures 12 to 17.— Metallic cauteries. These are formed of steel or copper, and the stem to which they are attached set in a movable handle. F^g. 12. Halbert or hatchet-shaped cautery. The thickness of the blade is shown in profile in the small figure adjoining. The handle, which istoo long for the space in the plate, is broken, or a piece taken out, as it were, at a. Fig. 13. — The three-sided prism of Rust. Hg. 14.— The reed-shaped cautery, (cautere en roseau,) formed like the mouth-piece of some musical instruments. Fig. 15. — The conical cautery. F^g. 16.— The olive-shaped or flat round. Fig. 17.— A modification of the common cylindrical cautery, devised by M. Charriere, for the cauterization of poisoned wounds. SETON.— ISSUE. 27 when the wound is deep to bring the lips extensively in contact, and admits of stronger traction on the threads, as these are pre- vented by their mode of application, from strangulating and cutting the parts. 4. Twisted or hare-lip suture, (fig. 10, 6.)— This is made by means of straight needles or pins, which may be either cylindrical or lance-headed. As they are to be left in the parts, it is ad- visable to have them made of the unoxydizable metals, silver, gold, platina or palladium. But the common sewing needles with a head of wax, the glass-headed pin of the toilet table, or the in- sect pin of the naturalist, answer very well under ordinary circum- stances. If greased at the point they will be found to pass more readily through the "tissues. This form of suture is the only one, the place of which cannot at need be supplied by adhesive straps and bandages. It is employed to fasten down angular flaps in cases where there is a section involving the whole substance of a part which is free on one of its margins, as the lip, the eyelid, or the ear j it is also used in a great variety of plastic and other ope- rations. The lips of the wound being exactly brought together, the operator takes one of the needles between his thumb and fore finger, with its heel resting against the nail of the middle finger, and passes it through both sides of the wound, traversing the tissues from right to left. The point should be entered nearly perpendicularly upon the skin a line and a half to two lines from the margin of the wound; the pin is then to be inclined horizontally and brought out afterwards with the point looking upwards over the end of the left fore finger, which should be placed so as to make pressure against it ; circumscribing in the case of the lip at least two-thirds of its thickness between the skin and mucous mem- brane. The first pin should be pa_ssed near the free border; over the heel of this, a loop of ligature is to be thrown by the assistant and crossed, under the point, so as to keep the surfaces from sepa- rating and in a state of tension. All the pins required are to be passed in a similar manner. The ligature is then to be wound separately round each of the needles in the form of a figure 8, or in a simple fellipsis, according to the will of the surgeon; or a single long ligature, in case of hare-lip, may be employed for the whole, commencing with the upper needle and then passing down to the second or third, finishing the wrapping of each in turn. To prevent the points from irritating the skin, or catching so as to be dragged by accident, they should be snipped off with the cutting pliers; or if the cambric needle be used, snapped between a couple of pairs of forceps. A pledget of linen or a strip of ad- hesive plaster may in addition be laid between the surfaces of the skin and the free ends of the needles. No other dressing is ordi- narily required. VII. OF THE SETON. The seton is employed in nearly the same places and under the same circumstances as the caustic issue. It is not now used so much as in former times. It consists of a suppurating wound with two openings through the skin an inch or more apart, trans- mitting a skein of silk, a piece of tape or gum elastic, or a strip of linen (mesh) with some of the threads removed upon its sides, through the subcutaneous cellular tissue. There are two methods of forming the seton. 1st. As made with the seton needle. (PI. 6, fig. 3, 4.) — A fold of skin is to be pinched up with the thumb and fingers, through the base of which the needle, threaded with the material to be intro- duced and previously covered with cerate, is to be passed. This is the most expeditious method and the one usually practised. 2d. With the bistoury and eyed probe. (PI. 6, fig. 1, 2.) — A fold of skin is to be raised as above described, the upper part of which is to be held by an assistant. The bistoury is pushed through the base of the fold up to the heel, and as it is withdrawn, made to enlarge the orifice to the requisite dimensions. The common eyed probe of the pocket case, threaded like the seton needle, is carried through the track of the wound before the fold of skin is relaxed. The wound is to be simply dressed ; on the back of the compress covering it, the tape or thread is to be folded up and secured with a bandage. By the third or fourth day suppuration is established, and the dressing should be re- moved. The tape is then to be oiled and drawn farther through the wound, and the soiled portion cut away. This process is subsequently to be repeated daily. If a strip of gum elastic or of sheet lead be used, simple washing will suffice to cleanse it, and the necessity of using a long portion, or of cutting away a part from time to time, is obviated. But to the tape or mesh, as more manageable, the author gives the preference. As the tract of the seton becomes indolent, it will be found requisite to smear the tape or mesh occasionally with some stimulating ointment in order to keep up the discharge. VIII. OF THE FORMATION OF AN ISSUE OR FONTANEL. For the purpose of eflfecting protracted counter-irritation at- tended by a discharge of pus, issues were frequently established in former times, and are still occasionally resorted to in chronic affections, especially for those of the bones and joints. They are small ulcers below the surface, kept artificially open by the in- troduction of some foreign bodies, as two or three garden peas, two or three pepper corns, the dried buds of the orange-flower, or a flat piece of wood with a rough surface, all of which require to be changed daily. They may be made in almost any part of the body, where the skin is not closely connected to a bone, a tendon, or a resisting fascia. The places of election, however, are the back- of the neck, the inner side of the insertion of the deltoid, the inner side of the thigh just above the knee joint, the depression between the vastus internus and the sartorius, and the internal surface of the legs between the belly of the gastrocnemius internus and the insertion of the sartorius. They are made either by in- cision or cauterization. By incision. — A fold of skin, of an extent proportioned to the size of the issue desired, is to be raised and divided through by a bistoury passed in at its base, so as to qxpose the subcutaneous cellular tissue. The lips of the wound are to be separated by a firm roll of lint or charpie, and this secured by a compress and roller. At the end of three or four days suppuration is established. The plug is then to be removed, and the dried peas or other foreign substances introduced and held applied by a square piece of adhe- • sive plaster, or if necessary, by a compress and bandage. This me- thod is expeditious and little painful. But there is no loss of sub- 28 ELEMENTARY AND MINOR OPERATIONS. stance in the skin ; and from the strong tendency to cicatrization, it is difficult to keep the ulcer open. The formation of the issue by caustic potash, as described at page 23, is, therefore, the plan more usually followed. IX. MOXA. Any inflammable substance burnt upon the skin for the purpose of effecting its gradual disorganization to more or less extent, is called a moxa. The pain and irritation attending this process increase progressively during the combustion, are felt at greater depth in the neighbouring tissues, and are believed to effect a more powerful derivation where deep-seated parts, as the bones or joints, are affected, than any other mode of counter-irritation, except the actual cautery or heated iron. If carried so far as to completely destroy the skin, the ulcer which follows the separation of the eschar resembles that from the use of caustic potash, and is to be restricted in like manner to certain parts of the body. But when tempered, or limited to the production of an acute glow upon the skin, it is more generally applicable. A variety of substances have been employed. Those commonly used are formed of cot- ton wadding, prepared spunk, cotton, lint or tow, rolled into the form of cylinders, soaked in a solution of chlorate or nitrate of pot- ash and thoroughly dried. The chlorate is preferred to the nitrate as the latter deflagrates as it burns. The cylinders should be from half an inch to an inch in diameter, and tightly sowed in a linen or silken covering, which should be coated with a thick solution of gum Arabic, so as to give them solidity. The cylin- ders are cut in sections of half an inch to three-quarters long, ac- cording to the degree of impression we wish to produce : each of these forms what is called a moxa. (PI. 6, fig. 5, 6.) They are to be moistened with saliva at one extremity and applied upon the skin, lighted at the other. They may be applied through a com- mon pill box, open at both ends, or held with a pair of common dressing forceps, or with the porte-moxa of Larrey. The sur- rounding skin should be protected by a piece of wet cloth, with a hole in the centre for the moxa. If not soaked previously in one of the solutions above mentioned, the combustion will require to be accelerated by blowing upon it with a common blow pipe, or with a pair of small bellows. As the combustion reaches the skin, it becomes exquisitely painful. The skin first reddens, shrivels, becomes then dry and yellow, and is covered with serous vesi- cles, which explode at the conclusion of the operation with a slight noise. The moxa is what is called tempered, when a piece of wetted paper or cloth is interposed between it and the skin. X. ACUPUNCTURATION. This operation consists in the introduction of fine, well-tem- pered sharp-pointed needles, through the integuments and into the subjacent tissues at variable depths. The fine point of the instrument is said to separate, not divide the tissues through which it passes ; it is at least well ascertained, that the puncture is not followed by any serious consequences, and but very slightly painful. Through the muscles, vessels, and even many of the nerves and yisceraj the needles have been passed with impunity. It is a practice borrowed from the Chinese and Japanese, No great value is now attached to it as a remedial measure, in this country or in Europe, though its use has occasionally been at- tended with advantage in neuralgia, chronic rheumatism, indolent tumours, indurated lymphatic glands, etc. It is employed in two ways ; the first consists in the simple use of the needles ; the second in the application of two needles connected by an electric current, [electro-puncture.) Simple acupuncture. — This is made from needles from one to four or five inches long, with round or annular heads, (PI. 6, fig. 9,) to prevent them from slipping below the skin. A handle that can be removed or fastened to the heads at pleasure, facili- tates their introduction. In the east, they are made of fine gold or silver ; but steel, finely tempered so as not to be broken by the action of the muscles, is the material invariably preferred in this country. The needle maybe introduced, as is the custom with the Japanese, by driving it forward with a small mallet; or by the following method, which is decidedly preferable. Having select- ed the point — which should be the seat of the pain or in its im- mediate vicinity — the operator stretches the skin with the fore and middle fingers of the left hand, pierces it perpendicularly with a gentle pressure, and then advances the needle to the desired depth, with a semi-rotatory motion of the head between the thumb and fore finger of the right hand. This process is to be repeated till the requisite number of needles are introduced. Their withdrawal, after they have been left in a sufficient length of time, is to be effected by the same movements, accompanied with slight traction. A drop or two of blood is occasionally seen oozing afterwards from the place of puncture. Care should -be taken to have the needles, before using them, perfectly smooth and free from rust, as otherwise the, introduction is more difficult and painful. For this purpose it is well, according to the advice of Dr. Elliotson, to pass them through an emery bag, both before and after using them. The number of needles employed is varied according to the will of the operator, from one or two to twenty, and there is no general rule in regard to the length of time that they ought to remain applied. The Japanese and Chinese keep them in only while the patient makes thirty inspirations. M. Cloquet and Dr. Elliotson state that they derived most advantage from the method when the needles were kept in for several days; and Professor Bache, who has extensively employed them in chronic rheuma- tism, observes that the more chronic and long-standing the disease, the greater will be the length of time that they should be retained in the tissues. Simple acupuncturation has been made through the coats of the arteries, for the purpose of obliterating their cavities; the needle being allowed to remain three or four days, so as to excite inflam- mation and serve as a mechanical obstacle, upon which the blood may coagulate. The practice, however, is one not to be relied on. Acupuncturation has also been employed with some success by Mr. Lewis and others, for the cure of hydrocele, for the removal of the fluid in anasarca, for oedema of the scrotum, penis, and eye- lids, and in exploring the nature of some deep-seated tumours or abscesses. Electro or galvana-puneture. — The needles for this purpose should have a small ring at the top. (PL 6, fig. 9.) Two of these MEANS OF ARRESTING HEMORRHAGE. 29 should be inserted at the limits of the region through which the electric current is to be passed, and the conducting wires of the two poles of a galvanic pile attached to the rings at their top. A horizontal galvanic pile of small dimensions, is much easier man- aged for this purpose than the vertical pile of Volta or the Ley- den jar. A few pins only should be used at first, and the number gradually augmented as the patient is found able to endure the action of the current. XI. MEANS OF PREVENTING HEMORRHAGE; OR, SURGICAL HEMOSTATICS. I. ON THE MEANS OF PREVENTING HEMORRHAGE, AS APPLIED PREVIOUS TO OPERATIONS. These measures are directed solely upon the large trunks of the arteries, and consist of two kinds, compression or previous liga- ture. The latter, however, is rarely resorted to with this object, and forms of itself an operation apart, which will be treated of under the head of ligature of the vessels. Compression for the purpose of arresting the flow of blood through an artery, must be applied with sufficient force to flatten the vessel, and cause the temporary obliteration of its cavity. It is to be carefully kept up during the whole course of the opera- tion. The vessel should be compressed at some part of its course, where it may be felt with pressure of the finger, and where it is at the same time placed over a bone or some firm fibrous structure that may serve as a point of resistance. It is to be made by the direct application of the hand, or by the medium of instruments. or THE MODE OF COMPRESSION IN GENERAL. WITH THE HAND. 1. With the thumb and fingers. — It maybe made with the point of the thumb alone, pressed downwards; with the balls of the two thumbs applied one above the other across the course of the artery ; or with the ends of the fingers of one or both hands placed parallel with the track of the vessel. Either one of these modes is rendered peculiarly applicable in certain situations by the anatomical position of the vessel. Thus the subclavian, deeply situated as it crosses the first rib, and accessible only through a narrow space, can be reached best with the end of the thumb, with which it may be compressed with considerable precision. The circulation of the femoral artery may also be controlled by pressure with the end of the thumb immediately over the pubic bone ; but immediately below the pubis it is better accomplished with the balls of the two thumbs, either hand taking a firm point of support by grasping the opposite surfaces of the thigh. On the other hand, the great arteries of the arm and thigh, which are placed at some distance from the bone, and disposed to roll under compression by the two first processes, may be obliterated more securely with the ends of the fingers of one hand placed in the direction of their length, while the palm grasps the mass of neigh- bouring muscles, and the thumb gets a resisting hold upon the surface of the bone, or by sinking itself into the flesh (PI. 7, fig. 3). From the difference in their length, the fingers, when they 8 act with force suflScient, as in the thigh, for instance, to overcome the resistance of the tissues, close on the artery in a curved line, so that the obliteration of the vessel is begun by the first finger, continued by the second, and completed by the third. If the fingers becoine fatigued during the continuance of the operation, the individual making the compression, should, without waiting till the hand begins to tremble so as to render the pressure un- certain, sustain it with the fingers of the other. One hand may even be readily substituted for the other, without interrupting the compression, by placing the ends of the fingers of the second hand along the track of the vessel, just above those of the hand first ap- plied, so that the new pressure is made before the first is relaxed ; the second hand sliding gradually into the place of the first. In the same way one assistant may be substituted for another, in case the lumbar muscles of the first become greatly fatigued in the con- strained position which he is obliged to assume. In making the compression, no more force should be used than is just sufficient to completely efface the calibre of the artery ; the requisite amount may be ascertained, according to the directions of Lisfranc, by placing a finger upon one of the larger branches of the main trunk. The pulsation in this will be found gradually to disappear, as the pressure with the fingers is augmented above, and as soon as it ceases to be felt, the temporary obliteration of the vessel may be considered perfect. Considerable coolness and intelligence are required on the part of the assistant in this simple manoeuvre with the hand, and it is far belter, especially if the operation is likely to be protracted, to resort to the tourniquet, which answers perfectly well in all cases in which the operation is not done so high on the limb as to forbid its application. 2. The whole hand is sometimes employed in cases of emer- gency, for the compression of the abdominal aorta and iliac ves- sels. 3. With the hand pad. (PI. 7, fig. 5.) — The hand pad is pressed downward upon the artery, so as to act precisely like the end of the thumb, to which, as not endowed with sensa- tion, it is very inferior. It is, therefore, rarely employed. It has been recommended in cases where the subclavian artery is unusually deep, and the separation between the scaleni very narrow. It is seldom, however, even under these circumstances, that the compression cannot be better and more safely accom- plished with the thumb or the end of the middle finger. The shape of the hand pad is to be varied according to the form of the part through which it has to act. It should be long and narrow' for the subclavian, large and broad for the aorta, and attached to a short handle to render it more manageable, like that of the letter seal, a door key, or a boot hook, which, when padded at the end, are occasionally substituted for it. MECHANICAL COMPRESSION, The instruments with which mechanical compression of the vessels is made, consist of the garat, the pad with a strap and buckle, the tourniquet, and the compressor of Dupuytren. 4. The garot. (PI. 7, fig. 9.) — This was devised by Morel in 1674, as a substitute for the circular bandages or ligatures em- ployed previous to that period, for the purpose^ of arresting hemor- rhage. As first used it consisted merely of a band or handker^ 30 ELEMENTARY AND MINOR OPERATIONS. chief twisted tight with a stick. This simple contrirance, from the convenience of its application on the field of battle, received the name of the field tourniquet. The garot, as it has been latterly modified, consists of a pad to be placed on the skin above the artery, presenting on its free surface a ring for the passage of the web or strap. On the side opposite the pad is applied a compress, or what is better, a concave piece of horn or metal, upon which the strap is to be firmly twisted with a stick, and the latter given in charge of an assistant, who is to diminish or increase the pressure according to the direction of the surgeon. The compression of the garot extends to the whole substance of the limb — arteries, veins, and nerves — and cannot, therefore, be safely kept up but for a short space of time. The advantage which it offers, of being constructed of the first things at hand, and at any time or place, renders it occasionally highly useful. It cannot, however, be gradually relaxed and tightened with precision like the proper tourniquet, which is always to be preferred. 5. Detached pad, (pad of Charriere,) with buckle teeth on its lateral margins, to which the two ends of the strap are attached. (PI. 7, fig. 5.) — This has but recently been introduced into practice, and is employed for the compression of superficial arteries of medium size. The pad is attached to a plate, and resembles somewhat the lower frame of the French tourniquet, (fig. 4,) and is forced down over the artery, by fastening the two ends of the PLATE VIL— COMPRESSION OF THE ARTERIES. OF THE TEMPORAL AND SUBCLAVIAN. Fig. 1. (A). Compression of the temporal artery, with the pad of M. Charriere, (see fig. 5.) The pad is applied in front of the ear, above the zygomatic arch, and is sustained by a simple strap, the ends of which are fastened upon the two rows of buckle teeth. The double compress under the jaw protects the skin from injury. (B). Compression of the subclavian with the newly devised instrument of Bourgery. This is composed of four principal parts. 1st. A broad rectangular pad (A) screwed to a steel plate, which, though not visible in the drawing, is fastened to a second plate (B). This pad is applied acrpss the attachment of the pectoralis major below the clavicle, which serves as a point of support to it. One end of the pad is thick, so as to fill up the depression below the coracoid process, while the other is thinner and rests on the sterno-clavicular articulation. By reversing the margins, the same pad may be applied for compression of the artery of the other side. 2d. A second plate of steel (B), of the same form as the preceding, upon which it is exactly fitted. They are fastened together by two small pivot keys (6), which enter into corresponding mortises in the plate (A). This second plate serves as a fixed point for the rest of the apparatus. At its ends are two copper pins for the attachment of the straps. 3d. A movable steel plate (C) fastened by a screw to the second plate, capable of being turned for a quarter of a circle to the right or left, so as to suit the obliquity of either clavicle. It serves as a fixed point for the lever of the movable pad (G), with which the compression is made. Above it is attached by a hinge joint (d) on each side with another plate of an elliptical or horse-shoe shape (D), which is thus made mobile so as to adapt itself to the projection of the trapezius. This elliptical plate is padded and provided with two pins (c), for the attachment of the posterior straps. The hollow within it is occupied by the artery pad (G) 4th. The last part of the apparatus is the elbowed lever (E), which supports the artery pad. The base of the upnght part of the lever is pierced with an opening, and is fastened by a screw (/) to plate (C); at its upper part It IS attached by a bullet joint (g) to the horizontal arm (F) of the lever, so as to allow tLe latter to be the^ollen-"^ ^7 . """^ ^"^ ^^^ " " *^' ^°"° "^"^'^ ^^°"g^*^^ --' *° P-^^rate readily between horirontal lever "' ' "'' " " ''''"''^* '""*'°"^ ^" consequence of its mode of attachment to the ''tstrrrlT?'^'^"'^ "/'•'' ''T''''' ''' P°^^^^°" ^y *^^ body bandage (H), and the anterior and ?he tven r 'i^ Z f ^^ . ' T^ '' '°T, "''' *'^ """ ^'^ ^^^ '''^'^ ^^^ -^^ - -" eases, according to the mventor, be made to act so as to arrest safely the circulation in the vessel. OF THE CAROTID AND BRACHIAL. ""''l^I^e'^y'::^:!^^^^^^^ ' P'^^ ''' ^^'^^i- °f *h^ n-k; and is so well shown as not to clTessor rDupuy^Z ' ' ''' ""' ^'^ ""^'^'^ °' ^'^ ^°™ °^ ^^^ ^^' -^ ^'^"^^ j-^' -^1- ^° '^^ ""'' g;^v?:rtt"v:{s?bet"'''"t:T' ""i" ? ^'"^"^ '^^^^■^ ^^^ ^^^i"- ^^^ ^^^-^ -« -- sunk in the fhu:b^^e::':u;;::;;rt^e:p^^^^^^^^^^^ -^^ ^''' iJsTZlnZf- t ir -^-fr'fr ? ''''''' '^ ^'^ ^^^^^ '^ ^-^ ^^-" - -^^^ ^y t^e common ±.nglish tourmquet , the instrument to which preference is usually given in this country. A thick compress or MEANS OF ARRESTING HEMORRHAGE. 31 strap after they have passed round the limb, upon the rows of buckle teeth, with which its raised lateral margins are provided. The general compression of the limb may be obviated at will, by placing a thick compress under the pad, and another on the side of the limb opposite. I have in some instances employed this method with advantage ; but as a general means, the pressure can- not be made sufficiently firm or certain to be relied on. 6. The common tourniquet. (PI. 7, fig. 6.) — This most useful instrument was invented by Petit, and is so well known as not to need particular description. Several modifications have been made in the form of the instrument, as will be seen by reference to PL 7, but the rules for its application are much the same in all. When the instrument is applied, the frames should be put in contact, before the strap is buckled round the limb, as the tight- ening of the strap, ia order to compress the vessel, is made by turning this screw, so as to separate the upper plate from the lower. The form of the tourniquet in common use in this country and Great Britain, is represented at PL 7, fig. 6, and fig. 8. In ap- plying this instrument it is not a matter of much moment, whether the operator places the frames, or the free pad attached to the strap directly over the vessel. In either case, a stout compress or roller is to be laid immediately on the surface above the artery. In general, however, it will be found preferable to buckle the pad over the vessel, and keep the frames on the upper surface of the limb, so as to prevent their position becoming deranged by their weight. In some of the recent modifications of the French instrument, the lower plate of the tourniquet is forced downward by the screw, and should, therefore, be placed immediately above the vessel. The tourniquet, though far more manageable, presents some of the disadvantages of thegarot, in producing a general constriction of the limb, so as to dam up some blood in the veins, which is necessarily lost during amputation ; and produces, if too long con- tinued, engorgement and even gangrene of the parts below. It is, however, well suited to effect the temporary compression re- quired in amputation and other processes involving the large ves- roller is observed lying over the artery, upon which it has been pressed down by the tightening of the strap, caused by the separation of the plates in turning the screw. Fig. 9. — Compression with the garot or field tourniquet is seen in fig. 9. A small compress rolled tight (a), is applied over the vessel [b). A transverse bandage is applied to hold the compress, and twisted tight with the stick (e). The stick is secured with a cord, as at (d), to prevent its turning ; (e) is a plate of wood, horn, a piece of card, or some similar substance, introduced below, before the tightening of the bandage, to protect the skin. OF THE FEMORAL ARTERY. Pig, 4. — The thigh is semiflexed on a pillow, and the artery compressed both at its upper and middle part. Compression at the pubis, with the modified tourniquet of Petit. This instrument is preferred to all others by the French surgeons. Unlike the English instrument, it has an artery pad (a), sewed upon the lower plate (6). This is moved by a screw (c), and kept straight in its descent upon the artery by two conducting rods (d d), which pass through another smaller metallic plate (e), that supports the compressing strap {g g). On the opposite side of the limb is a counter pad, supported on a plate not seen in the drawing. The strap envelops the whole apparatus, by passing longitudinally over the upper plate and over that of the opposing pad. The strap is split where it passes over the first, to transmit the screw and the two conducting rods, and its two ends are fastened by a buckle (z) upon the side of the limb. At (A), a sort of staple is seen by which the pad is kept from slipping off the upper plate. The instrument is here seen applied. The pad (a) rests upon the artery over the pubis. The straps pass under the folds of the buttocks, and compresses are placed below them to protect the skin. As the pad, at its application upon this part of the limb, has a tendency to rock over upon the thigh, it is secured by a long com- press (B), which is attached to a body bandage (&). Compression is made by turning the screw, so as to force the pad towards the vessel. jFig.T. — Compression upon the middle of the thigh with the compressor of Dupuytren. This instrument is composed of two elliptical metallic bars, which slide over each other so as to lengthen or shorten it. Near each end there is a strong hinge joint. Its anterior end sustains the screw (G), the two conducting rods (H), and the movable artery pad (I) with which the artery is compressed. Its posterior part is constructed precisely as the posterior portion of the instrument shown at fig. 2. The counter pad (F) supported on the arm (E) is applied over the muscles at the back part of the thigh. The manner in which the two sliding bars are joined together and rendered fixed by a screw, is shown at (D D, fig. 2). Fig. 5. The artery pad of Charriere. The pad is attached to a metallic plate, upon the upper part of which is placed a small saddle of the same material. Between the two branches at either end of this saddle are the rows of buckle teeth, and a sliding roller over which the strap plays. One end of the strap is secured in the drawing to a row of these teeth, the other, having formed a loop as in embracing the limb, is passed over the roller, and is ready to be drawn tight and secured on the second range of teeth. Fig. 6. The ordimry English tourniquet. The two plates have been separated by turning the screw, in order to show the manner in which the strap is connected with them. 32 ELEMENTARY AND MINOR OPERATIONS. sels, when the operation is clone sufficiently far from the trunk to leave room for its application. The French instrument is shown applied at PI. 7, fig. 4, on the upper part of the thigh ; the English at PI. 7, fig. 8, and at PI. 43, fig. 6, where it is made to compress the artery of the thigh in a position that will be found to answer in amputations of the leg. When we desire to daily check for some hours the circulation of the vessel above an aneurisraal tumour, for the purpose of ef- fecting the coagulation of the blood and the gradual obliteration of the sac — a process to be preferred to the ligature of the vessels when an aneurisraal diathesis is known to exist — the following instrument is entitled to a decided preference over the tourniquet, as it makes positive pressure upon the limb only at two opposite points. The same instrument, though capable of serving in cases of amputation, possesses in that respect no particular advantage over the tourniquet, and is more liable to displacement. 7. Compressor of Dupuytren. (PI. 7, fig. 7.) — This instrument consists of two steel plates, from one to two fingers broad, which are curved on their flat and joined at their middle, so as to slide over each other, in order to allow it to be lengthened or shortened at will. To the ends of these plates two others are attached by a joint which supports the pads, the one movable, the other fixed, the whole instrument being curved so as to form when complete the two-thirds of a circle. When the compressor is applied, the pads rest upon the opposite sides of the limb ; the movable one is placed over the artery, and is made to descend by turning a screw, so as to compress the vessel. The construction and mode of ap- plying this instrument will be best understood by reference to the plate. COMPRESSION OF THE INDIVIDUAL ARTERIES. Of those of the face and cranium. — The compression of these is seldom required except as a means of arresting traumatic hemor- rhage. When there is no urgent reason to the contrary, it is better to resort to this measure merely for the purpose of temporarily checking the hemorrhage while the bleeding orifice can be properly secured by a ligature. 1. Of the tem.poral artery. — This is easily compressed against the cranial bones, in any part of its course above the zygomatic arch. For the main trunk, the detached pad to which the two ends of the strap are buckled, described at page 30, and shown in its application just in front of the ear at PI. 7, fig. 1, is the most appropriate. A graduated compress secured with the nodose or knotted bandage, suits very well to arrest the hemorrhage from one of its branches, and may be made to serve in the absence of a more fitting apparatus for compression of the main trunk. 2. The frontal and infra-orhital arteries may be compressed by similar means, where they come out from the orifices in the bones to take a position under the skin. The graduated compress for the infra-orbital should be placed nearly vertically, in the direction of a line from the external canthus of the eye to the ala of the nose of the same side— and for the frontal laid just above the super- ciliary notch. 3. 1\e facial artery may be compressed just be- low the jaw and in front of the masseter with the finger, or by a graduated compress, secured in one of the modes just mentioned. 4. In injuries of the occipital or posterior auricular arteries, it is best to apply two graduated compresses, one above and one below the lips of the wound. Arteries of the neck. — In consequence of the mobility and great sensitiveness of the parts in front of the neck, the carotid is the only vessel of this region which it is possible to subject to com- pression. The ligature of this vessel would, however, except in cases where its temporary occlusion only was required, be a pre- ferable, as it would be a more certain, and even in the end, a less distressing or painful proceeding. The compression may be made with the fingers, or with the proper compressor devised by Bour» gery and Malapert, and shown in its application at fig. 2. The freedom of the anastomosis between the branches of the two carotids is so great as to render either the ligature or compression of the trunk of a single side of but little avail in erectile and other vascular tumours of the neck and head. When compression is resorted to, it has been advised to make it upon both trunks at the same time. For this purpose an instrument has been contrived with two pads, each of which is to be depressed with a screw between the edge of the sterno-cleido-mastoid, and the lower bor- der of the larynx. The compression should, however, be made gradually, giving time for the vertebral arteries to dilate, in order to avoid the danger that might arise from suddenly interrupting the columns of blood sent to the brain by the two great carotid trunks. Arteries of the arm. — The subclavian artery, as has been before observed during an operation involving the great branches round the shoulder joint, may be temporarily compressed by the thumb and finger inserted endwise between the scaleni muscles, as di- rected by Camper. For the permanent compression of the artery, in the cure of axillary aneurism, various forms of the tourniquet have been devised. No instrument, however, appears so well calculated to accomplish its object as the one lately devised by M. Bourgery, and shown in position, PI. 7, fig. 1. The axillary artery is only susceptible of compression, at its passage over the second and third ribs. But at this place, from the thickness of the two pectoral muscles which cross in front of the vessel, it is impossible to command the circulation completely except in very thin subjects. The compression may be made with the ends of the fingers, as shown at PL 7, with the knuckle or with the hand pad. To facilitate the compression, the pectoral muscles should be relaxed by bringing them to the side of the chest, placing the shoulder in the state of adduction. The compressor invented by Dalh for this artery, is not to be relied on. The humeral artery may be readily compressed at its upper part, just below the tendon of the pectoralis major, and between the biceps and coraco-brachialis, either vnth the fingers or one of the several instruments above mentioned; though from the con- tiguity of the nerves, that with the fingers is found least painful. In any other part of its course no difficulty attends the compres- sion ; the thumb or the fingers usually sufficing as well as any of the more complicated instruments. When at liberty to choose, the junction of the inferior with the middle third of the arm, is the most favourable site, as the median nerve is here found running in- wards so as to separate itself from the artery. The radial and ulnar arteries may be compressed against the corresponding bone, in any part of the inferior third of the arm, temporarily with the fingers, or permanently with the free pad and strap (described page 30 ;) or, if MEANS OF PREVENTING HEMORRHAGE. 33 at hand, the more complicated compressors of Dupuytren, of a suitable size, may be used. Arteries of the lower extremity. — The femoral artery may be temporarily obstructed, at the upper or lower surface of the os pubis, -with the end of a single thumb, or the flat surfaces of both, as observed at page 29. The tourniquet may also be applied in the same location, provided it be placed as represented in plate 7, fig. 4, with the strap passed under the fold of the buttocks, and the skin protected with double compresses behind and upon the sides, so as to admit of the strap being tightly drawn, and the frames of the tourniquet raised up upon the pubis, by a compress fastened to a body bandage. In the upper or middle third of the thigh, or in the popliteal region, compression is easily effected with the ordinary tourniquet or the compressor of Dupuytren. Compression of the artery at the latter point rather than in its course along the thigh is preferred by Professor Ferguson in am- putation of the leg, as being attended by a smaller loss of venous blood, in consequence of the less capacity of the veins below the place of constriction. The posterior tibial artery is accessible to pressure at two points: at the inferior extremity of the leg, between the tendo- achilles and the flexor tendons above the ankle ; and between the internal ankle bone and the heel, in its course along the sinuosity of the OS calcis. The anterior tibial artery may be readily compressed over the middle of the front surface of the ankle joint where it can be felt pulsating. The graduated compress secured with the pad and buckled strap answers well for this object. Arteries of the trunk. — The external iliac artery may be com- pressed for a brief space of time with the hand pad or the back of the fist, against the upper margin of the pelvis, provided the abdominal muscles be placed in a state of relaxation. Little advantage, however, is likely to be derived from this measure, except to gain time by the temporary control of the circulation for the application of a ligature, in cases of accidental injury of the artery or its branches, near Poupart's ligament. The aorta, as has been before observed, may be compressed in the lumbar region, provided the muscles of the abdomen be thoroughly relaxed, by a mutual flexion of the trunk and pelvis. The back of the hand placed crosswise, and pressed down with moderate force, or a large hand pad, may suffice for the purpose. The application of the latter is occasionally made in the operation for ligature of the iliac arteries, though in the hands of a skilful surgeon it may very safely be dispensed with. When employed for the purpose of arresting uterine hemorrhage after accouchement, six or eight minutes compression, according to Trehan, Baude- locque, and others, has been sufficient to permit the uterus to assume its contracted state, and thus present the natural obstacle to the recurrence of the hemorrhage. The hand pad should be applied across the linea alba two inches above the umbiHcus, and ■with its lower edge a little inclined downward, n. MEANS OF ABEESTING HEMORRHAGE DURING OPERATIONS. ' Measures for this purpose are rendered necessary, when from the situation of the part, as in operations upon the root of the neck, shoulder, or hip joint, it is difficult to compress the principal 9 trunks ; or in other cases where the means of compression are liable to become temporarily displaced. The bleeding may take place either from the arteries or veins. As the peculiar applica- tion of these measures will be noted in reference to each important operation, it is not necessary to do more in this place than briefly enumerate them. Arterial hemorrhage. — There are three different processes, by which this may be arrested during the operation. The 1st process consists in a direct compression of each bleed- ing orifice with the end of a finger. This is done usually by one or more assistants, and may, according to circumstances, be main- tained to the end of the operation, — until the compression has been re-estabhshed on the main trunk if it had previously become displaced, — or until a ligature may be got ready to tie the opened vessel. The 2d process is a mediate or indirect compression of the divided vessels, and is principally used in flap amputations about the joints, where the fingers of an assistant can follow the knife so as to grasp between them and the thumb the vessels in the whole thickness of the flap. It is employed also in operations upon free margins, like the lip, nose, and ear, which are held by both sur- faces in a similar manner. The 3d process consists in a previous ligature of the main trunk, as in Larrey's method for amputation at the hip joint. ^ Venous hemorrhage. — This arises from two causes: 1st, from the compression of the limb necessary to flatten the artery, which prevents the ascent of the blood through the veins. In this case the bleeding ceases of itself, as soon as the compressing force is removed. 2. From some impediment to the circulation of the blood through the lungs, dependent upon the cries and efforts of the patient — met with commonly only in operations near the root of the neck, or the top of the chest. When it arises from this cause it suffices usually, in order to arrest the hemorrhage, to cause the patient to make several long inspirations in quick succession. It is important, however, in operations on the root of the neck, to make pressure when it is possible upon the vein before it is cut, especially if found in the midst of hardened tissues, in order to prevent the passing of air into the course of the circulation. If the bleeding should not cease, pressure may be made on the orifices for some minutes with the finger ; this, by causing a co- agulation of the blood, may arrest the flow. As a last resort, each vein may be tied as an artery, though this measure is always attended with more or less risk of phlebitis. The same plans are to be pursued for the purpose of arresting the bleeding from the veins after operations. III. MEANS OF ARRESTING ARTERIAL HEMORRHAGE AFTER OPERATIONS. Direct ligature of the open mouths of the divided vessels, aided by compression of the cutaneous surfaces with adhesive straps, compresses and bandages, are the means ordinarily relied on for this purpose. Various other ingenious measures have been de- vised, some of which may occasionally be practised with advan- tage. These will be noticed in succession. By ligature. — This process is applicable to arteries of all sizes, from those of the largest calibre, to such as emit only a feeble jet 34 ELEMENTARY AND MINOR OPERATIONS. of blood. Its first effect is to close immediately the opening of the divided vessel, put an instant stop to the bleeding, and cause a stagnation of the blood between the place at which it is applied, and the first collateral branch of importance given off' by the vessel above. Subsequently the coagulum becomes absorbed, and its place is supplied by the efi"usion of lymph from the sides of the lining membrane, which gradually obliterates the cavity and con- verts the end of the vessel into a cord ; the ligature is finally loosened by the division of the part within its grasp, and causes an effusion of lymph on the outer side of the vessel, which attaches it firmly to the surrounding parts. Material employed. — A single silk or hempen thread sufficiently large and strong, to admit merely of being drawn tight enough to compress firmly the coats of the vessels, or cut the internal and middle coats, is that commonly used, and in the author's opinion entitled to the most decided preference. A ligature too large in proportion to the size of the vessel, does not close it effectually, and is more liable to slip ; and provided it should not slip, does not cut through the parts embraced in the loop, till long after the vessel is thorou_ghly obliterated, when, from its presence being no longer needed, it becomes a source of useless irritation. On the other hand a ligature relatively too small, by embracing but a narrow line of the vessel, might detach itself too early so as to occasion secondary hemorrhage. For the largest class of vessels usually operated on, such as the femoral, brachial, or axillary, a single strand of the saddler's sewing silk will be found of the" proper size. For the larger trunks, such as the innominata, the iliacs, or the aorta, a round cord of greater dimensions is con- sidered more appropriate. Various other kinds of material have been employed. Animal ligatures, made of various substances, but especially of kid skin rolled into small cords, were employed by Physick, Dorsey, and Jamieson, under the belief that the knot would soften, and become absorbed after it had been applied a sufficient length of time to obliterate the vessel, so as to offer no obstacle to closing of the wound by first intention. Dr. Paul Eve, Prof, of Surgery in the Medical College of Georgia, has employed with the same views, fibres from the sinews of the deer. Experiments with the metallic ligature have also been successfully made upon the arteries of the inferior animals.* The instruments required in the application of the ligature after operations, consists of a tenaculum or hook, and a pair of dissecting or proper catch artery forceps. The tenaculum suiting best usually for the smaller branches, the orifices of which are not very obvious on the bleeding surface, and have to be taken up with some of the surrounding cellular tissue or muscular fibres. The forceps answers for the larger vessels, the mouths of which are usually conspicuous, and into each of which one point of the instrument can be introduced so as to seize the vessel firmly and draw it out from the nerves and veins that usually accompany it. In parts which are inflamed, the structure of the artery is sometimes found so soft, and occasionally even its investing sheath, as to cut across in the closing of the knot. The mediate ligature, as it is called, is then to be applied in the following manner: a thread is to be armed with a curved needle at each end ; one of these needles is passed in a semicircle through the tissues at a little distance from ■ Vide paper, by Dr. Levert, in the Amer. Journ. Med. Sciences for 1839. the artery, and the second in a similar manner on the other side of the vessel, coming out near the point where the first entered. The thread thus passed is to be tied on the parts which it embraces, and the bleeding orifice will be found inclosed. Care should be taken, however, to avoid including any nerves in the loop. The same results I occasionally obtain in a more expeditious manner by raising the tissues on either side of the vessel with a couple of tenacula, while an assistant throws a ligature round and ties the raised part firmly below. The mediate ligature is also applicable in cases where after the arteries are tied a free capillary oozing con- tinues from a part of the surface of the wound, so as to be likely to fill it with blood after the application of the_compressing bandage. One tail of each ligature is to be cut off" near the knot, and the other brought on between the lips of the wound ; the whole are then to be covered by a greased compress, and secured by the dress- ings so as to prevent their being unnecessarily disturbed. The ligature is to be left as a general rule till it becomes spontaneously loosened, and can be removed by a slight pull upon the free end. The length of time required for its separation will depend upon the size of the vessel. If any fibrous or other resisting tissue has been included in the loop, the time will be longer in proportion, and it becomes sometimes necessary to hasten its separation by slightly pulling or firmly twisting the thread from day to day. Jones and Travers, in their experiments upon animals, found the temporary application of a ligature sufficient to effectually close the artery. Twelve, twenty-four, or at most fifty hours, according to the latter surgeon, causes an obliteration sufficiently solid to admit of the division of the knot and the removal of the ligature. But there is no object likely to be gained by the removal of a ligature at this early period, that would counterbalance the risk of hemor- rhage, to which, to a greater or less extent, it certainly exposes the patient. Occasionally we find the large artery after amputation so ossi- fied in its structure, as not to close without crushing under the loop. Under such circumstances I have succeeded satisfactorily by plugging the orifice with a piece of linen compress and tying the vessel over it; when the ligature becomes detached it will bring away the plug. Professor Miitter has succeeded in nearly a similar way, by plugging the orifice with a portion of muscle from the detached limb. If the orifice of the bleeding artery is found in the substance of the divided bone, the hemorrhage may be eflTectually checked by plugging it with a piece of wax or soft wood. IV. MEANS WHICH HAVE BEEN APPLIED TO THE ARTERIES OF SMALL AND MEDIUM SIZE ONLY. 1st. Cauterization. — The eschar produced by the hot iron forms a sort of impermeable plug, adherent to the tissues, and may, as has been before observed, be eminently useful in arresting hemor- rhage from the smaller vessels. It is applied in cases of bleeding — from the surface of a bone, from the ranina artery, from the branches of the internal maxillary after operations upon the face, or in cases where bleeding follows the removal of fungous, erectile, or cancerous tumours ; or where the coats of the arteries are so softened by inflammation as to tear under the thread, and when the mediate ligature is found unavailing to check the flow. For MEANS OF PREVENTING HEMORRHAGE. 35 an artery of medium size, as the radial or anterior tibial, it is ne- cessary to repeat two or three times in succession the application of the iron, in order to form a plug sufficiently firm to arrest the blood during the period required for the obliteration of the cavity by adhesive inflammation. 2. By tearing or rupture, — It is well known that where arteries of considerable size are torn off by mechanical force, as in the lacerated wounds produced by ma- chinery, but little bleeding follows. This is OM'ing to the external coat being drawn out into the form of a cone, and forming when it snaps several spiral turns, which offer resistance to the passage of the blood, while the two inner coats, broken at different heights, curl inwards so as to form little septa, between which the blood forms itself into a clot. This process is occasionally imitated by surgeons in the tearing out of large tumours from their beds in the cellular and vascular spaces, after they have been exposed by a superficial incision. In this way, tumours of great size have been removed with but little hemorrhage. 3. Pinching or mashing the walls of a vessel for a little distance from its bleeding orifice with a pair of toothed forceps, causes in a similar manner the laceration and shriveling of the two inner coats. This process is found of useful application in many plastic and other operations, when it is desirable to avoid the irritation arising from the presence of the ligature. 4. Inversion with rupture of the two internal coats. — This is effected by Amussat by seizing the artery between two pairs of forceps, one of which is to be placed transversely and the other applied lower down in the direction of the vessel, as shown at PL 5, fig. 5. With the lower pair of forceps, the two inner coats are ruptured, and the fragments, pressed or stuffed upwards as it were, into the cavity of the vessel. It is a process, however, deserving of but little reliance. 5. Torsion. — This may be em- ployed on arteries of small calibre with far greater prospect of success. Process of Amussat. (PI. 5, fig. 7.) — The artery is to be isolated and drawn out so as to expose it for half an inch above the free surface of the wound. With the narrow round pointed forceps it is then to be seized transversely on a level with the wound and mashed so as to rupture its two inner coats, while the proper torsion forceps are applied transversely on the free end of the vessel to hold it drawn out. With the latter a half turn of the vessel is given so as to twist it on the first pair of forceps which holds it tight. The torsion forceps without loosening its hold is then to be brought down in the direction of the vessel, and the artery twisted upon its axis from three to eight times, according to its size. The upper pair of forceps is then to be removed, and the operation is completed by sinking the twisted end of the vessel into the flesh with the other pair. Process of Fricke. (PI. 5, fig. 8.) — This is much more simple than the above. It consists in isolating the artery so as to expose half an inch or more of the end by pushing back the tissues which cover it, in order to grasp it with the thumb and fore finger of the left hand. The end is then to be seized with a pair of forceps and twirled eight or nine times completely round. 6. The Seton. (PI. 5, fig. 11.) — To complete the description of these various processes, which we owe to the ingenuity and the desire to originate something novel on the part of various surgeons, it may be necessary to mention the following. It has been proposed to make two openings in the side of the vessel just above its open mouth ; the free end of the vessel is then to be folded and pushed into the cavity with a pair of deli- cate forceps, and made to protrude on each side through the slits. It is a process long and diflScult, and, as it could only be per- formed on a vessel of large calibre, deserving of no confidence. Several of the various processes above detailed for arresting hemorrhage after operations, may be found occasionally useful in practice ; but the surgeon who would wish to leave his patient with the nearly positive certainty that he will not be troubled with secondary hemorrhage, should tie the vessels. In regard to the use of refrigerants, astringents, styptics, absorbents and cau- terizing substances for the arrestation of capillary bleeding, the reader is referred to the usual treatises on surgery. PART SECOND. GENERAL OPEEATIONS: OR THOSE PRACTISED WITH REFERENCE TO ONE OR MORE PARTICULAR TISSUES. UNDER THIS GENERAX HEAD ARE CONSIDERED: 1. THE OPERATIONS WHICH ARE PRACTISED UPON THE VEINS; 3. THOSE FOR LIGATURE OF THE TRUNKS OF THE ARTERIES; 3. THOSE FOR DISEASES OF THE BONES AND JOINTS; AND, 4. AMPUTATION OP THE LIMBS. I. OPERATIONS UPON THE VEINS. The operations that are performed upon the veins consist of those for phlebotomy, which hare already been described ; those for the transfusion of blood ; and of various processes for the cure of varicose veins, and the troublesome ulcers to which these affec- tions give rise. TRANSFUSION OF BLOOD. The wound of an artery, the rupture of an aneurismal tumour, and various other causes, may give rise to such sudden and ex- cessive loss of blood, as to leave the heart without a supply of fluid sufficient to maintain it in proper action. Under such cir- cumstances, it has been proposed to make a transference of blood from the system of another individual into that of the patient. This custom, which was formerly much in vogue, had until lately been completely abandoned. The favourable results obtained by its experimental employment on animals, and the benefit arising in some cases from its use on the human subject, render it proper that the processes for its performance should be briefly mentioned. Operation. — The instruments usually employed consist in the ordinary ligature for venesection, a scalpel, a thumb lancet, a pair of forceps, and a small metallic syringe, perfectly clean and fur- nished with a shifting tube or pipe. The orifice of the tube which receives the nozzle of the syringe should be large, and to make the operation more rapid, the parts should be made to fit tight without screwing. Having all the apparatus prepared and at hand, a ligature as for phlebotomy is applied both upon the arm of the patient and the individual from whom the blood is to be taken. The largest superficial vein found in the bend of the elbow is to be exposed on the patient by a longitudinal incision isolated by careful dissection, and raised upon a probe. At the upper and lower part of the wound the vein should be compressed by an assistant, while the surgeon opens it in the middle by a lon- gitudinal incision : the pressure at the upper part is for the pur- pose of preventing air from entering the circulation, and that at the lower of avoiding any effusion of blood. Into the opening of the vein, it is advised to insinuate next the small end of the metallic shifting tube, the larger end of which is prepared to receive the nozzle of the syringe; both instruments being raised to near blood heat, by having been previously placed in water of the proper temperature. The ligature on the arm of the patient is then to be removed ; the pressure being still kept up with the fingers of the assistant. The tube in the vein is then ready to receive the pipe of the syringe, when the latter has been charged with blood from the veins of the other individual. A better process, inasmuch as it would be less likely to injure the coats of the vein, and more effectually obviate the possibility of any introduction of air, would, as it appears to me, be the fol- lowing : Take a caoutchouc tube, one end of which shall by trial be found to enter the orifice of the vein, attach to its larger end a metallic pipe that may in a moment be affixed to the nozzle of the syringe, to which it should closely and securely fit. Then withdrawing the piston of the syringe, (this instrument having been previously raised to the proper temperature,) receive into its cavity about four ounces of blood taken in full stream from the arm of the healthy individual. The operator then adjusts the piston, attaches quickly the metallic extremity of the caoutchouc tube to the nozzle of the syringe, holds the instrument with the OPERATIONS UPON THE BLOOD-VESSELS. 37 handle downwards till by pressing up the piston he expels all the air from its cavity, and finds the fluid appear at the mouth of the caoutchouc tube. The instrument is then brought horizontal, and the end of the flexible tube insinuated into the openiiig of the vein, and carried on, above the upper point at which the vessel is com- pressed ; the assistant shifting his finger so as to renew the com- pression upon the vein and tube. The operator then injects the blood gently into the vein, so as to avoid any sudden shock as it reaches the heart, an assistant at the same time making gentle friction with the finger towards the armpit along the course of the vessels. The process thus described in detail to render it intelli- gible, should be executed without a moment's loss of time, lest the blood should chill or coagulate in its transit. It is necessary to warm the syringe as above directed, but care must also be observed that it does not much transcend the proper temperature, as the excessive heat might curdle the serum. Another danger to guard against is the introduction of air, as this in all probability would be attended with fatal consequences. This accident has not, however, taken place in any of the cases reported, and may be readily obviated by observing the precautions mentioned. As a further measure of protection, and especially if there was any dribbling of blood from the end of the caoutchouc tube, this might be flattened by pressure between the thumb and fore finger, and thus inserted into the vein. The introduction of four ounces of blood has usually been found sufficient to prevent death from ansemia ; but if this amount did not produce the requisite effect, the process might be repeated. The wound in the skin is to be after- wards closed, so as to cause it to heal by the first intention. The injection of medicated fluids into the venous system has been ^ practised according to the same method, though it is questionable that any case -can arise that would justify the measure. Dr. Blundell, who may be said to have revived this operation in England, invented an apparatus for the purpose of transfusing the blood in an almost continuous stream, which, as it has been modified by the makers, consists of a syringe, to which a tubule and basin are permanently attached. It is employed in the fol- lowing manner, and should be preferred when at hand to the more ordinary instruments described above. The blood is permitted to flow into the brass basin attached to the extremity of the syringe. As it accumulates in the basin, it should be absorbed by raising the handle of the syringe, and then propelled onwards through the tubule attached to it. When the air has all been expelled from the tubule, and blood unmingled with any bubbles issues from the end, the beak should be inserted in the vein. The blood is then to be alternately drawn up from the basin and propelled into the vein, not more than an ounce and a half ever being per- mitted to accumulate in the basin. This process should be steadily and gently performed, the operator watching from time to time the expression of the patient's countenance, and if unpleasant symptoms occur after two or three ounces of blood have been transfused, the proceeding should' be suspended for a moment to allow them to subside. Dr. Blundell thinks that sejdom more than half a pint or a pint of blood can be needed, A case has recently been re- ported by Dr. J. C. Prich'ard,* in which a pint was successfully transfused at a single operation. Prov. Med. Journal, cited in Phil. Med. Examiner, Sept., 1843. VARICOSE VEINS. (PL. V.) The permanent dilatation of the veins is known under the name of varix, the most frequent seat of which is in the lower extremity. It is attended by various forms of pathological alteration. In the varicose vein, there may be either a simple dilatation without change of texture, or a dilatation with thinning of the coats ; or there may be a general or partial thickening of the coats, with elongation of the vessels so as to cause them to assume aflexuous direction. The valves are sometimes so thickened and enlarged as to form pouches across the cavity of the vessel in which the blood lodges and becomes coagulated, and in which also small rounded osseous bodies occasionally form, known under the name of phleboliths. A great number of processes have at different times been em- ployed in the treatment of this affection, viz. , compression, ligatures, suture, resection, section, incision, excision, and cauterization. Compression. — Simple compression is but a palliative measure, and if employed at an early stage, and habitually continued, will check the progress of the disease, so as to render it a source of but little inconvenience. In the old and infirm and in individuals with much constitutional irritability, compression is almost the only means of relief to which the surgeon can with propriety re- sort. It is made with a laced stocking, or a roller bandage, neatly and closely adjusted to the limb, and extended from its extremity to a little above the upper limits of the affection. Surrounding the limb with a succession of adhesive straps is a measure that has also been occasionally employed for this purpose. Compression with the immovable apparatus applied as in the treatment of fractured limbs, has been employed by Mr. Teale, of Leeds, Eng., and alleged to have been successful in effecting a permanent cure. Compression at several points, so as to close the vessel by adhesive inflammation. {Process of Sanson, PI. 5, fig. 1, c.) — The instru- ment employed by this surgeon consists of two small parallel plates forced together by a screw. Between these two plates the vein, rE(ised in a fold of skin, is to be placed. The pressure made with the screw should be but moderate, and at the end of twenty-four hours shifted to another portion of vein, in order to avoid pro- ducing mortification. Several cases of successful treatment by this method have been reported. It is, however, but little used. The same process has been applied to the veins of the cord and scrotum. Compression after incision. {Process of Delpech. ) — This consists in laying bare the vein by a longitudinal incision an inch long, and gliding below it a piece of prepared spunk over which the vein is to be flattened by the application of two adhesive strips, with the object of causing its sides to unite by adhesive inflamma- tion. This process has been but little employed, and is little deserving of confidence. Compression over a pin or needle. {1st Process of Davat, PI. 5, fig. 1, a, and fig. 3.) — Raise the vein in a fold of skin, through the base of which and below the vein a pin or needle is to be passed transversely. Around this needle is to be wound a hare- lip suture, sufficiently tight to keep the anterior and posterior surfaces of the vein in close contact. Several pins, from four to ten or twelve, should be employed at little distances from each other, upon the main trunk and its principal branches, so as to cut 10 38 GENERAL OPERATIONS. off effectually the route of the blood through the superficial veins, and cause it to return by the deep-seated. Velpeau prefers to sur- round the two ends of the pin merely with the thread in vertical turns (PI. 5, fig. 1, No. 2,) rather than in the form of a figure oo, as it is less disposed to cause ulceration of the skin. An elliptical wrapping of the pin, however, as shown at fig. 4, is decidedly preferable to either. ^ 2d Process of Davat. — After the introduction of one pin, as above described, a second is to be entered a little lower, perpen- dicularly through the skin and both surfaces of the vein ; it is to be carried in the direction of the vein under the first pin and brought on the opposite side, piercing a second time the two surfaces of the vein and that of the skin. The two pins are at right angles with one another, and are each to be wound with the hare-lip suture. In my own practice, the first process has answered best. When the vein, as for instance the saphena on the thigh, is covered by a layer of superficial fascia, it is difficult to raise it up so as to pass the second pin readily in the prescribed longitudinal direction. Its effect also has appeared to be rather injurious than otherwise in producing two transverse folds of the vein, which keep the sides from coming so well in contact as when the single pin or needle is passed across and covered with a compress and bandage. From the sixth to the tenth day the obliteration will be usually found complete, and the pins may be removed. I have several times employed two or three separate pins in this way, upon the saphena along the inner face of the thigh, when the enlargement of the vessels had extended from the leg upwards upon this region; while others were introduced concurrently upon the vessels of the leg. In no instance have I failed by this method to produce a cure, or very marked amelioration. A bandage wound tightly on the extremity from the groin downwards, and perfect rest in the horizontal position, were the means employed to guard against the supervention of phlebitis, which, as reported by Velpeau, Lallemand, and Serres, has in some instances been attended by fatal consequences. This process, in the opinion of the author, is greatly to be pre- ferred to any of the other modes of operation, so perplexing by their number, which have been devised for the management of this troublesome affection. Suture. {Process of Fricke.) — This consists in passing a nee die in a longitudinal direction, so as to twice traverse the coats of the veins, as in the introduction of the second needle of Davat. The needle is to be drawn through at once, so as to leave a thread in the wound, over which a compress and bandage are to be ap- plied. In two days, according to Fricke, a coagulum forms so as to obliterate the vein. This process has been received but with little favour, and has only been in a few instances employed. AcupuNCTURATiox.— Little more value is attached to the pro- cess by acupuncturation with a fine needle, employed by Lalle- mand. The needle is passed through both sides of the vein, making of course two punctures in the skin. It is to be left in from two to six days, or in fact till the parts around it become swollen and reddened, and the vein is felt more compact and cord- like. The irritation of the needle is said to cause in the first instance a coagulation of the blood, and finally an effusion of lymph, which obliterates the vessel. In large trunks the simulta- neous introduction of two other needles is advised. Ligature. {Process of Sir E. Home and Beclard.) — The princi- pal trunk of the diseased veins is to be exposed at its most super- ficial position and tied like an artery. The vessel is then to be divided above the knot. Others leave the vessel uncut ; some surround it with two ligatures, and remove a portion of the vein between them. It has even been directed to divide the vessel transversely with a cut from within outwards through a fold of the skin, and then to draw out the upper portion of the divided vessel with the forceps,- and tie it; the bleeding from the lower to be checked with a compress and bandage. Fatal results have but rarely followed the application of this process ; but as the vessel is interrupted only at one point of its course, the other superficial veins are disposed to enlarge subsequently, so as to render the relief only temporary. In operating upon the saphena, near the bend of the knee, it is necessary to avoid including in the ligature the accompanying nerve. As the clot in the veins becomes thoroughly solidified, accord- ing to Mr. Wise, in forty-two hours after the operation, he has proposed to diminish as much as possible the irritation arising from the ligature, by tying it with a running knot, (PI. 4, fig. 2, No. 5,) and removing it as early as twenty-four or thirty-six hours after its application. Various plans have also been proposed for the subcutaneous obliteration of the veins by ligature ; these will be described under the head of Varicocele, to which the method is commonly considered more appropriate. Resection without ligature. — After the vein is exposed by a longitudinal incision, it is to be isolated and cut across at the two extremities of the wound, and the separated portion removed. The retraction of the two ends of the vein under the skin, pre- serves them from the contact of the air, and exposes them less to the risk of inflammation than when ligatures have been applied. Section. — The section of the vein may be made by one of two processes. 1st. By simply dividing across, the vein and the fold of skin raised with it, or by introducing the knife flatwise by a puncture between the skin and vein, tyrning the edge backwards and dividing the vessel by a subcutaneous cut. The latter, which is the process of Sir B. Brodie, was devised for the purpose of preventing the introduction of air, which he supposed to be the common cause of the phlebitis that occasionally followed section by the former method. It has been lauded by many English sur- geons ; but experience has shown that it is not altogether exempt from this danger. When the skin is cut across at the same time with the vein, the blood should be pressed out from the vessel, and the wound dressed flat with charpie or lint. The suppurative inflammation which follows causes the obliteration of the vein. Of forty cases in which this method was employed by Velpeau, death followed but in one. The section, to be effectual, must be made on all the separate knots of dilated veins. Incision. — This method differs from the preceding chiefly in the direction of the cut, which is longitudinal. It has been em- ployed only in cases, where from the great number and size of the enlarged veins, the knots were of unusual dimensions, and not amenable to other modes of cure. OPERATIONS UPON THE ARTERIES. 39 Multiplied incisions. (PI. 5, fig. 2, No. 7.) — Two circular liga- tures are to be applied over the skin, above and below the dilated mass of veins. Several incisions with a lancet, one to two inches long, are to be made through the skin and outer wall of the veins, so as to allow them to be completely emptied of the coagulated blood they contain. The wounds are then closed with adhesive straps, and compression made immediately with a roller bandage, in order to flatten the veins and prevent their filling anew with blood. Single incision. Process of Richerand. (PI. 5, fig. 1.) — The skin and walls of the tortuous varicose veins, are to be divided longitudinally with a convex bistoury, down to the aponeurosis. The length of the incision required, will be varied according to the extent of the disease, from three to six or seven inches. The coagula of the veins are to be forced out by pressure, and the wound filled with lint, which is to be retained by a roller lightly applied. At the end of three or four days the dressings are to be removed ; the veins will then be found obliterated. The wound is to be dressed afterwards as under ordinary circumstances. The ^enormous wound occasioned by this process is frightful to the patient, and more or less liable to be followed by phlebitis or phlegmonous erysipelas. It does not admit of the immediate application of a compressing bandage, like the process by several small incisions, which is clearly entitled to a preference as being less dangerous and equally successful. Excision or extirpation. — This should only be employed, if at all, in circumscribed masses of the convoluted veins of the leg, which can be isolated and removed without involving the larger venous trunks. If the skin is sound, it is to be raised in a transverse fold over the vein, and divided with the bistoury from within outwards. The vein is then to be cut across at the two ends of the incision, and compression with a ribbon made below in case the flow of blood is troublesome. The mass of dilated and con- voluted veins is next to be dissected out. If the skin is adherent to the vein, an elliptical incision is to be made, so as to remove the diseased portion of it with the latter. Cauterization. This was practised by the older surgeons, who made use of the heated iron. Latterly, the caustic potash has been much employed for the purpose by MM. Gensoul, Bonnet, and several English and American surgeons. The process is effectual, but painful and tedious; and if the disease is so exten- sive as .to require the application of the caustic on many points, it is liable to be followed by cedema of the limbs. It is alleged, however, that it is less frequently succeeded by a relapse, from the reopening of the channel of the vein at the places where it had been previously obliterated, than any of the other processes for the same objects which have been noticed. M. Gensoul limits, and it appears to me with propriety, the use of this means to cases in which there is ulceration of the part attended with hemorrhage. M. Bonnet employs it as his usual treatment. Process of Bonnet. — The directions given by this surgeon are, to apply upon the track of the vessel, as in forming an issue, several portions of the caustic, at points three or four inches apart, and where the vein is found overlaying a muscle. The application of the caustic over the bony or fibrous structures might be followed by troublesome ulceration. It should not, therefore, be made below the middle third of the leg, nor above the middle of the thigh. Two successive applications of the caustics are required upon the same site to reach the vein, since the use of a single piece sufficiently large to open the vein would produce too extensive a destruction of the skin. The first appli- cation is to destroy only the skin and cellular tissue, without inter- rupting the course of the blood in the vein. The second application is to be made upon the centre of the eschar three or four days after the first, and if the vein lies deep, the eschar should be previously cleft with the knife. When the second slough comes away, the vessel is found laid open, and some hemorrhage follows. The inflammation which attends the cure of this adventitious ulcer blocks up the vein. No other precaution is needed as a guard against the occurrence of phlebitis than confining the patient to his bed. This process, according to its author, generally succeeds in the adult, but has failed in the cases of old men. If the plan of cure by caustic is adopted, it will be found more rapid, certain, and less painful, to adopt the following process of M. Laugier, viz., to make an incision over, but without opening the vein, so as to expose its walls for about half an inch. The incision in the skin should be about an inch long. A piece of greased lint with a longitudinal fissure in the centre, is then to be laid over the wound, and through this opening a piece of stiff Vienna paste, (see page 21,) half an inch square, aqd tapered on one side into a wedge, is to be passed with its thin edge be- tween the lips of the wound, so as to rest firmly upon the vein. The loose ends of the lint are then to be turned over the back of the wedge and fastened down with a strap of adhesive plaster. The pain is over in about half an hour, and is not severe. In a case in which this practice was successfully employed by Mr. Clay, of Manchester, England, a large slough was formed in three days, and was thrown off" under the use of poultices at the end of fourteen. II. OPERATIONS UPON THE ARTERIES. LIGATURE OF THE ARTERIES IN THEIR COURSE. (PL. VIII.) General observation. — An artery is tied in its course, for the purpose of arresting the flow of blood along the trunk of the vesselj beyond, the place at which the ligature is applied. It is practised occasionally for incised or gunshot wounds, when the retracted ends of the divided vessels without ceasing to bleed are so masked by effused and coagulated blood, that they cannot be seized with the forceps or tenaculum ; when an artery is lacerated by the sharp edge of a fractured bone ; in cases of secondary hemorrhage from the face of the stump not otherwise control- lable ; in continuous bleeding from the cavity of a wound, left by the ablation of tumours ; but more frequently than all, for the cure of the various kinds of aneurism. It is the larger vessels only that in this way become the subject of operation. These are usually lodged, for the greater part of their course, in the interstices between particular muscles, and have definite rules as regards their origin and direction, which are subject only to occa- sional variations, well defined in the different treatises on anatomy. Each artery is composed of three tunics — one of them, fragile and polished, called the internal or sero-mucous — a second, fibrous, 40 GENERAL OPERATIONS. 1 . To expose the sheath of the vesselsS a. When about to commence the operation, the surgeon from his knowledge of the structure of the parts, is to figure out in his mind's eye the exact position of the vessel, and the depth at ■which it runs. He should make the muscles contract, between contractile and yielding, called the middle or elastic — a third, forming a dense, compact envelope, closely embracing the latter, called the external or cellular coat. The artery is attended by one or two satellite veins, and very commonly by a nerve. These are again immediately surrounded by a general cellular sheath, which, with the parts it contains, is lodged under one, two or more of the layers, called fasciae or aponeuroses. Three objects are to be held in view in the operation for tying an artery, in its course. 1st. To uncover the common bundle formed by the artery, veins and nerve. 2d. To isolate the artery from the accompanying parts ; and 3d. To place the ligature round the artery. which he is to cut down upon the vessel, in order to discover the real line of their interstice, as this is found to vary according to the different degrees or development of the muscular system. If the artery be superficial it may be traced by its pulsations. If too deeply placed for this, its prescribed course may be gently traced on the skin with the handle of the scalpel, or, if need be, marked with ink, and the operation proceeded with according to the rules PLATE vm.— LIGATURE OF THE ARTERIES IN GENERAL. This plate exhibits under their several heads the successive steps of the surgeon in the common method of tying the vessels. The success, safety, and neatness of the operation, will depend to a great degree on the surgeon rendering himself familiar with the processes by practice on the dead body, and following them closely in the order indicated in the figures, in his operation upon the living. Fig. 1 . — Incision of the sJdn. In the drawing, the incision of the skin is represented as made with the bistoury in the first position. Tlje common scalpel in the third position, as has been before observed, answers fully as well for this purpose. a. The wound, which should extend only through the skin and superficial fascia, b. Bistoury in the first position. Fig, 2. — Incision of the superficial aponeurosis upon a grooved director. a. Bistoury held in the second position, cutting edge upwards, dividing the aponeurosis, b. Grooved director, c. Wound. Fig. 3. — Separation of the muscles. a. Ring and middle fingers of the surgeon's left hajid. b. Fingers of an assistant placed on the opposite side of the limb, drawing the muscles out of the way, on that side of the wound, c. Grooved director held in the right hand ; with this the surgeon tears the intermuscular tissue, till he brings into view the sheath of the vessels at the bottom of the interstice. Fig. 4. — Opening the sheath of the vessels. a. Dissecting forceps held in the surgeon's left hand, and elevating a portion of the sheath of the vessels, b. Bis- toury held in the seventh position, incising the base of the fold. Without relaxing his hold of the forceps, the operator next lays down the bistoury, and takes the grooved director in order to enlarge with its point the opening in the sheath as seen at fig. 5. Fig. 5. — Isolation of the side of the artery next the operator. a. Sheath raised with the forceps in the left hand. 6. One-half the diameter of the artery exposed by breaking with the point of the director the cellular tissue by its side. Fig. 6. — Isolation of the opposite side of the artery. a. Sheath raised on this side with the forceps, b. Grooved director used for the same purpose as in fig. 5. As soon as the vessel is isolated on this side, the hand is inclined so as to pass the point of the director under it in the direction of the operator. This is the most important step of the operation, as great care is required to avoid all injury of the accompanying veins, nerve, or of the artery itself, and to raise the latter only, astride of the instrument. The curved aneurismal needle is occasionally employed instead of the director, and especially for deep-seated vessels. Fig- 7. — Introduction of the eyed probe, threaded with the ligature. ■ This is required in case the grooved director has been used to raise the vessel. The eye may be near the probe point, or at the opposite end. If near the point, the instrument may be only passed part way under the vessel, and one end of the ligature drawn out with the forceps or blunt hook, the other end of the ligature becoming detached as the probe is withdrawn. ^g- 8. — Elevation of the artery in the loop of the thread. This step IS employed merely as a precautionary measure, in order that the operator before tying the thread may assure himself by a circular inspection of the artery, that it alone is enclosed in the loop. I^g- 9. — Double /molting the ligature. The drawing represents the uniform action of both hands on each extremity of the ligature, and the mode of applying the thumbs to increase the tightness of the knot. P/aie 8. OPERATIONS UPON THE ARTERIES. 41 which are laid down in each case with almost mathematical pre- cision. It is prudent also in most instances, before and during the operation, to determine by the touch whether there be any neighbouring or anomalous branch in tlie way, which, if such should be the case, it would be desirable to avoid. The tourni- quet or other means of compression need not usually be applied ; as, by interrupting the pulsation, it would destroy a useful guide to the discovery of the vessel. But if a large artery is to be tied, and the surgeon has not had experience in the particular case, it is a useful measure of precaution, and may be tightened during the operation in case of sudden hemorrhage. If, however, the operator intends to open the sac of an aneurism, turn out the blood and apply a ligature to the vessel" above and below the tumour, it is a step which, should not be neglected. b. The integument is now to be opened. If the artery be su- perficial, the skin should be incised directly over its track. If it be somewhat deep, it is better, as giving a greater certainty of falling upon the muscular interstice, to divide the skin, after the direction of Lisfranc, somewhat obliquely over the course of the vessel. Having decided upon the most accessible or appropriate point for operation, the surgeon, making the skin tense in the ordinary manner without altering its relation to the artery, di- vides it carefully from without inwards, with the scalpel, for an extent of two to four inches, according to the depth of the vessel from the surface. Or, placing his thumb and fore finger on the course of the vessel, raises up with the aid of an assistant a fold of skin, and divides it from within outwards, with the bistoury entered at its base. By raising up one lip of the wound with the thumb and finger^ the incision can then be readily enlarged to the requisite extent. This latter plan is not applicable in all parts of the body, for where large superficial veins exist along the Une of incision, they run a greater risk of being wounded by this method than by the incision from without inwards. It has been suggested by M. Lisfranc, that the ends of the fingers of the left hand should be placed vertically over the line of the vessel, and the incision made along their dorsal edge. This method I have found very satisfactory in practice. Care, however, must be observed to make the pressure directly down upon the pulsa- ting yessel so as not to disturb the relations of parts, and confuse the subsequent steps of the operation. c. The fascia superficialis, and the superficial aponeurosis, which cover even the most superficial of the trunks that require a hgature, are next to be opened. These may be divided, if the vessel be deep, directly over its course with the knife ; if super- ficial, slightly to one side. But it answers equally well, and is safer and surer, to make a small puncture through these mem- branes at the lower end of the wound,' push in the grooved di- rector so as to raise them up one at a time, and having observed that there is no superficial vein or nerve in the way, run the knife along the channel in the instrument the whole extent of the in- cision of the skin. If the artery be superficial, it is now seen in its sheath ; if deep, we must seek the proper muscular interstice, according to the rules given in each case, open it by breaking the cellular tissue with some sweepS of the finger, the point of the director, or the handle of the scalpel, and, if need be, with a few touches of the edge, until the shining surface of the second apo- neurosis which covers the deep vessels is brought into view ; this 11 is then to be opened in like manner as the first or superficial apo- neurosis. If the tension of the superficial fasciae presents an ob- stacle to the separation of the muscles, it may be cross cut with the •scalpel at the ends of the wound. If the surgeon follow method* ically each of these steps, avoiding all precipitancy in searching for the vessel, he will accomplish his object in a short space of time, and with great certainty and safety. 2. TIte isolation of the artery. a. The lips of the incision are to be held asunder with the fingers of an assistant, or a pair of blunt hooks, and the blood removed from the bottom of the wound by pressing in a sponge wetted with cold water. If compression has been employed on the main trunk of the artery, it is to be slackened in case of doubt as to the position of the vessel, in order to render this evident by its pulsation. When the sheath of the vessel is fairly exposed, it is to be raised with a pair of forceps over the artery, and opened by a horizontal cut with the point of the knife, the edge of which is to be held so that no accidental slip will endanger the parts below. Without loosening the hold of the forceps, the end of the grooved director is entered at the opening thus made. If the sheath be found too resisting to be readily torn with the point of the director, it is to be raised on this instrument and slit for a few lines along the groove with the scalpel or a probe-pointed bistoury. Then breaking cautiously the cellular tissue on either side of the artery, so as to separate it from the veins and nerve, the operator passes the point of .the grooved director below and brings it out on the opposite side of the vessel. This last step is the most difficult part in the isolation of the vessel. The end of the fore finger of the other hand should be placed at the point of emergence, so as to present resistance to the instrument, and push out of the way the nerve or vein, in order that neither may be contused or raised with the artery. If the cellular tissue, which is pushed before the director, does not yield to its point, it may be nicked with the edge of the knife. If the vessel be super- ficial, the director is to be carried at right angles to it. If some- what deep, it should be passed rather obliquely to its course, the deeper sides of the wound offering less obstacle in that direction : at the same time the instrument should be bent near the end ; the common silver or steel director being sufficiently flexible to take any curve requisite for the occasion. But in vessels still deeper placed, as the posterior tibial, iliac, and subclavian, some one of the various kinds of curved aneurismal needles must be em- ployed. 3. ^Application of the ligature. Having ascertained, by careful examination, that the artery alone is raised on the director, a common eyed probe, threaded with the ligature, and slightly bent upwards at the entering end, is passed along the groove of the instrument. This end of the probe is to be seized with the thumb and fingers, or a pair of for- ceps, and carried through, at the same time that the director is withdrawn in the opposite direction. If the ordinary aneurismal needle be employed, no director is required ; the ligature, which is carried near the point, is passed with the instrument under the vessel, and is to be seized on the opposite side with the forceps. A very admirable instrument for securing deep-seated vessels, on 42 GENERAL OPERATIONS. the plan of Bellocq's tube, has been devised by Professor Gibson, of the University of Pennsylvania. Professor Horner, of the same institution, employs an instrument shaped like the shoema- ker's awl, notched near the point for the attachment of a ligature with a slip-knot. Many surgeons employ the needle of Mott, which unscrews near the end, so that the beak may be detached and drawn through with the ligature. Various other aneurismal needles will be shown in connection with the plates, the two best of which, accord- ing to my own experience, is that of Graefe, which is curved on the side; and that of Physick, consisting of a blunt-pointed needle, held in the artery forceps of that surgeon, a drawing of which is given in the operation for suture of the palate. b. Knotting the ligature.— Having raised the artery by draw- ing on the two ends of the ligature, to see whether it arrests the pulsation below, and thus avoid all possibility of a mistake which has sometimes been made — that of tying a nerve instead of the artery — the ligature is to be firmly secured with the common double knot. It should be tied directly across the vessel, for if the direction of the loop be oblique, it might, by descending on one side, become so loose as not sufficiently to compress the ar- tery. If the vessel lay at the bottom of a deep and narrow wound, each fold of the knot should be firmly tightened by the ends of the fore finger of either hand passed down,, back to back, upon the artery ; a method which will be found in almost every case superior to the use of any of the complicated serre-ncBuds that have been invented. It was till recently considered indispensa- ble, for the safe obliteration of the vessel, that the ligature should be tied so tight as to divide the middle and internal coats; and though this is more usually and properly the result, experience has shown that the blocking up of the vessel by the formation of a coagulum and the efiTusion of lymph, is as completely effected when the inner walls of the vessels are merely held in close but firm contact. Abernethy and John Bell were in the habit of ap- plying two ligatures, and dividing the vessel between them, in order to allow it to retract as an additional precaution against hemorrhage — a practice which is now abandoned. c. Dressing. — The dressing of the wound should be simple. It has for its object the accomplishment of union as far as possible by first intention. One tail of the ligature is to be cut off near the knot, and the other brought out over the nearest portion of the skin. The French practice of carrying it out at the lower end of the wound is not always the most advisable, as it may, from the length and obliquity of the tract, lead to the formation of a sinuous ulcer. The wound is to be closed with adhesive straps, and lightly secured, when practicable, with a compress and roller. The member is to be placed in a position that will relax the mus- cles. If the artery tied has been a large one, as for instance the iliac, femoral, or subclavian, the limb, to preserve the vital warmth, should be for a time wrapped with flannel, or what answers better, as serving to prevent the weight of the part from interfering with the enlargement of any of the superficial capillaries, laid upon a bed of loose soft wool. If the loss of temperature in the limb that at first attends the operation be persistent, friction should be made in addition, with a slightly stimulating and aromatic lini- ment. The ligature is to be left untouched for eight to ten days for the smaller arteries, and for two weeks or more for the larger ; and is not in any case to be removed till it follows a very slight pull, as that is the only evidence we have of its having; divided the vessel by ulcerative absorption, and of the probable closure of the calibre for some little distance above. The three principal classes of accidents to be dreaded, are, 1. Those which may result from plethora, on account of the mass of blood being confined to a smaller circuit than usual. This is to be obviated by blood-let- ting and the usual antiphlogistic regimen. 2. Hemorrhage about the period of the separation of the ligature. From whatever cause this may arise, it requires immediate compression to be made on the surface of the wound, or over the trunk of the vessel above, or, this not sufficing, the tying again of the vessel, if practicable, at a higher point. 3. Gangrene, where the principal trunk of the limb has been tied for aneurism. This disaster has sometimes, though very rarely, been known to follow. It occurs more fre- quently when the ligature has been required on account of a severe gun-shot wound, compound fracture of a bone, or other severe injury. But it is more especially to be dreaded when, in conse- quence of a previous wound, or from bungling during the opera- tion, the large conducting vein from the limb has been likewise injured, or where an aneurismal communication has been formed between the artery and its accompanying vein. When gangrene, notwithstanding the use of all proper precautionary measures, follows, the only chance for the ultimate safety of the patient is speedy amputation. The rules for the application of ligatures to the different vessels, are as follows. LIGATURE OF THE DIFFERENT ARTERIES. OF THE ARTERIA INNOMINATA. Surgical anatomy. — The arteriainnominata is, after the aorta and pulmonary arteries, the largest arterial trunk in the body. It is given off from the top of the arch of the aorta to the left of the middle part of the upper boneof the sternum, and a little more than half an inch from its upper margin. It passes from this place obliquely upwards and outwards, to a point immediately behind the sterno- clavicular articulation of the right side, at the upper margin of which it divides into the right primitive carotid and right subeta- vian. In its rout it traverses the superior thoracic fascia of Coo- per, (which is an important means of protection to the cavity of the chest,) about four lines below its place of bifurcation. The trunk of this vessel is usually found from an inch and a quarter to an inch and a half long. Its diameter, in a well developed adult, is about half an inch. The place of its division is deep behind the sternum, from half an inch to three inches from the inner face of the top of that bone. In front, the vessel is separated from the sterno-hyoid and thyroid muscles by some loose cellular tissue, in which are lodged many of the inferior thyroid veins that dis- charge into the left subclavian. Between these and the bone lies one part of great importance, the transverse vein, (left vena inno- minata,) which passes over from the left to the right side, but so near the root of the vessel ; however, as to be out of the way of the operation. When the head is thrown forcibly backwards and to the left side, the arteria innominata is drawn upwards, so that its point of bifurcation, as seen in Plate 9, fig, 1, is considerably above the LIGATURE OF THE DIFFERENT ARTERIES. 43 sterno-clavicular articulation. Posteriorly, it crosses obliquely the root of the trachea. On its inner face is the left carotid, and in the angle of divergence between these two vessels, projects the trachea. Externally, it rests for the greater part of its course upon the pleura covering the upper surface of the right lung. The right subclavian and right jugular vein, and the common trunk they form, as well as the pneumogastric nerve, are placed so much on the outer side of the artery at the point where it is tied, as not to be endangered in the operation, unless the surgeon errs by hijnting too far outwards for the vessel, which, it is to be recollected, is lodged between the right margin of the trachea and the right sterno-clavicular articulation, immediately behind the sternal origin of the sterno-cleido-mastoid. Anomalies. — This great trunk is but rarely seen to deviate from the usual description. It occasionally, however, varies in regard to its direction and length, and has been- found altogether wanting. I have in my cabinet several specimens of transposition of the great vessels coming off from the arch of the aorta. In one, the right subclavian originates on the left side, and crosses to the right between the trachea and oesophagus. In another having the same origin, it passes behind both these tubes. In a third, the two carotids spring from a common trunk, etc. Anastomosis. — Spontaneous aneurism of the arteria innomi- nata itself, has many times been met with, and instances have been noted by two observers,* where it was found with one or both of the branches that arise from it, obliterated after death. The anastomosing branches that may restore under such circum- stances the circulation to the right side of the head and neck, are the branches of the left vertebral and carotid; the thyroid, cervical, intercostal and internal mammary of the two sides, anastomose together so as to be able to return the blood to the right arm by the way of the supra and sub-scapular, external thoracic and circumflex vessels. The fact of its accidental obliteration serves in a measure to show the possibility of a successful result in the case of its being tied. The honour of having first performed this most serious, but as yet unsuccessful operation, is due to Professor Mott, of the University of the city of New York. Operation. Process of Mott. (Plate 9, fig. 1.) — The patient is placed in the recumbent position, with the neck slightly flexed and supported with a pillow, and the face turned to the opposite side in order to relax the sterno-cleido-mastoid muscle. The surgeon, standing upon the right of the patient, makes a traijs- verse incision of three inches in length, commencing at the me- , dian line O'f the neck, and extended outwards parallel with but half an inch above the upper border of the clavicle. Another incision of the same length is made along the internal border of the sterno-cleido-mastoid, terminating at the commencement of the first. The platysma muscle and the superficial fascia are next carefully opened so as to expose the sternal portion of the sterno- cleido-mastoid, which is to be divided on the grooved director previously passed behind it. The inner two-thirds of the cla- vicular origin of the muscle is to be cut in a similaj naanaer,; the muscle is then to be reversed upwards and outwards, as seen in Plate 9. The stemo-hyoid and thyroid muscles are now to- be divided, after having, been cautiously raised on the director. The * Pelletan and Dr. Wm. Darrach. surgeon then opens with the finger or the director the cellular tissue lying above the vessel, carefully avoiding the right internal jugular vein, which is found a quarter of an inch to its outer side, and the inferior thyroid veins, which usually cover it in front, and are to be drawn off laterally. The finger falls first upon the primi- tive carotid near its root. The surgeon traces this vessel down- ward, and cautiously tears the cellular tissue till the innominata is exposed. The vessel in question being now discovered, it is to be separated on its outer or right margin from the vena inno- ' minata of the same side with the end of the director, and then pressing off lightly from it the vein and the recurrent laryngeal nerve, the ligature is carried with a curved aneurismal needle from without inwards around the vessel. In operations upon the subject, I have found it more convenient to make the longitudinal incision first, as the skin becomes relaxed after the transverse one is made. Before attempting to pass the ligature, I find it also best to raise with the forceps and di- vide on the front of the Vessel a dense cellular layer, which is an extension downwards of the deep-seated fascia of the neck. Pro- fessor Mott secured the vessel with the ordinary silk ligature. Several other processes have been devised for the ligature of this artery. Graefe, who followed Dr. Mott in the operation, made only a longitudinal incision, along the inner side of the sterno-cleido-mastoid, and partly with his finger, and partly with the handle of the scalpel, separated the parts down to the carotid near its place of origin. Following this vessel, he reached the innominata,. which he detached behind the upper part of the sternum from its sheath,, so as to get his finger around it. M. Manec directs only the transverse incision to be made, and through that proceeds to isolate the vessel. Process of King. — This as last, modified consists, cf an oblique incision, carried inwards and upwards, from the right sterno-cla- vicular articulation over the supra-sternal fossa, to. the left. sterno- cleido-mastoid muscle, the surgeon standing on the left side. The artery is. to be sought for between the trachea and the sterno- hyoid muscles, and surrounded with a ligature passed from with- \ out inwards. This process, though brilliant in its execution on ' the dead body, must be attended with great difficulty in its appli- cation to the living, from the contraction of the muscles- and the effusion of blood in so narrow a wound.. That of Mott is to be preferred to all, as the most judicious in its plan, and leaving less to hazard in the delicate manipulations required. In each of the several instances in which the operation has as yet been performed, the patient sunk from hemorrhage between the periods of nineteen and sixty days; and it is yet a question whether the great size and depth of the artery, its proximity to the heart, and the probability of its disease in aneurisms of the carotid and subclavian do not present such difficulties in regard to the formation! of a clot on the side next the heart by the time the ligature separates^ as to offer insurmountable obstacles to its successful performance-. In Manec's experiments upon the inferior animals, in which the effusion of eoagulable lymph- takes place with greater facility than, in man, the safe obliteration of the vessel, even when previously healthy, occurred but twice in four times. Still, circumstances might possibly arise to justify its performance, especially when it i is considered that the only alternatives presented are little to be relied on, viz: the securing of the carotid or subclavian on the- 44 GENERAL OBSERVATIONS. distal side of the tumour after the methods of Brasdor and War- drop, or the uncertain process of Valsalva. LIGATURE OF THE COMMON CAROTID— PLACE OF ELECTION. Surgical anatomy. — The primitive carotid arteries pass out at the root of the neck upon either side of the trachea, placed about an inch apart, and ascend obliquely upwards and backwards in the direction of the angle of the jaw. The higher they ascend the farther they recede from the front line of the neck. On a level ■with the superior margin of the thyroid cartilage, they divide into two branches, the internal and external carotid. The position of the head materially influences the relative distance of the angle of the lower jaw from the place of bifurcation. When the head is depressed or the mouth opened, the arteries are covered by the angle of the jaw. When the base of the skull is horizontal, the point of division is nearly an inch below it; and if the head be carried backwards, the distance is of course increased. The right carotid is shorter than the left, and somewhat more super- ficial near its origin, in consequence of its coming off' from the arteria innominata. The left primitive carotid arises from the aorta, and as it passes up the neck, crdsses the root of the trachea, is separated from the first bone of the sternum by the vena trans- versa, and has passing at a little distance behind it, the arched ex- PLATE II,— LIGATURE OF THE ARTERIA INNOMIMTA AND SUBCLAVIAN. b. c. d. e. Fig. 1. (A) — Ligature of the arteria innominata. (Process of Mott.) The neck of the patient is slightly flexed, the head thrown back, the surgeon standing on the right side. The process for laying bare this great trunk exposes also the origin of the subclavian, carotid, and several other important parts. 1. Triangular flap of the skin and superficial fascia, raised and pushed upwards and outwards. 2. Sternal portion of the sterno-cleido-mastoid muscle, divided and reflected back. , 3. Divided tendon of the same portion of this muscle left connected with the sternum. 4. Clavicular portion of the same muscle left undivided. 5. 6. Place of division of the sterno-hyoid and sterno-thyroid muscles. 7. 8. Upper section of the same muscles retracted and pushed inwards precisely as they appear on the operation upon the dead body. 9. Deep-seated cervical aponeurosis, forming a covering to the artery in front, above which it has been divided on the grooved director — lower section only seen. a. Arteria innominata, raised above the sternum by the head being thrown backwards. Origin of the right primitive carotid. Origin of the subclavian. Anterior edge of the internal jugular vein. Thyroid vein crossing to the internal jugular. f. Phrenic nerve crossing in front of the subclavian artery. g. Descendens noni nerve crossing obliquely over the outer face of the carotid sheath to the sterno-hyoid and thyroid muscles. A ligature is seen applied about the arteria innominata, at the proper place for securing that vessel. Two more are thrown around the roots of the carotid and subclavian, showing the manner in which these vessels may be secured by the process of Mott for tying the arteria innominata. Fig. 1. (B).— This represents a similar opening of the integuments and soft parts as in fig. 1, A, with an exposure of the roots of the vessels that come off from the subclavian near its origin, a ligature being placed below each, to show the possibility of tying them in case of accident. 1. Line of the transverse wound at the root of the neck. 2. Line of the longitudinal wound along the inner border of the sterno-cleido-mastoid. 3. Reflection of the triangular piece of integument. 4. Deep-seated fascia of the neck, involving the sterno-hyoid and sterno-thyroid muscles, and covering the' trachea. Lower end of the scalenus anticus. Internal jugular vein. Graefe's aneurismal needle carried under the arteria innominata. 8. Origin of the subclavian. 9. Vertebral artery, embraced by a thread near its root, and raised up so as to come into view. 10. Inferior thyroid artery. 11. Internal mammary. 12. Transverse cervical artery. Fig. 2.-Ligatureof the subclavian below the clavicle, or more properly speaking, of the axillary under the pectoral muscle. (Process of the author.) .' ^ r 5. 6. 7. fl_,J J l^lafr // ■m /'i , -.-''A'"'*'*^'^:!^''**---''**"*^,, "*9?«"«>»««»B^ LIGATURE OF THE DIFFERENT ARTERIES. 45 tremlty of the thoracic duct, -which above the level of the sternum gets into the space between it and the left vertebral artery. With the exception of their lower end, they have similar rela- tions with surrounding parts. Each is enveloped in a sheath, behind which and separating it from the muscles on the front of the vertebrae, is the trunk of the great sympathetic nerve, and at the lower part of their course the inferior thyroid artery and recur- rent laryngeal nerve. The sheath embraces besides the artery the par vagum nerve and the internal jugular vein. The artery lying upon the inner side next the trachea and larnyx, the vein without, and the nerve between but somewhat posterior to the two. Delicate pi-ocesses of the sheath pass between these parts, from behind forwards, so as to keep them asunder; but not so as to prevent the vein from slightly overlapping the artery. Just above the middle part of their course, the omo-hyoid muscle runs obliquely upwards and inwards over the front part of the sheath. Above this point the sheath of the vessels is covered only by the skin, platysma muscle and superficial fascia, and the descendens noni nerve which runs obliquely downwards and forwards. The artery is so superficial, that it may be seen or felt pulsating in a trian- gular space, bounded without by the anterior part of the sterno- cleido-mastoid, within by the ascending portion of the omo-hyoid, and above by the digastric. At its superficial position here, oppo- site the larynx, the ordinary operation for ligature of the carotid is performed. Below the omo-hyoid, the artery is more deeply placed. It is covered there, in addition to the parts above men- tioned, with the sternal portion of the sterno-cleido-mastoid, and the sterno-hyoid and thyroid muscles. Anomalies. — Anomalies in the course or origin of these vessels are very unusual. They have been referred to in the preceding article. Anastomosis. — The anastomosing communications between the branches of these arteries and the surrounding vessels, are so nu- merous, that the circulation is readily re-established after the trunks have been tied. The vertebral, the internal carotid, the thyroid, lingual, facial, temporal, &c., of the two sides, communicate so freely together, that the pulsation in the trunk above the ligature returns in a short space of time. It is for this reason that ligature of the carotid is now so commonly abandoned in the treatment of erectile tumours seated on the branches of that vessel. Remarks. — The ligature of this vessel is rarely practised now, except for the cure of aneurism of the trunk or some of its branches, or in extensive wounds of the face and neck. In former times, it was much employed as a preparatory measure in resection of the jaws, removal of tumours from the face, and ablation of the parotid gland. But it has been found by experience, that secondary hemorrhage is apt to follow from the return of blood into the divided vessels, and that it is better to secure these as they spring, as the loss of blood may be temporarily checked so as to give time to find the divided branch, by pressure of the lower part of the carotid against the spine, which is suflSciently superficial for that purpose. Both carotids have been obstructed by ligature in the The patient is inclined upon the left side, with the right shoulder raised as high as the case will admit. An assistant places his thumb above the clavicle so as to make pressure on the main trunk between the scaleni muscles, in case it should be needed by an accidental wound of the vessels. The incision of the integument is made directly over the interstice, which maybe felt through the skin separating the sternal from the clavicular portion of the pectoralis major muscle. The upper section consisting of skin and clavicular portion of the muscle, has been divided on the finger or director from within outwards, and in a direction at right angles with the course of the muscular fibres. a. Portion of the pectoralis major muscle, which takes its origin from the sternum. 6, h. Clavicular portion divided across, and the ends reflected to expose the parts below. c. Posterior fascia of the pectoral muscle, found immediately on its inner face. d. Part of the same fascia, all the intervening portion having been removed. e. Tendon of the pectoralis minor near its insertion on the coracoid process, drawn slightly downwards with a , blunt hook. f. Axillary vein at the front and inner side of the artery. g-, g. Axillary artery — both these vessels are seen just as they got below the clavicle, where they take the name of subclavian. h. Anterior root of the brachial plexus of nerves, lying behind and to the outer side of the artery. Posterior to this root are seen the other branches of the brachial plexus. i. Cephalic vein of the arm crossing in front of the nerves and the artery, to empty into the axillary vein. Above this, another small vein is seen winding over the artery to reach the axillary vein. A third small venous branch is seen coming up in front of the artery. k. Origin of the external thoracic arteries by a common trunk from the axillary, as was the case in the subject from which this drawing was taken. I. One of the external thoracic nerves. A ligature is seen applied about the artery in the upper part of the wound near the clavicular fossa, at the usual place of operation. Another at the lower part of the wound, embraces the artery just above the pectoralis minor and below the cephalic vein. One of the many advantages which attend this process, is the facility of largely uncovering the vessel without much dissection, so as to apply the ligature upon either one of these points as may be desired. 12 46 GENERAL OPERATIONS. sarae individual. Professor Mott lied them nearly simultaneously in a case of desperate necessity. The patient died in the course of twenty-four hours, and it is questionable whether the human brain could sustain the sudden deprivation of two such columns of blood as those sent up by the carotids. Where a considerable interval of time has elapsed between the operations for ligature of the two vessels, the result has been more successful. The artery may be tied at two points, either above or below the omo-hyoid muscle. LIGATURE AT THE PLACE OF ELECTION OR UPPER THIRD OF THE CAROTID. (PL. X.) Operation. — The patient is placed in the recumbent posture, with his shoulders a little elevated, the face turned to the opposite side and supported by an assistant, and the chin carried back so as to extend the integuments on the front of the neck. An inci- sion is then made on the anterior edge of the sterno-cleido-mastoid, commencing an inch below the angle of the jaw, and extended half-way down the neck. Before commencing the incision, de- press with the fingers of the left hand, the groove intermediate to the trachea and the edge of the muscle, so as to make the latter more conspicuous. After section of the skin, raise and divide successively on the director the platysma muscle and superficial fascia, taking care to avoid wounding*the anterior jugular vein,— a branch usually met with connecting this with the external jugu- lar,— or any of the lower superficial nerves. The deep-seated layer of fascia, connecting the edge of the sterno-cleido-mastoid to the sterno-thyroid and hyoid muscles, is to be divided in like manner on the director. The scalpel is now to be laid down, the chin lowered to its usual position so as to relax the muscles, and the margins of the wound held asunder by blunt hooks or the fingers of an assistant. With the point of the director or forceps, or the end of the left fore finger, break the cellular tissue so as to expose the sheath of the vessels, over which and partly through which will be seen crossing the descendens noni nerve. In some operations on the living subject, I have seen this nerve as large nearly as the par vagum, but easily distinguished from it by its oblique and superficial position. Raise the sheath carefully with the point of the forceps, and open it upon its inner side over PLATE X.— LIGATURE OF THE ARTERIES OF THE HEAD AND NECK. OF THE PRIMITIVE CAROTID AND EXTERNAL CAROTID ABOVE THE OMO-HYOIDEUS. The incision is made along the internal edge of the sterno-cleido-mastoideus and is larger than necessary in operations on the living subject, in order to render the plate more useful, by showing fully the relation of the different parts involved. The head is represented thrown back, and the face a little inclined to the opposite side. (A). One edge of the divided platysma-myoides. (B). Anterior margin of the sterno-cleido-mastoid. (C). Anterior belly of the omo-hyoid, running up to its insertion on the os hyoides. (D D). Sheath of the vessels, laid open so as to show the primitive and external carotid arteries. 1. External carotid, with a ligature below it, showing that this vessel may be taken up by a slight extension upwards of the ordinary incision for ligature of the common trunk. 2. Primitive carotid. It is raised on the ordinary aneurismal needle, which, previous to being used on the living subject, is to be threaded with the ligature. 3. External jugular vein. 4. Descendens noni nerve, pushed a little out of its course by the needle. The pneumogastric or par vagum nerve lies between the carotid artery and jugular vein, and is not seen in the drawing. OF THE FACIAL ARTERY. The incision is made just in front of the masseter, and, for the reason above given, it is made of large size. (A). Anterior edge of the masseter muscle, exposed by an incision through the skin and the platysma. 1. The facial artery, raised on the needle. 2. The facial vein. 3. Branches of the portio dura nerve. OF THE TEMPORAL ARTERY. The incision is made just in front of the ear. 1. The temporal artery, which is seen branching at the upper part of the wound. The trunk is raised on a ligature. 2. Temporal vein. POSTERIOR AURIS. A curved white line is drawn below the ear, to indicate the place of incision for the posterior auris artery. Plate W. \ V^*^^^>^>-%-3: LIGATURE OF THE DIFFERENT ARTERIES. 47 the cai'otld, so as to avoid the nerve, and enlarge the orifice on a director in order to expose the vessel. At the lower part of the wound the middle tendon of the omo-hyoid^is seen crossing the sheath. If it be in the way in opening the latter, it may be de- pressed, or, if necessary, divided. The internal jugular vein is to be held slightly downward and outward; and if it swell up so as to obscure the artery, as is apt to be the case when we operate on a struggling patient, it may be compressed with the finger at the upper angle of the wound. With the point of the director, isolate the artery for a little space first on its outer and then on its inner side. The end of the grooved director, slightly curved, or an aneurismal needle, is to be passed from without inwards behind the vessel, so as to avoid disturbing the par vagum, — placing the index finger of one hand on the inner side of the artery to give it a point of support. The ligature is then to be placed and secured as described at page 41. If the operation be neatly done, the pneumogastric nerve is not brought into view, and provided the rules above detailed are carefully observed, neither the sympa- thetic nerve behind the sheath, nor the recurrent laryngeal on its inner side, parts of great functional importance, run any risk of being injured. If the internal jugular vein should by accident be punctured, a casualty which has sometimes happened, it is to be seized at once with the thumb and finger ; a couple of fine pins are then to be passed through the edges and across the orifice, and a delicate silk ligature tied below so as to embrace the opening ; the pins may then be withdrawn. If the opening be of much size, the vein should be tied both above and below the orifice. In a case of extensive wound, Mr. Simmons, of Manchester, tied the main trunk of the vein, and was so fortunate as not to lose his patient. In wounds of this vein, it might be possible even to save the patient by plugging and compression, as was -the case with an ancestor of the distinguished Mirabeau, But it is an accident which ought not to occur in an operation like this, which is one of no great difficulty. LIGATURE OF THE COMMON CAROTID AT ITS LOWER PART. PLACE OF NECESSrry. (PL. XI.) Circumstances that would render this operation necessary, as the existence of an aneurism of the carotid occupying a consider- able part of the side of the neck, must, of course, from the addi- tional embarrassment presented, make it one of considerable difficulty. It has, however, several times been successfully per- formed on the living subject, under such embarrassments. The difficulty encountered is in laying bare the root of the carotid, between the tumour and the sternum. The method, therefore, which shall best expose the parts to the eye, is the one to which preference should be given. The difficulties here are much the same as in ligature of the innominata, and for reasons given when treating of that operation, the plan of Mott, somewhat modified as to the length of the incisions, as it has been by Coates, will in the author's opinion be found most appropriate. An incision of three inches in extent is to be made along the inner margin of the sterno- cleido-mastoid, terminating at the top of the sternum ; an inch from the top of the sternum another incision parting from this is made parallel with the direction of the clavicle, ending just beyond the sterno-clavicular articulation. The sternal portion of the muscle is to be divided in the latter direction, and turned up- wards. The remaining steps of the operation for the isolation of the carotid is nearly the same as that detailed in the operation of Mott, p.-43. When the aneurism of the carotid is small and placed near its bifurcation, the vessel may be readily uncovered and tied for OF THE SUBCLAVIAN ABOVE THE CLAVICLE. A large transverse incision is made just above the clavicle, and the two lips of the incision are pushed in opposite directions to enlarge the surface of the wound. The sterno-cleido-mastoid is in part divided near its origin, for the purpose of exhibiting the parts below more distinctly in the drawing. (A). Clavicle, bared by the depression of the inferior lip of the wound. (B). Platysma-myoides, divided in the whole length of the cutaneous incision, and seen on both the lower and upper lips of the wound. (C C). Clavicular portion of the sterno-cleido-mastoid divided. (D). Anterior edge of the trapezius at its insertion on the clavicle. (E). Scalenus anticus, seen at its insertion on the first rib. (F). Commencement of the anterior belly of the omo-hyoideus from its middle tendon. 1. Subclavian artery raised on the aneurismal needle at the place for applying the ligature. 2. Transversalis colli, or posterior scapular artery. Very commonly we find here another artery with which it is important the operator should be familiar, called the supra-scapular, that comes off either from the subclavian directly, or, which is more usual, from the thyroid axis, crosses the cellular space in which the subclavian is lodged, and skirts the inner and upper margin of the clavicle, being connected to the subclavius muscle by some cellular tissue. When the artery has this position, it is liable to be wounded in the operation on the subclavian, unless care is observed. In the subject from which the plate was taken, the supra-scapular artery was a branch of the axillary. 3. Internal jugular vein, emptying into the subclavian vein near the junction of the latter with the internal jugular. 4. Vein corresponding to the branches of the supra-scapular artery. 5. Brachial plexus of nerves, lying on the outer and posterior side of the artery. 6. Phrenic nerve, passing to the inner side of the insertion of the scalenus anticus muscle. 48 GENERAL OPERATIONS. some distance below the omo-hyoid, by an incision along the anterior surface of the sterno-cleido-mastoid muscle, as shown at PI. XI. following the same rules as for the operation above the omo-hyoid. Great care is required to avoid wounding a vein of considerable size, which is usually found descending behind the inner border of the lower third of the sterno-cleido-mastoid. Process of Sedillot and Zang. — If it should ever become necessary to tie the carotid at its lowest point in the neck, when the relation of the parts is not disturbed or marked by the presence of a tu- mour or effused blood, it may readily be done in the following manner. The head being thrown back and to the opposite side in order to make the sterno-cleido-mastoid tense, an incision two and a half inches long is to be made in the direction of the .fissure between the sternal and clavicular portions of this muscle. The cellular interval between them is to be carefully opened ; the head is now to be inclined towards the side of the operation, and the two portions of the muscle thus relaxed, held asunder with blunt hooks. The sheath of the vessel is next to be exposed at the bottom of the wound, and carefully opened with the point of the director. In the attempt to do this, the internal jugular vein first comes into view. This vessel is to be drawn outward and back- ward, and the artery will be found on its inner side, lying in front of the pneumogastric nerve, and is to be raised from without in- wards with the curved aneurismal needle or bent director. In the operation on the left carotid low in the neck, it is to be recol- lected that the artery, in consequence of its origin from the de- scending turn of the aorta, is deeply placed. From this cause, and the presence of the thoracic duct behind it, it will be found one of greater difficulty and delicacy than on the right side. The operation terminated and the wound dressed, the patient'is to be placed in bed with his head elevated so as to keep the artery in a relaxed position. LIGATURE OF THE EXTERNAL CAROTID. (PL. X.) Surgical anatomy. — The primitive or common carotid divides, as has been before observed, into its two branches, external and internal, nearly on a line with the upper border of the thyroid cartilage. But in females it is well to remember that, in conse- quence of the greater. proportionate- length of the neck, the divi- sion usually takes place lower— nearly opposite the middle of the cartilage. The external is found at its origin, a little in front and to the inner side of the internal carotid, and it, as well as the in- ternal, is readily found by tracing up the course of the common carotid. Both are sufficiently superficial to be tied, if necessary, on the living subject. The course of the internal is short, before it enters the carotid canal of the temporal bone to supply the brain; it has never been the subject of operation. The external carotid is covered in front only by the integuments, the platysma-myoid muscle, and the superficial cervical fascia. It is crossed in front, shortly after its origin, by the posterior belly of the digastric muscle and the hypoglossal nerve, and is lodged in a groove, the walls of which are formed by the pharynx and os hyoides on its inner side, and the internal edge of the sterno-cleido-mastoid without, and the submaxillary and parotid glands above. In this region it sends off its various branches, the superior thyroid, lingual, facial, occipital, and posterior auris. The continuous trunk passes up deeply til rough the substance of the parotid gland, and divides in the space between the neck of the lower jaw and the external auditory meatus, into the temporal and internal maxillary. Remarks.— It is only in its cervical portion that the artery can be cut down upon and tied. It is most superficial and accessible below the digastric. The extension upwards for near an inch higher than usual of the ordinary incision for the common carotid, serves, as shown in PI. X., for the exposure of the lower part of its external branch. Above this point the difficulty of the operation is much increased, from the number of important parts which sur- round the vessel. It has been several times tied, and the patients have recovered without secondary hemorrhage, a result which is always to be dreaded when a large artery is secured near the place of its ramifications, even though they be on the distal side of the ligature; for it has been shown by Mr. Porter, that this serious accident may arise from blood returned by large anastomosing trunks into the vessels beyond' the place of its obstruction. It has been tied for wound or aneurismal' enlargement of its branches ; and as a preparatory step against hemorrhage — in operations for the resection of the jaws and parts of the tongue, for tumours of the antrum, and the removal of the parotid gland. But it is ques- tionable, as before observed, whether, in consequence of its nume- rous anastomoses, this artery should ever be tied except in cases of wound where its cut extremities are exposed ; and it is con- sidered better, in hemorrhage from operations on the face, not to be checked by ligature of the divided vessel or the use of the actual cautery, but to proceed to the simpler and safer process of tying the common carotid. Usual operation. — To tie the external carotid, an incision should be commenced half an inch below the angle of the jaw, and ex- tended as low as the middle of the thyroid cartilage, parallel with but half an inch in front of the edge of the sterno-cleido-mastoid muscle. The platysraa-myoides and cervical fascia being divided on a director, and the sheaths of the siibmaxillary and parotid glands loosened from their attachment below, the glands them- selves are to be pushed upwards and forwards. The digastric and stylo-hyoid muscles are now to be laid bare at the bottom of the wound with the point of the director or forceps. The muscles are to be drawn upwards and forwards with a blunt hook. The sheath of the vessel is now exposed, crossed in front by the hy- poglossal nerve and the facial vein. The sides of the incision are to be held widely separated, the nerve and the vein are to be carried backwards with the end of the finger, the sheath of the vessel cautiously opened, and the artery, which is seen pulsating by the side of the pharynx, separated and raised with the aneu- rysmal needle. LIGATURE OF THE SUPERIOR THYROID. Surgical anatomy. — This is the first branch given off by the external carotid ; it arises a little above the place of bifurcation of the primitive trunk. Passing first upwards and forwards to the corner of the os hyoides, it then turns downwards, forming an arch convex towards the chin, to reach the upper part of the thyroid gland and the larynx. As it passes upwards and inwards it is superficial — covered only by the integuments, platysma-myoides, and superficial fascia. In the lower part of its course it gets be- LIGATURE OF THE DIFFERENT ARTERIES. 49 neath the omo-hyoid, sterno-hyoid and thyroid muscles. The hypoglossal nerve is placed above, and the superior laryngeal a little distance behind it. Remarks. — This artery, in consequence of its anterior position, is frequently divided in abortive attempts to commit suicide. If in the gaping wound which is left, the two orifices of the divided vessel can be discovered, they are to be seized and tied ; but from the effusion of blood in the surrounding cellular tissue, and the heaving motion of the parts in respiration, which is always more or less laborious, I have found it in some cases difficult to discover them, and especially the one on the side next the origin of the vessel. Under such circumstances, I have been obUged to have recourse to ligature of the primitive carotid. Walther, Theden, Langenbeck and others, have tied the superior and inferior thyroid artery of each side, in the hope of diminishing by atrophy the size of the thyroid gland in goitre. These vessels have also been tied by surgeons who have deemed it prudent to attempt the extirpa- tion of this gland, for the same species of enlargement. The pro- cess by which the superior thyroid is tied, varies but little from that for the ligature of the facial, to which the reader is referred. OF THE LINGUAL ARTERY. (PL. XL) Surgical anatomy. — The lingual artery is given off a little above the last named, above which it forms a small arch, convex to- wards the ramus of the jaw. It is found near its origin on the outer surface of the middle constrictor muscle of the pharynx, and runs upwards for half an inch, almost in contact with, and obliquely across the extremity of, the great cornu of the oshyoides, to get beneath the hyo-glossus muscle. In the second pari of its course, the artery continues ascending obliquely forwards and up- wards, but much curved for the distance of an inch, when it turns, vertically, into the substance of the tongue, giving off its raninal and sublingual branches. In the first part of its course, from its origin to the hyo-glossus, it is at first merely covered by the integuments, platysma, fascia, and a few small veins ; but it is crossed near the cornu by the tendon of the digastric, the stylo- hyoid muscle, and the ninth nerve, which, placed below it in the neck, ascends so as to cross it at tjjis point. In the second part of its course it is covered by the hyo-glossus and mylo-hyoid muscles, and is separated by the former muscle from the ninth nerve, which is here placed higher up than the artery, but again gets lower than the vessel at the anterior border of the hyo-glos- sus muscle. At the end of its second course the vessel is found three-quarters of an inch above the body of the os hyoides. The glosso-pharyngeal" nerve is placed above the artery, so as to be out of the way in the operation. Anomalies. — The artery, instead of coming off as a separate trunk from the carotid, may have a common origin with the facial or the superior thyroid, or the three may arise together by a single root. Remarks. — The ligature of this vessel on the living subject is by no means easy, and requires a thorough knowledge, on the part of the operator, of the structures concerned. The vessel is invariably found deeper than the description of its position, or its appearance after the superficial parts are cut away would lead one to suppose ; the prominence of the os hydides and larynx on one 13 side, and the position of the sterno-cleido-mastoideus on the other, keeping the skin, platysma, and superficial fascia stretched between them, at some distance in front of the vessel. This ope- ration has been but little practised. It was proposed by Beclard as a precautional measure, in wounds or extensive operations on one. side of the base of the tongue, where the artery is found so large, that there is reason to fear, that the eschar produced by the actual cautery, the usual means of arresting hemorrhage in opera- tions on this organ, would not be sufficient to check it. It has been tied by Amussat and Mirault on the living subject, with the view of arresting the progress of cancer of the tongue, a project presenting little prospect of success. Operation. (Process of the author.) — The patient is placed as for the ligature of the carotid. The operator ascertains with the finger, as a fixed point of guidance in the operation, the exact position of the body and great cornu of the os hyoides.* An in- cision of about two inches in length is to be made carefully through the skin, beginning it about three-eighths of an inch above the junction of the cornu and body of the os hyoides at a point equi- distant from the ramus of the jaw and the chin, and extended outwards to the inner margin of the sterno-cleido-mastoid. The incision should be directed slightly downwards, so as to pass above the extremity of the cornu of the os hyoides. The super- ficial fascia and platysma muscle are next to be opened at the inner border of the wound, and diA'ided for the same extent in the previous direction. The submaxillary gland covered by its cap- sule is now exposed to view. The cellular tissue below it is to be ruptured with the point of the director, and the gland drawn upwards on the blunt hook. The facial vein, which is observed passing across toward the external jugular, is to be drawn to the back part of the wound. The shining tendon of the digastric muscle is now seen crossed above by that of the stylo-glossus. The anterior belly of the digastricus, immediately adjoining this tendon, is to be denuded and slightly raised with the point of a director. Immediately below it is seen the hypoglossal or ninth nerve, and one line below this nerve the artery may be felt pulsat- ing under the hyo-glossus muscle. The fibres of this muscle are to be cut on the director, and the artery is found, unaccompa- nied with either vein or nerve, and may be readily raised and tied. The artery may likewise be laid bare, posterior to the stylo- hyoid, over the extremity of the cornu. For this purpose, the posterior belly of the digastricus is to be drawn downwards. The hypoglossal nerve then comes into view below this nerve, and a little deeper lies the artery, which may be secured and tied at a point not far from its origin. Several processes have been detailed for the ligature of this vessel ; but the one given above appears to me preferable, as it is attended with greater certainty of finding the vessel, less embarrassment from the sur- rounding parts, and admits of at least equal celerity in its per- formance. OF THE FACIAL ARTERY. (PL. XI.) Surgical anatomy. — This artery usually arises from the external carotid just above the lingual, but sometimes by a common trunk with the latter. It mounts over a groove in the lower jaw, at the 50 GENERAL OPERATIONS. anterior border of the masseter muscle, where it may be felt pul- sating. It supplies the lips, alae nasi, and adjoining portion of the face. The best place for tying it is at the edge of the mas- seter after it has turned over the bone. It is somewhat deeply placed in consequence of the thickness of the masseter, and is covered by the integuments, platysma myoides, and a layer of dense yellowish cellular tissue. The facial vein is at its posterior or temporal side, and it is crossed by some branches of the facial nerve. Remarks. — This vessel may be readily compressed under the jaw, as has been before observed, (page 32,) with a graduated co&press and bandage, or the pad of Charriere ; though if the pressure be protracted it becomes too painful to be borne. Tem- porary compression with the finger is more often employed, in order to diminish the hemorrhage, in plastic or other operations about the face. Its trunk has been many times tied in front of the masseter for the same object, but unnecessarily, as the position of its branches is superficial, and may readily be secured during an operation ; the communication between the branches of the two sides is so direct, that it sometimes becomes necessary to twist or tie both orifices of each divided branch. Operation. — An incision through the skin and platysma an inch and a quarter long, is to be made across the jaw bone at the anterior edge of the masseter, which, with the artery, may be readily felt at this point. The cellular tissue covering the vessel is to be opened on the director, avoiding the branches of the portio dura. The artery will be found immediately below. PLATE XL— LIGATURE OF THE ARTERES OF THE HEAD AND NECK. LIGATURE OF THE PRIMITIVE CAROTID BELOW THE OMO-HYOID MUSCLE. The artery is here more deeply placed and more difficult of access, than it is above the omo-hyoid. (A). Platysma-myoides divided with the skin and superficial cervical fascia. (B). Sterno-cleido-mastoid drawn to the outer side of the wound. (C, D). Sterno-thyroid and'sterno-hyoid, drawn in the opposite direction. (E). Anterior belly of the omo-hyoid. (F). Portion of the sheath of the vessels laid open over the carotid. 1. Primitive carotid. 2. Internal jugular vein. 3. Anterior jugular vein, usually found on the inner edge of the sterno-cleido-mastoid. 4. Descenderis noni nerve, drawn to the tracheal side of the wound. LIGATURE OF THE LINGUAL ARTERY. The incision is made a little below the base of the jaw, from the os hyoides to the sterno-cleido-mastoid muscle. (A). Platysma-myoides divided with the integument. (B). Anterior belly of the digastric muscle, after its middle tendon has pierced the stylo-hyoid. (C). Stylo-hyoid muscle, inserted on the os hyoides. a. Inferior edge of the submaxillary gland. b. Greater cornu of the os hyoides. 1. Lingual artery raised on the ligature thread. 2. Hypoglossal or ninth nerve. 3. Facial vein, running down to form the anterior jugular. 4. Hyo-glossus muscle. The fibres are divided to expose the lingual artery, which, in this part of its course, is found below the muscle. 5. Posterior part of the mylo-hyoid muscle. 6. External carotid, raised to show its position. 7. Anterior edge of the sterno-cleido-mastoid. LIGATURE OF THE OCCIPITAL ARTERY. The incision is made from just behind the point of the mastoid process obliquely upwards and backwards. (A). Position of the mastoid process. (B). Tendinous expansion of the sterno-cleido-mastoid muscle. (C). Splenius capitis muscle divided. (D). Posterior border of the trachelo-mastoideus muscle. (E). Superior oblique muscle. (G). Occipital artery, raised on a ligature. 7. The two occipital veins, which are seen sending branches of communication over the artery. I'UtW // •^i?"^; LIGATURE OF THE DIFFERENT ARTERIES, 51 OCCIPITAL ARTERY. Surgical anatomy. — It arises from the posterion part of the ex- ternal carotid, nearly opposite the facial, and at the lower border of the digastric muscle. It runs obliquely upwards and back- wards to the inner surface of the mastoid process of the temporal bone, where it is covered by all the muscles that are inserted into the mastoid process. From this part it runs rather horizontally backward, parallel to, but above, the inferior ridge of the occi- pital bone, lodged between the splenius and the complexus and superior oblique muscles; after which it turns upwards to be distributed over the posterior part of the cranium. It is in its middle or horizontal portion only that it can readily be taken up, between the insertion of the sterno-cleido-mastoideus and the trapezius. At this point it is surrounded by two veins closely united to it by dense cellular tissue, covered by the splenius, the aponeurosis of the sterno-cleido-mastoid which is attached to the superior ridge of the bone, and the thick integument. Remarks. — The ligature of this vessel has not yet, I believe, been made upon the living subject. The position of the artery is such that in cases of wounds involving it, it may either be secured at the place of injury or compressed against the bone. Circumstances, however, may possibly arise, — such as aneurism, or a tendency to erysipelas presenting an obstacle to compres- sion,' — that may render its ligature necessary. A wound of the vessel near its origin, in consequence of the depth at which it is placed, and the difficulty of ascertaining precisely the trunk from which the hemorrhage arises, must He met by ligature of the external or rather of the primitive carotid. Operation. — The scalp having been shaved behind the ear, an incision is made through the skin an inch and a half to two inches long, beginning it at the posterior border of the sterno-cleido-mas- toid, about half inch behind and a little below the point of the mastoid process, and carrying it obliquely backward and upward in the direction of the superior curved line of the occipital bone. The aponeurosis of the above muscle is next divided, and the splenius exposed just below the line of its insertion. The splenius is next to be divided the whole length of the wound, either by incision from above downwards with the knife, or on the groove of the director. The artery, which may now be felt pulsating, is to be isolated and tied. M. Manec has observed that particular care should be taken not to open either of the accompanying veins, as from their connection with the lateral sinuses of the brain through the mastoid foramen, they might bleed very freely. POSTERIOR AtJRIS; Surgical anatomy. -^The posterior auris, or stylo-mastoid artery, arises from the external carotid just above the digastric muscle. It escapes from under the parotid gland, on a level with the mas- toid process, and runs obliquely backward and upward towards the roots of the hair on the occiput. It crosses the styloid process in the neck, and sends a branch in at the stylo-mastoid foramen. It has passing in front of it near the same point, the portio dura nerve. More posteriorly, it is found crossing the surface of the mastoid process, in the interval between this protuberance and the concha of the ear,. and about a quarter of an inch bglow the latter. It is here covered with a dense subcutaneous cellular layer, through which the artery may be indistinctly felt pulsating, and is attended by the posterior auricular branch of the facial nerve, and usually one or two filaments from the auricularis magnus of the neck. Remarks. — In former times it was the custom to bleed from this artery by opening it in front of the mastoid process ; and though the practice has been abandoned by all reputable practitioners, it is still resorted to occasionally by empirics in certain portions of this country. The nerves which attend this vessel render com- pression after arteriotomy painful, and false aneurism sometimes follows as a consequence of the operation. I tied the vessel, according to the following process, for a tumour of this descrip- tion occurring in the case of a gentleman who had been his own bleeder, and which, after it had attained the size of a small walnut, burst and flooded him with blood. Operation. — An incision is to be made from an inch to an inch and a half long, somewhat obliquely across the course of the vessel. It should be begun near the lower point of the mastoid process, on a level with the lower end of the lobe of the ear, and carried obliquely downwards in the direction of a point half-way between the lobe and the angle of the jaw. In dividingthe super- ficial fascia, — which, on account of the density of the tissues of the part, has usually to be done without a director, — two branches of the great auricular nerve will be observed passing upwards and backwards. Between these, though somewhat deeper, lies the artery, which may be tied either after or before it has given off the auricular branch. The line for the cutaneous incision is shown in Plate 10. TEMPORAL ARTERY. (PL. X.) We have already, in treating of arteriotomy, (page 19,) spoken LIGATURE OF THE SUBCLAVIAN BELOW THE CLAVICLE, SOMETIMES CALLED THE HIGH OPERATION ON THE AXILLARY. The incision is made a little below and nearly parallel with the clavicle. From the depth at which the vessel is placed, and its intimate connection with the vein and nerves, this, which is the ordinary process for ligature of the artery below the clavicle, is perhaps one of the most difficult of any required for the treatment of aneurism. (A A). Portion of the pectoralis major, cut through after the section of the skin and platysma. (B). Anterior edge of the deltoid muscle. (C C). Pectoralis minor muscle, coming up from under the pectoralis major to attach itself to the coracoid process. ' (D). Lower edge of the clavicle, occupied by a few of the divided fibres of the pectoralis major. 1. Subclavian artery, raised on the ligature. 2. Subclavian vein, a little in front and to the inner side of the artery. 3. Plexus of nerves, behind and to the outer side of the artery. 52 GENERAL OPERATIONS. of the points at which may be laid bare for the purpose of bleed- ing, the trunk and anterior branch of this vessel. The ligature of this artery is sometimes required in consequence of aneurism formed either spontaneously, or as the result of a wound. It is in general considered most advisable in such cases, to open the tumour by an incision and turn out the clot, and secure the vessel above and below the place of enlargement after the old method. The author has, however, succeeded perfectly, in several instances, by an operation of much less severity, and which leaves a less deforming cicatrix, — that of cutting down upon and tying the vessel on the cardiac side of the tumour. The tumour afterwards disappears by absorption, accelerated by the use of cold evaporat- ing lotions and compression with a roller bandage. An aneurismal tumour formed on the middle meningeal artery may, after it has produced an absorption of the walls of the cra- nium, project without, and be mistaken, if proper caution be not observed in the diagnosis, for one of the temporal artery. A swelling formed in this manner below the temporal muscle, in which no pulsation was noticed, has been mistaken for one of the common cystic tumours of the scalp, and the attempt at its removal followed by death.* LIGATURE OF THE ARTERIES EXTREMITY. OF THE UPPER OF THE SUBCLAVIAN. _ Surgical anatomy. — The subclavian artery of the right side arises from the arteria innominata, at its termination behind the sterno- clavicular articulation. That of the left side comes off directly from the arch of the aorta, and is at first nearly vertical in its course. The right is consequently shorter than the left, and situated on a plane more superficial, as far as the inner edge of the scaleni muscles. After either vessel has passed below the clavicle, it takes the name of axillary. The artery in its course is divided in reference to its surgical relations into three portions. 1st. That between its origin and the scaleni muscles. 2d. That between the scaleni muscles. 3d. That which crosses obliquely over the first rib. The arteries of the two sides vary so much in regard to their direction and surgical relations, as to require a separate description. First portion. — On the left side it passes nearly vertically, hav- ing but a slight inclination externally till it reaches the level of the top of the lung. At this point it suddenly turns horizontally outwards to get at once between the scaleni muscles. The point at which it turns is on a level with the upper surface of the clavi- cle. The artery is covered by the pleura in front, where this membrane passes off to form the posterior mediastinum ; the par vagum passes down on its inner side and nearly parallel with it. It lies at first on the trachea and recurrent nerve, then on the oesophagus which projects to the left of the trachea, then ou the thoracic duct which crosses beneath to get between it and the carotid ; it is next situated on the body of the first dorsal vertebra, and rests at the place of its turn on the last cervical ganglion of the sympathetic, at the upper margin of the first rib. The left * Aneurism, Diet, de Med. et de Chir. Prat. vena innominata crosses in front of it, behind the upper bone of the sternum. The right subclavian, from the place of its origin, is directed obliquely outwards and upwards; and instead of form- ing a right angle at the place of its entry between the scaleni, it reaches it by an arch which is convex upwards. It lies in front of the pleura, with which it only comes immediately in contact at the margin of the scalenus. Anterior to it lie the muscles of the sternum, the junction of the internal jugular and subclavian veins, the par vagum and phrenic nerves, the latter of which crosses it obliquely from without inwards just at the margin of the scalenus. Over all these parts lies in addition the clavicular portion of the sterno-cleido-mastoid muscle. Behind, it is crossed by the recur- rent nerve. The five branches supplied by the subclavian are given off at irregular intervals during the first portion of its course, and near the internal margin of the scalenus. In the second and third portions of theii- course, the subclavian arteries of the two sides have nearly similar relations. The second portion has a length equal only to the breadth of the anterior scalenus, (the insertion of which covers it in front,) and terminates at the external margin of the first rib. The ex- ternal surface of the right subclavian alone touches the rib. The left subclavian closely embraces it, so that the latter is even here more deeply placed than the right. The third or last portion of the artery extends from the outer border of the scalenus obliquely downwards and outwards in the direction of the axilla, to the lower border of the first rib, where it takes the name of axillary, as before observed. The curve which it thus describes, rests in a superficial groove on the upper surface of the rib. The point where the artery first touches the rib, is, in a well-formed adult with a clavicle of near six inches in length, about two inches and a half from the sterno-clavicular articulation, and a quarter of an inch to the outer side of the internal third of the clavicle. The point where it leaves the lower margin of the rib, is three inches and three-eighths from the same articulation, near the outer termination of the middle third of the clavicle ; so that the oblique course of this portion of the artery may be considered as lodged under the middle third of the clavi- cle, when the shoulders remain in their natural square position. The artery is found always, immediately at the outer side of the tubercle upon the first rib, on which is inserted the anterior scale- nus muscle ; on the outer side it is bounded by the brachial plexus of nerves, the large cords of which run down over the rib, parallel, and nearly of equal size, with the artery, so that they resemble somewhat the four fingers of the hand laid over a sur- face convex and sloping backward, of which the first one is repre- sented by the vessel. By this arrangement, the artery is placed about a quarter of an inch more in front, and a quarter of an inch more within than the front cord of the brachial plexus ; a fact which it is important for the operator to bear in mind, as he may thereby avoid the risk of tying a branch of the plexus instead of the artery, — an accident which has been known to occur. Below and anterior to the artery, runs the subclavian vein, separated from it by the scalenus anticus muscle. At the outer side of the muscle the vein is closely in contact with the artery, and receives there the external jugular, supra-scapular, and sometimes the anterior jugular and acromial veins. Between the vein and the clavicle lies the subclavius muscle. LIGATURE OF THE DIFFERENT ARTERIES. 53 The position of this third portion of the subclavian is Superficial, when the clavicle is depressed, as it is lodged in a fossa above the middle part of that bone into which the fingers can be readily sunk, called the supra-clavicular triangle. The sides of this tri- angle are formed by the clavicle below, by the anterior margin of the scalenus behind, and in front by the posterior margin of the sterno-cleido-mastoid. Covering the vessel at the base of this triangle just above the clavicle, we have 1st, the integuments; 2d, the superficial fascia and platysma muscle — between the layers of this fascia passes downwards and obliquely inwards the external jugular vein; 3d, a layer of cellular tissue surrounding a chain of lymphatic glands ; 4th, the superior scapular artery, which passes across the space in a second fascia just above the clavicle, and the transverse cervical which is found a little higher up : below these we find the artery and brachial plexus, lodged in a smaller trian- gle called the omo-clavicular, formed by the posterior belly of the omo-hyoid, the clavicle and sterno-cleido-mastoid. The depth below the skin at which this superficial portion of the vessel is usually found, is about an inch. But this distance may be greatly increased by the presence of a tumour which has displaced the clavicle, or by an enlargement of the chain of lymphatic glands. Anomalies, in regard to this vessel, are very rare. The vein and the artery have been known to change positions, and Manec has found both in front of the scalenus. The omo-hyoid muscle sometimes has an anomalous insertion by its middle tendon upon the clavicle ; and in certain cases, still more rare, is attached to it by the intervention of a small muscle, called the supra-clavicular. Anastomosing vessels. — If the artery be tied on the inner side of the scaleni muscles, and within the origin of the five large branches it gives off, the restoration of the circulation to the upper extremity can only take place by the same branches that perform this office after ligature of the trunk of the arteria innominata. But if the artery be tied on the outside of the scaleni, the blood will be restored to the limb chiefly by the anastomosis of the in- ternal mammary, the posterior cervical, and the supra-scapular, — with the thoracics, the common scapular, and the circumflex, which are connected with the great axillary trunk. Remarks. — Compression of this artery, which it is often desira- ble to make in the diagnosis of axillary tumours and in operations upon the shoulder and breast, can only be efficiently established at the point where the vessel crosses the rib, and when the shoulder is depressed. It is, however, exceedingly difficult, by the ordinary measures, to check completely the circulation for any length of time ; the involuntary elevation of the clavicle having a "tendency to carry away from the vessel the compressing force. And it is yet to be seen, whether the lately devised and com- plicated instrument of Bourgery (pi. vii.) will prove an effectual means of producing permanent compression. The artery has been tied, in cases of wound or axillary aneu- rism, in each of its three portions. The operation has been done in all between fifty and sixty times, but the result appears to have been more unfavourable than the ligature of any of the other great vessels, with the exception of the arteria innominata and the aorta; death having followed in about one-half the number of cases, the consequence apparently of the great size of the vessel ; its proxi- mity to the heart ; the dimension and number of the branches it gives off; its unhealthy condition when the operation has been 14 performed for spontaneous aneurism of the axilla ; or of a singular tendency in this variety of aneurism to suppurate after ligature of the main trunk, and form a communication, either with the cavity of the pleura, or with the branches of the bronchia where the lung had been rendered adherent by inflammation to the walls of the chest. After the operation the circulation is generally re-estab- lished with great rapidity in the upper extremity. It returned at the end of forty-eight hours in a patient of M. Roux. Though gangrene is little to be feared, serious disturbances of the lungs, heart, and brain, may occur in consequence of the sudden change produced in the movement of the circulating fluid. In the several instances reported of ligature of the trunk on the inner side of the scaleni muscles, the result has been always unsuccessful, and it is a serious question whether it should again be attempted. On the left side it has been but once tied* in this first portion of the vessel, and the complicated surgical relations which it has in that region, will serve to show that the operation, though not wholly impracticable, must be hazardous in the extreme. The greatest difficulty is encountered in the safe isolation of the vessel. Apart from this, the smaller size and greater length of this portion of the left subclavian would seem, by giving a better chance for the formation of a coagulum, to offer more hope of its safe obliteration than the ligature of the same portion on the opposite side. The only alternatives, where circumstances will not admit of the tying of the vessel more externally, are the method of Valsalva, the plans of Brasdor and Wardrop, or the seemingly shocking propo- sition of Mr. Ferguson to amputate the arm at the shoulder joint, and keep up afterwards regulated pressure on the diseased part^ But these are so disheartening, as regards the prospect of a cure, that the operation upon the right side, even within the scaleni, must still be considered justifiable. LIGATURE OF THE OUTER PORTION OF THE ARTERY, OR OVER THE FIRST RIB. Lin£s of incision. — Surgeons vary in opinion in regard to the best method of making the external opening. Roux has proposed an incision nearly perpendicular to the clavicle along the outer edge of the sterno-cleido-mastoid. Ramsden, who first tied this vessel, f made his incision in the shape of a J reversed, the hori- zontal cut being made along the upper border of the clavicle. Physick recommended an incision in V ; Hodgson one merely horizontal. Under ordinary circumstances, where simple ligature only is required, the horizontal incision of Hodgson will enable the operator with great ease and facility to uncover and tie the vessel. But in cases of large aneurismal tumour, which keeps the clavicle elevated, or where the neck is unusually thick and short, a necessity for a wider separation of the lips of the wound may exist. This may be gained, even during the course of the opera- tion, by the addition of a vertical cut. Ordinary process. (PI. X.) — The patient is to be placed upon his back, with his chest moderately elevated, his head turned to the opposite side, and the shoulder carried downwards and back- wards as much as practicable, in order to make tense the skin and muscles, and render the artery more superficial. The surgeon, * By Mr. CoUes of Dublin. The palient died on the ninth day. f In 1809. 54 GENERAL OPERATIONS. standing by the side of the patient, feels for the edge of the sterno- cleido-mastoid and trapezius, ascertains if possible the direction of the external jugalar vein, and makes a horizontal incision merely through the skin, from near the edge of the trapezius, on to the sternal edge of the first named muscle. This gives in the adult an opening of about three inches in extent. If the indivi- dual be fat, the incision may, according to the direction of Lis- franc, be carried within an inch of the sternal edge of the clavicle. The wound should be about half an inch above the upper border of the clavicle.* Raise carefully on the director, and divide the superficial fascia and platysma, avoiding the external jugular vein, which may now be seen either at the external border of the sterno- mastoid, or at the middle of the wound. If it is in the latter position, and cannot well be drawn out of the way, it, as well as some other veins that are occasionally found in this place, must be tied with two ligatures and divided.t Some small arteries will have been cut, which may require to be tied. The wound care- fully absterged with the sponge, and some loose cellular tissue broken with the point of the director, we come to a portion of the deep-seated fascia, which connects the omo-hyoid to the clavicle. This is to be cautiously opened, raised on the director, and, satisfy- ing himself that there is no artery astride the instrument, the ope- rator divides it. If an artery exist there, as I have occasionally seen, and it cannot be drawn out of the way, it must be tied and cut. With the point of the director or forceps, or with the finger nail, we tear the cellular tissue below the fascia, in which are lodged lymphatic glands and veins ; at times some of the layers are found so resisting as to require to be raised on the director and touched with the point of the knife. The omo-hyoid muscle, which is now exposed, is to be drawn upwards and backwards by an assistant. The edge of the scalenus may next be felt and traced down to its tubercle of insertion ; if the clavicular margin of the sterno-mastoid overlaps it, as it does in most muscular sub- jects, it should be divided for the space of half an inch or an inch. Before attempting to look for the vessel, the end of the fore finger should be brought in contact with the sharpened point of the tubercle of the first rib ; if this is not readily found by tracing down the scalenus, carry up the finger along the rib from the ex- ternal margin of the wound. Once found, we are sure of the artery, which is usually felt beating just at its outer side. But if the beating be obscure, or not at all obvious, as has been observed in consequence of a thickening of its coats, we may still satisfy ourselves, by pressure upon it so as to stop the passage of blood into the limb, that the rounded body immediately to the outer side of the finger is the vessel in question. The nerves of the brachial plexus, recognizable by their whiteness and hardness, will be found to the outer and back part of the artery. With the finger on the tubercle as a guide, move the point of the director up and * Some operators direct the incision near the margin of the bone ; others an inch above. But the height prescribed in the text, I find, as we proceed in the operation, furnishes the best security against the accidental wounding of the scapular artery, which is placed near the margin of the clavicle or the transver- saJis cervicis, which is an inch to an inch and a half above. j- The ligature of the vein, if it be divided, must by no means be neglected, and especially if there be any consolidation of its surrounding tissue, as there would otherwise be a possibility of air passing down it to the cavity of the heart, and producing a dangerous syncope. A large vein should be tied, when this is practicable, previous to its division. down upon each side of the vessel, so as to isolate it in its groove upon the rib ; next conduct the beak of a bent director, or an aneurismal needle not too much curved, along the finger to the rib, between the vessel and the tubercle; insinuate it under the artery ; then shift the finger over so as to depress the nerves, using it at the same time to guide and receive the point of the instru- ment as it is carried obliquely round the artery from within out- wards, and from below upwards. On the left side it is equally if not more convenient, to enter the instrument between the artery and first branch of the nerves, and carry it from below upwards and from within outwards. If the operation be featly performed, neither the subclavian vein, which lies in front and to the inner and lower part of the vessel, nor the superior scapular artery, will come into view during the operation. It has been proposed by Cruveilhier in cases where there was such difficulty in discovering the vessel as to lead to the abandonment of the undertaking, as happened to Sir A. Cooper, to saw through the clavicle and look for the artery below it. This has not yet been put in practice in the living subject, and as it would have to be done in all probability over an aneurismal tu- mour, the walls of which not unfrequently form an attachment to the bone, it is a proposition of very questionable utility. It would be much better, under the circumstances, to follow the practice of Dupuytren, and tie the vessel in the second part of its course by the following process. LIGATURE BETWEEN THE SCALENI. This does not, however, deserve to stand apart as a separate method ; since the mode of its performance by a vertical incision, as first practised by Dupuytren, has been abandoned for the com- mon transverse cut, made as described above. When the artery is to be tied between the scaleni, a measure which has often been practised with success, all that is required in addition to the former process, is to extend the incision of the skin inwards to near the sterno-clavicular articulation, divide the clavicular origin of the sterno-cleido-mastoid, and expose completely the front surface of the scalenus anticus, underneath which a director is to be passed downwards and inwards, and brought out immediately by the inner side of its insertion so as to avoid the phrenic nerve, which, after crossing it just above, is separated from it by a little triangu- lar interval. The muscle is now to be divided on the director by cautious cuts, in order to avoid all risk of wounding the in- ternal mammary at its origin, which lies more deeply and just at the outer side of the phrenic nerve. The retraction of the divided ends of the muscle leaves the artery exposed, which runs here obliquely upwards and outwards, and may readily be raised and tied. The common scapular artery I have often found, shortly after its origin, crossing the scalenus near the place of operation; it may easily be discovered by its pulsation, and drawn out of the way by an assistant. The vessel is here so much within and above the first rib, that no elevation of the humeral end of the clavicle can prevent our finding it. If from the commencement it was determined to tie the vessel between the scaleni, the incision of the integuments need not extend farther back than within an inch of the trapezius. LIGATURE OF THE DIFFERENT ARTERIES. 55 LIGATURE WITHIN THE SCALENI. If this perilous operation should be attempted on the living subject, the following process appears entitled to a preference over any other, as it exposes the field of operation more com- pletely to the eye, and enables us to avoid the three principal and immediate sources of danger — the injury of the par vagum or its recurrent branch, and that of the internal jugular and subclavian veins. The general details of the operation will be much the same as for ligature of the innominata. The patient is to be placed as for the latter operation. The surgeon, standing at the end of the table, so as to look over the patient's head, makes an incision, beginning i"n the fossa at the top of the sternum, three inches in length, along the inner border of the sterno-cleido-mastoid. A second transverse one, commencing half an inch above the top of the sternum, is to be carried from the first, just beyond the sterno-clavicular articulation. The fascia superficialis and a layer of the deep-seated fascia, which extends to the border of the- muscle, are to be divided along the vertical incision. The sternal portion of the muscle is also to be cut and drawn upwards by an assistant. The sterno-thyroid and hyoid muscles are next to be cautiously raised on a director and divided. With the finger or the handle of a scalpel, the operator clears away the cellular tissue at the bottom of the wound, keep- ing to the outer and lower part, in the direction of the inner end of the clavicle. The aim is to expose the artery between the par vagum nerve and the internal jugular vein. In consequence of the oblique direction outwards of the latter, sufficient space is here found to pass the ligature. The aneurismal needle in passing round the artery should be kept closely in contact with it, arid at the same time be directed upwards and outwards in order to avoid injury of the pleura, (which was wounded in the operation of Mr. Colles,) and the inclusion of the recurrent nerve, which is seht upwards and inwards round the vessel. If applied at this point, the ligature will rest at the inner side of the origin of the branches given off by the subclavian. The exact position of the internal jugular and par vagum ought to be previously ascertained, and both held carefully out of the way with a blunt hook. Either of these might serve as a guide to find the vessel. If the surgeon work too much at the inner border of the wound, he will fall on the carotid. This vessel may then, however, as in the operation on the innominata, be followed downwards to the origin of the subclavian, and the latter traced outwards, for the space of three- quarters of an inch, to the point where the ligature ought to be applied, just at the outer border of the par vagnum. If the ligature of this artery should be attempted on the left side, the same process would be found the most appropriate. Great care would be required to avoid injury of the pleura and of the thoracic duct which are close behind the vessel. Greater embar- rassment would be presented on this side by the inferior thyroid and deep cervical veins ; the latter forming a large trunk immedi- ately in front and nearly parallel with the artery. OF THE BRANCHES OF THE SUBCLAVIAN. The arteries furnished by the trunk of the subclavian, which may in case of necessity, be exposed and tied, are the vertebral, inferior thyroid, and internal mammary. The necessity for secur- ing the other two branches; given off is little likely to occur; it could only exist in case of an accidental wound, at the bottom of which they might be found and tied. Of the vertebral. — This artery runs up to the brain, through the foramina in the transverse processes of the six upper cervical vertebrae. Two instances of wound of this artery in its course have been lately reported. One, that of a French soldier, stabbed in the back of the neck with a knife, the point of which divided the artery between the transverse processes. The other case, in which the artery was divided by a side cut made upon the throat with a razor, occurred in this city. In both, the hemorrhage was fatal. In such cases there is no resource, when the nature of the injury is ascertained, save ligature of the vessel at its origin, or of the subclavian trunk. The former, when practicable^ is of course to be preferred. The parts are to be opened precisely in the same manner as for ligature of the subclavian between the scaleni. With the finger carried to the bottom of the wound, we may feel, about two inches above the clavicle, the projection of the transverse process of the sixth cervical- vertebra, distinguished as the carotid tubercle by M. Chassaignac. The vertebral artery is found immediately below this projection, when about to enter the foramen at its base, just at the inner margin of the scalenus anticus. Nuntiante Ippolito* relates two cases, in which this artery was tied at its origin with success. Inferior thyroid. — This vessel passes a little above the carotid tubercle in a direction upwards and inwards behind the sheath of the carotid artery and jugular vein, to reach the lower border of the thyroid gland. To find this artery, an incision may be made along the inner border of the sterno-cleido-mastoid. The muscle is then to be drawn outwards with a blunt hook, and the sheath of the vessel separated from the side of the trachea and oesophagus. The artery, though somewhat variable in regard to its origin, will be found in its course to the outer side of the recur- rent laryngeal nerve. Several thyroid veins cross the line of operation. If it becomes necessary to seek the vessel near its origin, the same process as described for ligature of the vertebral will answer. The thyroid originates from the subclavian, just before it enters between the scaleni, and commonly at the outer side of the vertebral. Internal mammary. — This vessel runs down obliquely by the side of the sternum, between the pleura and the posterior face of the costal cartilages, and intercostal muscles. In the middle part of its course it is near half an inch distant from the side of the sternum, but is almost in contact with it below. In case of aneu- rism or wound of the vessel, it may very readily be exposed and tied in the third or fourth intercostal space. The operation has not, however, been done on the living subject. Operation. — Make an incision through either one of these spaces, outwards from the side of the sternum for the distance of an inch and a half, in the middle line between the costal cartilages. Divide the intercostal muscle cautiously on a director, upon the thin aponeurosis which is stretched between the ribs, and we per- ceive the artery, which may readily be isolated from its veins, and raised and tied without risk of injuring the pleura. Scarpa re- commends the incision to be made between the first and second ribs, dividing the pectoral as well as the intercostal muscle. But * Froriep's Notisen, 1835. S. 304. 56 GENERAL OPERATIONS. this position should not, except in case of emergency, be selected, as the position of the artery is here so close to the sternum as to offer some embarrassment. OF THE AXILLARY AKTERY. We understand by this name, that portion of the arterial trunk of the upper extremity, extending from the lower border of the first rib to the inferior border of the tendon of the latissimus dorsi muscle. It is continuous above with the subclavian, and below ■with the brachial. Surgical anatomy.— The axilla or armpit is that space between the side of the chest, and the inner side of the shoulder and upper part of the arm. It is triangular in shape, the apex being above at the outer termination of the inner third of the clavicle. The base which is below is bounded by the tendon of the pectoralis major in front, and by the tendons of the latissimus dorsi and teres major behind. The serratus magnus, which covers the side of the chest, forms its internal wall. The depth of this hollow be- tween the tendons will vary according to the relative position of the arm to the trunk. When the arm is rotated outwards and raised to a right angle with the body, the depth is the greatest; but if the arm is carried still higher, the depth is diminished, as the head of the humerus then descends into the hollow, the folds ofithe axilla being overstretched. Through this space the axillary artery runs down in a line which is gently curved. The vessel is deeply placed just below the clavicle. Proceeding from with- out inwards, we find it here covered, 1st, by the skin, superficial fascia, and platysma muscle ; 2d, by the thick belly of the pec- toralis major, which arises by two sections with an intervening cellular space, one of which comes from the internal two-thirds of the clavicle, the other from the side of the sternum; 3d, by the pectoralis minor muscle the fleshy tendon of which, running to the coracoid process, crosses the artery about an inch below the clavicle. From this tendon a dense cellular layer* passes to the subclavius muscle, covering the artery above; and another descends into the armpit, covering the vessel below. When these two aponeurotic layers are laid open, we find the artery divided as it were by the pectoralis^minor, into three portions; one be- tween it and the clavicle ; one immediately behind and covered by it ; and a third situated below the muscle, or, more properly speaking, at the inner border of the arm, near the lower margin of the armpit. In each of these three positions the artery has been the subject of operation. 1. When the clavicular portion of the pectoral muscle is raised, the upper portion of the artery is found lodged in a sort of trian- gle, the base of which is formed above by the middle third of the clavicle, the inner side by the upper edge of the sternal portion of the pectoralis major which runs from above downwards and outwards, and its outer side by the pectoralis minor, which runs from below outwards and upwards. The artery is placed be- tween the brachial plexus of nerves, (which lies here, to its outer and posterior side,) and the great axillary vein, which lies to its inner side, slightly overlapping it in front. The plexus is sepa- rated from the artery by a cellular interval, and consists here of * Commonly called ihe costo-coracoid membrane, from its connection at its inner end with the costo-coracoid ligament. two large trunks which lie side by side. The great cephalic vein of the arm crosses this triangular space immediately in front of the artery, to throw itself into the axillary vein. Three branches, the superior, the inferior, and acromial thoracic, are given off from the axillary artery in this triangle, immediately below the course of the vein. Sometimes they come off by a single and sometimes by a double trunk. 2. TJie middle part of the axillary artery, or that behind the pectoralis minor muscle, is completely surrounded by the plexus of nerves, behind which is seen the subscapularis muscle. Seve- ral arterial branches are given off at this point. The axillary vein is still found at the inner side of the artery, and is here crossed by the small nerves which go to the thorax. 3. Below the pectoralis minor, the artery is found crossing near the head of the os humeri, and passing down to the inner border of the coraco-brachialis, at the junction of the anterior with the middle third of the space included between the tendons of the pectoralis major and latissimus dorsi muscle. It is here so super- ficial, that when the arm is thrown out from the body its position may be noticed under the skin and brachial aponeurosis, which alone cover it. The artery is either found between the two roots of the median nerve, or between this nerve and the internal cuta- neous. The latter nerve soon takes a position in front of the artery. The vein and the other nerves of the arm given off from the plexus are placed to its inner and posterior side. Jlnastomosis. — In ligature of the axillary artery, high up, the same vessels are concerned in restoring the blood to the arm, as in the common operation on the subclavian. If tied below the origin of the subscapular and circumflex, these vessels, by their anastomosis with the profunda and other branches of the brachial, become the channels of communication. '-Remarks. — Ligature of the axillary artery has been called for in cases of wounds and aneurisms at the upper part of the arm. When the circumstances of the case admit of the application of the liga- ture in its lower portion, which is, however, rare, the operation is perfectly simple and easy. But in the upper part of its course, in consequence of its depth, the thickness and transverse direction of the muscle which covers it, its intricate connection with the nerves of the brachial plexus and the axillary vein, and the num- ber of secondary vessels which are liable to be cut in reach- ing it, it is justly considered one of the vessels the most difficult to secure. Dupuytren was compelled in one case to tie twelve or thirteen arteries which were divided in the operation. In the hollow space below the clavicle, the true aneurismal tumours of this vessel, when they have attained much size, usually make their appearance. In false aneurisms of some standing, the loose oozy cellular substance placed about the vessels and filling up the whole axillary space as high as the region of the clavicle, yields readily to the pressure of the effused blood, from which region, owing to the peculiar arrangement of the fascia of the part, the fluid is notable to escape. The sac of a large aneurism is in consequence modeled on the form of the axillary space ; thus rendering it almost impossible to expose the artery below the clavicle, without opening the sac. For these various reasons, surgeons of the present day usually prefer, and especially in cases of aneurism, to cut above the cla- vicle, and tie the sucblavian in the third part of its course. Seve- LIGATURE OF THE DIFFERENT ARTERIES. 57 ral surgeons of distinguished eminence, White, Pelletan and Desault, in attempting to tie the artery below the clavicle, have been compelled, from the difficulties they encountered, to termi- nate their operations unsatisfactorily. It has, however, been many times successfully tied in this region ; and in suitable cases, where we have reason to believe the artery is healthy, and that the aneurism has not encroached upon the subclavian hollow, the desire to place the ligature as far from the heart as we can with safety, leaving room for a second operation on the subclavian in case of disaster from secondary hemorrhage, the process will still be practised. The ligature of the vessel immediately behind the pectoralis minor has been justly abandoned, leaving now but two points for operation ; — that above the pectoral muscle, and that in the hollow of the axilla. There is one circumstance which the surgeon should bear in mind, that occasional instances of anomaly occur, where the axillary divides into its radial and ulnar branches as high up as the subclavius muscle. 1. Ligature above the pectoralis minor, called the high operation upon the axillary, and sometimes spoken of as ligature of the subclavian below the clavicle. (PI. XII.) a. Ordinary process. — Horizontal incision. — The patient is to rest upon his back with his head and shoulders raised, the shoulder of the diseased side moderately elevated, and the elbow carried out from the body at an angle of forty-five degrees. Compression may be made by an assistant upon the artery above the clavicle. The surgeon then, depressing with the fingers of the left hand the clavicular portion of the pectoralis major muscle, makes, half an inch below and parallel with the clavicle, an incision through the integuments and platysma muscle, three or four inches long, ex- tending from near the margin of the deltoid muscle to within an inch of the sternum.* The fissure between the deltoid and pecto- ral muscles, may previously be readily ascertained by putting them into contraction ; in this fissure is lodged the cephalic vein, which must be carefully avoided. Next, the whole thickness of the pectoral muscle is to be divided layer after layer for the entire length of the wound, tying or twisting the branches of the thoracic arteries as they spring, which, though not large in their normal state, are found dilated in cases of aneurism. Having reached the posterior face of the muscle, (in doing which there is usually little difficulty,) the firm aponeurosis behind it is to be divided on a grooved director. The subclavicular triangle is now exposed ; the lower and outer boundary of which, — the pectoralis minor — may be felt with the finger, and will serve as a guide to find the vessel which lies at its upper and inner side, between it and the clavicle, surrounded by some loose cellular tissue that is covered in with a thin fascia connected with this muscle. The arm is now to be brought to the side of the trunk, and rotated inwards so as to put the parts in complete relaxation. With the end of the finger or the point of a director, we cautiously break up the cellular structure in the triangle, and lay bare the edge of the pectoralis minor, which is afterwards to be held downwards and outwards with a blunt hook, or the fore finger of an assistant. Sometimes the fascia running up from the pectoralis minor is so strong as to * In very fat or muscular subjects the incision may, if necessary, be carried still nearer to the sternum, the operator recollecting that the artery is to be found considerably to the outer side of the internal third of the clavicle. 15 require to be raised with the director and touched with the point of the knife ; but care must be observed in so doing to avoid wounding the thoracic vessels which are placed immediately below. The cephalic vein will usually be seen crossing just below the clavicle to reach the axillary vein; this may, if it im- pede the operation, be drawn upwards by an assistant. Of the parts within the triangle*, the first exposed to view is the axillary vein. This is seen swelling up at each expiration, partially cover- ing the artery, which is placed behind and to its outer side, and to which it serves as a guide. With the point of a directoi^ passed in at the groove at the outer side of the vein, we separate this from the artery and draw it carefully downwards and inwards with a blunt hook. The artery is now to be separated in like manner from the plexus of nerves, which is found without and behind it. The bent director or the aneurismal needle is then to be passed from between the artery and nerves upward and inward, bringing it out between the artery and vein, the latter of which is to be carefully guarded against laceration by being pressed off with the fore finger of the other hand, which serves at the same time as a point of support to the end of the instrument. I prefer to pass the instrument from without inwards, as there is less risk of including one of the branches of the brachial plexus, — an accident which has several times occurred in the operation ; it is even passed with greater facility in that direction, since the needle moves from the deeper to a more superficial point of the wound. The ligature is to be placed as far as possible above the origin of the thoracic arteries, lest the blood passing through these vessels should prevent the formation of a proper clot. b. Transverse curvilinear incision. (Process of Hodgson.) — The principal object of this process is to expose largely the subcla- vicular triangular fossa, in which are lodged the vessels and bra- chial plexus. A semilunar incision convex downwards is directed to be made below the clavicle, extending from the sternal end of the clavicle to near the point of the acromion scapulae and carried through both the deltoid and pectoralis major muscles. The flap of muscles is to be drawn upward, and the vessel is then isolated and tied according to the method above given. The injury done to the soft parts in this operation is, in ordinary cases, unnecessarily extensive. It may however be found justifiable, when it is con- sidered requisite to expose completely a circumscribed aneurismal tumour in the subclavicular fossa. If the line of the incision be limited externally to the fissure between the deltoid and pectoral muscles, after the manner of Dupuytren and Velpeau, the objection will be in a great measure obviated. c. Angular incision. (Process of Chamberlaine.) — A horizon- tal incision is made in the usual manner below the clavicle. A vertical incision is dropped from the outer angle of this in the space between the pectoral and deltoid, carefully avoiding injury of the cephalic vein, \vhich is closely adherent to the deltoid, as well as a branch of the thoracic acromial artery lodged in the fissure. The incision will have the form of an 'j reversed. The triangular flap formed by these two incisions is to be drawn in- wards and downwards. The pectoralis minor will be brought to view just at the inner margin of the deltoid, and immediately above it will be found the vein, artery, and nerves. This process exposes the artery well in the neighbourhood of the pectoralis minor, which may at want be cut and the artery looked for behind 58 GENERAL OPERATIONS. it. But it produces too much disturbance of the soft parts, to be resorted to except in cases of difficulty, and then the ordinary operation may if necessary be converted into this, by adding to it the vertical incision. It has, however, been employed successfully on the living subject. d. Incision in _i_reversed. (Process of the author. PI. IX. fig. 2.) — For many years past I have been iil the habit of exhibiting to my class the following operation, which uncovers the artery more completely than any other and at the very point at which we wish to tie it in cases of aneurism, — immediately below the clavi- cle. It involves the division of a much less extent of muscular substance, and leaves consequently fewer arterial branches to be tied. Placing the patient in the position already indicated, we feel for the interval between the sternal and clavicular portions of the pectoralis major muscle. In thin subjects this will be indi- cated by a superficial depression. This interval commences near the sterno-clavicular articulation, extends obliquely downwards and outwards in the direction of the lower margin of the anterior fold of the armpit, and is rendered very obvious by carrying the arm well out from the body. The integuments and platysma are to be divided immediately over it. The interval between the muscular fasciculi, which is marked by a yellow line in fleshy, and is loose and cellular in thin subjects, is to be freely opened with the finger merely, or, if it be resisting, with the aid of the director and scalpel. If any difficulty should occur in finding the fissure, raise the fascia of the muscles with the forceps, and with a few strokes of the scalpel it will be revealed. The arm is then to be brought to the side so as to relax the parts, and the cellular tissue above the fissure well separated, with the finger nail or the handle of the scalpel, from the posterior surface of the clavicular portion of the muscle, up near to the clavicle ; some small nervous and vascular branches passing here will then be laid bare. Hooking PLATE XU.— LIGATURE OF THE HUMERAL AND ULNAR ARTERIES. LIGATURE OF THE HUMERAL OR BRACHIAL ARTERY IN OF THE AXILLARY ARTERY. THE AXILLA— COMMONLY {Process of Lisfranc.) CALLED LIGATURE The arm is carried from the trunk and rotated outwards. The incision is made at the junction of the anterior with the^posterior two-thirds of the armpit, and the lips of the wound separated by the hands of an assistant. Another assistant makes pressure upon the trunk above the clavicle, though this is not necessary, save as a measure of precaution. The references are seen in the sketch below, in which the aneurismal needle of Grffife is placed below the artery. 1,2. Section of the skin and superficial fascia. 3. Inner edge of coraco-brachialis muscle. 4. Basilic vein. 5. Artery covered by the common sheath of the vessels and nerves. 7. Ulnar nerve — the median lying between it and the artery. 8. Artery exposed for the passing of the needle, which is seen below. 9. This figure indicates the position of the internal cutaneous nerve. LIGATURE OF THE HUMERAL NEAR THE MIDDLE OF THE ARM. The biceps muscle is pushed a little outwards by the hand, applied as above sketch in the corner of the plate. 1, 2. Section of the skin and brachial aponeurosis. 3. Sheath of the vessels — seen well opened below the aponeurosis. Median nerve. Internal deep-seated humeral vein. Very commonly one vein only attends this artery Artery raised on the director. Biceps flexor muscle. Internal portion of the triceps. The references are seen in the 4. 5. 6. 7. LIGATURE OF THE ULNAR AT ITS UPPER THIRD. References seen in the sketch adjoining. 1. Section of the superficial fascia and brachial aponeurosis. 2. Flexor carpi ulnaris. 3. Flexor sublimis digitorum. 4. Ulnar nerve. 5. Ulnar artery embraced in a ligature ; a vein on either side. 6. Common interosseous trunk raised on a ligature to show the possibility of tying it at this point. fnoie n LIGATURE OF THE DIFFERENT ARTERIES. 59 next the fore finger of the left hand under the clavicular portion of the muscle, opposite the middle of the clavicle, we divide it through from without inwards by a careful use of the knife. The direction of the incision must be obliquely upwards and outwards, at right angles with the course of the clavicular fibres. Few arte- ries will be cut ; but such as are of much size must be tied at once, to prevent the blood obscuring the latter steps of the operation. The divided portions of the muscle will retract and may be still further separated with blunt hooks so as to leave a wide triangular space in which we are to hunt for the vessel. The posterior fascia of the pectoral muscle is to be opened in the same Hne on the director. Below this fascia is seen another running from the pecto- ralts minor to the subclavius muscle. This must be raised with the forceps and torn with the point of the director, or divided cautiously so as to avoid injuring the thoracic arteries which are placed immediately below it, or their common trunk which stands out prominently. If we desire to tie the artery near the clavicle, we break away the cellular tissue in a similar manner, above the origin of these thoracic vessels. Crossing near the upper margin of these vessels is seen the cephalic vein of the arm, and above this the artery is found deeply lodged on the first interosseous muscle, with the great axillary vein at its inner side, thrown some- what more in front by the rising prominence of the rib. The nearest root of the brachial plexus is placed nearly a quarter of an inch behind and to the outer side of the artery. A small vein is seen crossing in front of the artery to the great venous trunk, and between this and the cephalic, (which is to be gently drawn down- wards,) we isolate the artery first on its inner and then on its outer side, and pass the ligature from within outwards and backwards, bringing the arm close to the trunk at the time, so as to relax the vessel. If it be deemed expedient to tie the artery at the upper margin of the pectoralis minor, this muscle, if it has not been pre- viously exposed, is to be brought fully into view by breaking away the cellular aponeurosis along its upper border, which will be found on a line drawn from the point of the coracoid process to the junction of the second rib with the sternum. The muscle is then to be drawn downwards with a blunt hook in the direction of the lower angle of the external incision, and the cellular tissue opened as above directed between it and the origin of the thoracic artery. The artery will now be found raised from the ribs over the second head of the scalenus ariticus, with the vein within and a little posterior to it, and the first branch of the brachial plexus close at its outer side and slightly overlapping it. The artery is to be isolated with care, and the ligature passed round it, the brachial nerve being pushed outwards with the left fore finger so as to prevent its being included in the loop. After the operation, the parts are to be drawn together by a single suture passed through each angle of the integuments above, and secured to the skin on the opposite margin of the wound. This method of proceeding admits of a ligature being applied upon the artery in any part of its course, which is more than an inch in extent, between the clavicle and the lesser pectoral muscle. It will, I believe, be found attended with less diflJculty on the part of the operator, with -less hemorrhage, and less liability of injuring important parts, than any other that-has been devised. Marjolin and Lisfraric have proposed to tie the axillary artery by simply opening the interstice between the two portions of the pectoralis major. But the artery by this plan will be uncovered too low, and the resistance offered by the contraction of the undi- vided muscle would render it nearly inapplicable in the living subject. Could it be accomplished, the opening left would not be sufficiently free to admit of the escape of the purulent secretion which is apt to follow the disturbance of the cellular tissue of the part. 2. Ligature of the artery behind the pectoralis minor. [Process of BesauU as modified by Delpech.) — The arm is to be carried out from the body at an angle of 45 degrees, and compression made upon the subclavian between the scaleni. An incision three to four inches in length is then made downwards and slightly out- wards, from the junction of the external third with the two inter- nal thirds of the clavicle, along the interstice between the pectoralis major and the deltoid, carefully avoiding the cephalic yeifi. The arm is now to be brought to the body, in order to relax the pecto- ralis major; the cellular tissue uniting the muscles along the inter- stice is to be divided with the finger or the point of the direc- tor, the border of the pectoralis major drawn downwards and inwards with the blunt hook or the finger of an assistant, and that of the deltoid carried in the opposite direction. The pecto'- ralis minor is now exposed, and is to be raised on a director, and divided about three quarters of an inch from its place of insertion on the coracoid process. Passing the fore finger to the back and the outer portion of the wound, the mass of the vessels and nerves is to be hooked up and brought to the surface. The vein is then to be isolated at its outer side from the artery and carried inwards; the artery is next to be isolated from the nerves, and the aneu- rismal needle carried round it from within outwards. The objec- tion to this process is, that the ligature is placed too near the origin of the thoracic vessels, and that the artery closely embraced by the nerves, cannot, from the depth at which it is placed, be brought to the surface without making strong traction upon the parts. 3. In the armpit. {Process of Lisfranc, PI. XII.) — The arm is to be carried from the body so as to form an angle of 80 degrees with the trunk, and rotated outwards. We then feel at the inner edge of the coraco-brachialis, — just at the junction of the anterior with the posterior two-thirds of the armpit,* the pulsation of the vessel as well as the prominence formed by the brachial plexus of nerves. Along this artificial division of the axilla, a longitudinal incision of two to two and a half inches is to be made through the skin. The basilic vein, lodged in the thickness of the brachial aponeurosis, is then exposed to view along the internal border of the wound. This aponeurosis is to be opened and divided on the director at the external side of the vein. If a simple incision of the aponeurosis does not afford sufficient room to reach the vessel with facility, a cut may be made across the outer portion of the membrane. The vessels and nerves are now exposed. The arm is to be lowered in order to relax the parts; then proceeding from before backwards, starting from the coraco-brachialis as a fixed point, we find first, the median nerve, and immediately within it the axillary vein. Beyond, or to the inner side of the vein, are to be seen the internal cutaneous and ulnar nerves, and the basilic vein. The sheath of the vessels is to be carefully opened with the point of the director, and the vein carried inwards - Half an inch to three quarters behind the tendon of the great pectoral, accord- ing to Manec. 60 GENERAL OPERATIONS. and backwards. The artery will be found immediately within and behind the median nerve. Denude the artery slightly on either side, and pass the director below it, from within outwards, between the vein and median nerve. The above is the usual direction given, but I find it equally as convenient to carry the median nerve inwards along with the vein, and take up the artery between the nerve and coraco-brachialis. Occasionally the artery is found between the two long roots of the median nerve. It is then to be taken up between them. This method of Lisfranc is the easiest process for ligature of the axillary artery, but is only applicable in affections of the brachial between the armpit and the elbow joint. Before beginning the operation it is well to mark first with the eye the position of the outer border of the scalenus, at the upper margin of the clavicle, which is an inch and five-eighths out from the sternal end of that bone ; as this is in the line of direction of the axillary artery. LIGATURE OF THE BRACHIAL ARTERY. (PL. XII.) Surgical anatomy. — This artery, which is a continuation of the axillary, descends in a straight line in the muscular groove found between the inner edge of the coraco-brachialis and biceps in front, and the triceps extensor cubiti behind. About an inch and a half above the elbow joint, it bends slightly outwards along the interior edge of the biceps, and crosses the face of the brachialis anticus so as to reach the middle of the bend of the arm. At this point, it is covered by the aponeurotic expansion sent off inwards and downwards from the tendon of the biceps, and divides into the radial and ulnar arteries, just at the insertion of the muscle on the tuberosity of the radius. The brachial artery, in a sub- ject moderately muscular, is found about half an inch below the surface. It is covered by the integument, a superficial fascia consisting of two thin layers, and a deep-seated muscular or bra- chial aponeurosis. Just above the elbow joint, it is slightly over- lapped by the internal edge of the belly of the biceps. On its inner side, and in close connection, is found the trunk of the bra- chial vein; but where there are two satellite veins, the artery is placed between them. The median nerve has important relations with the artery, and serves as a guide for its discovery in ligature of the vessel. At the superior and middle third of the arm, the nerve is found at the external and front margin of the artery. About two inches and a half above the elbow joint, it crosses obliquely in front of the artery so as to get completely to its inner side. The ulnar nerve passes down the arm at some little distance within and behind the artery, in the direction of the back part of the internal condyle. The internal cutaneous is found at the inner surface and somewhat in front of the vessel. The vessSs, in their descent along the arm, are surrounded by loose cellular tissue rather than a distinct sheath. The artery, in a healthy state of the parts, can be felt pulsating through the skin, and may be tied in any portion of its course. Anomalies. — Nothing is more common than anomalies in the distribution of this vessel. It may divide, as before observed, into its radial and ulnar branches as high as the armpit; or at any part of its course down the arm. The frequency of this irregular distribution should be well understood. It is said by Prof Quain to occur in one case out of five. Fortunately, it may usually be detected by careful examination ; otherwise, the surgeon might become embarrassed in attempting to check a hemorrhage or cure an aneurism, in finding that he had exposed a vessel which was not the subject of disease. He may, before beginning the incision, by alternately compressing the respective branches, be able to discover which is the proper subject of operation. It may be necessary even to tie both branches, as they are sometimes found to have direct communication with each other at the elbow ; and this double operation could be attended with no greater danger than the single ligature of the undivided trunk. In cases of divi- sion high up, the branches are usually found running down near together, (the radial usually being the more superficial and exter- nal,) to the neighbourhood of the elbow joint where they diverge. Anastom.osis. — The anastomosing branches by which the Cir- culation is carried on after obliteration of the brachial trunk, are the profunda major, profunda minor, and the anastomotica on the part of this artery. The profunda major is usually given off near the armpit, the principal branch of which, the musculo- spiral, winding round the bone with the nerve of that name, forms a continuous trunk with the recurrens radialis in front of the external condyle, and is connected also by a branch with the interosseal recurrent at the back part of the joint. The pro- funda minor, descending behind the brachial artery as far as the middle of the arm, sends a branch of considerable size down with the ulnar nerve behind the inner condyle, which inoscu- lates with and forms a continuous tube with the recurrens ulnaris. The anastomotica, coming off an inch or two above the elbow joint, winds across the brachialis anticus, and divides into two branches, one of which, passing in front of the outer condyle, unites with the radial recurrent, and the other dips down between the capsule and olecranon process to anastomose with the inter- osseal recurrent. Remarks. — The brachial artery, in consequence of its proximity to the bone, may be readily compressed in any part of its course with the extremities of the fingers or a compress and bandage. If the latter means be used, the compress should be of moderate size, so as to admit of being pressed under the edge of the biceps. It is well to avoid making compression at the point where the artery passes over the insertion of the coraco-brachialis muscle, as here the median nerve is placed in such relation to it as to be pain- fully affected by the force applied. From the mobility and exposed position of the arm, and the frequency of venesection at the elbow, it is of all the larger arte- ries most exposed to traumatic injury. If there be lesion of the vessel above the elbow, we may tie it either at the place injured, or, if there is such infiltration of blood as to mask the parts, cut down upon it in any point above. In case of puncture of the artery in venesection at the elbow, the course to be pursued varies according to circumstances. Pressure made with gradu- ated compresses, covered with a piece of coin or other metal, or with a special apparatus for the purpose, may, particularly if the. wound be longitudinal, so diminish the calibre of the vessel as to allow the wound both in the artery and vein to heal. But to suc- ceed, it must be immediately applied, and is not even then a cer- tain measure. If it fail, or the case be altogether neglected in its first stage, even though the wound on the two surfaces of the vein should heal, we may have a false aneurism developed in its sheath or in the surrounding cellular tissue, constituting a resisting LIGATURE OF THE DIFFERENT ARTERIES. 61 pulsating tumour below the bicipital aponeurosis, limiting the extension of the arm, and as it grows in size bulging up just above the upper margin of this membrane, where the fascia is weakest. Or there may be instead, direct communication between the artery and superficial vein. The posterior wound in the vein and that of the artery not healing by first intention, and being brought into close contact by the compression necessary to stop the hemor- rhage, the blood of the artery leaves its route to the hand, and turning in a direction in which it meets less resistance, forms an oblong prominent pulsating tumour in the superficial veins at the elbow, constituting what is called a varicose or arterio- venous aneurism. The communication, as has been observed, may be made di- rectly between the artery and the superficial vein, both of which become matted together by the effects of the compression, and closely adhere to the opposite surfaces of the intermediate bicipital aponeurosis ; or it may be indirect, the cyst of a circumscribed false aneurism being formed, which receives the blood at its bot- tom through the opening in the artery, and discharges it at its top, through the orifice in the posterior wall of the vein. The punc- ture in the anterior wall of the vein is always found closed through union by first intention. Or another kind of arterio-venous aneurism may be formed ; the artery first pouring out its blood into one of its satellite veins, through which as well as the superficial vein, the lancet has in that case passed ; the two orifices of the latter vein healing up, while the blood of the artery poured into its satellite, finds its way through the deep communicating radial vein (see page 16) into the super- ficial veins, and generally into the median basilic, which is often found dilated and pulsating in all its course up the arm. Three cases only of this description have been well reported,* and a fourth has lately occurred in this city, which came under the notice of Dr. John Wilson Moore, with whom I saw the patient in consulta- tion. But they must be" unquestionably of much more frequent occurrence ; for the manner in which the satellite veins overlap the brachial artery, show that they are more or less exposed to injury whenever the lancet is carried so deep as to open the latter vessel; and the discrepancies which exist among writers, in their description of arterio-venous aneurism at the bend of the arm, show that the pathology of this form of the disease has been but imperfectly understood. This latter form, to which, for the sake of distinction, I would restrict the name of aneurismal varix, is an affection not to be lightly attacked by an operation, and perhaps only with safety in its early stages ; a retaining bandage or a laced sleeve, serving even where the disease is advanced, to check the distension of the vein, and preserve in a good degree the uses of the limb. Each vein, cut in these cases at the bend of the elbow, bleeds as an artery in consequence of the arterial blood being mainly directed through the veins. Profuse irrepressible hemorrhage, gangrene, and subsequent death, followed an attempt to cure by operation an aggravated case of this kind, in the hands of M. RouTp-t It is to be distinguished from the ordinary kinds * One by Park, of Liverpool, (Bell's Principles of Surgery. Vol. I. p. 303,) one by P. Adelmann, (Tractatus Anat. Ohirurg. de Aneurysmatice Spurio Vari- cose, Wurceburgi, 1821,) and one by Claudius Tarral, (Cyclop. Pract. Surg.) f Vide Cyclop. Pract. Surgery, article Bend of Arm, by C. Tarral. 16 of aneu^rismal varix, by the general dilatation and pulsation of the vein, (owing to the oblique direction in which the blood comes from the communicating branch,) rather than by a single rounded prominence ; by the fact that the blood is found to enter below the cicatrized puncture of the vein ; and that by pressure of the thumb below the puncture so as to flatten completely the commu- nicating vein, we stop without arresting the action of the artery all pulsation in the superficial vessels. In the commoner form of aneurismal varix, when the communication between the super- ficial vein and artery exists at the place of puncture, either directly or by the intervention of a cyst formed out of the intermediate cellular tissue, pressure made as described, at the entrance of the communicating vein, will have little or no influence on the pulsa- tion of the superficial vessels. As soon as the injury of the artery by venesection or other means is detected, it is incontestably the surest course at once to recur to the ligature of the vessel, in order to prevent either of the consequences that may follow — the common form of false aneurism, varicose aneurism, or that to which I have limited the term of aneurismal varix. Two methods of proceeding are then open to the practitioner — to incise the parts at the bend of the arm, and tie the artery above and below the place of puncture; or follow the method of Hunter, and tie it where it is more readily exposed in its course along the biceps muscle. If the operation be done shortly after the occurrence of the injury, the former method is not ordinarily the best, inasmuch as if is desirable to avoid an incision at the elbow, in consequence of the deeper covering of the artery, its complex relation with the veins of that region, and its obscuration from the extravasation of blood which to more or less extent takes place. The method of Hunter is a more simple process, and if soon applied is equally successful ; for it has been fully proved by experience, that the anastomosing vessels will not dilate so as to restore the circulation of the wounded trunk till sufficient time has been allowed for the healing of the puncture made in it by the lancet ; and to this, compression may if necessary be added at the bend of the arm. A great accumulation of ef- fused blood at the bend of the arm, pressing on the origin of the recurrent radial and ulnar arteries, might, however, as a case of exception, render it better to cut down, turn out the clot, and tie the brachial above and below the place at which it is wounded. The principles involved in the Hunterian operation of tying the artery at a remote distance from the tumour, are not so bind- ing here, where we have to deal with a sound vessel accidentally injured. A distant ligature, though it may answer if applied immediately after the injury, is not to be relied on in case much time has elapsed since the occurrence of the injury, if a large aneu- rismal tumour has been formed, or if compression has for some time been made from without; for froni all these causes the anas- tomosing branches become enlarged, and the blood will find its way into the trunk at the elbow, both by the inferior arteries of the joint and the superior branch called the anastomotica magna. For these reasons I prefer always to tie the trunk an inch to an inch and a half above the joint and below the origin of the anas- tomotica. This simple operation has in ray hands succeeded per- fectly in four cases, which were respectively of four, five, eight, and nine weeks standing, in each of which, tumours of considera- ble size had already formed. In another of nine weeks stand- 62 GENERAL OPERATIONS. ing, a case of proper aneurismal varix, upon which firm pressure had been steadily kept up, so as to cause great enlargement of the profunda minor, the pulsation of the reins, though not entirely removed by the ligature of the brachial, was and still remains considerably reduced by the operation, so that the arm has been Restored to very nearly its former degree of usefulness. A circum- stance connected with the operation in this case is worth noting; — ^pressure made upon the brachial (which was a single trunk) through the integuments above the elbow, stopped all pulsation in the artery and veins below; the profunda minor, which was after- wards found greatly dilated, having been at the same time in the line of compression. But after the ligature of the brachial, the profunda served to keep up some pulsation in the vein, through its anastomosis with the vessels below the joint. In old cases, the profunda minor has been found enlarged to a size nearly equal with that of the brachial, and in calculating the effect of a single ligature above the elbow, it is necessary that pressure should be made separately on the brachial trunk so as not to interrupt the current in the profunda minor. Such is the tend- ency to rapid dilatation of the branches in general about the joint, that in instances of longer standing than those already specified, and much less even if strong compression has been employed, the method of operation commonly deemed proper is the old plan of opening the parts at the bend of the arm, and tying the artery above and below the place of puncture. Yet there are unques- tionable exceptions to this rule. Within the last two months the author has applied a single ligature upon the brachial artery within an inch of the tumour, in the case of an elderly lady, a patient of Dr. Ridgway, residing in Columbus, New Jersey. The tumour, which consisted of a varicose aneurism, was of sixteen weeks' standing, and of very large size. Pressure upon the brachial artery being found to arrest all pulsation in the tumour, and believing that the anastomosing vessels would yield less readily to the dilating forces in old persons, I deemed it proper to try the effect of a single ligature, in the manner above described. A complete and speedy cure was the result. The basilic vein was found as large as the finger, pulsating like an artery, and crossed the line of the incision just above the base of the tumour, rendering it necessary to observe great caution in the use of the knife in open- ing the sheath of the vessels. In conclusion, it may be observed that Dr. Colles, of Dublin, has stated that in no case of aneurism at the bend of the arm, has he found it necessary to open the sac, or apply more than one ligature, and that immediately above it. LIGATURE AT THE MIDDLE PART OF THE OS HUMERI. (PL. XII.) Operation. — The arm is to be moderately carried out from the body, the forearm placed in extension and supinated. The shoul- der is to be sustained by one assistant, and the forearm and hand by another. The surgeon feels along the inner edge of the biceps (or of the coraco-brachialis, if the operation be done higher up) for the groove formed between it and the triceps, in which are lodged the vessels and nerve. Lisfranc's direction is, to place the four fingers of the left hand on the median nerve, and incise the skin along their inner border. But in the living subject, the pulsation of the artery itself forms a better guide. The cellular tissue may, however, from inflammation, be found so cedematous and pasty, as to obscure both vessel and nerVe. I prefer, there- fore, in all cases, to cut neatly down immediately upon the in- ternal edge of the biceps muscle, upon which the ends of three fingers of the left hand are to rest. An incision of two and a half inches in extent, beginning below, if it be the left arm, and above, if it be the right, is to be made first through the skin merely, for fear of wounding the basilic vein. The brachial aponeurosis is then to be opened and slit at the bottom of the wound its whole length on the director, the basilic vein being carried out of the way and to the outer side of the wound. Immediately adjoining the edge of the muscle, we find the median nerve. This, with the muscle, is to be drawn gently outwards with a blunt hook, or, which is to be preferred, the fingers of an assistant. Sometimes, however, from the position of the nerve, it will be found most convenient to draw it to the inner side. Below it is seen the sheath of the vessels, and to its inner edge, the internal cutane- ous nerve; the ulnal: nerve lying about half an inch farther back. The sheath is to be carefully opened and the artery will be found either lodged between two veins or with one large venous trunk at its inner side. Isolate the artery on either side with the point of the director, and glide the instrument below from within out- wards, pushing up with the left fore finger the median nerve, so as to prevent its being raised with the artery. If by any blunder with the knife, the artery be wounded during the operation, the hemorrhage may be instantly arrested by pressure made above with the fingers of an assistant as shown in Plate VII. Some apply a tourniquet upon the arm, but this arrests the pulsation of the ves- sel, and renders the finding of it less easy. If used at all, it should merely be laid loosely upon the arm as a measure of precaution. LIGATURE IMMEDIATELY ABOVE THE ELBOW JOINT. (PL. XIII.) Operation. [Process followed by the author for aneurism at the bend of the ai-m.) — The arm, placed in the same situation as above described, an incision two and a half inches long is to be made over the inner edge of the inferior termination of the belly of the biceps. The lower end of the incision will be just above the fold of the elbow, and its direction will be upwards and slightly inwards. The skin alone is to be first divided. The superficial fascia is to be punctured on the edge of the muscle, raised on the director and carefully opened. The basilic vein will be found parallel with and to the inner side of the wound. The deep- seated or brachial aponeurosis is next to be raised and cut in the same manner. The inner edge of the biceps is now to be moved outwards with a blunt hook, and the basilic vein and internal margin of the wound carried in the opposite direction. Adjoin- ing the edge of the muscle we observe first the median nerve, distinguished by its whiteness, which has crossed over in front and now lies to the inner side of the artery, covering the inner brachial vein ; it is to be drawn inwards and the vessels will be seen about a quarter of an inch behind it, previously overlapped by the belly of the muscle. The sheath is to be careifully raised with the forceps, and opened with the point of the director. The artery is now seen lodged between its two satellite veins, from which it is to be isolated on the director. The ligature is then carried round it in the usual manner. Occasionally the median nerve has different relations with the artery, crossing behind it LIGATURE OF THE DIFFERENT ARTERIES. ea iastead of iij front, and getting at the place of this operation near a quarter of an inch to its inner and posterior side. In such cases the first part seen by the edge of the muscle would be the artery itself. LIGATURE At THE BEND OF THE ELBOW. (PL. XIV.) Operation. — It is practised for recent traumatic injury of the vessel, for false aneurism, or one of the forms of arterio-venous aneurism. The arm is to be placed in the position, and secured as indicated above. The artery is to be compressed with a tour- niquet or the fingers of an intelligent assistant. The surgeon ascertains with his finger the course of the artery from the middle of the elbow joint inwards and upwards along the inner edge of the biceps, and which is usually well indicated by the course of the median basilic vein. Depressing the skin in this direction with the fingers of the left hand, he makes an incision which should extend an inch above and an inch below the level of the condyles. The skin, which is very thin in this region, should alone be divided by the first incision. The median basilic vein and the internal cutaneous nerve will be seen lodged in the su- perficial fascia, at the inner side of the cut. Raise and open the superficial fascia carefully on the director, and carry the vein to either side that is most convenient ; — usually it will be found easiest to move it downwards and inwards. The brachial apo- neurosis next comes into view, strengthened at this point by the expansion of the biceps tendon. With the forceps, raise at the middle of the wound a fold of this double niembrane, puncture it with the scalpel, and then open it upwards and downwards on the director. The artery and its veins and the adjoining nerves next come into view. To the inner side of the artery, and more super- ficial than it, may be felt first the median nerve at the top of the wound. At the middle of the elbow it is removed farther from the line of incision, and is sometimes not brought into view at all during the operation. The nerve, whether felt or seen, is to be carried gently inwards with a blunt hook. The sheath of the vessels, which lies about, a third of an inch to the outer side of the nerve, is now to be opened in the usual manner, and the artery is found lodged either between two veins, or, as occasionally hap- pens, with a single large venous trunk to its inner side. Isolate the artery from the veins with the point of the director, first upon its outer and then on its inner side; or if there have been much inflammation and thickening of the cellular structure, it may be necessary, as I have found it in one case, to raise the vein with the forceps, and separate it from the artery with gentle touches of the point of the scalpel. The director is then to be passed below the artery from within outwards, carefully excluding the vein or veins, and the ligature passed as usual. The passing of the di- rector will be facilitated by a slight flexion of the forearm. OF THE ARTERIES OF THE FOREARM. LIGATURE OF THE RADIAL ARTERY. Surgical anatomy. — The radial artery usually arises from the brachial near the bicipital protuberance of the radius, and descends nearly in a straight line frotn the middle of the bend of the elboW to the inner margin of the styloid process, at the lower extremity of the same bone. In the upper half of the forearm the artery lies between the fleshy belly of the supinator radii longus on the outer side, and that of the pronator radii teres on the inner, and in thin subjects is covered only by the skin, superficial fascia and brachial aponeurosis; but in muscular subjects it is concealed by the edge of the supinator, which projects over it. It rests on the supinator brevis above, and somewhat lower on' the tendinous insertion of the pronator radii teres. The radial nerve is placed above, at some distance on the outer side of the artery, and comes in contact with it only (and still at the outer side) near the middle of the forearm. The lower half of the radial is very superficial, lies just in front of the bone, and can be felt pulsating. It has the tendon of the supinator longus immediately at its outer side, and the tendon of the flexor carpi radialis within. It turns round the base of the thumb under its extensor tendons, to get to the back of the hand, and dips down between the metacarpal bones of the thumb and fore finger to reach the palm, where it forms the deep-seated palmar arch. Before it turns to the back of the hand, it sends a branch over the ball of the thumb to form a direct anastomosis with the ulnar or superficial arch. This branch, the superjicialis voice, is sometimes so large that when cut it will require to be tied, or have a ligature thrown upon the radial. The radial nerve is in contact with the artery only at the middle third of its course, leaving it four inches above the wrist to pass under the tendon of the supinator, and becomes cutaneous on ths back of the hand. Two satellite veins attend the artery. The radial artery may be tied at its upper, middle, or inferior third. Anomalies. — The principal anomalies in reference to the origin of this vessel and the ulnar have already been described. It may be observed, that the radial of one side sometimes receives the anterior interosseal artery, which, when large, serves to explain many of the cases of disparity existing in regard to the size of the arteries of the two wrists. AT THE UPPER THIRD OP THE FOREARM. (PL. XIV.) Operation. — The arm is to be extended and laid on its dorsal aspect. The artery is to be sought for along the inner margin of the supinator longus. If the artery can be felt pulsating, or this muscle can be made to contract so as to show its inner border, the line of incision is at once designated. But if neither of these rules can be applied, we are to recollect that the course of the artery at this region is exactly in that of a line drawn from the external border of the tendon of the biceps to the inside of the styloid process of the radius. In this direction the skin is to be incised for two inches, crossing the line of the vessel a little at its outer border. Any superficial vein crossing the wound is to be drawn to one side ; the superficial fascia and brachial aponeurosis are to be divided on the director. The inner margin of the supi- nator is then to be sought for. The first yellow line observed starting from the lower and outer part of the incision, indicates the interval between this muscle and the pronator. The muscles are to be separated with the point of the director, and the supi- nator with its investing fascia drawn outwards. The artery and its veins are now exposed in their sheath, the radial nerve run- 64 GENERAL OPERATIONS. ning down at a little distance on their outer side. The sheath of the vessels is sometimes seen masked with fat. Tear this as well as the sheath of the vessels with the point of the director, a fold of the latter being previously raised with the forceps. The vessel may now be isolated and secured in the usual manner. AT THE MIDDLE OR LOWER THIRD OF THE FOREARM. (PL. XIII.) Operation. — In either of these situations, the artery is super- ficial and the operation easy. Placing the arm in the position designated above, and tracing the line of the vessel already given, we find it pulsating at the inner border of the tendon of the supi- nator longus. In the groove between this tendon and that of the flexor carpii radialis, we depress the skin and divide it for the space of two inches. The superficial veins and nerves crossing the wound are to be drawn to one side, and the superficial and deep-seated fasciae divided. The sheath of the vessels is now exposed. This is to be opened, and the artery isolated and raised on the director, which is to be passed from within outwards. LIGATURE ON THE BACK OF THE WRIST. (PL. XIV,) Operation. — The radial artery may readily be tied on the back of the wrist, as has been proposed in case of wound of the deep- PLATE XIIL— LIGATURE OF THE ARTERIES OF TEE ARM. {Fig. 1. A A^). OF THE ULNAR ARTERY IN ITS MIDDLE THIRD. The incision is made along the radial edge of the flexor carpi ulnaris muscle. The position in which the arm is placed, to show the other operations, brings the wound apparently too near the inner edge. a. Forefinger of an assistant drawing off the inner lip of the wound. b. Blunt hook, of a convenient form, curved at the end so as to resemble in shape a bent finger, with which one lip of the wound and the flexor sublimis of the fingers are drawn outwards and depressed. 1. Line of division of the skin. 2. Section of the aponeurosis. 3. Flexor carpi ulnaris drawn inwards. 5. Flexor sublimis digitorum drawn outwards and depressed. 6. Ulnar nerve. 7. Ulnar artery, raised on the aneurismal needle. 8. Ulnar vein. (B B^). OF THE RADIAL IN ITS INFERIOR THIRD. The skin is divided along the inner edge of the supinator radii longus. 1, 2. Division of the skin and aponeurosis. 6. Radial artery between its satellite veins (7). (C C^). OF THE ULNAR NEAR THE PALM. 1, 2. Section of the skin and aponeurotic layers. 5. Ulnar artery raised on an eyed probe, accompanied by a satellite vein (6) on either side. (D D^). OF THE BRACHIAL JUST ABOVE THE ELBOW JOINT. {Process of the author.) The incision is made over the inner edge of the biceps just above its insertion, and the lips of the wound widely separated to show the neighbouring parts. 1, 2. Skin and brachial aponeurosis divided. 3. Median basilic vein drawn inwards ; a branch of the internal cutaneous nerve passing at its outer side. 4. Inner edge of the biceps drawn outwards. 5. Median nerve. 6. One of the deep-seated or satellite brachial veins, as seen in the subject from which this drawing was taken. 7. Brachial artery raised on the ligature from between its satellite veins. (EE^). OF THE ANTERIOR INTEROSSEAL. {Process of the author.) The incision is made at the lower part of the middle third of the arm, so as to cross slightly the intermuscular depression between the superficial and deep-seated flexor muscles. /'V'y / riate J 3 l/r »' ■J !l //' ■I I '■ i-iS j.#<^'' .,^-^ i / ■n' /'; ''>y ^' LIGATUEE OF THE DIFFERENT ARTERIES. 65 seated palmar arch. But the process is unused ; preference being justly given to ligature of the radial in its lower third, since the volar branch would still be left to supply the superficial arch which is intimately connected by anastomosis with the deep- sieated. To tie it on the back of the wrist, the hand should be placed in half pronation, with its radial edge upwards. The thumb is to be extended and abducted so as to render prominent the tendons of the extensor major, and the extensor minor pol- licis manus. From the triangular depression between them, the artery will be felt pulsating in the cleft between the posterior ex- tremities of the first two metacarpal bones, an inch and a half to an inch and- three-quarters above the commissure of the thumb and forefinger. The tendon of the extensor major pollicis in a fleshy hand cannot be very distinctly felt; that of the extensor minor pollicis, and that of the extensor ossi-metacarpi pollicis, lying ■ immediately on the radial side of the extensor minor, can always be found. On the ulnar side of the two latter, the artery may be felt. Divide the skin between the tendons above men- tioned for the space of an inch and a half, draw to one sid* the superficial radial vein and nerve, and open the aponeurosis below to the same extent on a director. The artery is then to be isolated from its veins, and a ligature placed about it in the usual way, just where it crosses the os trapezium to dip into the palm. LIGATUBB OF THE ULNAR ARTERY. Surgical anatomy,— It arises from the brachial artery at the same point with the radial, and for the upper third of the fore* 1. Skin and brachial aponeurosis divided. 2. Flexor sublimis drawn outwards. 3. Deep-seated flexor muscle of t^e fingers drawn strongly inwards with a blunt hook, the fingers being flexed so as to relax the muscles. 4. Margin of interosseous ligament, seen below the fibres of the muscle over which runs the interosseous nerve. The nerve, before it is drawn outwards, lies slightly to the radial side of the artery. 5. Interosseous artery, with its vein (7). The artery is raised on a ligature. (F). OF THE TERMINAL PALMAR BRANCHES OF THE ULNAR ARTERY. These will scarcely ever require to be tied, except in case of wound. The palmar aponeurosis has been excised so as to expose the course of the vessel. 1. Ligature placed round the termination of the ulnar trunk, which has here formed the superficial palmar arch. 2. A ligature round the. branch, by which it anastomoses with the radial. 3. Another ligature round a branch which goes to the outer side of the forefinger. Fig. 2.-' This is intended to show the surgical relations of the ulnar and radial arteries in their descent. (A). 1, 1, 2, 2. Section of the skin and aponeurosis. 4. Humeral artery raised at its place of bifurcation. 5. Common radial vein. 6. Median basilic. ' 7. Median cephalic. ' ' 8. Deep-seated humeral or brachial. 9. Median nerve. ' ' (B). 1, 2^. Section of skui and aponeurosis. 3. Flexor Carpi ulnaris' drawn inwards. 5. Flexor sublimis drawn outwards. 6. Ulnar nerve. 7. Ulnar artery between its two veins (8, 8). ' (C). 2. Section of the aponeurosis investing the artery over the anterior palmar ligament. 5, 5, 5. Ulnar artery betwe'en its tVo satellite veins (6). ,7. Ulnar nerve. (E). 3. Tendon of the supinator radii longus. 5. Radial nerve. 6. Radial artery. 7,7. Radial veins. (F). ,2. Section of aponeurosis, 3. Pronator radii teres and palmaris longus drawn inwards, 4. Supinator muscle drawn outwards. 5. Radial a|ttaph,nient of- the flexor sublimis digitorum. 6. Radial nerve. 7. Radial artery. 8. Inner radial vein. 17 66 GENERAL OPERATIONS. arm runs obliquely downwards and inwards, under all the muscles which are attached to the internal condyle of the os humeri, and in the direction of a line drawn from the external border of the tendon of the biceps, to the radial margin of the ulna at the junc- tion of its upper and middle third. The artery is here deeply placed, lying between the superficial and deep-seated layer of muscles, resting as it does on the anterior surface of the flexor profundus, and covered by the deep-seated aponeurosis which separates these muscular layers. In the middle and lower third of the arm, it runs perpendicularly downwards, in the course of a line drawn from the epitrochlea* of the os humeri to the radial margin of the pisiform bone. In its middle third the artery is * The epitrochlea is the internal tuberosity of the os humeri above its surface of articulation with the ulna. overlapped by the bellies of the flexor carpi ulnaris, and the flexor sublimis digitorum, which are often in muscular subjects united together by a line of dense yellow cellular tissue over the vessel. In the inferior third of the forearm the artery is lodged between the tendons of these muscles, and is superficial, being covered only by the skin, superficial fascia and brachial aponeurosis. From the side of the pisiform bone, the artery is extended over the annular ligament of the wrist so as to form on the palm the superficial palmar arch, and is covered by the skin, palmaris brevis muscle, some dense layers of fatty cellular tissue, and the palmar aponeurosis. It is attended by two satellite veins throughout its course. The ulnar nerve joins the artery just above the middle of the arm, and is continued down on its ulnar side to the palm. With the exception of the recurrent to the elbow, the ulnar artery PLATE XIV.-LIGATUIIE OF THE ARTERIES OF THE FOREARM. {Fig. 1. A^) OF THE BRACHIAL AT THE BEND OF THE ELBOW. The integuments are divided in the direction of a line drawn from the middle of the space between the condyles of the humerus obliquely upwards and inwards towards the inner margin of the biceps muscle. (A). Median basilic vein. (B B). Aponeurotic expansion of the biceps, divided. (0). Pronator radii teres. 1. Brachial artery with its accompanying vein. 2. Median nerve. The vein is seen lying between the nerve and the artery. The ligature is seen placed around the artery. (B^). OF THE RADIAL AT THE MIDDLE THIRD OF THE FOREARM. In the drawing, the operation is placed a little too high.. The incision is made over the inner edge of the supinator radii longus muscle, a, a. Superficial aponeurosis of the forearm divided. (B). Supinator radii longus muscle. (G). Outer edge of the flexor sublimis digitorum. 1. Radial artery raised on a ligature with a satellite vein on either side. (C^). OF THE ULNAR ARTERY AT ITS LOWER THIRD. The incision is made along the radial or outer edge of the flexor carpi ulnaris muscle, a, a. Superficial aponeurosis divided. 1. Ulnar artery with its venee comites. 2. Ulnar nerve. (D). OF THE SUPERFICIAL PALMAR ARCH FORMED BY THE ULNAR. The ligature of this vessel is rarely practised, except in wounds of the palm, which it is merely necessary to dilate in order to reach the vessel. J " ' 1. Incision of the skin. 2. Section of the palmar aponeurosis. 3. Ulnar artery between its two veins. One ligature is passed below the artery where it appears in the calm • and another under the first digital branch, which might continue the bleeig in the cTe f a wounf^n consequence of its anastomosis with the deep-seated arch formed by the radial artery. {Fig. 2.) LIGATURE OF THE RADIAL ON THE BACK OF THE HAND. ^V^ /^^rf/^ //. Missing Page Missing Page 68 third of the arm, and carried downwards in the direction of the styloid process pf the ulna. The skin and fascia being divided, ■we fall into the line of separation between the superficial and deep- seated flexors, the latter of which will be known by the tendinous matter on its front surface. The space between these muscles is to be separated with the finger, which should be worked down in the direction of the inner edge of the radius, until the interosseous ligament is felt. The finger is then to be pressed inwards on the membrane so as to loosen and raise up the edge of the deep-seated flexor under which the artery is placed. The needle is then to be passed round the vessel from without inwards, so as to avoid the interosseous nerve, which is seen upon the edge of the muscle. After the opening of the skin and fascia, the knife is no more to be used. ARTERIES OF THE TRUNK. LIGATURE OF THE ABDOMINAL AORTA. Surgical anatomy. — The abdominal aorta, after passing the diaphragm, where it is a little to the left of the middle line, gets gradually more in front of the vertebral column, and divides into its two primitive iliac branches at the lower border of the fourth lumbar vertebra. The lower portion of the aorta, or that be- tween the transverse part of the duodenum and its bifurcation, is the only one which particularly interests the surgeon ; the upper division of this portion, from the facility with which, in the neigh- bourhood of the umbilicus, we may by strong compression arrest the flow of blood down the vessel, and thus temporarily check hemorrhage from the arteries within the cavity of the pelvis ; and vits lower division, that, immediately above the origin of the in- ferior mesenteric, half an inch to an inch or more in length, in consequence of the possibility of applying a ligature upon it in aneurism or wound of the primitive iliacs. On the right side the aorta is flanked by the ascending vena cava, and on the left by the psoas muscle ; it is covered directly in front, in common with that vein, by an aponeurotic sheath, in which are lodged numerous branches of the sympathetic nerve, a chain of lymphatic glands, and in front of these a layer derived from the posterior parietal peritoneum. The distance of the artery from the abdominal in- teguments will vary in proportion to the thinness or obesity of the subject; but on the average will be found to be between three and four inches, covered only by the walls of the abdomen and the mass of small intestines. Anastomosis. — There are several anastomosing vessels, by which the circulation of the blood might be restored to the lower extremi- ties, a result which has many times been found attendant on acci- dental obliteration of the aorta in man, and its experimental liga- ture in dogs. The most important of these are the internal mammary, which anastomoses with the epigastric ; the lumbar and interosseals, which are connected at their extremities with the ileo-lumbar and circumflexa ilii: and when the ligature is placed, as is considered most advisable, above the origin of the inferior mesenteric, the blood might be' restored to the leg through the agency of this latter artery, which is more or less directly in com- munication through the hemorrhoidal with most of the branches GENERAL OPERATIONS. that go out from the pelvis, and is united above to the superior mesenteric by some very large anastomosing branches. Remarks.—S'mce the attention of surgeons has been called to this subject, more than forty cases have been reported of con- traction or accidental obliteration of the aorta from the pressure of tumours or other causes, all of which tend to prove the possi- bility, as before observed, of a return of the circulation to the lower extremities after the obliteration of the lumbar portion of this vessel. Upon these facts, in cases admitting of no other chances of relief, has been founded the hope of success in cuttingi down upon and tying this important trunk, rather than upon the results of experiments on dogs, whose tenacity of life surpasses that of man. In the three cases in which it has been tied in the living subject, the issue did not justify the boldness of the pro-i ceeding, and it is very questionable whether any case could occur- that would fully sanction the step. Apart from the great size of the vessel, we run the risk of finding it diseased in aneurism of the primitive iliac, and of many of the collateral vessels being ob- literated by the tumour. If there be wound of the iliac arteries of much size, time would not be afforded for the operation ; and if it be a puncture, merely, the surgeon could not satisfy himself' sufficiently well in regard to the origin of the hemorrhage to justify the tying of the aortic trunk. Gangrene, from want of a return of the circulation to the lower extremities, peritonitis and hemor- rhage, are the accidents to be apprehended in ligature of the aorta. The first operation of this kind was done by Sir A. Cooper' in 1817, and his patient died at the end of forty hours. Mr. James,* of Exeter, operated in 1829, and the patient sunk three hours after: Mr. Murray performed a similar operation at the Cape of Good Hope in 1834, and his patient died at the end of twenty-three' hours. ' Operation. (Process of Sir A. Cooper.)^— The patient laid upon his back, with his thighs and head flexed upon the trunk, an incision three inches in length is made on the left side of the um- bilicus in the direction of the linea alba. A slight curvature is given to the line, in order to avoid the umbilicus, which sh<*Urld be just opposite the centre of the incision. The linea alba is to be cut through, and, an aperture being made in the peritoneum behind it, the finger is to be introduced, and that membrane di- vided with a probe-pointed bistoury to the exteht of the external wound. Gliding the fore finger down upon the spine, pushing' to one side the intestinal convolutions, the pulsations of the aorta are readily felt. With the finger nail an opening is to be scratched in the peritoneum and aponeurotic layer immediately upon the left side of the vessel. The finger is then to be passed between it' and the spine, and brought out on the right side between it and the vena cava. The finger serving as a conductor, the ligature is carried by a blunt needle under the vessel, and tied in the usual manner, care being taken at the same time to keep the noose clear of the intestines. The wound in the parietes is to be closed with the quilled suture and adhesive straps. One end of the ligature is to be removed with the scissors, the other secured on the left side of the wound. Sir A. Cooper tied the vessel three quarters of an inch above its bifurcation and below the origin of the inferior mesenteric, and in this he was followed in the two other cases above noticed in which it was tied. It has been proposed, instead of opening the peritoneum, to incise the walls of the ab- LIGATURfi OF THE DIFFERENT ARTERIES. 69 domen on the left flank, and push off the serous membrane with the fingers till the artery could be reached. LIGATURE OF THE ILIAC ARTERIES, Surgical anatomy. — The primitive iliac arteries are formed by the bifurcation of the aorta. They diverge from each other, and running obliquely downwards and outwards, each divides oppo- site, or nearly so, to the sacro-iliac symphysis, into the internal and external iliacs. The average length of the common or primi- tive iliac arteries is about two inches and a half. The relation of the arteries of the two sides is, however, different. Each of the common iliacs has in front of it the peritoneum, and is crossed near its bifurcation by the ureter, by the spermatic vessels and nerves, and has the psoas muscle to its outer side. The right crosses in front of the left common iliac vein, and rests upon its own corresponding venous trunk. The left common iliac ar- tery is crossed in addition by the branches of the inferior mesen- teric artery, which descend into the pelvis; its vein is below and slightly to its inner side. Neither iliac artery gives off branches previous to its bifurcation. The internal iliac artery in the, adult is a short, stout trunk, about an inch and a half long. It is directed almost perpendicu- larly downwards and inwards, from the sacro-iliac symphysis to the upper part of the sacro-sciatic notch, where it divides into several branches. The vein which accompanies it lies on Its outer and posterior surface. ' The external iliac is apparently the continuation of the primi- tive trunk, as both are placed at the inner side of the psoas muscle ; and in the unopened abdomen a line drawn from the umbilicus to Poupart's ligament a half an inch internal to its centre, will be found directly over both of these vessels. The external iliac artery has its vein lying on its inner side ; on its outer are two or three small branches from the lumJ'ar plexus of nerves, and be- yond these again to the outer side of the psoas muscle lies the anterior crural nerve. Near Poupart's ligament it crosses in front of the psoas, and, emerging upon the thigh below that ligament, takes the name of femoral. Near this point of emergence it is crossed by the spermatic vessels, by the circumflexa ilii vein, and by the vas deferens, which, on turning down into the pelvis, touches its inner side. Above the ligament it gives off the epi- gastric and circumflex iliac arteries. . It, as well as the primitive and internal iliac, is covered in front with peritoneum and some very loose subserous cellular tissue. On the right side it is cross- ed by the small intestines as they go to terminate in the caecum, and on the left has in front of it the sigmoid flexure of the colon. Anomalies. — In reference to these great arterial trunks, anoma- lies as to origin or distribution are exceedingly rare. In some few instances the external iliac has been known to come ofi' di- i^ctly from the aorta. Anastomosis. — After the ligature of the primitive, the internal or the external iliac of one side, the intimate union which exists between the branches of the vessels of the two sides, (apart from the arterial communications mentioned in reference to tying the aorta,) renders easy the re-establishment of the circulation in the parts below. In cases of aneurism within the cavity of the pelvis, it is possible, especially if the tumour be large and of long stand- 18 ing, that some of these branches may have been obliterated by pressure, so as to present an obstacle to the return of the blood. Remarks. — The successful results that have many times at- tended the ligature of these large and important vessels, may be looked on as among the most important achievements in modern surgery. In an anatomical and physiological point of view, the issue in these operations might well have been expected to be more favourable than in those for the obliteration of the arteries which emerge from the aorta at the root of the neck. For the iliac vessels can be reached without the division of any important nerves or blood-vessels; the peritoneum covering them is so hap- pily provided with loose flocculent cellular tissue on its outer face, as to be readily pressed off from thetij without itself receiving necessarily any serious injury; and the vessels themselves are intended in a great degree to supply merely the organs for loco- motion. While in regard to those of the neck the immedi- ate proximity of the vessels to the heart ; the vitally important parts which are necessarily more or less disturbed in the opera- tion : the distress of the great organs of circulation and respiration on the one hand from the sudden stoppage of a large and direct outlet of the blood, and that of the brain on the other, which may suffer either by the increase, diminution or irregularity in the amount which it receives; and the singular discrepancy existing in reference to the place of origin of their anastomosing branches, serve to explain the difference as to the result which attends the ligature of the great arteries, at the two opposite extremities of the trunk. Of ligature of the external iliac, practised mainly for inguinal aneurism, about sixty cases have been collected. Of these, two- thirds have been cured, and not more than three have resulted fatally in consequence of gangrene of the lower extremity. The deep situation of the internal iliac protects it against traumatic injury, and the shortness of the trunk itself does not allow space sufficient to act upon it, in case it should be affected by aneurism — an occurrence so exceedingly rare, that as yet the instance re- ported by Sandifort maybe considered the only one well authenti- cated. It has been tied in several cases for aneurism of the gluteal artery. Mr. Stephens, of Santa Cruz, tied it in 1812 with suc- cess ; Mr. Atkinson, of York (England), in 1817, but death followed at the end of twenty days. In four other instances it has been, tied with success — by Dr. S. P. White, of Hudson, New York, by Mr. Thomas, of Barbadoes, by a Russian army surgeon, and by Professor Mott. The primitive iliac has been many times tied; by Professor Gibson, of this city, in 1812, in a case of severe gunshot wound, from whiph, rather than from the operation, the patient died thir- teen days after ; successfully by Professor Mott, of Npw-York, in 1827 ; and in 1828, with a less happy result, by Sir Philip Cramp- ton. It has also been tied by Syme, Guthrae, Salomon, and other operators ; and recently with perfect success, so far as the operator was concerned, by Dr. Edward Peace, of this city.* The patient of Dr. Peace, however, after he had recovered so as to engage in his usual labour for more than twelve months, had a return of the disease in the portion of the sac below Poupart's ligament. This sac was supplied by the anastomosing vessels which entered into • Vide Amer. Journ. of Med. Sciences for April, 1 843. 70 GENERAL OPERATIONS. the external iliac near Poupart's ligament, and did not pulsate. It finally ulcerated and burst. As the upper lumbar arteries were concerned in the anastomotic circuit of the blood, pressure on the trunk of the aorta did not arrest the hemorrhage, and therefore rendered a resort to the ligature of the main trunk, injudicious. On an autopsic examination the primitive and external iliac of the diseased side were found completely obliterated. LIGATURE OF THE INTERNAL ILIAC. (PL. XV.) Operation. — The patient is to be placed on his back, with the thighs and trunks slightly flexed in order to relax the muscles of the abdomen. The surgeon stands by the side of the patient with his face towards the pelvis, (if he operate upon the right side,) and makes an incision in the manner of Mr. Stevens, of about five inches in length, slightly convex outwards, commencing about half an inch to the outer side of the external abdominal ring, and an inch above the ligament of Poupart, so as to avoid injury to the spermatic cord. The incision is to be nearly parallel with the course of the epigastric artery, but a half to three quar- ters of an inch at its outer side, and inclined more outwardly above to a point, fifteen lines above and as much to the inner side of the anterior superior spinous process of the ilium. If the ope- ration be on the left side, I find it more convenient to stand with the face fronting the patient, as it leaves the left hand at liberty to support the abdominal parietes and subsequently press inwards the peritoneum and the parts which it contains. In this case the external incision may be made from above downwards. The in- teguments, superficial fascia, and the three layers of muscles, may be divided by successive strokes with the knife, from above down- wards, or cut from within outwards on the grooved director. Some branches of the superficial epigastric and circumflexa ilii arteries may require to be tied. The fascia transversalis is now to be opened with the finger nail, or by a cautious use of the knifej and the orifice enlarged upwards and downwards on the director. This membrane will be found more resisting at the upper part, than near the ligament of Poupart. The peritoneum is then to be care- fully separated on its outer face with the index finger, and drawn by a blunt hook, with the intestines which it loosely invests, towards the linea alba. With the left index finger we continue the sepa- ration of the peritoneum towards the sacro-vertebral articulation, following the movement with the thumb and fore finger of the right hand, till they reach the vessels. The external iliac artery will be first felt or seen ; trace this up to the bifurcation, where, below and within, we find the artery in question, nearly opposite the centre of a line drawn from the anterior superior spinous pro- cess of the ilium to the umbilicus. The artery is then to be iso- lated on its inner side with the left fore finger, and on its outer side with the right ; and either hooked up on the left fore finger, or grasped between the thumb and index finger of the right hand. PLATE XV.— LIGATURE OF THE ARTERIES OF THE TRUNK, The subject from which this drawing was taken is represented as laid on the back, in order to contrast the operation of the two sides. INTERNAL ILIAC. (Right side.) (A A). Division of the skin and abdominal muscles. (B). Psoas magnus muscle. (C). Sac of the peritoneum, detached with the finger and carried inwards with the eye speculum. The bulging of it at the upper part of the wound is made by a loop of small intestine within the sac. (D). Ureter, crossing the internal iliac artery from above inwards and downwards. (E). Fascia transversalis laid open. 1. Common or primitive iliac artery. 2. External iliac artery, the margin of which only, is shown under the spermatic vessels. 3. Internal iliac raised on the point of the aneurismal needle, and dragged farther forwards (in order to give a clear view of its position) than would be proper on the living subject. 4. Spermatic vessels. 5. Internal iliac vein, deeply placed. 6. Branch of lumbar plexus of nerves. The same process as shown on the drawing would suffice for ligature of the primitive iliac. (A). (B). (C). (E). 1. 2. LIGATURE OF THE EXTERNAL ILIAC NEAR ITS ORIGIN. (Left side.) Division of the tendon of the external oblique muscle of the abdomen. Cut edge of the internal oblique muscle. Lower border of the transversalis muscle, sending an investment down over the spermatic cord (D). Fascia transversalis, in which is formed the internal abdominal ring; the ring being enlarged in this case to get at the artery below. Internal iliac artery and vein, the vein lying to the inner side. Epigastric artery and veins. The iliac artery is seen raised on the needle at the place for applying the ligature. /'/u/r /S. LIGATURE OF THE DIFFERENT ARTERIES. n The ligature is next to "be passed from within outwards, taking care to avoid raising the ureter and peritoneum on the inner face of the artery, or the external iliac vessels, which latter are so loosely connected as to admit of being pressed by an assistant backwards and out of the way towards the iliac fossa. The ligature may readily be carried round the vessel with the instrument of Pro- fessor Gibson, the needle of Deschamps as modified by Graefe, or with a flexible silver probe bent to the proper shape, and conduct- ed along the back surface of the finger. In Plate XV, intended to illustrate this operation, it will be observed that the artery is more forcibly elevated in order to bring it clearly into view than would be proper on the living subject. LIGATURE OF THE PRIMITIVE OR COMMON ILIAC. (PL. XV.) The only difference in regard to the operation for securing this trunk, from that which has been just described, is the necessity of extending the line of incision for two or three inches higher up. The incision should also be made more vertically, as this gives a greater facility for reaching the artery, which is so deep that it may be found distant the whole length of the aneurismal needle, ■when the walls of the same side have been rendered prominent by an aneurism of the external iliac, — the common cause which ne- cessitates the operation on the primitive trunk. The more the top of the incision approaches the median line, the greater, however, will be the risk of wounding the peritoneum, and the tendency of this membrane with the intestines which it contains to bulge oufwards through the external wound. The risk of injury to the peritoneum (which membrane, though it has been woundeJ with- out serious consequences by Mr. Tait, it is by all means import- ant to avoid,) may in a great measure be obviated by making the first opening in the transversalis fascia near the lower end of the wound, carefully avoiding the epigastric artery. The tendency to bulging of the intestines will be best overcome by a curved spatula, or thin flat piece of board two or three inches broad, in- troduced into the bottom of the wound and held by an assistant. The ureter should be raised with the peritoneum from over the vessel, and the ligature placed about half an inch above the bifur- cation of the latter. By the same process, and without opening the peritoneum, the lower part of the aorta may be reached ; such was the plan followed by Mr. Murray in his operation on the latter vessel already noticed, LIGATURE OF THE EXTERNAL ILIAC. (PL. XV. and XVI.) This artery may readily be tied in any part of its course, but the lower third is usually selected for the operation. Aneurism at the groin is the common cause of its ligation, and as this is sometimes found with an elongated pouch extending up above Poupart's ligament, we maybe compelled often to seek the artery higher up than was first intended.* The patient is to be similarly placed as for the preceding opera- tion. If the abdomen is flat, the pelvis may in addition be inclined to the side of the operator ; — if tumid and prominent, it is to be turned in the opposite direction, so as to allow the mass of the • See the case of Professor Horner.— Amer. Journ. Med. Sciences, 1842. small intestines to fall away from the place of operation. The aorta may in this, as in the two preceding operations, be compressed at the umbilicus by an assistant; the surgeon is to stand likewise at the outer side of the pelvis. An incision, convex outwards and downwards, three to four inches long, is to be commenced just above the margin of the external abdominal ring, and carried up nearly parallel with Poupart's ligament, terminating about three quarter^ of an inch above and as much within the anterior superior spinous process of the ilium. After the skin the super- ficial fascia is to be divided; in this fascia, crossing the wound, is found the arteria ad cutem abdominis or superficial epigastric which may be tied and cut. The aponeurosis of the external ob- lique next comes into view ; this may be opened from above down- wards with the knife, or, which is better, cut on the grooved director the whole length of the cutaneous incision. The point of the fore fint^er should now be introduced at the lower end of the wound under the arch formed by the inferior border of the internal oblique and transversalis, so as to separate them from the fascia transversalis and spermatic cord. These muscles are then to be hooked up on the fore finger and divided across to the ex- tent of half an inch with a curved probe pointed bistoury. Some small branches of the epigastric and circumflex iliac arteries will now require to be secured. The fascia transversalis is next to be opened. This should be done at the lower part of the wound by scratching it with the finger nail, or by raising a fold with the forceps and puncturing it with the knife. The finger is then to be intro- duced between the fascia and the peritoneum, upon which tke fascia is to be further divided or torn. With the fore and middle fingers the peritoneum is next to be detached from the iliac fossa and pushed upwards. The thigh is to be now well flexed, and an assist- ant carrying his hand to the bottom of the wound, draws upwards and towards the opposite side the divided edge of the abdomi- nal muscles and the bag of the peritoneum containing the mass of intestines. The spermatic cord will be left below and hardly at all brought into view, if the artery is to be tied high up. But if the artery is tied near its middle, as in PI. XV, the cord may be at the same time raised up by the hand of the assistant. The lower or outer lip of the incision should be depressed with a blunt hook, and the ^rtery will be found pulsating along the brim of the pelvis, covered with a thin sheath, in front of which a small nerve is observed. The sheath is to be raised in a fold with the forceps, and opened with the point of a director; the artery is to be denuded, first on its outer and then on its inner side ; and the aneurismal needle carried from within outwards between it and the vein ; the small nerve, as the needle emerges from below the artery, being pushed outwards with the finger so as not to he included in the loop of the ligature. Remarks. — The direction of the external incision has been sin- gularly varied in this operation. Abernethy cut nearly directly over the course of the vessels; this plan answers well to uncover the artery high up, but is attended with risk of injury to the peri- toneum. Sir A. Cooper cut from the internal margin of the ex- ternal abdominal ring to the anterior superior spinous process of the ilium, following the curve of Poupart's ligament. The processes of Norman and Velpeau (PI. XVI) are mere modifications of that of Cooper, but do not aflTord the same facility for reaching the artery in the upper part of its course. Some have opened the 72 GENERAL OPERATIONS. parts with incisions in the form of a J_ reversed, the lower line being curved ; but the process which is above described in full, I have found the most convenient, as it enables us to reach the ar- tery with great facility in any part of its rout, and exposes as little as any other to the chances of subsequent hernial protrusion. Bogros has devised a plan for securing the artery just above the ligament, which is equally well suited to ligature of the epigastric, and will be described in reference to that vessel. LIGATURE OF THE EPIGASTRIC ARTERY. (PL. XVI.) Arising from the outer side of the external iliac just above the crural arch, this vessel forms an elbow near its origin, and as- cends between the two abdominal rings and behind the cord to the rectus muscle to the abdomen, which it reaches about an inch and three quarters above the place of its origin, and in the direction of a line drawn from this point to the umbilicus. It may be tied either at its place of entry into the rectus, or near its origin. Ligature at its place of origin. {Process of Bogros.) — Make an oblique incision two inches long parallel with the fold of the groin and two lines above Poupart's ligament, with its two ex- tremities equi-distant from the spine of the ilium and the pubic symphysis. The superficial fascia and aponeurosis of the exter- nal oblique are to be opened to the same extent on the director. Draw upwards the spermatic cord, in order to discover behind it the orifice of the internal ring. Dilate this opening with the finger or director, and the epigastric will be found immediately behind and to the pubic side of its inner margin. By following the epi- gastric back to its origin, we fall upon the external iliac artery, which may at this point be isolated and tied by the same process. An incision at this portion of the abdominal parietes, must of course render the patient afterwards more or less liable to the develop- ment of a hernial tumour. At the point where it enters the rectus, the epigastric artery may be exposed and tied by dividing parallel to the external border of this muscle, the skin, the aponeurotic ten- dons of the external and internal oblique, and the lower fibres of the transversalis muscle. By drawing the muscle inwards, the artery will be exposed. LIGATURE OF THE GLUTEAL ARTERY. Surgical anatomy. — The gluteal artery comes off from the in- ternal iliac. It is a short thick trunk, which escapes from the pelvis above the pyriformis muscle, close against the upperpart of the great sciatic notch, near which it divides into a superficial and deep-seated branch. The superficial supplies the under surface of the gluteus maximus ; the deep, which is the larger, runs be- tween the gluteus medius and minimus. The trunk is attended PLATE XVL— LIGATUUE OF THE EXTERNAL ILIAC AND FEMORAL ARTERIES. {Fig. 2.) OF THE EXTERNAL ILIAC JUST ABOVE POUPART'S LIGAMENT. {Process of Mr. Mrman as modified by Velpeau.) a. The left hand of an assistant, drawing upwards and inwards the superior lip of the wound, and supporting at the same time the weight of the abdominal viscera. 6, 6. Blunt hooks, depressing the inferior lip of the wound. 1. Line of division of the skin. 2. Section of the three abdominal muscles. 3. Peritoneum, covered with its subserous cellular layer. 4. Spermatic cord, pressed downwards. 5. Iliac fossa. The iliacus internus muscle is seen covered with its aponeurosis or fascia ; below the aponeurosis is seen a branch of the lumbar plexus of nerves. 6. External iliac vessels, inclosed in their sheath. 7. Epigastric artery, shown at its origin. Around this vessel is passed a thread, showing the possibility of tying it at this place in case it is accidentally wounded. 8. External iliac vein, to the inner and the posterior side of the artery. 9. Small nerve descending with the artery, which should be carefully excluded from the ligature. 10. External iliac artery, isolated and raised on the aneurismal needle of Grsefe. {Fig. l.~Fig.3.) OF THE FEMORAL ARTERY AT THE UPPER PART OF THE MIDDLE THIRD OF THE THIGH. {Process of Hunter.) 1. The sartorius muscle. Its inner edge is drawn outwards with a blunt hook. 2. The fascia lata, which, with the superficial fascia, is divided over the muscle nearly the whole length of the cutaneous incision. 3. Sheath of the femoral vessels, laid open near the middle part of the wound. 4. Femoral artery, raised on the ligature. 5. Femoral vein. 6. Saphenus nerve, to the outer side of the artery and involved in the sheath. r/aJe /6'. LIGATURE OF THE DIFFERENT ARTERIES. 73 by a vein and nerve. A line drawn from the posterior and, supe- rior spine of the ilium to the middle of the space between the trochanter major and tuberosity of the ischium, crosses the vessel, which will be found at the junction of the superior with the middle third of this line. The artery is covered from without inwards, by the skin, a thick layer of dense fatty cellular tissue, the belly of the gluteus maximus, «nd a strong aponeurotic membrane. It rests upon the upper margin of the gluteus medius. Remarks. — The vessel is so deeply placed that it cannot be influenced by compression. It has been four times tied in conse- quence of traumatic injury. In the celebrated case of John Bell, the first instance in which it was tied, it had been cut across in a punctured wound, and gave rise to an extensive tumour. A first incision was made by Mr. Bell eight inches in length. The pa- tient came near bleeding to death, " although in a moment twenty hands were about the tumour, and the bag was filled with sponges and clothes of all kinds." The. operator "then run the bistoury upwards and downwards, and at once made an incision two feet in length^'' by which he was enabled to secure the vessel. The pa- tient barely escaped with life, and unquestionably ran a greater risk than if a ligature had been placed instead around the internal iliac. The position of the gluteal artery should be well understood by the surgeon, for Theden mentions a case in which it was divided across in dilating a gunshot wound, and the patient in consequence lost his life. Operation. {Process of Lizars and Harrison.) — The patient is to lie on his belly, with the thigh extended and the toes turned in- wards. An incision three to four inches long is to be begun an inch below the posterior superior spine of the ilium, and an inch to the outer side of the sacrum, and carried down obliquely toward the great trochanter, crossing the vessel. Having divided the skin and subcutaneous fatty matter at the first cut, separate in the same direction the fibres of the gluteus maximus, without cutting, if possible, as the muscle is exceedingly vascular; tear with the director or cut the aponeurosis cov€ring the gluteus medius, and the vessel will be found covered by a loose sheath at the top of the sciatic notch. Care must be observed not to mistake the deep-seated branch for the main trunk. From the depth of the parts, the ligature must be carried round the vessel, with the curved aneurismal needle. LIGATURE OF THE ISCHIATIC ARTERY. Surgical anatomy. — The artery emerges from the pelvis at the lower part of the great sciatic notch, and, as shown by Lizars, nearly at the middle of a line drawn from the posterior superior spine of the ilium, to a point somewhat within the middle of the space between the trochanter major and sciatic tuberosity. The artery will be found a little in front of the great sciatic nerve, and rather more than an inch and a half below the gluteal. The two vessels have nearly the same coverings. The ischiatic, though smaller than the gluteal, has been more frequently found aneurismal. The operation for its ligature will differ but little from that just described.. Harrison advises the incision tO' be made in the same direction as for the gluteal, but begun an inch and a half lower down, and looks for the vessel after having divided the same number of layers. 19 LIGATURE OF THE INTERNAJ. PtlDlC. Surgical anatomy. — This artery passes from the pelvis just be-; low the ischiatic, and is separated from it only by a mass of fat. It winds immediately round the outer surface of the spine of the ischium, and returns into the pelvis again through the lesser scia- tic notch, to place itself on the inner face of the tuberosity of the ischium. In this part of its course it is covered exteriorly by the external border of the great sacro-sciatic ligament. Posteriorly, it is covered by the gluteus maximus and the thick integuments of that region. If the subject be placed on his back, the leg ex- tended and the toes turned inwards, the artery, as indicated by Harrison, will be found crossing the spine of the ischium at the junction of the external with the middle third of a line drawn from the summit of the trochanter major, to the base of the os coccygis ; an inch and a half above the most prominent part of the sciatic tuberosity, and about two inches from the external bor- der of the OS coccygis. Remarks. — ^The artery, as it winds round the spine of the ischi- um, may be compressed against the bone. Mr. Travers succeeded by this means in arresting an alarming hemorrhage, occasioned by a gangrenous ulcer of the glans penis, when all other measures had failed. He placed his patient on a hard bed, with two firm compresses so arranged as to press against the spine of each ischium. Operation. {Process of Harrison.) — To tie this artery, an inci- sion Is to be made three inches long, extending from the outer border of the fourth sacral vertebra, in the direction of the root of the great trochanter, parallel with the fibres of the gluteus maxi- mus. These fibres are to be well separated, or cut if necessary. We then fall upon the great sacro-sciatic ligament, the external border of which, as well as a dense fascia which comes off from it, is to be divided. The coccygeal branch of the ischiatic aftery appears first. This is to be tied and cut, and should not be mis- taken for the pudic, which lies deeper. With the finger, we feel for the spine of the ischium, and near the point of it, the artery in question will be found pulsating. It is to be isolated with the handle of the scalpel, and the ligature carried around it in the usual way, taking care to avoid the nerve, which lies to its inner side. The vein, which is of less importance, is covered by the artery. The rules given for the finding of the three last arteries must be varied somewhat according to the development of the pelvis,, and as they are usually tied only in cases of wounds or traumatic aneurism, when the jet of blood directs us in a considerable de- gree to the vessels concerned, it has not been thought necessary to accompany them with any illustration. LIGATURE OF THE FEMORAL ARTERY. Surgical anatomy. — The femoral artery extends from near the middle of Poupart's ligament to the top of the inferior third of the thigh, where it passes through the opening in the tendon of the adductor roagnus, to be continued , down behind the knee joint under the name of popliteal. At the upper fourth of the thigh the femoral artery is placed in a triangular space; the base of this triangle is formed above by Poupart's ligament, the inner margin by the pectineus and adductor muscles, and the outer by the sar- torius ; the apex is found from three to four and a half inches lower where the adductor muscles are crossed by the sartorius. 74 GENERAL OPERATIONS. In the female, owing to the greater breadth of the pelvis, the artery under Poupart's ligament is usually found about a quarter of an inch- nearer the spine of the pubis than it is in the male. In the triangle above described, the artery is placed very superficially, and can be felt strongly pulsating throughout its whole extent, but more especially where it passes over the head of the os femoris. It rests near the pelvis on the tendon of the psoas, and then crosses the insertions of the pectineus and adductor brevis. It is covered in front by the integument, superficial fascia, the fascia lata, and its proper sheath over which is spread a thin cellular layer; near the ligament of Poupart, some lymphatic glands involved in the superficial fascia, and the funnel-shaped extension of the transver- salis and iliac fasciae of the pelvis, are also found above it. The femoral vein, placed at first to the inner side of the artery, gets gradually behind it as it descends. The crural nerve, as it emerges from the pelvis, is about half an inch to the outer side of the artery, and quickly divides into many branches, some of which descend along the outer side of the sheath ; and one — (he saphenus major — enters the sheath at the point of this triangle, and passes along the outer and fore part of the artery down the middle third of the thigh. .The most important branch which the artery gives off in this part of its course is the profunda. This arises from the posterior surface of the artery, sometimes close to the ligament, but most usually an inch and a half to two inches below it. The artery, after leaving the apex of the triangle, becomes deeper seated, and is covered by the sartorius muscle, which crosses it rery obliquely from above downwards and slightly in- wards, so as to leave the artery at the termination of the middle third of the thigh, opposite the outer edge of this muscle, and between it and the vastus internus. As the sartorius muscle varies in breadth according to the muscularity of subjects, from one to two inches, the extent of the artery covered by it, will of course vary in proportion ; the inner edge of the muscle meeting I LATE XYIL— LIGAIURE OF THE FEMOJRAL ARTERY. ABOVE THE ORIGIN OF THE PROFUNDA. Fig. 1 and Fig. 2. — The leg is flexed and the limb rests upon its outer side. The patient lies on the back with the trunk a little inclined to the side of the operator. 1. Line of division of the skin. 2. Incision in the fascia superficialis, which is very thick at this point. 3. Lymphatic ganglion, drawn out of the w-ay of the knife. 4. Superficial artery cut across, which is to be tied or twisted. 5. Incision of the sheath of the femoral vesse-ls, formed from the iliac and transversalis fascice. 6. Femoral vein lying within and behind the artery. 7. Incision in the proper sheath of the vessels, made directly over the artery. 8. Femoral artery, raised on the aneurismal needle. AT THE UPPER THIRD OF THE THIGH. {Process of Scarpa and Hodgson.) Fig. 1 and Fig. 3 (A). Right hand of the operator holding the grooved director. (B). Left hand of the operator. The first two fingers draw outwards the external lip of the wound and the sartorius muscle— the nail of the fore finger guiding the beak of the director. 1. Incision of the skin. 2. Division of the fascia superficialis. 3. Division of the fascia lata. 4. Division of a layer which comes from the edge of the sartorius. 5. Incision in the sheath of the vessels. 6. Inner edge of the sartorius muscle. 7. Artery denuded and raised on the director. AT THE LOWER THIRD OF THE THIGH. (Process of Hutchinson and Roux.) Fig. Ynd Fig. 4-The incision is here made so as to fall upon the artery on th^outer side of the sartorius z. Incision of the skin and superficial fascia. 3. Longitudinal division of the fascia lata. '^' htTZ'f T' ""T °^ '^" T'"''"' """''' "^''^' ^" '^'' °P^^^*^°°' ^^ *° ^' P'-^^^^'l J°^'"^-^-l ^nd inward by an assistant so as to expose the artery. 5. Opening made in the sheath of the vessels, through which the artery is seen raised on the grooved director. The ligature is shown as just passed along the groove on an eyed probe. Fig. 5. J.atomical relations of the artery in its course down the thigh. This drawing is designed to illustrate the operation at the vpper avd hioer third of the thigh. ^ illustrate ine !iC;s^' ,43 I - ' V fei&ss^ /'/ /■Uu'aUci/- ih(,< . i'uA^ 3^ '■-liil*!!**''"'*''"" ' LIGATURE OF THE DIFFERENT ARTERIES. 79 It has not yet, however, been sanctioned by use on the living subject. Operation. — The patient is to be placed on his back or side, and the limb abducted and laid on its outer border, with the thigh and leg slightly flexed and supported by a pillow. The surgeon feels for the groove which exists between the internal border of the inner head of the gastrocnemius and the internal spine of the tibia, and follows it obliquely backwards till he feels the promi- nence of the soleus. In the course of the groove thus depressed with the fingers, he makes an incision of three inches, commenc- ing just below the point where the tendons pf the sartorius, gra- cilis, and semi-tendinosus sweep round upon the tibia. The saphena vein and its attendant nerve, exposed by the division of the skin, are to be drawn forwards, and the superficial fascia and the deep-seated aponeurosis of the leg, which is here very thick, laid open. The internal head of the gastrocnemius is now to be separated with the finger or director, and drawn strongly outwards with the blunt hook. At the depth of about an inch we find the vessels. The vein first appears, covering the artery, which lies to its outer side, — the pophteal nerve being situated between and behind them. The vein is to be slightly denuded, and drawn backwards and outwards with a blunt hook or the fingers of an assistant. The artery then comes into view, resting on the surface of the popliteus muscle, and is to be raised with the" aneurismal needle. M. Jobert has proposed to tie the artery above the joint, by a somewhat analogous process — making a lateral incision on the inner side between the vastus internus and the inner hamstring tendons. OF THE ARTERIES OF THE LEG. LIGATURE OF THE ANTERIOR TIBIAL UPON THE LEG. Surgical anatomy. — This artery, arising from the popliteal just below the muscle of the same name, passes directly forward in an opening in the interosseous ligament, between the head of the fibula and the outer margin of the tibia. From this point it is direct- ed downwards in a straight line to the middle front portion of the ankle joint. In all this course it gives off" but one branch of im- portance, the recurrens tibialis. For the three superior fourths of the leg it rests on the anterior face of the interosseous ligament, and upon the tibia in its lower fourth. It is accompanied by two veins, and crossed diagonally by the anterior tibial nerve, so that the latter is found external to it above, anterior in the mid- dle, and internal below. In the upper third of the leg this artery is situated between the belly of the tibialis anticus muscle, (which lies upon its inner side and overlaps it,) and the extensor digi- torum communis on its outer, and is placed on an average about an inch below the surface. In the middle third of the leg it still has the tibialis anticus at its inner side; and is bounded on its outer by the extensor pollicis pedis; which shortly crosses in front of the artery so as to get to the opposite side. At the inferior third of the leg the artery becomes much more superficial, and is lodged between the tendons of the extensor pollicis and the ex- tensor communis digitorum pedis. Anomalies.- — The anterior tibial artery has been occasionally observed placed quite superficially below the, integuments. The posterior interosseal sometimes comes in front of the interosseous ligament, and throws itself as a trunk of considerable size into the anterior tibial. Remarks. — True aneurism of the anterior tibial artery is a rare affection, and the author does not remember to have observed more than two instances of it in the course of his practice ; false aneurismal tumours, diffused or circumscribed, the Consequence of wounds, are, on the contrary, not unfrequently met with. If the wound implicating the artery be recent, the surgeon may dilate it if not sufficiently open ; or if a small aneurism have formed, cut down upon the vessel, and apply in either case a ligature above and below the place of its injury. The necessity of this double application of the ligature always increases the farther the injured vessel is removed from the centre of the body, for the greater then will be the degree of intercommunication which exists by anas- tomosis between the surrounding branches. But if the vessel be affected in the upper fourth of the leg, the depth, at which it is placed and the disturbance of the muscles necessary to reach it there, will in general make it preferable to secure the femoral at the middle region of the thigh. The place of election in ligature of the anterior tibial, is the middle third of the leg. At the lower third, the artery is too closely in relation with the sheaths of the tendons and the ankle joint, and in the upper is too deeply placed to be cut down upon except in cases of necessity. LIGATURE IN THE MIDDLE OR UPPER THIRD. (PL. XIX.) Operation.-— -The patient rests on his back, with his leg ex- tended, and held at the knee and foot by two assistants. The sur- geon takes his position at the outer side of the limb. He traces out in his mind or marks with the handle of a scalpel the line of direction of the vessel, causes the patient to flex and extend the foot so as to render the position of the anterior tibial muscle more conspicuous, and feels with the fingers of the left hand for the groove along the external border of this muscle. The skin is to be opened by an incision three inches long, directly over the vessel lodged in this groove ; or, which I greatly prefer, in a direction ■obliquely across the course of the vessel, commencing over the anterior tibial muscle, a half or three-quarters of an inch from the spine of the tibia — and crossing the vessel so as to terminate be- low as much at its outer side. On the right side the incision is to be made from above downwards; and on the left from below upwards. The superficial fascia and aponeurosis are next to be slit the whole length of the wound, and divided transversely for half an inch or more at either end of the incision, so as to facili- tate the separation of the muscles. We then seek with the finger for the first cellular groove, or the first yellowish intermuscular line (starting from the end of the incision next the tibia), which will be found between the tibialis anticus on the outer side, and the ex- tensor pollicis pedis, or the extensor communis digitorUm, accord- ing as the operation is in the middle or upper part of the leg. This space is to be opened by rupturing the cellular tissue between the muscles the whole length of the wound with the index finger merely, or the point of a director. The foot is to be flexed, and the muscles in question thus relaxed are to be held asunder by the so GENERAL OPERATIONS. finffers of an assistant, or with blunt hooks. The sheath of the vessels is now exposed at the bottom of the groove, and is to be raised with the tbrceps and opened. The nerve is to be drawn to one side, and the sheath of the vessels seized on the outer side of the artery with the forceps; the artery is then to be isolated from its accompanying veins, and raised on the director. In con- sequence of the depth of the vessel the director should be slightly curved; and if presented diagonally, it will pass more readily under the artery. If the rules here laid down for discovering the groove in which the vessels are lodged, are not regularly followed, the operator may get too far from the tibia, and fall into the space between the two extensors. Should this happen, it will be neces- sary for him to look about a third of an inch to the inner side of this opening for the intermuscular space by the outer side of the tibialis antieus. In the operation for tying the artery at the upper third of the leg, Lisfranc proposes to make the external incision in an oblique direc- tion from the head of the fibula to near the crest of the tibia ; it has, however, no particular advantage over the process already described. In ligature of the artery at its lower third, the vessel will be found between the two extensors, and is so superficial that j its position is readily detected by its pulsations. j LIGATURE OF THE ANTERIOR TIBIAL ON THE DORSUM OF THE FOOT. Surgical anatomy. — From the middle of ihe interval between the two malleolar processes, the artery is continued forwards in a straight line to the interosseal space between the metatarsal bones of the first and second toe, where it dips down to the sole of the foot. It rests upon the tarsal bones, and runs between the exten- sor pollicis pedis, which is on its inner side, (and serves as a guide for the vessel,) and the first tendon of the short common extensor at its outer; the' muscular fibres of the latter slightly cover the vessel, and constitute the first point to be looked for in the opera- tion. The vessel is situated nearly a third of an inch below the skin, covered by the dorsal aponeurosis, and a second fibrous ex- . pansion spread between the extensor tendons, and is accompanied by two veins and a nerve. Its pulsation, nevertheless, can usually be readily ffilt. Re7narks. ^^This artery, as has already been observed, is occa- sionally increased in size by union with the posterior interos- seal. On the other hand, it is sometimes entirely deficient, or so small that it is with difficulty distinguished in operations on the cadaver. It may be tied in any part of its course, but the middle of the tarsal arch is the place usually preferred. Its proximity to PLATE iH.-^LIGATUKE OF THE ANTERIOR TIBIAL ARTERY- Fig. 1. The limb is laid on a pillow, with its external and anterior surface looking upwards. (A A"), AT THE UPPER THIRD. 1. Line of division of the skin. 2. Aponeurosis of the leg laid open. 3. Tibialis antieus muscle, carried inwards by a blunt hook, 4. Extensor communis digitorum pedis, pressed outwards by two fingers of the surgeon's left hand. 5. Sheath of the anterior tibial vessels. 6. Anterior tibial nerve. 7. Venae comites or satellite veins. 8. Anterior tibial artery raised on the aneurismal needle. (B B^). AT THE JUNCTION OF THE MIDDLE WITH THE INFERIOR THIRD OF THE LEG. 1. Line of division of skin. 2. Aponeurosis of leg. 3. Anterior tibial tendon, carried inwards. 4. 5. Extensor tendons of the toes, carried outwards, 6. Anterior tibial nerve. 7. Venfe comites. 8. Anterior tibial artery raised on the director. I. 2. 3. 4. 5. (C C^). ON THE DORSUM OF THE FOOT.. Incision of the skin. Incision of the dorsal aponeurosis of the foot. Inner margin of the extensor brevis digitorum carried outwards. Tendon of the extensor proprius of the great toe. ^ Anterior tibial artery between its two veins,, raised on the ligature. Fuj / A \ * ■^^ K . ' :-,-, ^ -- '. A FUile. 79. 'A> LIGATURE OF THE DIFFERENT ARTERIES. 81 the tarsal bones enables us, in cases of wound, to apply compres- sion with so much advantage that ligature of the vessel at this point may frequently be dispensed with. Operation. — The foot held in extension, an incision two inches long is to be made directly over the course of the vessel, the lower end of the incision being opposite the posterior angle of the first interosseous space. The subcutaneous cellular tissue, and the dorsal aponeurosis, having been divided on the director, we fall upon the first tendon of the extensor brevis digitorum communis. The inter-tendinous fascia is next to be opened along the inner border of this muscle, and the muscle itself dra-wn a little out- wards. The sheath of the vessels appears immediately below, which is to be opened, and the artery isolated and tied in the usual manner — the director being passed below it from within outwards. LIGATURE OF THE POSTERIOR TIBIAL. Surgical anatomy^ — The posterior tibial artery, from its size and direction, may be considered the continuation of the popliteal, from which it comes off about two inches below the articular surface of the tibia. It is placed on the posterior part of the leg, and passes down nearly in a straight line, from the central hollo-w of the ham to the middle of the space between the internal mal- leolus and the tendo achillis, curVeH slightly inwards near the middle. Above, it rests by its anterior face on the tibialis pos- ticus muscle ; in the middle part of its course, upon the flexor longus digitorum ; and near the ankle, it is separated only by a padding of fat and cellular tissue from the bone. Throughout its course it is covered on its posterior face by the deep-seated aponeurosis of the leg ; which separates the superficial from the deep layer of muscles; and for the upper two-thirds of the leg, by the gastrocnemius and soleus. Below, these muscles become tendinous, and depart from the artery so as to leave it superficial where it runs down at the inner side of the tendo achillis, being covered there only by the skin and two aponeurotic layers. It then turns round the os calcis, midway between the tendon and malleolus, from the latter of which it is separated only by the tendons of the posterior tibial, and flexor communis muscles, both of which are lodged in a groove in the bone and protected by a sheath. It is accompanied throughoyt its course by its two veips, and the posterior tibial nerve which lays to its outer side. At the top of the leg, as before observed, the artery is nearly in the miid- dle line, and an inch to an inch and a half below the surface. In the middle third, it is about an inch from the outer edge of the tibia, and at a hand's breadth above the ankle, only half an inch. Remarks. — This artCry is little subject to anomaly ; it has, however, been found in a few instances very small or entirely wanting. It may be tied at the superior, middle, or inferior part of the leg ; or, in case of necessity, in any other portion of its course. The operation is usually called for in consequence of a direct injury from a wound; and in such cases, for reasons already mentioned, it is advised to apply two ligatures — one above and one below the place of lesion. True aneurismal tumours occur but rarely in the course of this vessel. Diffused false aneurisms may attain here to a size considerably greater than those observed on the anterior tibial, in consequence of the greater extensibility 21 of the surrounding tissues. , The vessel is placed so deeply in the upper third of the leg, that it cannot be reached but by a deep and extensive wound, and very considerable derangement and some destruction of the muscular fibres. In most instances. where it would not answer to secure the artery lower down, we should best promote the safety and comfort of the patient, by tying in pre- ference the femoral in the middle region of the thigh. But in a wound complicated with extensive effusion of blood between the muscles, we have the high authority of Mr. Guthrie for securing the popliteal trunk. This surgeon, in the instance alluded to, pre- ferred to the ordinary operation, the splitting down of the muscle in the middle line of the calf. LIGATURE IN THE UPPER THIRD. (PL. XX.) Operation. — The leg should be half flexed so as to relax the muscles, and laid flat upon its inner side. Three quarters of an inch to an inch (according to the muscularity of the limb) behind the inner edge of the tibia we make^an incision, four inches in extent — parallel with that bone ; or slightly approaching the bone below, which I prefer, as being more directly over the course of the vessel. The superficial fascia and aponeurosis are to be divided to the same extent, taking care to avoid the saphena vein, which runs up nearly in the direction of the cut. A crucial incision should be made across the aponeurosis at the two extremities of the wound. The internal head of the gastrocnemius is now ex- posed, the cellular connections of which, on its anterior surface, are to be separated with the finger or director, and the muscle itself drawn outwards on a blunt hook. The belly of the soleus, which arises in great part from the tibia, now comes into view;* this is to be divided layer by layer with the knife after the manner of Manec, in the direction of the external wound, and at the distance of about three quarters of an inch from the tibia. After dividing the belly of this muscle, we fall upon its tendinous fibres of inser- tion, which form a strong, white, shining layer. This is to be raised on the director, and divided the whole length of the wound. We come next to the deep-seated muscular aponeurosis, which is to be cautiously opened and divided in the same manner on the director. The vessels enveloped in their sheath are now fully exposed. The sheath is to be opened, the artery denuded in the usual manner, and the aneurismal needle passed below it frx)ni within outwards. LIGATURE AT THE MIDDLE THIRD OF THE LEG. (PL. XX.) Operation. — Take for a starting point in this operation, the pos- terior or internal angle of the tibia, which may always be readily discovered by depressing the mass of muscles on its posterior face. By the older method it was customary to open the skin, by an incision parallel with the tibia, a,o4 about half an inch from its * By the old method it was customary to shave the soleus off directly at its connection with the tibia, and then draw (he muscle outwards, in place of dividing the belly of the muscle as directed in the text. This process serves easily enough toe^xpose the vessels on the dead body ; htit is attended with much difficulty on the living subject in consequence of the strain of the muscle, and the excessive contraction to which it is provoked. To overcome this resistance, M. Boucbet, of Lyons, was compelled le divide the soleus directly across over the course of the ve!Sse;L 82 GENERAL OPERATIOffS. iuternal border. But there is greater certainty of falling directly upon the vessels, by adopting the following modification of Lis- franc. Make an incision of two and a half to three inches in ex- tent obliquely downwards and backwards from the posterior angle of the tibia to the inner border of the tendo achillis, so that it shall form with the axis of the leg an angle of about 35 degrees, and cross diagonally over the intermuscular groove in which are lodged the vessels. Divide in the same direction the superficial fascia and aponeurosis; glide the forefinger, with its palmar face turned backwards, into the bottom of the wound and under the tendo achillis, and sweep it upwards and downwards so as to detach the cellular connections freely; the belly of the soleus comes into view as it leaves the tibia, forming the upper border of the w^ound. and is to be drawn upwards and backwards, .or if it descends low upon the artery, divided together with its aponeurosis of insertion at its origin from the tibia. At the bottom of the wound/ is next observed the shining deep-seated intermuscular aponeuro- sis, covering the vessels. This is to be punctured so as to admit the grooved director below it, and freely divided. The sheath of the vessels which is now exposed is to be opened, and the artery isolated and tied in the usual manner. The same process as here described is applicable to the ligature of the artery in any part of its inferior third.* • It is perhaps useless to repeat that the incision must be made from above downwards, or below upwards, according as we act on the right or left limb. The description in the text is confined to the right side. PLATE XX.— LIGATURE OF THE POSTERIOR TIBIAL AND PERONEAL ARTERIES. Fig. 1. — Of the posterior tibial. The leg rests upon a pillow, and is laid upon its outer side. (C C^). AT ITS UPPER THIRD. 1. Division of the skin and superficial fascia. 2. Division of the superficial aponeurosis of the leg. 3. Section of the soleus muscle, made near its attachment upon the tibia. One portion is carried towards the tibia by the left fore finger of the operator; the other is carried backwards by the fingers of an assistant, so as to make the wound gape. 4. Section of the aponeurotic tendon of the soleus. 5. Deep-seated aponeurosis of the leg covering the flexor muscles of the toes, and separating them from the soleus. 6. Posterior tibial artery, exposed between its satellite veins and raised on the aneurismal needle. (B B^). AT THE INFERIOR THIRD OF THE LEG. 1, 2. Division of the skin and superficial aponeurosis. 3. Division of the deep-seated aponeurosis covering the flexor muscles of the toes. 4. Posterior tibial artery isolated and raised from between its veins on the grooved director. (A A^). BEHIND THE INTERNAL MALLEOLUS. The lips of the wounds are held separate— posteriorly by a blunt hook— anteriorly by the fore finger of an assistant. 1, 2. Division of the skin and superficial aponeurosis of the leg. 3. Division of the deep-seated aponeurosis, which covers the flexor tendons as well as the artery. 4. Posterior tibial artery, raised on the ligature. Fig. 2.— .Anatomical relations of the vessel, designed to illustrate the three preceding operations. 1, 2, 3, 4, 5, designate the same parts as in the three side sketches. 6. Internal part of the gastrocnemius externus. 7. Posterior tibial nerve. 8. Posterior tibial artery, between its two veins. 9. Superficial or investing aponeurosis of the leg. 10. Internal saphena vein. 11. Saphenus nerve accompanying the vein. 12. Tendo achillis. ^^' IpZtrol '^' ^'''°' ^°"^"' communis digitorum pedis. Both these tendons are seen through the deep-seated Fig. 3.— Of the peroneal or fibular artery. 1, 2. Division of the skin and superficial aponeurosis. 3. Peronei muscles carried in front by a blunt hook. 4. Division of the peroneal attachment of the flexor pollicis muscle. 5. Peroneal artery between its satellite veins. The artery is raised on the aneurismal needle. ■u,. / !■',,, -y F/aJe ZO KiMVi tf ■"«%. /' LIGATURE OF THE DIFFERENT ARTERIES. 83 LIGATURE BEHIND THE MALLEOLUS INTERNUS. (PL.- XX.) Surgical anatomy. — The artery is curved, as before observed in its course behind the malleolus, presenting a concavity in front. At the end of this durve it is divided into its two plantar branches. It is lodged in sorffe dense cellular tissue, accompanied by its veins, and with the nerve at a little distance behind it. It is covered by the superficial and deep-seated ap"oneurotic membranes, which are often strengthened by some fibres from the annular ligament of the joint. It is found about a finger's breadth behind the malleolus, and in the middle of the space between it and the tendo achillis. The tendons of the two muscles which separate it from the mal- leolus are each covered by respective portions of ligament, and ought not to be seen at all in the operation upon the artery. Remarks. — Wounds of the foot involving the plantar branches are the most frequent causes which render" necessary the ligature of this portion of the artery ; for it would be most unwise, as well as extremely painful and difficult, to cut down upon the plantar branches, which are lodged in the sole at a depth of at least three quarters of an inch. The remarks made in reference to ligature and compression of the arteries of the hand, are equally applicaible to those of the foot. It is quite practicable to arrest the circulation of blood in this vessel by compression behind the ankle, but this method becomes after a short time too painful to be borne. Th'e case, however, can hardly be conceived, except there be direct ■wound of the vessel in this region, in which ligature of the trunk in the inferior third of the leg would not be equally efficacious as that behind the ankle ; and as the latter process is liable to be fol- lowed by chronic inflammation of the ligaments of the joint or the sheaths of the tendons, the former operation ought, in the opinion of the author, to be preferre^l. Operation. — The limb is to be placed in the position indicated for the two operations last described, and a vertical incision of two inches in length made in the middle line between the teiido achillis and the internal malleolus. The fibrous subcutaneous cellular tissue is to be cut with the skin. The superficial aponeurosis is to be raised carefully and cut on the director. A layer of fatty tissue covering immediately the deep-seated aponeurosis next comes into view, both of which are likewise to be divided on the director. The sheath of the vessels which is now exposed, is to be opened, and the artery isolated on either side and raised on the director according to the usual process. LIGATURE OF THE PERONEAL ARTERY. (PL. XX.) Surgical anatomy.— The peroneal artery comes off from the posterior tibial below the popliteus muscl«, and runs down along the internal face of the fibula, from which it is separated only by the flexor lorigus pollicis pedis. Near the os calcis, it terminate:s by dividing into two branches. In the upper part of the leg, it is covered by the sqleus muscle ; in the lower half, it is mote superficial. It rests on the interosseous ligament, and in the intermuscular fissure between the flexor pollicis and the tibialis posticus muscles. Very frequently, however, it is found lodged in the midst of the fibres of the first named muscle. It is covered by the superficial and deep aponeurotic membranes, like the artery last -described. Remarks. — This artery rarely requires to be tied, except in cases of compound fracture or punctured wounds. Too deeply seated above to become the subject of operation, and so small below as to render it unnecessary^ it is only in the middle third of the leg that it can be requisite to tie it. In traumatic injuries of the upper third, necessitating some remedial measflre., it would be better surgery to secure the femoral artery tlian to do so much violence to the deep-seated structures of the leg as would be necessary to reach the peroneal in that region. The peroneal artery, it is to be recollected, lies between the tendo achillis ancl the fibula, while the posterior tibial lies on the opposite side of the limb, between the tendo achillis and the tibia. Operation. — The leg is to be semiflexed and placed upon its inner face witbthe front "portion turned toward the operator. The foot should be extended and its external margin elevated so as to relax the gastrocnemial and peronei muscles. An. incision below the middle of the leg of two to two and a half inches in extent, is to be made after the method of Lisfranc, between the external border of the tendo achillis and the' external face of the fibula, taking care to avoid injury of the external saphena vein, by first cutting merely the skin, and drawing the vein to one side before the deeper parts are divided. The incision should be directed, at an angle of about thirty-five degrees with the course of the vessel. The superficial fascia and aponeurosis are next to be cut. With the index finger, we then push inwards the tendo achillis, and destroy the cellular tissue down to the deep-seated aponeurosis,, which is stretched between the tibia and fibula. An. assistant now draws the tendo achillis inwards. The deep-seated aponeurosis is next to be raised and divided on the grooved director. Starting from the fibula, we look for the first intermuscular space below this aponeurosis, which, if it interfere with' the separatioii of parts^ may, as well as the superficial, be cross cut at the two gxtremities of the wound. This space is to be opened with the finger, and we fall upon the vessel lodged between the two- muscles already noticed, — the flexor pollicis and the tibialis posticus. The flexor pollicis is ta be drawn outwards, and the sheath of the peroneal vessels comes into view deep behind the fibula. The sheath is to be opened, and the artery isolated and raised upon the aneurismal needle or with a director highly curved and passed diagonally below it. In case the artery be lodged among the fibres of the flexor muscle, these must be cautiously cut till we reach the vessel; or should there -be dilEculty of succeeding by other means, the muscle with the artery may be cut across, and the- bleeding orifice of the latter secured with the tenaculum and ligature-^pressure beiag made at the timB on the femoral so as to prevent much effu- sion of blood. By the older method, a straight incision was made directly over the course of the vessel ; but it does not afibrd the same degree of certainty of falling directly upon the artery, especially if we tie it at the usual point, below the middle of the leg, and just at the place where the sole us. and external gastrocnemius tendons join. 84 III. GENERAL OPERATIONS. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. Under this head will be considered: — 1. The operations for dropsy of the joints. 2. Those for the removal of foreign bodies from the joints. 3. For ganglions or cysts on the bursal sheaths of the- tendons. 4. For hygroma or dropsical tumours of the bursas rnucpsffi. 5. For complicated fractures and luxations. 6. For false joints, or ununited fractures. 7. For deformities from the irregular union of broken bones. 8. For exostosis. 9. For cysts in the bones. 10. For necrosis. 11. For trephining — and, 12. For resection of the bones. HYDRARTHROSIS.— ARTICULAR DROPSY. Every articulation consists of the extremities of two or more bones appropriately fitted to each other, covered M'ith a smootli, polished, elastic substance called cartilage, and held firmly together by strong inelastic bands called ligaments ; and as in all machinery ■where there is much motion, it is necessary to interpose some unctuous substance to prevent friction, there is in every movable joint a slippery fluid called synovia, thrown out by the inner mem- brane which lines it. This is undergoing a continued process of secretion and absorption, exactly proportioned to the degree of motion to which the joint is subjected. As a sort of secondary ligaments, serving to strengthen the arti- culation, we have the tendons of the muscles playing over them, and sometimes, as in the shoulder, apparently passing through the joint itself. Each of these in the neighbourhood of the joints is provided, for the same purpose as the joints themselves, with the same secreting membrane, which is extended along the tendon in the form of a long purse or bursal sheath, and when disteaded is about three or four times the diameter of the tendon it embraces. Not only in the joints and around the tendons, but wherever there exists steady friction in the play of parts, as that of the skin or a tendon over a bone or other resisting structure, do we find the same kind of serous sac under the name of bursa mucosa. All these closed secreting sacs, like other serous membranes, are liable to an accumulation of their fluid contents, constituting dropsy. This is, however, most generally but a symptom occa- sioned by a sprain, wound, contusion, some internal afTection of the joint, or the development of movable cartilages, — and may usually be removed by antiphlogistic treatment, conjoined with rest and compression. The joints most subject to this dropsical accumulation are the large ones, the knee, elbow, hip, and wrist. The bursal sheaths most commonly affected, forming the tpmours called ganglions, are the ones subjected to most frequent move- ment ; viz., those which cover the wrist. The bursae mucosae most commonly found distended, are those most liable to compression — as the one between the skin and ligamentum patellae, forming when enlarged by disease the affection known as the housemaid's knee, and the one covering the olecranon, which, from being commonly observed among miners who rest much on the elbow, constitutes in its morbid condition what has been called the miner's elbow. Dropsy of the knee joint. — When the synovial fluid has in- creased to such a quantity as to properly constitute this disease. we find a soft fluctuating tumour with no change of colour in the skin, which yields to the pressure of the finger, without leaving an impression as in oedema. If the leg be stretched, the patella can be made to strike on the condyles and rebound. If there be a communication, as is most commonly the case, between the joint and the bursa above the condyles of the os femoris, there will also be a great degree of fullness or swelling under the extensor tendons. The capsule protrudes at both sides of the patella and rectus tendon, but most on the internal, and is very tense when the knee is best. A protrusion of the capsule sometimes takes place into the popliteal region when the leg is extended, to which the artery of the ham from its proximity comraunicales a pulsatile movement. By bending the joint, however, the tumour disap- pears, and its nature is at once made known. In dropsy of the elbow joint, the distension of the capsule forms an oblong tumour on either side of the olecranon process, when the forearm is extended. At the ankle joint, the fluctuating tumour is obvious chiefly in front of the malleolar processes. At the vy>-ist, it is scarcely perceptible on the sides of the joint; it is observed to some extent on the back part, Imt is found mainly on the front portion of the articulation. At the shoulder \i is found on the front portion of the joint, and is especially obvious between the deltoid and pectoral muscles. Operation. — All therapeutic measures having failed, after a tho- rough trial to cause a removal of the dropsical accumulation, we may discharge it either by incision with a bistoury, or puncture with a trocar. The great object in the operation is to avoid the entry of air, which might provoke irritation in the cavity of the joint, and give rise either to suppurative inflammation of the serous membrane, or even ulceration of the articular surfaces. The ope- ration is, therefore, not unattended with danger, and is only to be undertaken when the patient is not able, by the aid of a com- pressing bandage, to serve himself with the limb. The bistoury is to be preferred to the trocar, as the incision it makes is not more irritating than the puncture with the latter instrument, and allows better the discharge of the flaky pus sometimes found mixed with the serum-, or of a movable cartilage, the presence of which is occasionally discerned only after the fluid has in part escaped. We should select the most depending portion of the tumour, and if possible at the same time the most prominent. If it be the knee, and seldom any other joint requires the operation, the inner portion is selected, as the limb can be so turned as to make it dependent; The skin being drawn to one side, in order to pre- vent any parallelism between the inner and outer portions of 4;he wound, the bistoufy is to be passed in perpendicularly to the surface, and the incision moderately enlarged as it is withdrawn. After the discharge of the fluid, a simple dressing is to be laid over the wound, and the limb, which is to be kept for a coaple of weeks or more perfectly at rest, covered with a compress wetted with Goulard's or some other resolvent lotion. The fluid is so soon reproduced, that Boyer directs at the end of twenty-four hours to re-open the incision and discharge it anew. If the lips are merely slightly agglutinated he would separate them with a director, or with a bistoury if the union be more firm. If there is a probability of having to make several successive punctures, his direction is to keep OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 85 the passage open, by introducing through it a strip, of linen or some charpie. But I have preferred in my own practice, to this constant presence of a foreign body in the cavity of the joint, an occasional oblique puncture under a valvular fold of the skin ; resorting to gentle compression after each operatioft, in order to overcome the tendency to a re-accumulation of the fluid. Floc- culent portions of pus or decayed membranes may be occasionally washed out with advantage by emollient injections ; and as a sub- sequent treatment, an injection of the same sort allowed to remain in the cavity of the joint as directed by Recamier, it is said has been attended with advantage. M. Malgaigne prefers the use of the trocar, and, contrary to common experience, asserts that the puncture of the articulations is an operation perfectly innocent. He has operated, he observes, six times in this manner for dropsy of the knee joint without the least inconvenience. He only regards it as insufficient of itself for a cure, requiring in addition the use of compression, counter- irritation, and the various other therapeutic means to effect radical relief. However, there is always reason to fear that the paracen- tesis of a joint will be followed either by anchylosis, by suppura- tion from its cavity, by destruction of the cartilages, or caries of the bones. Weak iodine injections, after a partial removal of the fluid by tapping with an oblique puncture, have been employed with considerable success in this affection, by M. Bonnet of Lyons and M. Velpeau. FOREIGN BODIES OR MOVABLE CARTILAGES IN THE JOINTS. Cartilaginous bodies have been observed in several. of the large ginglymoidal articulations, but their most common seat by far is in the knee joint. In the latter they commonly exist singly ; sel- dom more than two or three are ever met with, though Morgagni mentions a case in which he found thirty-five ; but when observed in the other joints, they are frequently found to exist in conside- rable numbers. Haller found twenty in the articulation of the jaw, and M. Malgaigne sixty in the elbow. They are variable as to form and size, and are usually smooth and polished. They seldom have the hardness of bone except at their centre, and are formed principally of soft and yielding cartilage,' which is readily crushed under strong compression. They are distinguished ac- cording as they are loose or adherent, the consequence of some sprain or injury of the joint, and formed originally,- as recent observations would seem to show, in the thin stratum of cellular tissue on the outer side of the synovial membrane ; they project inwards towards the articular cavity as they" increase in size, and finally are left hanging by a small pediculated portion of the invest- ing synovial tissue. The pedicle very frequently gets broken off in consequence of the cartilage becoming pinched between the surfaces of the joint. In this -state the cartilages remain afterwards as a loose foreign body and give rise every now and then to symptoms which make their diagnosis easy. Their presence is usually attended by an increased amount of synovial fluid which distends the capsule of the joint. When they rest between the capsule and the sides of the bones, little or no inconvenience is felt. But when they slip between the articular faces of the bones, as they are apt to do in a false step or a quick movement of the limb, violent pain is immediately produced. The cartilage soon sliding 23 back again into its former position, the movements of the joint in the course of an hour or two become perfectly restored. Two measures of relief are resorted to in these cases, — com- pression and extraction. Compression. — This consists in moving the foreign body which may be felt from without, to some corner of the articulation, where it will' give rise to no inconvenience, and at the same time admit of its being compressed against a resisting base. In the knee, for instance, it may be carried above the patella, or on the side of one of the condyles of the os femoris. In this position, it is to be secured by adhesive strips, and firmly compressed by a well padded knee strap or a laced bandage. By a long continuance of these measures, the foreign body has in a few instances become fixed in its new position, so as to be no longer a source of discomfort. The difficulty of retaining it in its new location, and when we suc- ceed in this, the frequent failure of the attempt to render it adher- ent, has caused the process to be in a great measure abandoned. Extraction. — It is only in the knee as yet that the attempt has been made for the removal of these bodies. Before undertaking the operation, it is necessary by restj and other appropriate ineans of treatment, to remove all pre-existing inflammation of the joint. The patient being laid on the side of the bed, witb his knee supported on a piilpw, the operator searches for the foreign body. This will sometimes fly from before his fingers into the cavity below the patella or into the space between the condyles, and to displace it, it is necessary to cause the patient to flex or extend his limb. Having secured it, it is to be drawn on the outer or inner side of the joint, as is most convenient, and as high up as possible on the condyle of the femur. It is to be firmly fixed with the thumb and finger, or an acupuncture needle, the assistant at the same time drawing the skin upwards and outwards, so as to prevent any parallelism after the operation, in the wounds of the skin and capsiile. An incision is then to be made in the direction of the limb, of a length in proportion to that of the body to be removed, at once down upon it, through both skin and capsule. The incision need seldom be more than from three-quarters to an inch and a half long. The continued pressure of the thumb and finger, which is not for a moment to be relaxed, brings the body upon the surface, and, if it is entirely loose, causes it to shoot out from the opening. If it hang by a pedicle, the latter is to be drawn out as far as possible, and snipped away with the scissors. If there exist several foreign bodies, they are all, if it can readily be done, to be drawn forwards- and removed at the same orifice. If all cannot, however, be got away, without resorting to such mancEuvres as would surely be followed by inflammatory action, it is better to close the wound, and extract them if it become necessary, at a subsequent operation. The orifice in the skin is to be carefully closed with adhesive plaster, and the knee sur- rounded with a bandage, which is to be kept wetted with a cool- ing lotion for the purpose of preventing inflammation. The limb must be kept for -two or three weeks after in a state of perfect quietude, and should be sustained with a splint. It is usually recommended to place it in the state of extension, so that in case anchylosis should follow^ it would be found in the most useful position. Malgaigne, however, recommends, and with some reason, moderate flexion as being less painful, and exposing less to the consecutive stiffness of the joint. In the course of twelve or fifteen 86 GENERAL OPERATIONS. days nfter the operation, the author has been in the habit, and he thinks with advantage, of commencing gentle and passive motion of the joint, in order to prevent that union of opposite portions of the synovial membrane, constituting one of the varieties of false anchylosis which is here most apt to occur. This is a measure, however, deserving much care on the part of the surgeon ; for it must be remembered, that the fearful consequences sometimes following these wounds of the joint do not usually show them- selves before the eighth day. To obviate the danger of this incision directly through the skin into the joint, it has been proposed by Goyrand to employ a sub- cutaneous operation. The foreign body being held fixed as above directed, a long shanked tendon knife is to be passed by a punc- ture through the skin, two or two and a half inches below the point at which the capsule is to be incised, and carried above the foreign body so as to divide on its withdrawal the capsule and the synovial membrane immediately covering it. The cartilage is to be squeezed out of the joint through this opening, and lodged in the subcutaneous cellular tissue, where -it maybe allowed to remain, or, if preferred, extracted at a subsequent period, after time has been given for the subcutaneous cut in the membrane of the joint to close. Before the knife is made to act on the capsule it should be pressed downwards, so as to loosen the integuments, and form a bed into which the foreign body may be readily pushed. This very ingenious method has been successful in several instances in which it has been employed, and appears to the author worthy of imitation, as-being less likely to produce the terrible consequences that have sometimes followed the usual method, viz., suppuration and caries of the joint, extensive ab- scesses of the th jh, and even death. ON THE BURSAL SHEATHS OF THE TENDONS. Ganglions or synovial cysts, — hydatiform cysts. The tendons of the muscles, as they play over the joints, espe^ cially those of the hand and foot, are placed, as has been before observed, in fibrous canals, the inner face of which is lined by a synovial membrane, reflected, as in the manner of other double serous sacs, over the surface of the tendon. Over the wrist and ankle, the fibrous canals for the tendons are partly formed by the annular ligament of the articulation, which passes on the outer surface of the tendons. From this cause, when the synovial sheaths are largely distended with fluid, the tumours which they form often bulge up irregularly above and below the annular liga- ment ; the fluid when compressed, passing readily up and down underneath the ligament. On the palmar surface of the hand especially, the synovial sheaths are long, extending from a little distance above the wrist, with more or less interruption from trans- verse septa;, to the phalanges along the flexor tendons of the fingers. On the sole of the foot, the tendons which are deeply placed are likewise surrounded by bursal sheaths, and there is much reason to believe that many obscure and intractable cases of lameness arising from contusions in this region, may be attributed to disease of their bursal lining. Ganglions, or synovial cysts.— The consequence commonly of a sprain or contusion, but arising often, like dropsy of the joints, without obvious external cause, they form indolent fluctiiatino- tu- mours without change of colour in the skin, along the tract of the tendons. They diminish or disappear when the tendon is relaxed, but increase when it is put in a state of tension by the muscle, so as to interfere more or less with the movements of the joint. When they have existed for a considerable period, no topical application whatever, or compression in any way that it can be applied, is to be relied on for their cure. The indication in these cases is to destroy the integrity of the shut sac, so as to allowfthe fluid it contains to be poured out in the surrounding cellular tissue, from whence it will be removed by the absorbents. This may be efTected sometimes by sudden and strong compression with a letter seal wrapped in linen ; or, which is more likely to succeed, by a sudden blow with the closed hand, or the back of a book, the extremity (the wrist being the point in which it is most gene- rally observed), being placed on a firm support, as the surface of a table or the back of a sofa. The joint should be subsequently kept at rest for a few days, and bathed with an evaporating lotion, in order to obviate any tendency to inflammation, which in some cases might otherwise follow. Sometimes the sac will be found so strong as to resist all such efforts. It is then to be punctured with a tendon knife, or a small bistoury, which is to be introduced according to the subcutaneous method, the skin being previously drawn to one side so as to destroy the parallelism between the wound in the skin and sac, and thus prevent the introduction of air. Sometimes a simple puncture of the sac will suffice, the synovia difTusing itself freely into the surrounding cellular tissue under gentle pressure of the finger. It is necessary, however, that the effect of this pressure should be tried before the knife is withdrawn, for sometimes the cyst is divided by partitions into separate cavities, so as to require, in order to leave' no pouch unopened, a freer incision of its walls in various directions, which is to be made without enlarging the orifice of the skin, and- with- out pricking the tendon or dividing the superficial Veins and nerves. If, under these circumstances, the tumour does not subside, and especially if there is some effiision of blood in the cyst, it will I believe be better, for the reasons given in the next article, to make a free external opening at the place of puncture, so as to empty the contents of the sac, or to make a second punc- ture at any point of the tumour which has not subsided. The limb must be kept perfectly at rest for some time, and surrounded with a compress and bandage, and, if necessary, some cold astring- ent or evaporating lotion applied. Distension of the sheaths of the tendons about the fingers, hand and wrist, of an entirely difTerent description, and requiring ope- ration, is sometimes met with. In the case of a gentleman of this city afflicted with granular degeneration of the kidneys, whom I attended in conjunction with Professor Dunglison, we found in addition to the general dropsical tendency, a bursal swelling or hygroma on several of the flexor tendons of the foot.. The accu- mulation of the fluid became so great as to cause much lameness and pain, and finally produced a luxation of the corresponding phalanges from the metatarsal bones. The bones ultimately be- came fixed in nearly a vertical position, from the flexor tendons sliding over their grooves and getting on the back of the metatar- sal bones, so as to be converted into extensors. On opening the bursal sheath, the cellular and fibrous tissue on its outer surface was found to have undergone the lardaceous degeneration, for the OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 87 removal of which caustic potash was used, with the effect, finally, of obliterating the cyst. In paronychia, we not unfrequently find the sheaths of the flexor tendons of the fingers involved, so as to become greatly distended by synovial fluid. If this affection be not treated sufficiently early by free incision, in place of the synovial fluid we njiay find, the sheaths filled with pus, attended with great aggravation 6f the accompanying symptoms. The sheaths of these tendons arfr com- monly, though not always, separated by transverse sfepta from the synovial covering of the same tendons in the palm and wrist. Where the septa either do not naturally exist, or have been -broken down, we find in extreme cases the same collection of serous or purulent fluid forming tumours in the hand and wrist, and requir- ing to be freely opened. In such instances, it becomes necessary, after the operation, to keep the fingers extended for a considerable period on a splint, in order to prevent the muscular fibres, which become influenced by the disease, from retaining them permanently flexed. There is, however, always a risk of such a result after these operations, of which the patient should be apprised. In a case that I attended in consultation with Dr. Spackman, of this city, in which a poisoned wound on the ball of the thumb had been followed with immense swelling of the hand, suppuration in the theca of its long flexor tendon, and an extensive abscess deep in the palm of the hand, I was enabled to effect a cure without deformity, by laying open the sheath of the tendon on the thumb, and passing a curved probe-pointed bistoury along the tendon up into the palm ; the incision of some resisting fibres with the bistoury at the end of the track, allowed the pus from the palm to gush out through the external opening. Hydatiform cysts, — synovial cysts enclosing a number of small white bodies.— In. many instances on the back of the wrist and ankle, and on the palmar surface of the fingers, but more espe- cially in the former position, the synovial cysts, which have already been described, are found to contain a great number of staall white semi-transparent bodies, of a shape that is very varia- ble, but frequently resembling that of a small bean. In two cases of this kind for which I have operated, (in both of which the swell- ing was on the back of the carpus,) I discharged by incision in one over a hundred, and in the other a still greater number of these bodies ; some of these were three-eighths of an inch in length, and others, so small as hardly to be separately distinguished, were matted together in a heap. Double this number have frequently been met with. Mr. Ferguson speaks of having removed several hundred from an oblong swelling of the sheath of one of the flexor tendons of the finger. The mode of development of these bodies, and of similar ones found in the bursee mucosse, is believed in a great degree analogous to fliose of the joints. It has been assigned to the effusion of lymph, ultimately converted into a semi-cartilagi- nous state, like the productions found on the pleura and arachnoid. But the opinion of Velpeau, that they arise from effused blood, is certainly in a great many instances that which may be considered the true one. I have known ganglions on the wrist previously free of these bodies, present the evidence of their existence in great numbers after a severe accidental contusion of the part, or an unsuccessful attempt to cure them by incision, which had left the cavity around the tendon filled with blood. It has been supposed that the blood by coagulating in the cavity, and becom- ing divided into many portions by the friction of the tendons, gets macerated in the serum so as to lose its colour, and in the state of fibrin either by becoming attached to the membrane, or simply floating in the serum, takes on an obscure sort of growth. This, however, is but an hypothesis, though a plausible one. Dupuy- tren believed them hydatid cysts; capable of motion; but in this opinion he was unquestionably mistaken. Cysts on the back of the wrist or ankle' containing these bodies usually belong to the class of double tumours already noticed, one of which is found above and one below the annular ligament, under which they communicate together. By alternate pressure on these tumours we displace the fluid and the bodies floating in it; this gives a sensation of something slipping, with an indistinct sense of crepi- tation, forming the diagnostic mark of the existence -of these little cartilages-^ The orily method of effecting a radical cure in these cases consists in opening the cysts, discharging the cartilages, and causing the obliteration of the cavity. The extirpation of,the cyst, from the manner in which it is connected round the tendons, would be an operation as difficult as it might be dangerous. The usual method of proceeding is to open the cyst above and below the annular ligament by an incision parallel with the tendons, and after emptying it, introduce into the cavity a mesh of charpie or a piece of linen, which is to be removed at the end of the second day-, so as to cause it to suppurate and close by granulation. But this plan I have found liable to be followed by greater or less stiffness about the joint, and in more than one instance reported, it has been attended by such extensive sub-aponeurotic inflamma- tion of the hand and fore arm, as to cause death. In the two cases referred to on the last page, I made an incision under the skin, (obliquely, in order to avoid the introduction of air,) through which I forced the bodies by gentle effort; the surfaces of the cyst were then compressed together, with a view of obliterating them, with a stout leathern splint buckled tightly round the wrist. In one of the cases, success was immediate ; in the other, there was a/e-deve- lopment of the cartilages, requiring a second and third operation, leaving in the end a fibrous knot upon one of the tendons. Du- puytren passed a seton through the cavity, but was compelled to abandon the practice, in consequence of the excessive inflamma-" tion it produced. HYGEOMA.-ENLARGED BURS^ MUCOSA. Dropsy of the Bursee. From causes analogous to those above mentioned in reference to the other synovial tumours, but especially from contusion, do we have a dropsical accumulation of the synovial fluid in the bursae. It may occur in any of the numerous bursal sacs, but those of the knee and elbow are the only ones~ in general which require any operation beyond that of simple puncture for the removal of the fluid. The former is found between the skin and the ligament of the patella — the latter between the olecranon process and the skin, and is much'less frequently the subject of disease. In both instances a prominent, obscurely fluctuating tumour is observed, often from the effect of pressure accompanied with a slight^change of colour in the skin. Sometimes the tumour consists of a single cyst; but more often, according to my own experience, especially in hygroma of the knee, (housemaid's knee,) of a series of cells in 88 GENERAL OPERATIONS. the interior of a common cyst, filled with a fluid so viscous and gelatinous as to render its discharge by puncture slow and difficult. Treatment. — The principle of cure consists not only in remov- ing the secretion, but in obliterating the sac, so as to prevent eflectually the reproduction of the tumour. Puncture and injection. — A simple puncture will seldom suf- fice for a cure. I succeeded completely, five years ago, in the case of a Methodist preacher, in eflectually curing a tumour of this description below the knee, by puncturing the sac, lacerating the enclosed cells with the point of the knife, pressing out the glairy fluid, and injecting into the cavity tinct. iodi. diluted with four parts of water. Pressure was also applied subsequently by the aid of a compress and bandage. This plan of treatment, which is on the same principle as the modern practice in hydro- cele, has lately been employed to a considerable extent by M. Velpeau, and is one deserving of much confidence. By the seton. — It is the custom among some practitioners, when the tumour has become troublesome from its size, as well as sore from continued pressure, to puncture it and introduce a seton through the cavity of the sac. A cure may unquestionably thus be accomplished, but it is usually tardy, painful, and attended by profuse suppuration. By shaving off" the anterior wall. — M. Masnier* has advised, in these and all other encysted tumours, to shave ofi' the anterior half of the sac, after having previously opened and dissected oflT the skin; or, if the tumour be small and prominent, shaving off with the point of the sac the corresponding portion of integument. But this is not a method which has received the sanction of gene- ral use. By ablation. — The tumour has in some instances been com- pletely dissected out. This is an effectual means of cure and in many instances the most advisable; but where the tumour is large, and the walls, as is commonly the case, firmly adherent on their outer surface, the proximity of important parts renders it a proceeding accompanied with some danger. Velpeau reports two cases of death following this method of operation. Sometimes, from habitual pressure on the surface, suppuration takes place spon- taneously in the cavity of the sac ; the abscess thus formed opens by ulceration, and is commonly followed by a cure. Foreign bodies of the same semi-cartilaginous character as those above described are occasionally met with in the burs£e, and require a similar method of treatment. ANCHYLQSIS. There are two forms of anchylosis of the joints. 1. That which is called true or complete, resulting from causes that have acted on the interior, of the joint ; such as frattures running into the articular cavity, extensive wounds of the joint, abscesses, erosion of the cartilages or ends of the bones, either of which may pro- duce such an ossific union of the articular surfaces, as to prevent all motion between them. 2. That which is called false or in- complete, where the abnormal junction between the ends of the bones, instead of being ossific is ligamentous; or is the result of the adventitious attachment of portions of the synovial membrane of the contraction of the muscles or ligaments or cellular tissue • Theses de la Faculle de Paris, 1803. round the joint, or of extensive cicatrices following burns and ulcers. In fact, the remote causes which may give rise to false anchylosis are exceedingly numerous; but our object at present is to consider the first variety, which, though far less frequently met with, becomes more directly the subject for consideration in this place, where we are treating of the operations upon the bones themselves.* Each of the joints may be affected with anchylosis ; but in those of th% hinge-like form, as the knee, elbow, ankle, and jaw, it is most frequently observed. The diagnosis between these two forms of the aflfection is gene- rally though not always easy, and is of the first importance as re- gards the treatment. In true anchylosis, the joint is solid, perfectly immovable, and all the attempts to produce motion are unattended with pain ; and not unfrequently we are enabled to feel through the integuments the uneven surface of the callus which has united the articular faces of the bones. In false anchylosis, on the con- trary, there is in most cases some degree of mobility between the ends of the bones. Occasionally, however, the stiffness and rigidity of the surrounding parts are so great even where there is no bony union, as to render the joint perfectly inflexible. But here from the previous history of the case, especially if the affec- tion has had its origin exterior to the cavity of the joint, and from the fact that in false anchylosis the joint usually becomes swollen and painful after active eflTorts have been made in order to pro- duce motion, we are enabled to decide with a great degree of pre- cision in regard to the actual state of the articulation. There are three methods of remedying the inconveniences re- sulting from the solidification of the joint, which constitutes true anchylosis. 1. To re-establish the movements of the joint, by rupturing the adventitious junction between the bones. 2. To establish a new point of motion by the creation of a false joint. 3. To place the limb in a new position by taking out a wedge- shaped portion of bone, when it is anchylosed in a direction that renders it inconvenient or useless. Rupture of the anchylosis. — No surgeon of experience can have failed to observe cases where an anchylosed knee, elbow, wrist or finger, has had its movements restored to a greater or less degree by an accidental rupture of the new bond of union, the con- sequence of a fall, or some external violence. The results in these cases, where in all probability the bony union has been but very partial, such, for instance, as the adhesion of the sides of the patella to the condyles of the os fempris, have led surgeons to imitate the process, by producing a forced rupture of the uniting medium between the ends of the bones. The consequences of these attempts, have not, however, been such as to sanction the adoption, especially as regards the large joints, of a highly dan- gerous experimental operation, for a mere deformity, which does not in itself compromise life. .M. Louvrier lost five patients out of twenty-one by this process for straightening bent and anchy- losed knee-joints, and in some of those that survived, the violence employed was followed by excessive inflammation of the sur- rounding parts, luxation of the knee backward, and a secondary anchylosis at an angle more or less obtuse. He has, however, in • The surgicaltreatment of false anchylosis will be considered under the head of Sabcutaneous Operations. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 89 some cases, obtained complete success by rupturing the attach- ments; and instances no doubt may be occasionally found where the union of the bones is so partial, as to justify the attempt. It will be difficult, however, to determine beforehand the cases in ■which it may be employed with impunity from those where its application would be highly dangerous or fatal. The strietching apparatus of Louvrieris thus arranged : — A linen roller bandage is first fastened tightly around the knee, in order to prevent by its pressure any resistance from the contraction of the muscles, and should embrace both the lower part of the thigh and the upper part of the leg. The inequalities of the surface of the latter are to be filled up with cotton wadding, which is to be sustained by another bandage rolled over it, so as to give the leg the shape of a cone, the basis of which is at the knee. The an- terior and posterior surface of the thigh and leg are then covered ■with hollow splints of strong leather, (which should be fastened ■with straps,) in order to protect the soft parts against the pressure of the apparatus. The foot is then covered with a woolen stock- ing and a leather half boot, secured in like manner to the leg by straps. On the inner surface of the heel of this boot is a strong screw with a perforated head. These preparations completed, the patient is placed upon a table, with a pillow for his seat, and with his back leaning against the wall. The diseased extremity is now to be placed in the apparatus. This consists of an oblong box, from which the cover and end pieces have been removed, provided at its foot end with a horizontal beam, turned by a crank on its outside. Around this beam is wound a strong cord, of the thickness of a quill, one end of which is fastened to the screw in the heel of the boot. A very wide leather splint, reaching from the middle of the thigh down to the middle of the leg, is then placed on the posterior surface, so as to surround about two-thirds of the circumference of the extremity. This splint is composed of two pieces, with a circular joint at each condyle, so as to allow the lower part to follow the movements of the leg. Four iron bars, rising perpendicularly from the four corners of the joint, support a metal frame, below which is attached a leathern bolster, to be applied upon the anterior surface of the knee. Through this plate and bolster, the downward pressure upon the knee is made, by means of a cord that runs from the metal frame and turns round a pully to the beam, around which it is tightened by turn- ing the crank. The leg, as it lies on the box, forms with the bottom of the latter a hollow triangle, the apex of which is in the ham. It is now the object of the surgeon to press down the knee, until its posterior, surface touches the bottom of the box. This is accomplished by turning the crank of the machine so as to tighten the cords ; one of which pulls out the foot and stretches the leg, and the other, by means of the frame and bolster, effects a powerful down-ward pressure on the knee. In about thirty seconds, the operation is usually completed. The pain during this time is excessive, and is compared by the patient to that caused by the extraction of a tooth, but soon ceases on the removal of the appa- ratus, which is to be taken away immediately after the operation. At the last step of the process, a crackling .sound is heard, which denotes the forcible separation of the parts. If the rupture of the anchylosis has been complete, the leg may be moved freely and without pain. The patient is then placed for two hours in a warm bath ; and the parts are entirely freed from all local pres- 23 sure. The day following, narcotic poultices are applied about the knee, and a simple support given to the limb, in order to prevent the involuntary contraction of the muscles. 2. Formation of an artificial joint. — This method, for which we are indebted to the ingenuity of Dr. John Rhea Barton, of this city, has been applied as yet but to the anchylosis of a single articu- lation — that of th^ hip joint. It has, however, been suggested by this skilful surgeon, that it might likewise be found applicable to similar affections of the lower jaw, Icnee, elbow, fingers, and toes, when the muscles of these respective articulations remain uninjured. The method consists in the uncovering of the bone at or near the diseased point, dividing it across with the saw, and subsequently moving the lower portion from time to time upon the upper, to prevent a solid reunion of the divided parts. By this mode of proceeding, there is the same disposition of parts for the formation of a false joint, as we often find leading to that result in fractures, where the bones are not kept sufficiently at rest. Under such circumstances, the two opposing surfaces of bone may be expected to unite by flexible ligamentous matter, or be- come smooth and polished by the friction: the lower fragment, in the latter case, rounding itself into the form of a head ; and the upper hollowing itself more or less into the shape of a cup, in which the lower fragment plays; the periosteum and surrounding cellular tissue becoming condensed and thickened, so as to per- form the office of a fibrous capsule, and the muscles modified to a certain extent, to accommodate themselves to the new articula- tion. For anchylosis of the hip. {Process of Barton, PI. XXII, fig. 3.) — The ingenious idea of remedying this deformity by the estab- lishment of an artificial joint, was practised by Dr. Barton, in 1826. A similar operation was repeated four years subsequently by Dr. J. Kearny Rogers, of New York; the two constiti|ting the only instances in which it has yet been attempted on ihe living subject. The patient of Dr. Barton was a young man twenty- one years of age, in whom the thigh -was held immovably bent at a right angle with the pelvis, and the foot turned in rotation in- wards. A crucial incision was made over the projecting portion of the trochanter major, the vertical division of which was seven inches in length, and the transverse five. The four laminae thus formed were dissected and turned back, and the fascia freely opened. The muscular fibres were then detached from over the trochanter by turning the scalpel sideways, so as to allow the two index fingers to be passed freely round the neck of the femur, till they met on the opposite side. With a strong straight saw the bone was then nearly divided through the upper part of the great trochanter and part of the neck of the bone. The operation lasted but seven minutes, and no artery was opened that required to be tied. The limb ■was then drawn to its proper position, when the undivided portion of the bone separated with a snap. The , wound was closed with a few points of suture, and the extremity secured in the fracture apparatus of Desault.* On the twentieth day after the operation the inflammatory symp- toms had in a great measure subsided ; some slight passive move- ments were then made with the limb, in directions natural to the healthy joint, which were cautiously repeated from time to time. -* North Amer. Med. and Surg. Journal, April, 1827, 90 GENERAL OPERATIONS. assistance of a cane. The new joint, however, in the end became anchylosed in this case, as in that of Dr. Barton. In conse- quence of the shortening of the limb of the opposite side from fracture. Dr. Rogers, instead of making a simple section, re- By the sixtieth day the wound was completely healed ; the patient was able to stand erect with the aid of crutches, and could advance his limb exclusively by muscular exertion. At the end of four months he was able to walk without apparent lameness, and all the movements of the limb were executed without pain. The foot could be carried twenty-two inches forward, twenty-six back- wards, and twenty outwards, and could be rotated inwards to the extent of six. The patient enjoyed the use of his artificial joint for a period of six years, at the end of which time, from causes attributable to intemperance and repeated falls upon the hip, the new joint became permanently anchylosed. The operation of Dr. Rogers was equally successful, and his patient left the hospital at the end of four months, apparently with a perfect use of the new joint, as he could walk with ease by the moved a wedge-shaped portion of the bone, in order to render the relative length of the two limbs more equal. In place of dividing the bone after section of the soft parts, as above described, it has been proposed, by M. Louvrier, to produce directly by mechanical means a fracture of the neck of the thigh bone, a measure which he believes less dangerous than the former, and affording equal facilities for the formation of a false joint. But provided it were possible to succeed in fracturing the bone at the desired point, there would be such danger by this method of doing violence to the surrounding parts, that it can offer no proba- PLATE III.— OPERATIONS UPON THE BONES. {Fig. 1.) RESECTION OF THE ENDS OF THE FRAGMENTS IN UNUNITED FRACTURE OF THE OS HUMERI. (Process of the Author.) The operation is represented on the left arm, which is raised at the shoulder joint and depressed at the elbow, so as to cause the bones to protrude at the wound. The limb is seen on its outer face. The incision has been made in the intermuscular space between the brachialis anticus and the triceps muscles, just below the insertion of the deltoid. The parts are slightly dissected, so as to render the anatomy clearer than it would appear during the operation. In other respects the operation is precisely the same as one performed by the author for false joint at this part of the arm. a. Insertion of the deltoid muscle, which is exposed along the inner border of the incision. b. Outer edge of the brachialis anticus. c. Triceps extensor cubiti muscle, the fibres of which have been divided across at the upper paft of the wound, to give a better view of the false joint. d. Lower end of the upper fragment of the bone, which has been turned partly out of the wound, after the section of the ligamentous matter which had connected the ends of the two fragments together. e. Upper end of the lower fragment. The ligamentous matter is represented as removed from the end of the bone, showing that it is covered with a compact lamina like the extremity of a bone after amputation. /. Musculo-spiral nerve, winding very obliquely in its groove round the outer face of the bone ; it is, unless great care is exercised, liable to be cut in the operation. g, h. Musculo-spiral artery and vein. i. A long narrow compress, used to raise the end of the bone and protect the soft parts below from the action of the saw or forceps, with which the rounded end is to be excised. {Fig. 2.) INTRODUCTION OF THE SETON, FOR UNUNITED FRACTURE OF THE TIBIA. In this case two incisions have been made on opposite surfaces of the bone, (which is supposed to have been obliquely fractured,) in the manner of Wardrop, and the seton has been carried through, after a perforation had been made with a trephine needle through the overlapping ends of the fragments. In the arm or wherever the bones can be separated so as to obtain room, the common seton needle may be passed at once without previous incision. {Fig. 3 and 4.) REMOVAL OF A LOOSENED AND NECROSED PORTION OF BONE FROM THE WALLS OF THE CRANIUM. An incision in the shape of a "f has been made, and the two angular flaps dissected up and reversed. The point of an elevator is seen insinuated under the edge of the dead bone, In order to raise it up and slide it outwards, so that It can be seized with the forceps and removed. F7g. 4 IS the piece of bone shown separate. It is rough and serrated on the edges from the action of the absorbents which have detached it from the living tissue. I' I ah' ZI. i-'uf a OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 91 ble advantages to cause it to be compared with the neat and methodical section of the bone according to the plan of Dr. Barton. It would be rather more easy to divide the femur below the tro- chanter, but, by this naeasure an all-important object would be lost — that of obtaining a new and solid articulation upon the pelvic bones, so as to re-establish the functions of the limb with the least possible shortening. 3. Removal of a wedge-shaped portion of hone, for straightening a bent and anchylosed knee joint. (Process of Barton, PI. XXI. fig. 6.) — In bony anchylosis of the knee joint, when there is so much angular deformity as to render the leg a mere incumbrance to the patient, it was not till recently that any measure of relief had been proposed, save that of amputation. To Dr. John Rhea Barton* we are indebted for the introduction of a new pro- cess for the relief of this deformity, which in 1835 was success- fully employed by him in the case of a young physician from the south. The process is as follows : — the object being to expose a portion of the anterior surface^of the os femoris just above the condyles, and as low down as within half an inch of the patella, which will be found firmly adherent on the face of the joint. Two incisions are to be made across the femur, just above the patella ; one commencing at a point opposite the upper end of the internal condyle, and the other two and a half inches higher and on the same side ; both are to be extended over the bone till they meet on the opposite side, forming a sort of tongue-shaped trian- gular flap. This flap, consisting of the integuments, the tendon of the extensor muscles of the leg at its place of insertion, some of the fibres of the rectus and cruralis muscles, and a greater part of the vastus externus, is to be dissected up, with the fascia and muscles, from the sides and front of the bone, and turned over upon the leg. This flap in some instances will be found stiff and * Vide Amer. Journ. Med. Sciences for 1838. resisting, in consequence of the deposit of new bony matter in the sub-aponeurotic cellular tissue. The soft parts are next to be detached at the outer side of the femur, from the base of the flap towards the ham, bypassing a knife over the circumference of the bone, so as to admit the use of the saw. A wedge-shaped piece is then to be removed from the spongy tissue of the head of the femur, by two sections with a saw, sloped so as to meet within a few lines of the posterior face of the bone, but not so as to divide it entirely across, for fear of injuring the vessels in the ham. The base of the wedge on the front part of the thigh must have a width proportioned to the degree of deformity that is to be remedied — say from two to two and a half inches. The leg is then to be pressed backwards, so as to cause a rupture of the undivided portion of the bone without disconnecting the fragments. No blood-vessel is likely to be wounded that will require a ligature. The wound is to be lightly dressed, and the limb supported on a splint having an angle corresponding to that of the knee previous to the operation. When suSicient time has been allowed for the asperities of the ruptured fibres on the back portion of the bone to become smoothed by softening and absorption, so that the pres- sure backwards cannot cause ulceration of the artery, the limb is to be somewhat straightened by substituting for the first splint an- other with an angle less obtuse. By thus varying every few days the angle of the splint, the limb is brought by degrees into a posi- tion nearly straight. To protect the popliteal vessels from all chance of pressure, two long bran bags are laid lengthwise on the splint, with a vacancy of four or five inches between them, (which is to be filled with carded cotton,) opposite the lesion of the bone. Protracted suppuration and constitutional irritation, such as are attendant on compound fractures, (to which the wound of the operation may be compared,) must necessarily be expected to follow, and during the treatment particular care should be ob- {Fig. 5.) EXTRACTION OF A SEQUESTRUM, OR NECROSED PIECE OF THE CLAVICLE. A quadrilateral flap has been turned down from over the bone. The shell of new bone, or inVolucrum, has been opened with the cutting pliers, so as to allow the loosened sequestrum to be grasped with the forceps and withdrawn. {Fig. 6, 7 and 8.) REMOVAL OF A WEDGE-SHAPED PIECE OF BONE FOR TRUE ANCHYLOSIS OF THE KNEE JOINT. (Process of Barton.) a. Patella, adhering to the face of the condyles. b. Tendon of the extensor muscles, cut oS" near its insertion on the patella. c. Lower end of the femur ; the two black lines crossing the bone meet together a little short of the posterior surface. of the bone, and indicate the two tracks of the saw by which the wedge-shaped piece is removed. d. The tongue-shaped flap of integument, muscle, and tendon, raised by two semi-oval incisions, and reverted on the inner side of the knee. 7 is a sketch illustrating the manner in which the limb is made straight, by gradually bringing up the leg, so as to throw the knee upwards till it ^effaces the space made by the removal of the wedg^-shaped portion. a. Femur. b. External condyle. c. Adherent patella. > d. Head of the tibia. e. Fibula. Fig. 8 represents the limb in its state of angular deformity. g. Is the outline of the wedge of bone removed. The other references correspond to the same parts as in fig. 7. 92 sensed, that in straightening the limb the lower fragment be not allowed to slide backwards, so as to shorten the leg, and render it nearly impossible to give the extremity the requisite degree of straightness. Four months after the operation, the patient of Dr. Barton was able to Stand erect, with his feet in their natural position; at the end of eight, he could mount his horse with facility and walk with ease, notwithstanding the loss of motion at the knee, from forty to fifty miles a day. The same procedure has been repeated by Professor Gibson on a patient in the Philadelphia Hospital; this, and the former case, constitute the only instances, within my knowledge, for which this truly valuable American method for the treatment of anchylosis has yet been employed. In fifty-six days after the operation in the second case, there was firm union at the place of section ; and though the thigh was shortened about an inch, the limb was nearly straight, and the patient could .sustain himself upon it with ease, COMPLICATED FRACTURES AND LUXATIONS. Occasionally, these aflfections call for the performance of some specific operation. 1. In extensive laceration of the flesh and skin, with projection of the bone, occurring either in comminuted fractures, or compound fractures and luxations. In such cases, if the projecting fragment or the head of a protruding bone cannot be easily reduced, the wound should be enlarged by an incision, and a subsequent effort made to replace it. If this fail, the end of the bone is to be cut off with a saw, or a pair of strong-cutting forceps. The bones are then to be adjusted, and the wound treated so as to reduce it as much as possible to the state of simple fracture. 2. Where the fracture is attended with the separation of splinters or scales from the hone. — If the fragments are completely or nearly loosened from the bone and driven off into the soft parts, so as to be readily obserA'ed from without, an operation is required for their removal. An incision should be made opposite the irritating body, at the point where the bone is most superficial, selecting the intermuscular spaces when it is possible, and avoiding the side upon which the great vessels are located. The fragments are then to be removed with the forceps. Sometimes the splinters or scales are firmly attached to the periosteum by one end, while the other is lodged in the muscles, and will require to be loosened with the knife before they can be twisted out with the forceps. Sim- ple fissures or splintering of the bone, without displacement of parts, call for no operation, as they readily become consolidated by the subsequent effusion of callus, under the ordinary plan of treatment for fracture. 3. Where there is laceration of the vessels and nerves. — When the vessels are lacerated, the different means of arresting hemor- rhage suited to the peculiarities of each case, already noticed, have to be put in requisition. If the branches of the nerves be partially torn and exposed, they should be divided completely across with the bistoury. But extensive injuries of this description indicate the necessity of immediate amputation, a subject which will be hereafter considered. GENERAL OPERATIONS. PSEUDO-ARTHROSIS.-FALSE JOINT.-UNUNITED FRACTURE. FanV/i'es.— Fractures in which no bony union has taken place, may from the facts revealed by dissection, with propriety be di- vided into three classes. 1. Those in which the ends of the frag- ments, rounded and thinned by the action of the absorbents, are connected by an intermediate fibro-ligamentbus tissue. This con- stitutes by far the largest class. 2. Where the end of one of the fragments has become rounded into a head, and the other con- verted by the constant motion of the parts, and the thickening and condensation of the surrounding tissues, into a cup or socket; both portions being surrounded by an adventitious capsular mem- brane, and lined by a new-formed synovial tissue. 3. Where the fragments have not been brought into opposition, but are kept separate by a portion of muscle, or a detached or necrosed piece of bone. Causes. — The cause of the non-union in regard to the third variety, is sufficiently obvious; In respect to the first and second, it depends upon a number of circumstances very different in their character; and in some cases the accident occurs in despite of the most judicious treatment, and where no apparent cause can be assigned for the want of bony union. Among the most common causes, may be placed a mal-adjustment of the ends of the bones, imperfect support from the splints or other dressings applied, in- docility on the part of the patient in keeping the limb at rest, meddlesome interference of the surgeon by too frequeiitly chang- ing the dressings without cause when they have once been properly adjusted, some morbid alteration of the bone, as that of caries or necrosis, the development of hydatids in its cavity, advanced age, or an impaired or exhausted state of the constitution. Sometimes, even after the bony matter has been deposited so as to unite the bones, it has been removed by absorption, leaving only a flexible cartilaginous bond of union. Remarks. — The period within which we may expect a perfect consolidation of a broken bone to take place by the usual method of treatment, varies so much in regard to different individuals, as to be scarcely subject to any general rule. Nevertheless, we may ordinarily consider that a false joint has been formed, when, after the lapse of six months from the occurrence of the fracture, the fragments still remain movable at the point of injury. False articulations have been observed in most of the bones ; but they are more frequently met with in those which are most movable, as the humerus and the lower jaw. In fracture of the neck of the thigh bone within the capsule, where bony union in general is not to be expected, a false joint near the former centre of motion may be viewed as the best result that can follow. In most other instances, the integrity of the bone, by which it serves as a lever for the muscles to act with, is destroyed ; and the limb to which it belongs (if it occur on an extremity), becomes nearly useless. But cases may occur, as rare exceptions to the general rule, especially where two bones are associated in nearly similar offices, as in the forearm and leg, in which an attempt on the part of the surgeon to solidify the false joint would be most injudi- cious. One of this description occurred in my service two winters ago at the Philadelphia Hospital. A man from the west had received in a fall a shock on the forearm, which dislocated the radius and carried it upwards on the humerus, and at the same time produced a fracture of the ulna about two inches and OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 93 a half beloysr the joint, with considerable angular displacement; the lower fragment being brought up in close contact with the radius. No attempt at reduction was made; the limb in its deformed condition being merely put up in splints. The conse- quence was that bony union took place between the ulna and radius at the point where they come in contact, and a false ball and socket joint formed between the broken ends of the ulna. In flexion and extension, both bones moved together as far as they were permitted by the end of the radius resting on the humerus. In pronation and supination, which was very well performed, the radius and lower fragment of the ulna moved together, the latter rotating in the new formed articulation. Under such cir- cumstances, the solidification of the false joint would have im- paired to a great extent the utility of the limb ; and the result here accidentally produced indicates the propriety of attempting to efTect some analogous artificial means of relief in certain states of deformity and loss of use of the forearm, that occasionally arise from ill-treated fractures. Treatment. — The general as well as the local measures of treat- ment, must vary according to the causes which have led to the defect. 1. Of the local measures. — It is here only necessary to note briefly the more important of tlie multitude that have been de- vised. No one of these Jn all cases being entirely sufficient to accomplish the object desired, it becomes advantageous to com- bine them, or try them in succession, according to the degree of action which they are capable of exciting in each case. 2. Friction of the ends of the hones. — This process, which is as old as the time of Celsus, consists in rubbing forcibly together the two fragments in order to excite a degree of inflammatory action that may lead to the deposit of earthy matter in tne new tissue. This procedure is only applicable where the ends of the bones do not overlap, when there has been a mere transverse fracture, and when it is attempted at so early a period, — say six, eight to ten weeks after the injury, — that the false joint cannot be-considered as fairly formed. The limb is then to be done up in splints, or what answers admirably well, the immovable appa- ratus prepared with dextrine or starch, and kept perfectly at rest for two or three weeks. After this period it is to be re-examined, and the measure, if it has been at all successful, repeated as before. If not, some of the succeeding processes are to be applied. Compression, — A method sornewhat analogous to the above was introducedby White, and has been occasionally found very advantageous. It consists in applying round the fractured limb a strong support,^ — such as that of an envelop of stout leather, well padded, and firmly secured with straps and buckles, — the patient to use the limb as much as possible, and if it be the lower extremity, even to move about upon it. As soon as a sufficient degree of action is provoked at the place of injury, as manifested by soreness and swelling, the limb is to be kept completely at rest, as directed after friction of the ends;. Simple compression of the ends of the bones together, by the fracture apparatus, while the limb was kept at rest, has succeeded in two cases in my hands, as late as the third and fourth months after the reception of the injury. 3. Cutaneous irritants. — The application of blisters frequently renewed, of caustic potash, tinct. iodine, and analogous substances 24 immediately over the point of fracture, has been much praised by Wardrop and others. It may be considered a useful process where the work of ossification proceeds slowly, and the bones lie superficial, as in the forearm and leg; but according to my own observation, has little effect, even in these cases, if not em- ployed within six or eight weeks after the injury. 4. Seton. {Process of Physick. PI. XXI. fig. 2.) — The use of the seton, for which we are indebted to the practical wisdom of the late Dr. Physick, is a measure which may be relied on with considerable certainty for the cure of false joint in the jaw and upper extremity. In the lower extremity, the results of its employment have not been equally successful. Extension and counter-extension having been made upon the limb, so as to cause a separation of the fragments. Dr. Physick passed the ordinary seton needle through the limb, traversing the interval between the bones — cautiously avoiding the track of the principal blood- vessels and nerves, and selecting the points at which the bone was least covered with flesh. A stout cord or a skein of silk, which has been previously attached to the eye of the needle, is then to be drawn through after the instrument. The wound is to be simply dressed, and the limb, after suppuration is estab- lished, placed in an appropriate fracture apparatus. The seton is then to be daily moved in the wound, and retained even for a year or more, if so long a time be required for the limb to become suflSciently stiffened by the deposition of callus to admit of its- executing its usual movements. If the necessary degree of irri- tation is not maintained by the simple seton, it may be smeared from time to time with some stimulating ointment. The first case of Dr. Physick was an ununited fracture of the humerus. At the end of twelve weeks the consolidation began, and' at the termination of five months and a half, the cure was complete. Professor Horner, of this city, has employed the sail- maker's needle in place of the ordinary instrument for carrying the seton. This is less liable to divide important parts, and I have found it to answer well, particularly in fracture of the lower jaw. In the latter affection, it should be carried from the cavity of the mouth, downwards and outwards, through the integuments covering the base of the jaw. Modification of Wardrop. — This gentleman has proposed to modify the method of introducing the seton where the bone is deeply seated, as in the upper third of the thigh, by previously dividing with a bistoury the soft parts over it, and introducing the needle inclosed in a sheath down to the bottom of the wound, when it is to be passed through as in the process of Physick. Modification of Oppenheim. — This consists in the introduction of two setons, so that one shall come in contact with each of the ends of the bones. Both may be introduced at the same time, or the second a few days after the first. When suppuration is fully established they are to be withdrawn. By such means, this sur- geon believes a sufficient degree of inflammation will be excited to insure a bony union without incurring the same risk of erysipe- las and abscess, which have in some cases carried off" the patient, when the seton has been maintained a long time in the wound. He does not consider it absolutely necessary that the seton should traverse the tissue between the bones, the same advantageous effects being produced w^hen they are placed merely in proximity or contact with the periosteal covering of the ends of the bones. 94 The value of this opinion has not perhaps been as yet sufficiently attested in practice. In some instances, it is found exceedingly difficult, if not im- possible, to pass the seton, either in consequence of the obliquity or overlapping of the fragments, or from the risk of injury of important parts ; and under such circumstances, Professor Fergu- son observes, he has seen a needle or probe left sticking in the fissure between the bones, followed by all the benefit that could have been expected if a cord had been carried through in the usual manner. In those cases where the fragments are held asunder by a necrosed portion of bone or a piece of muscle, the use of the seton would probably be attended with no benefit. SomviVs modification. Section of the fibro-ligamentous union by means of a wire. — In an ununited fracture of the femur, this surgeon pierced the limb from within outwards, with a long delicate trocar, grazing the inner surface of the end of the lower and the front portion of the upper fragment. The stilet was with- drawn and a silver wire passed through the canula, and left in the wound, after the canula was taken away. A second puncture was made with the trocar, but in the opposite direction, from without inwards and forwards, and brought out at the place of the first puncture. The end of the wire, which had previously passed through the limb, was again carried through the canula ; this instrument was then drawn through at the inner side of the limb and removed. The loop of the ligature thus surrounded the false joint, including the bridge of muscle and skin between the two posterior punctures, which was divided across with the bistoury to let the wire down to the bones ; the lips of the incision were then GENERAL OPERATIONS. brought together so as to unite by first intention. By gradually tightening from time to time the loop which embraced the liga- mentous tissue, this was by degrees divided, and an effusion of callus followed, consolidating the fracture at the end of six weeks, so far as to justify the removal of the wire. Three months after the operation, the patient was able to walk. 5. Jlcupuncturation. — M. Malgaigne has suggested, in place of the seton, to introduce a number of acupuncture needles through the fibrous tissue between the ends of the bones. The trials which have been made of tliis process do not, however, prove it to have been very efficacious. ■ v'' 6. Cauterization of the ends of the h^nes'.-; (Process of Green.) — An incision through the soft parts having been made so as to expose the ends of the fragments, the fibrous tissue uniting them is to be divided with the knife, and' each end rubbed with a' cylin- der of caustic potash, till it becomes of a black hue; Especial care must be taken to protect the surrounding parts from the action of the caustic, which is to be applied in the depth and without turning out the bones through the wound. Earl has advised, in order to render the process more efficient, to previously scrape off the fibro-cartilaginous, or fibro-ligamentous covering of the ends of the bones, and apply the caustic directly upon the osseous tis- sue. Some operators have satisfied themselves with merely cut- ting down and scraping the ends of the bone. Numerous in- stances of the successful application of the caustic are recorded. The process is not, however, unattended with danger, as the frac- ture is rendered compound by the incision through the soft parts ; and though rather less likely to produce severe constitutional PLATE XXIL— OPERATIONS ON THE BONES. (Fig. 1.) REMOVAL OF AN EXOSTOSIS, OF THE EBURNATED SOLID KIND, FROM OVER THE LAMBDOIDAL SUTURE. The tumour was of a globular form, and projected for about an inch above the bone. It was divided vertically in two Imes by the saw, so as to render its removal with Key's saw more easy in three separate portions. One portion has been removed, and the saw is shown in the act of dividing the middle part. {Fig. 2.) REMOVAL OF A TUMOUR OF THE SAME DESCRIPTION FROM THE UPPER THIRD OF THE HUMERUS. a. A triangular flap of the whole thickness of the deltoid has been raised between two incisions which run down parallel with the fibres of the muscles. The flap is reverted toward the shoulder so as to expose the diseased surface of the humerus. 6. A wooden ruler, which is placed on the inner side of the tumour so as to press inwards the biceps muscle and the brachial vessels out of the way of Hey's saw, with which the tumour is divided at its connection with the arm bone. {Fig. 4.) FORMATION OF AN ARTIFICIAL JOINT, FOR ANCHYLOSIS OF THE ARTICULATION OF THE HIP. {Process of Barton.) The patient is laid upon the sound side. A crucial incision has been made, with its centre over the trochanter ™T'il, , %^°"'" ^^P' ^'^ dissected up and reverted. The bone, after being denuded in its circumference wiin the knife, has been divided nearly across with .the saw, the section being made partly through the trochanter and partly through the lower end of the neck of the bone. The figure represents the last stage of the operation, when, after the section of the bone, the limb has been swung inwards in order to snap the°thin portion left unsevered by the saw. /■vy :' I :T!r n-f ., i-'i'f ri,.i..r.-iri--''"i-':''"-'' '■■ ''" .: H.i-t ))„,.,/■'"• OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 96 Symptoms, it is not in general so certain a means of effecting a •cure, (the fragments often overlapping so that the caustic cannot fee made to act on the proper point,) as resection of the ends. 7. Resection. (Pi. XXI. fig. 1.)— The ends of the fragments are to be exposed as in the last process, by a longitudinal incision through th€ soft parts, and the intervening fibrous tissue divided -across. The two extremities are then to be luxated, as it were, and made to project one at a time through the external wound, separating the adhering soft parts with the knife so far only as is absolutely necessary. The arteries are to be tied as they are cut. It will be found most convenient to protrude first the inferior frag- ment. The rounded ends of the bones are then to be removed with the saw or cutting forceps, after the manner of "White. The bones are then to be replaced with their raw extremities exactly in contact. The subsequent treatment becomes precisely the same as in ordinary compound fractures, and the risk following the operation may be considered even greater than that attendant upon these affections ; hence, when the thigh forms the seat of injury, it is so very dangerous that it should not be lightly under- taken. Sometimes, when the fragments are deeply placed, one is found so short and so little movable, that it is impossible to cause them both to protrude. Under such circumstances, Dupuytren has found that the resection of the end of one of the bones suffices for the cure, if the extremity is put immediately in contact with the other fragment, which may at the same time be rasped or shaved, or irritated with caustic potash. When the fracture has been very oblique, it is necessary to remove a sufficient portion of the bev- eled extremities, to prevent any unnatural lengthening of the limb, which would, in the thigh or leg, be productive of considerable inconvenience. M. Flaubert, of Rouen, has proposed after resec- tion to unite the ends of the bones by passing a wire in the man- ner of a suture through the fragments themselves. But the risk of necrosis, caries or abscess round the bone, and the constitu- tional disturbance consequent upon this process, would, it appears to me from what I have observed in one case, be so great as to render the measure as dangerous as it is unneeded. This propo- sition of uniting the ends of the bone in an ununited fracture by a wire suture is by no means new; the author having witnessed its performance many years ago in the Pennsylvania Hospital. In the fore arm and leg, we select for the purpose of exposing the ends of the bones, the surface which is nearest the skin. In the thigh and arm, the longitudinal incision is made on the outer side of the limb, for the purpose of avoiding the vessels and nerves. In the arm, the incision is made in the intermuscular space, sepa- rating the outer margin of the biceps from the muscles on the fore part of the limb. At the middle part of the arm, the musculo-spi- ral nerve is found on the outer side of the limb, and between the triceps and biceps; it pierces subsequently the septum between these muscles, and must be carefully avoided by keeping it behind the line of incision. Its division, as shown in a case from the country, recently under my charge for resection of the ends of the bones, may be attended by permanent palsy of the extensor and supina- tor muscles of the hand. The previous operation, which had failed in this instance, consisted of the application of caustic pot- ash to the ends of the bones. In the thigh, the opening should be made between the biceps flexor cruris and the margin of the vastus extefnus, whiere we may reach the bone, by following the intermuscular septum^ without dividing a single muscular fibre. For the purpose of introducing a seton between the ends of the bones, Wardrop cut down along the external border of the rectus femoris, and brought out the needle at the external border of the vastus externus. The method of resection for ununited fracture of the humerus is shown at Plate XXI, and fully explained in all its details. By the use of Heines' saw (see PI. XXXI.) the resection of the ends might readily be made without dislocating either fragment from its bed, and consequently diminishing the risk attendant on the operation. The section of the lower fragment, when protruded, is readily effected by the ordinary saw, as the limb can be rotated during its action, so as to make the division complete without disturbing the muscles on the other side. A strong pair of pliers, or a stout pair of dentist forceps I have found convenient in re- moving the pieces in cases where it was not deemed expedient to complete the section with the saw. A few touches of the knife may also be at times required to detach the adhering ligamentous shreds. In the arm, it is more difficult to make the complete sec- tion of the upp'fer fragment with the saw without doing violence to the surrounding parts, in consequence of the resistance made by the muscles of the armpit, even when these muscles have been relaxed by carrying the arm upon the chest for the purpose of turning out the end of the bone. The bone, however, may be always deeply notched on its surface with a narrow saw, and the section may then be finished with Liston's cutting forceps, acting in the track of the former instrument, The wound should be carefully closed with adhesive strips covered with a compress, and the limb surrounded with aroller bandage, so as to effect, if possible, union of the lips of the incision by first intention. The limb should be kept perfectly at rest in a well adjusted fracture apparatus, and ^11 pressure of the resected ends of the bones for several weeks carefully avoided, for fear of producing inflamma- tion and suppuration in the cellular tissue of the bone. Within a few months I have performed an operation of this de- scription before the class of the Jefferson Medical College, in a case where, from causes wholly unconnected with the operation, death took place at the end of the fourth week, when the patient was about preparing to leave the city. The wound had healed completely by first intention, and no more pain or suffering had been experi- enced from the limb than occurs in ordinary fracture. The ex- amination of the parts which I now have in my cabinet, shows a rigid thickening of the cellular tissue, aponeurotic layers, and neighbouring muscular fibres, about the place of fracture, which had given a considerable degree of solidity to the limb. The two ends of the bones were already coated over with a layer of tough gray matter, and adhered to each other by a tenacious filamentous lymph, which parted as the fragments were forced asunder. DEFORMITIES FROM THE IRREGULAR UNION OF FRACTURED BONES.-VICIOUS OR DEFORMED CALLUS. It is not unusual to meet with cases in which, from accident or mismanagement, the consolidation of a fracture has taken place, with shortening of the limb from the fragments riding over each other, or with a deformity in its direction owing to a mal-adjust- 96 GENERAL OPERATIONS. ment of the ends of the bones during the progress of the cure, or from its becoming bent or curved by a premature use of the limb while the callus was yet soft and yielding. \Yithout jroing into detail in reference to the different theories of the formation of callus, it will suffice to state that it passes through different stages of development, from that pf fibro-carti- lage to bone ; that it forms a temporary connection for holding the bones together, which, even when most consolidated, does not attain to the density of solid bone ; and that the permanent callus, which is formed between the surfaces of the divided bone and when it becomes solidified forms the true bond of union, is the last portion developed. The period requisite for these pro- gressive changes varies in different bones, but does not even in the larger consist of more than sixty or ninety days, beyond which period we may, under favourable circumstances, regard the union by permanent callus as having taken place. The longer, therefore, the callus has been in forming, the greater will be the difficulty of correcting the defects in the position of the bones. In general the temporary callus does not, before the fiftieth or sixtieth day, acquire so much solidity but that it may be readily made to yield by pressure and extension ; but it is most desirable that all deformities should be corrected as early as possible after they become known. Dupuytren has, however, furnished in- stances where the deformity has been removed by such measures, as late as one hundred and twenty days after the occurrence of the injury. Cases will present themselves that have been ne- glected for periods much longer than this, in which relief can only be aflTorded by other means more severe and hazardous, but which are nevertheless perfectly justifiable, when the use and symmetry of an important part are destroyed. There are three principal methods for cure of the deformities referred to under this head. 1. Pressure and permanent extension. — If not more than a few weeks have elapsed from the time of the injury, we may be able at once to straighten simple angular deformities by the hands with- out the aid of machinery, especially if they are found in the fore arm or leg, the operator using his knee as the point of resistance ; but if there be shortening from oblique fracture, it will in addi- tion be necessary to bring down the bones by extension and coun- ter-extension. Having once got the limb straight, the treatment is to be continued as in ordinary cases of fracture. But if a lono-er period has passed— thirty, forty, fifty, or sixty days— pressure a°nd extension must be made gradually with an appropriate fracture or orthopedic apparatus, and repeated every second or third day, strict care being observed to retain, by the steady use of the in- strument, what has been gained by the force applied. If the callus has become too solid to yield to these measures, it has been proposed to soften it previously by passing a seton through it so as to provoke a sudden inflammation, which is commonly attended with some softening of the new structure. Use of the seton. (Process of Wdnhold.)— In a case of frac- tured thigh of three months' standing, firmly consolidated with a great exuberance of callus, and with a shortening of two inches this surgeon was so successful as to ultimately restore the limb to withm two lines of its natural length. With a sort of trepan needle, mounted on a joiner's brace, entered through the soft parts an inch to the outer side of the femoral artery he perfo- rated the mass of callus. The needle was then carried out through the opposite side of the limb, dragging after it the ordi- nary seton. At the end of seven weeks the callus began to yield ; and the common extension apparatus was applied. 2. Rupture of the callus. — This may sometimes be effected by straining the limb over the knee, and rupturing the new union as we would break a stick. Velpeau has proposed to place the de- formed limb with its concavity upon a solid plane, while pressure is made suddenly and forcibly with the knee or hands on its con- vex surface. There is, however, always more or less danger of splintering the bone, or fracturing it at a new point, so that this plan, where much resistance is offered, is but little followed. It is considered better surgery under such circumstances, especially where there is a mere angular deformity, to endeavour to effect the object by the aid of machinery, properly padded and braced, so that the force shall be applied only over the new-formed union. A double inclined plane, truncated at the top, and opening with a joint at a similar angle with the limb it supports, answers the purpose nearly or quite as well as the complicated apparatus of CEsterlen, in which a pad, attached to a solid piece of board, is forced downwards with a screw, so as, to press on the convex sur- face of the callus. CEsterlen has reported forty cases of success by this method of treatment. 3. Section of the callus. — This is the only means left for reme« dying a deformity that has resisted the judicious application of the preceding measures, or for the treatment of a thoroughly consoli- dated fracture. It consists in laying bare the surface of the callus by incisions, and, instead of breaking, dividing it across with a saw, or the gouge and mallet. It is the only method left for managing the confused solidification which sometimes takes place after fracture of the bones of the fore arm. It converts the deform- ity into the state of a compound fracture, and is attended by the same risk to the patient, and requires subsequently similar treat- ment with that affection. A judicious surgeon would not, there- fore, attempt a cure by this means, except in cases where it was urgently indicated. Process of Wasserfuhr. — For a fracture, in a child of five years, of the upper third of the femur of three weeks' standing with a salient angle at the outer side of the thigh and great shortening of the limb, this surgeon made a transverse incision over the promi- nent point, equal to one-fourth the circumference of the limb. The callus, exposed by the retraction of the divided muscles, was cut nearly through with a fine saw, and the separation completed by fracture.* The limb was then placed in an extension appara- tus, and complete success is said to have followed the operation. In many instances the American method of cure for anchylosis, by removing a wedge-shaped portion of bone, and subsequently straightening the limb, will be found available in relieving this class of deformities. This principle has been several times suc- cessfully employed ; in one instance in a case of great deformity of the leg by Professor Miitter.f If in treating injuries of this description, the muscles on the concave surface of the limb have so shortened themselves as to refuse to yield readily on distension, * The solid state of the callus at this early period is to be explained by the youth of the patient— the process of bony reunion taking place more rapidly in children than in adults. f American Journ. Med. Sciences, April, 1842. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 97 a section of their tendons, especially in the lower extremities, made as described in this work under the head of subcutaneous operations, may occasionally be attended with advantage. EXOSTOSIS. (PL. XXII.) The tumours bearing this name may be distinguished : 1. Ac- cording to their original seat, which may be either between the periosteum and the surface of the bone, or between the medul- lary lining membrane and the cancellated structure. 2. Accord- ing to their nature — as they are cartilaginous, eburnated, porous, or osteo-sarcomatous. 3. According to their form and size, whether they are styloid, rounded, pediculated, circumscribed, diffused, etc. The proper periosteal exostosis, formed on the free surface of the periosteal membrane (periostosis), as shown by Professors Albers and Rognetta, are first formed like epiphysis, though they become ultimately solidly attached to the bone on which they rest. To all of these varieties, surgical operations for their re- moval are by no means applicable. If they are in their forming state, fibrous, or cartilaginous, they need not be interfered with except they produce great deformity. If they have degenerated so as to become soft and spongy, as in growths from the walls of the antrum maxillare, nothing short of resection of the bones involved, or amputation of the member will suffice. Simple ob- long enlargements on the surface of a bone are ordinary occur- rences ; and if no other inconvenience than slight deformity results from their presence, they should not be interfered with. Nothing in fact justifies their removal by operation, except that the tumour, from its great size or vicious direction, interferes with the functions of surrounding organs. Such as arise from syphilis, from scrofula (as is so common in children), and other constitu- tional affections, are curable usually by appropriate general and local treatment ; and, if touched at all, cannot-'be taken away with safety till after the removal of the constitutional disorder. Modes of operation. — The application of the actual cautery and caustic articles so much in use among the ancients, and still em- ployed for a like purpose in farriery, is now abandoned in the treatment of these affections — surgeons limiting themselves almost exclusively to the employment of mechanical measures, and using the cautery only as a means of arresting hemorrhage after the operation, or destroying a portion which cannot be readily extir- pated. If the exostosis is entirely cartilaginous, intermixed with plates of bone, and periosteal in its origin, it does not adhere at first very firmly to the bone, and may be prized off from it after having been exposed by incisions through-thelsoft parts covering it. Large tumours of this description I have found readily remov- ed from. round the "base and ramus of the lower jaw. If the tu- mour has beconae ossified, making a continuous structure with the bone below, it may, if pediculated, be detached by section with the saw, forceps, or.ehisel. If adherent by a large base, it must be separated in portions, either by several applications of the tre- phine, or divided perpendicularly in various directions with the saw, and the portions detached at their base with the' cutting forceps, or the mallet and chisel. If the bone below be merely inflamed, vascular, and expanded in its areolae, it may be left to .the influence of general and local therapeutic measures, on the same principle that we v?ould treat similar affections in the soft parts, when the offending cause had been removed. If there are 25 grounds for suspecting its degeneration, an exploratory perfora- tion may be made with a trephine, after the manner of Dupuytr«n, in order to decide whether it will be necessary to proceed to re- section or amputation. If the seat of the tumour be in the medul- lary cavity of a long bone, the soft parts are to be dissected off, the expanded shell of the bone laid open with the trephine, the mallet and chisel, a Hey's saw, or the cutting forceps, (the last answer* ing well to enlarge the space after the opening has once been effected)-^ — and the nucleus turned out from the cavity it occupies. The soft parts are then to be brought together, and a slip of linen interposed at the depending portion of the wound, so as. to permit a free escape of the purulent secretion, and allow of the introduc- tion of detersive fluid injections. In the after treatment I have derived great benefit from compression applied by the means of a roller, or of adhesive straps, as in Baynton's method for the cure of ulcers, which, though acting directly on the soft parts, exercise considerable influence on the bone. Remarks. The mode of proceeding in the removal of exos- tosis will be more or less varied, not only by the nature and form of the tumour, but also by the character and peculiar arrangement of the parts which surround or support it. As thes'e difficulties, as well as the means of surmounting them, cannot be subjected positively to any general rules, and as the latter must be founded upon the exigencies of each individual case, it will not be neces- sary to describe the process for the removal of these tumours in the various portions of the body. By reference to Plate XXII, the general method of proceeding will be well understood. The saw and the trephine will be found most appropriate in the removal of cranial exostosis, as the concussion attending the use of the mallet and chisel might injuriously affect the brain. In the removal of tumours deeply situated, the obvious necessity of protecting the neighbouring parts increases the dif- ficulty of the operation; and it is in these cases when we act in a narrow space, that great advantage may be obtained from the use of a chain saw, or the different steotomes that have been devised, the best of which is that of Heine. In laying bare the tumour, the rules generally laid down for avoiding thp vessels and nerves are to, be carefully followed. In many respects the method of incision can be advantageously modified so as to spare more or less important parts, according to the nature of the case and the ingenuity of the surgeon. In an exostosis with a narrow base, seated below the deltoid, M. Roux made two parallel incisions in the direction of the fibres of the muscle, isolated the tumour below the bridge formed between the two incisions, and detached it at its base with a saw, without any transverse division of the muscle. In some cases where the excision of the exostosis is dangerous or impracticable, and the tumour is neither large nor attached by a broad base, it has been recommended to lay it bare and strip off its periosteum, in order to deprive the external part of its nourish- ment from the periosteal vessels,, and cause the surface and the subjacent parts to slough away. The result of such a method would necessarily be tedious and more or less uncertain ; and it is hardly likely that any instances can arise in which its applica- tion would be advisable. CYSTS IN THE BONES. This peculiar form of degeneration has been frequently ob- 98 GENERAL OPERATIONS. served in the upper and ]ower maxillae. It has also been occa- sionally met with in the extremities of the long bones and the bodies of the vertebrae. The cavity of the cyst is most commonly filled with a mass of fibro-cellular matter, but sometimes its place is supplied by serum, pus, hydatid vesicles, gelatinous or colloid masses, etc. etc. The fibro-cellular cysts of Dupuytren may be considered the same affection as that ranged by Sir Astley Cooper under the head of cartilaginous medullary exostosis. The cysts in the bones vary in size from that of a musket bullet to that of the fist. The peculiar nature of the substance they contain it is exceedingly difficult to discover, except by an exploratory puncture, or during the progress of an operation for their removal. This, however, is not a matter of great import- ance, as the indications of treatment are nearly the same in all. That which is more easy, however, and more important, is to distinguish the cystic from the cancerous degeneration of the bones called osteo-sarcoma, in which the operation for the re- moval of the disease is nearly as unpromising as it is successful in the case of cysts. Osteo-sarcoma is characterized shortly after its commencement by a varicose tumour, and by a sirauUaneous affection of the surrounding soft and hard parts disposed to take on the character of fungoid degeneration, and by irregularities over the surface of the swelling. Osteo-sarcomatous tumours grow with great rapidity, and are traversed in their interior by fragments of bones, which are never observed in the cysts. These latter are slowly developed, smooth on the surface, and never involve the surrounding parts in disease, unless the contained substance has in the end degenerated into cancer. Their walls, which appear to be formed by a separation of the compact por- tions of the bone, grow thin in consequence of their expansion, and yield to pressure of the finger like a piece of parchment, followed in many instances by a crackling or crepitating sound, which, according to Dupuytren, is pathognomonic of this affec- tion.* Four principal methods have been employed in the treatment of these bony tumours. 1. By compression. — This has been attempted, but the trial has not been attended with any permanent advantage. 2. By incision. — The mere laying open of the cyst-s, and evacu- atins their contents, even when these are of a fluid nature so as to admit of the process, has not succeeded in effecting a cure. It is necessary to destroy or change the nature of the membrane lining the cyst, without which the orifice will close, and the con- tents accumulate anew. 3. By the seton. — A seton passed through the centre of the cavity, offers in the serous cyst a somewhat better prospect of a cure, by producing suppuration of its walls, and the elimination • Lecons Orale de Cliniqae Chirurgicale, t. iii. PLATE XXIIL— OPERATIONS ON THE BONES FOR NECROSIS. [Fig. 1.) EXTRACTION OF A SEQUESTRUM FROM THE OS HUMERI. An incision is made down to the bone, on the outer part of the arm, between the brachialis anticus and triceps muscles. The muscles have been dissected off from the bone, and the fore arm somewhat flexed so as to admit a wide separation of the lips of the wound. Two perforations have been made with the trephine through the new shell of bone, or involucrum, so as to expose the sequestrum or dead piece of bone inclosed by the involucrum. In the plate, the surgeon with his left hand supports the limb, and draws away the inner lip of the wound, (the external supposed to be drawn outwards by an assistant,) while, with a Key's saw in his right he begins one of the lines of section of the involucrum, between the two places of perforation, in order to remove the intervening bridge, and get hold of the sequestrum with the forceps. (Fig. 2. A C). EXTRACTION OF A SEQUESTRUM FROM THE UPPER AND MIDDLE PART OF THE TIBIA. (A). A wound in the shape of a J has been made, and the two angular flaps dissected up and turned back from the inner face of the bone. Two perforations have been made through the involucrum, and the intervening bridge removed as described in fig. 1. The perforator of Dupuytren, which consists of a pair of .serrated forceps and a drill enclosed in a canula, is seen applied for the purpose of dividing the sequestrum, so as to facilitate its removal with the forceps. (C). A crucial incision has here been made, and the four triangular flaps dissected from the bone and reverted. The drawing represents the parts as seen in one of the author's operations. The involucrum, which was soft, was opened with the gouge and mallet as seen in the plate. After a free passage was made through this part, the sequestrum was divided with a strong pair of cutting forceps, and the fragments subsequently removed wifh the pliers. The two instruments are shown at the same time merely for the purposes of illustration. (B). EXTRACTION OF A SEQUESTRUM FROM THE METATARSAL BONE OF THE GREAT TOE. A T shaped incision has been made, and the involucrum opened as in the operation last described. The dead ' bone is seen in the act of being withdrawn with the forceps. (hi Sivir Ay ./.>' tpiL,f OPERATIONS FOR DISEASES OE THE BONES AND JOINTS. 99 of the contained substance. This has succeeded happily in my hands in one case of a cyst developed in the lower jaw. ft is, however, much less to be relied on than the following process, ■which has received the sanction of more general use. 4. Excision. — It is usual to commence with an exploratory puncture to ascertain the nature of the contents. An incision through the soft parts is then to he made over the surface of the tumour. In many cystic tumours of the jaw bones, the incision for the purpose of avoiding a scar is made on the side of the mouth. A strong bistoury is then to be pushed through the walls of the cyst, at its most depending portion, laying it oJ)en throughout its whole extent. With the scissors or cutting forceps, two oblique sections are to be made so as to take away a triangular portion of the wall. The contents of the tumour having been turned out, its cavity is to be stuffed wilh charpie or lint to excite suppuration. Stimulating injections into the interior, or the passing of a seton through it, conjoined with external compression, become useful measures in the course of the after treatment, and sometimes are absolutely necessary to effect the complete obliteration of the cavity. RemarJog. — -Scrofulous enlargements of the phalanges of the fingers and toes, and of the metacarpal and metatarsal bones, ■with such softening of the bones "as to be readily perforated with a needle, are frequently, and especially in children, met with, that might -without attention be mistaken for this affection. In several instances, I have been called to cases of this description in which propositions had been made to lay open or amputate the parts. Such bony enlargements are usually got rid of without much dif- ficulty, by the ordinary treatment for the cure of scrofula. CARIES AND NECROSIS. These affections are essentially different in their nature — caries consistino- of the ulceration, and necrosis of the mortification of the bony structure. Yet in their general outlines there is such similarity, that advantage will be derived in briefly studying them in conjunction, inasmuch as they are often found combined in the affection of the same bone, or the one is found preceding the other, exactly, in the same i^nanner as ulceration and mortification of the soft parts. Both caries and necrosis are commonly pre- ceded by the symptoms of deep-seated inflammation, ■which is after a time m.anifested on the surface, and may be produced by. external cau'Ses, such as a blow, contusion or wound, but more generally is the effect of some constitutional affection, as scrofula, syphilis, and scurvy; in short, everything which gives rise to ulceration and mortification in the soft parts, may similarly affect the borif^s, the symptoms only being modified by the difference of texture in the latter. In caries, there is undoubtedly inflamma- tion of the osseous tissue. In necrosis, on the other hand, the periosteum is frequently alone involved; which, detaching itself from the bone, the latter mortifies, in consequence of its nourish- ment being interrupted. Formerly, it was thought that collec- tions of pus produced both caries and necrosis, by infecting the bone. This is not commonly the case ; and in general, when either caries or necrosis is discovered on the opening of an ab- scess, ■we may fairly presume that they have been the cause and not the consequence of the purulent deposit. The osseous tissue is^ not everywhere equally disposed to either of these affections. The more compact bones, and especially the bodies of the long bones, on accountof their low vitality, are more liable to mortify than ulcerate, though it is not true, as has been asserted, that the spongy textures, such as the apophyses and epiphyses, are never affected by-hecrosis. The spongy bones, and the spongy portion of the long bones, in consequence of the loosenessof their texture, and their vascularity, are generally the seat of caries. This latter affection, moreover, seldom penetrates to a great depth in the bone; necrosis, on the contrary, except it be the result of an ex- traneous injury, affects as often the inner table as it does the outer surface of the bone, and has therefore been properly divided into central and peripheral necrosis, according as the disease depends primarily on the affection of either the internal or external peri- osteum. But, as previously mentioned, the same bone may be affected by both caries and necrosis, — a complication which is most frequently found attendant on the venereal affection of the osseous tissue. Long before either of the diseases are made manifest externally, they are preceded by deep-seated pain ; that which is antecedent to caries, is usually less violent, raking, burning or shooting, and is attended ■with less feeling of heaviness in the limb, than that precursory to necrosis. As soon as the ulceration or caries of the bone is established, and an accumulation of sanious ichor takes place, the parts around will participate in the inflamma- tion, become swollen and indurated ; and the accumulated sanious fluid gradually makes its ■w-ay to the surface. This is attended with only partial relief, and sometimes without diminution of the symptoms. But if the bone has mortified, or become necrosed, the pain may altogether subside for some length of time, no symp- tom being left behind, except a great weakness and heaviness of the limb concerned. But as soon as an effort is made by nature to discharge the dead portion from the system, tumefaction and inflammation follow, confined usually to the region of the necrosed part, but generallyof a more chronic character than that accompa- nying carles. The abscess thus slowly formed round the dead bone,- opens early if the bone be superficially seated, but some- times not for months' if it be deep; or^ if the constitution^f the patient be weak, it may not be possible for nature without assist- ance to evacuate it at all. When the abscess opens, pus of a more healthy character is discharged than in cases of caries. The appearance of the external fistulous orifices, as well as the quan- tity of the discharge varies in the two forms of disease so as to constitute the characteristic symptoms, by which they may be distinguished from each other. In caries, the orifices are few in number, (and very frequently there is no more than one,) funnel- shaped, narrow, and surrounded by prominent callous margins. Exuberant and unhealthy granulations, which bleed feonji-^he- slightest touch, spring from the canals into which these orifisjes lead. On passing down the probe through these canals, which are very sinuous, the bone is found, from the hypertrophy of its Vascular tissue, soft, spongy, porous, and gives to the end of the probe a sensation as though it was passing through a bag of sand or wetted- sugar. The secretion is usually copious, compared with the extent of the ulceration, and blackens the silver of the probe. In necrosis, the apertures are generally numerous, irregu- larly shaped, and lead either directly to the seat of the disease. 100 GENERAL OPERATIONS. or through the cavity of the abscess if the parts above the bone have not yet sunk in, as is generally the case after the external opening is made, when the bone is superficial. When the bone is more remote from the surface, sinuous cavities form, which communicate with the outer apertures. The granulations which are sometimes found studding these orifices, as well as the matter discharged, present a more healthy appearance than those ob- served in fistulae formed from carious bones. If a probe be intro- duced through one of these orifices, the bone will be found bare, and gives a ringing sound when struck. In their further progress, the two diseases vary greatly. Caries goes on uninterruptedly in the destruction of the osseous tissue, unless arrested by treatment. In necrosis, on the other hand, the disease, properly speaking, is extinguished with the mortification of the bone; and the troublesome symptoms which subsequently arise, proceed from the efforts of nature to cast off the dead portion. This result has, therefore, always been considered a favourable circumstance to the disease of the bone, and has been made the basis of a treatment for the cure of caries, by changing the ulcera- tion into necrosis. SPONTANEOUS AND ARTIFICIAL CURE OF NECROSIS. To remove the dead portion of bone, a two fold action Is set up on the part of the system ; first, to reconstruct new bony matter for the use of the limb, and secondly, to detach or expel the old. The new bone is formed slowly from the periosteum, and in consequence the insertions of the muscles remain unchang- ed. In the interior of the new bone, which is called the involu- crum, is lodged the dead portion or shaft, which after a time be- comes completely isolated through the action of the absorbents, and takes the name of sequestrum. If the whole shaft be struck with necrosis, it is detached at its ends from the spongy extremi- ties of the bone ; and in cases of longstanding, is frequently, as I have had occasion to witness, separated from the involucrum as well as the heads, by an exceedingly vascular pyogenic mem- brane, which lines the interior of the involucrum, and stretches across between the heads and the dead portion. The sequestrum, acting as a foreign body, provokes a constant suppurating dis- charge from the membrane, and becomes itself diminished in bulk, though it is never wholly destroyed. The matter finds its way from the cavity through the orifices, improperly named cloaca, which it keeps open in the involucrum, and from these escapes by various sinuous channels leadingto openings in the skin, a7id lohich are placed most usually in the principal intermuscular spaces. In a long series of years, it is possible that the sequestrum, either in pieces or in mass, may be detached through these channels, espe- cially when, as sometimes happens, the limb bends so as to place one of the cloacje opposite one of the ends of the dead piece, which then advances itself to the surface, and may be at once removed —the cavity of the new bone from which it has been taken after- wards closing up. This is what is called the spontaneous cure for necrosis. It is, however, a process upon the occurrence of which the surgeon cannot rely, and which is never accomplished but at an expense of time and strength, which the patient in most instances can but illy bear. Cases have, however, come under my obser- vation, where the necrosed piece was of limited size, the source of little or no irritation, and the discharge so limited as to consti- tute little more than the drain from an ordinary issue, when, from the peculiarity of constitution, it has been deemed wisest to leave it undisturbed. As a general rule, however, the work of nature should be abridged by the interposition of the surgeon. This is to be done by methodically opening the involucrum and removing the dead portion by a process of art. EXTRACTION OF THE SEQUESTRU.M. This is not to be attempted until the dead portion is completely isolated from the living, as is made obvious by the application of probes through the fistulous openings upon the bone. As soon as the sequestrum is ascertained to be loose, the operation ought to be undertaken, lest by waiting, the system should become exhaust- ed, and the new-formed bone ' acquire, as it does in the end, so excessive a degree of hardness as to increase seriously the difficulty of the operation. Nor should it be attempted earlier, for fear that the new bone may not have become sufficiently firm to prevent the limb from bending under muscular action, after the removal of the sequestrum. In several instances after the removal of the shaft of the tibia in persons below the age of puberty, I have observed that the new-formed bone grew, so as to give to the affected limb a length greater than that of the other side. Operation. — If the sequestrum is small and visible through a large fistulous orifice, it can at times be seized with the forceps and withdrawn. Generally, however, it will be found necessary to enlarge the cloaca, by opening the involucrum, and break or divide the sequestrum, to facilitate its extraction. For this pur- pose the patient is to be placed horizontal, and properly secured. A semilunar, ~f, or crucial incision is then to be made, so as to lay naked a superficial portion of the bone by turning back the ilaps. The surgeon is then to enlarge one of the cloacae by the gouge and mallet, the cutting forceps, the trephine, or even a Hey's saw, as is found most convenient, so as to get at the se- questrum. If no cloaca presents itself, the use of the trephine becomes nearly indispensable, and may be employed to make two or more perforations, dividing the bridge between with the saw, as seen in Plate XXIII. If the bone is soft, the hand gouge or a strong scalpel sometimes may answer to open the passage to the dead bone. Having reached the sequestrum, it is to be seized at one end with a pair of forceps, and inclined from side to side to detach it from its bed. If it does not yield to the traction, it must be broken or divided near its middle with the cutting for- ceps, a small trephine, or the perforator of Dupuytren, and the fragments removed separately. Considerable caution should be used in this step, neither to break nor bend the new bony shell, nor tear the membrane lining its interior. The after treatment must be such as is suited to ordinary sup- purating wounds. The cure will* necessarily be protracted, and even afterthe wound is closed, the patient should begin cautiously to use the limb, for fear it may become curved or break. iiemarfe.— Cases occasionally present themselves especially in the thigh and arm bone where an abscess of the medullary cavity, protracted for years, gives rise to the thickening of the limb, the enlargement of the superficial veins and the formation of cloacee leading into the cavity, and in fact all the signs of necrosis except OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 101 that peculiar one the ringing and mobility of the fragment on sound- ing it with a probe. In such instances the proposal of Prof. N. R. Smith, of Baltimore, to tap the abscess with the trephine and give free vent to the matter, may, be followed with advantage. — The author treated with complete success by this process a case of internal abscess of the femur of seven years' standing, in a man whose constitution had been broken down by the protracted suppurating discharges. The operation w^s performed before the class at the Philadelphia Hospital in the winter of 1844-5. There were three narrow sinuses Upon the outer and two upon the inner side of the lower third of the shaft of the bone leading by circuitous routes into its cavity. These would occasionally close up more or less completely, and the closure be followed, by a new abscess round the bone. The operation consisted in makinp-, down to the bone through the outer sinuses, a vertical incision turned at the lower end, by a semicircular sweep of the knife, toward the front of the thigh, and through the vastus externus muscle; the tiap was then raised from the new bone, two perfo- rations made with the trephine, and the bridge between them removed with the cutting forceps. From the free opening thus made, the pus from the cavity of the bone had free exit. Abscess ceased to form around the bone^ the old cloacae closed up, and by the use of injections of sulphate of zinc, with the application, of dry lint and poultices, the cavity of the bone was gradually ob- literated. The treatment lasted for two months, during which time a few spiculee of necrosed bone were discharged through the wound. OPERATION FOR CARIES. This comprises two methods : — Cauterization and resection. Cauterization — ^Preparatory measures. — The affected portion of bone must be thoroughly uncovered -by reflexion of the flaps, after a crucial, a T, V, or elliptical incision. All the fungous growths are then to be first removed with the bistoury and scissors from the surface of the bone, and the_diseased fungous structure of the bone itself, taken away with the gouge and mallet and the raspara- tory,'till we reach a surface which is natural in regard to colour and organization. If a portion of the soft parts has undergone degeneration, it is directed to remove it, taking care, however, to preserve enough to form a covering for the denuded bone. The author has, however, found it better to be sparing in the removal of any of the soft parts, as the lardaceous state of the tissues, which is the common character of the degeneration, may commonly he corrected by the after treatment. Waiting till the' bleeding ceases, and carefully absterging the bone, cauterization is to be next employed.- This may be done with caustic sub- stances, biit better still with the heated iron, carefully protecting the surrounding soft parts from in}ury. Caustic substances. — The soluble nitrate of mercury, as well as various other liquid caustics, was formerly employed by dipping a piece of lint or charpie in the solution, and applying it for seve- ral times; at intervals of many days, upon the surface of the bone, till the exfoliation of a necrosed lamina took place ; a result which seldom occurred under fifteen or twenty days. By this method it is difficult to prevent the liquid from acting injuriously on the soft parts. The newer caustic preparations, as the zinc or Vienna paste, are more active and far less likely to run, and should 26 always be used in preference to the liquid articles. They 'may, as observed at page 21, be employed in some cases in preference to the actual cautery, when, from the nature of the parts, the latter cannot be used without danger. When the caustic is removed, the wound should be carefully cleansed, and dressed flat with a roll of charpie or lint, so as to keep the flaps everted. The common tediousness ofthecure by the use of caustics, and the difficulty of their application, have induced many surgeons to give a decided preference to the actual cautery, as the most prompt and certain method of arresting the progress of caries. Actual cautery. — The mode of employing the heated iron has already been described at page 24. The disk-shaped cautery will be found most appropriate where a large surface is to be acted on ; the conical or cylindrical where there are mere excavations or fistulous channels in the bone. After reflecting the flaps of s^in from the carious surface to protect them from the heat, a sortbf canula should be formed with a piece of moistened cord, which is easily adjusted to the particular configuration of-the diseased part. Having arranged this, and carefully removed all moisture from the face of the bone, the cautery heated to a white heat is to be carried rapidly and slightly over it. The. heat causes at first the blood, sanies, or pus, which fills the spongy tissue of the -diseased part, to boll up as it were from the surface; this fluid should be carefully removed as it rises, with a Sponge or roll of charpi« held in the left hand of the surgeon, or applied by an assistant. Two three, or if necessary,^ four irons, according to the extent of the disease, will be required'; carrying one of the irons into such fis- tulous passages, as come into view, in order to destroy as eflfectu- ally as possible every remnant of the caries. In order to diminish the pain of the operation, the iron should be changed as soon as it loses colour, which occurs speedily when there is much fluid in the carious structure. A sharp pain is felt in the bone as soon as the carious portion is_ destroyed, which serves as a proof that the cauterization has been carried to the requisite extent. The pain soon ceases on the removal of the iron. Simple dressing with dry lint or charpie is all that is required for a few days following the operation. At the end of a week suppuration is established, and the dark eschar left by the iron begins to be detached by the development of granulations from the healthy surface of the bone. If, on the contrary, partial exfoliation only takes place, attended, at the end of the second week, with sanious suppuration and fungous growth, the cautery must be re-applied. If any fungous granulations spring from the edges of the flaps, they may be re- pres^sed with the lunar caustic or the soluble nitrate of mercury. Resection. — The object of this operation is to completely re- move the carious portions of the bone with a cutting instrument. For the removal of small and saperficial portions, the parts are to be exposed by the elevation of flaps, and the altered bone removed with the gouge, the saw, or other fitting instrument. No particular rules need be given in cases of this description. The mode of resecting larger portions of bone will be particularly de- tailed, in a section devoted to that subject. TREPANNING OR TREPHINING OP THE BONES OF THE CRANIUM. (PL. XXIV.) The object of this operation is the elevation of a depressed GENERAL OPERATIONS. 102 bone, the removal of a fractured or diseased portion, the e^^tr.ac- tion of foreign bodies, or the evacuation of blood, serum, or pus, which has been effused within the cavity of the cranium. The use of the trephine dates from the time of Hippocrates, who has given in respect to it some very judicious instructions; but hi ho other operation have the opinions of the older and more modern surgeons differed so much in respect to its value. This is in a great measure owing to the delicacy of the structure and the important offices of the brain, the only circumstances that give to injury of the bones of the cranium any peculiar importance, the brain being liable to become involved in injuries of these bones in such a variety of ways, either from the direct or secondary effects of the injury itself, or as the immediate or renrote consequences of the operation for its relief. The proper indications for the use of the trephine, in depression, fracture, compression, etc., cannot here be satisfactorily shown, without going more extensively into a consideration of the effects of injuries of the brain than would accord with the limits of this wt)rk. Referring (he student, there- fore, to the -treatises on this subject, I shall, after a few brief remarks, proceed to consider the operation. Marchetti, Sala, La Motte, and several modern ^surgeons, as- sert that they have employed the trephine with success in cases of epilepsy; and Panarotti and Fabricius Hildanns, for chronic cephalalgia and hypochondriasis. Were such affections obviously dependent on the presence of a foreign body, a tumour, or an exostosis of the inner surface of the cranium, there would be some indication for the .operation. But in cases of this de.scrip- tion, even where the affection can be directly traced to local injjiryof the cranium, it is often exceedingly difficult to make jouf- the diagnosis with sufficient certainty to warrant the resort tD so serious a proceeding. It is, therefore, only in respect to injuries of the brain, that the operation will be here considered. As late, as the eighteenth century trephining was, as a general precept, practised without distinction in almost all sorts of wounds PLAT 3 iXlV.-TREPAMING OR TREPHINING OF THE CRANIUM. Fig, l._The patient is represented in a state of coma, in a horizontal position, with his head elevated and placed with the injured part uppermost. The hair has been removed from the place of operation, and the four flaps formed by a crucial incision, reverted, so as to expose the bone in the fronto-parietal region. Three instruments, for the purpose merely of exhibiting their use, are shown applied upon the wound ; but it must be recollected that one only is to be employed at a time, and that so extensive a removal of the bone as here shown is rarely justifiable in the living subject. a. The left hand of the sargeon, holding between the thumb and fore finger the top part (6) of the French trepan, upon which the surgeon rests his chin in order to steady the instrument. c. Thumb and fingers of the right hand grasping the rounded part of the brace, with which the surgeon gives the circular movement. Four circular pieces or disks have already been removed in this case, which is supposed to be one of extensive hemorrhage over the dura mater, and the trepan is shown as on the point of being removed after a fifth application, in order to give free issue to the fluid, as directed by many surgeons. d. Surface of the dura mater, exposed by the removal of the four first disks. e. The cutting pliers, applied to cut out the angular projections left by the removal of the "disks. f. The right hand of the surgeon, removing with the lenticular knife the rough edges of the under surface of the divided bone. Fig. 2. — Same region of the head as shown in fig. 1, with the flaps similarly reverted after a crucial incision. The injury has been inflicted with the corner of a brick bat, which comminuted and depressed a portion of the bone. A small central fragment has been detached with the point of the perforator (fig. 9), so as to make room for the end of the elevator, with which all the loose fragments are to be removed and the depressed margins elevated. Cases of this description frequently occur, in which the use of the trephine is not needed. Fig. 3. — This represents a fracture of the right parietal bone, with an extensive longitudinal wound of the scalp, which has been enlarged by a vertical cut at either end, so as to allow the operator to expose the bone (c), by reverting two flaps (a and 6), one upwards and the other downwards. The bone is extensively fissured, and a central fragment that was depressed has been removed by the application of a trephine, which has left the rounded edge at the lower part of the opening through the bone ; the pyramid or centre pin of the trephine having been applied near the lower margin of the longitudinal fissure seen in the bone. The dura mater {d), thus exposed by the removal of the fragments, and found covering a mass of blood or pus effused below it, is to be opened with a bistoury from below upwards as directed in the text. Fig. 4. — This sketch is intended to illustrate the manner of holding the English or ordinary trephine, as well as the rules for determining in many cases the proper point for its application, when it is deemed best either to raise or remove the depressed fragment. The os frontis has been fissured, and a fragment of considerable size depressed. The bone has been exposed by a crucial incision and the reflection of four large flaps. The trephine was first applied at 6, and the disk removed ; an attempt was then made without success to raise the depressed portion. Another disk was then removed at a, and a second attempt made with like want of success, on account of a shelvmg piece from the inner table being attached to the fragment, as is most commonly the case at the margin OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 103 and injuries of the head, not only as a means of cure for the symptoms of irritation or compression to which they might give rise, but as a means of ■protection before they were developed. The gross abuse of the application of the trephine, to which such indications would lead, has been vigorously opposed, espe* cially by Desault, Abernethy, Langenbeck, Physick, Gama, Coo- per, and others, who restricted its Use to cases in which the secondary sj'mptoms t)f irritation and compression were strongly manifested, wailing always as regards the operation until these should appear. This doctrine was founded chiefly upon the serious nature of the operation, and upon the well-known fact that effused blood may be completely removed by absorption under the influence of appropriate treatment, and that even the depression of a piece of bone will frequently be borne without injurious consequences. The reaction thus produced mainly by the influence of Desault and his school,* established on the other hand an excessive repugnance to the operation, and trephining came to be considered as a desperate resource, which, if used at all, was apt to be applied too late. But the careful opening of the walls of the cranium, where no inflammatory symptoms prevail, is not of itself an operation of very serious danger ; and the suc- * Saviard, more Itian one hundred years ago, found that most of the patients trephined at llie Hotel Dieii, (when many surgeons