^ WE % O itfilARICS q .'<■ yV •Smi- Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries http://www.archive.org/details/manualofprinciplOOsmit MANUAL OF THE PRINCIPLES AND PRACTICE OF Operative Surgery. STEPHEN SMITH, A. M., M. D., SURGEON TO BELLEVUE AND ST. VINCENT HOSPITALS, NEW YORK BOSTON: HOUGHTON, MIFFLIN AND COMPANY. NEW YORK : 21 ASTOR PLACE. ([n)t EtberatTie Pregg, CambrtUfft. 188L Copyright, 1879, Bt STEPHEN SMITH. All rights reserved. '(^H 32. 9 RIVERSIDE, CAMBRIDGE: ELECTROTTPED AND PRINTED BI H. 0. HOUGHTON AND COMPANY. PEEFAOE. The Handbook of Surgical Operations, prepared by the writer in 18G2, though specially designed for military practice, was received with much favor by the profession at large. The request has often been made, by both medical practitioners and students, that the plan of the work should be enlarged so as to include the general operations of surgery in civil practice. The present work is the result of an ef- fort to realize that object within the limits assigned, namely, general operations in surgery, the organs of special sense being excluded. The arrangement of matter and the structure of the text require explanation : (1.) In defining the qualifications of the surgeon no attempt is made to establish an ideal standard of excellence. On the contrary, the true estimate of his qualifications is found in the civil obligation which he assumes whenever he undertakes the care of any case. The judicious discrimination which the common law makes of the relation of qualifications to time, place, and circum- stances, are far more important than have ever been defined by any professional code. (2.) It follows that as conformity to the es- tablished principles of an art is a fundamental requirement of the civil obligation upon those who practice such art, a manual of this character should, as far as practicable, illustrate those principles. It has, therefore, been a constant effort to give to the text the high- est degree of authority, by embodying the teachings of recognized authorities on every subject, so far as they conform to what is be- lieved to be the present standard of surgical opinion and practice. And to the same end the various subjects have for the most part been submitted for revision to competent authority and receiveisEA.sEs OF B<)XE AND Special Operations . . 101 XIV. — General Operations on the Bones .... Ill XV. — Injuries of Joints and Special Operations . . 147 XVI. — Diseases of the Joints anu Special Operations . 154 XVII. — General Operations on the Joints .... 168 III. THE MUSCULAR SYSTEM. THE MUSCLES; THE TENDONS; THE FASCI.5: ; THE BUKS.E. XVIII. — IX.HRIES OF THE MCSCULAR SYSTEM, AND SPECIAL OP- ERATIONS 193 XIX. — Diseases of the Muscular System, and Special Op- erations 196 XX. — General Operations ox the Muscular System . 202 vi CONTENTS. IV. THE CIRCULATORY SYSTEM; THE HEART; THE ARTERIES; THE CAPILLARIES; THE VEINS; THE LYMPHATICS. XXI. — The Injuries of the Circul.^tory System and Spe- cial Operations 213 XXII. — Diseases of the Circulatory System and Special Operations 220 XXIII. — General Operations on the Circulatory System . 232 V. THE NERVOUS SYSTEM.. THE BRAIN; THE SPINAL CORD; THE NERVES. XXIV. — Injuries of the Nervous System, and Special Oper- ations 275 XXV. — Diseases of the Nervous System and Special Oper- ations 283 XXVI. — General Operations on the Nervous System . . 291 VI. THE TEGUMENTARY SYSTEM. THE SKIN; THE HAIR AND GLANDS; THE NAILS. XXVII. — Injuries of the Tegumentary System and Special Operations 302 XXVIII. — Diseases of the Tegumentary System and Special Operations 313 XXIX. — General Operations on the Tegumentary System . 325 VIL THE DIGESTIVE ORGANS. XXX. — The Lips 340 XXXI. —The Palate 350 XXXII. — The Alveolar Process; The Salivary Glands; The Tonsils 358 CONTENTS. Vll XXXIII. — The Tongue . 367 XXXIV. — The Phauy.nx; The CEsophagus . 375 XXXV. — The Stomach 381 XXXVI. — The Ulodexum; The Jejunum; The Ileum . . 388 XXXVII. — The Cecum; The Colon .... 39C XXXVIII. — The Kkctum . 405 XXXIX. — The Anus 410 XL. — The LiVKii; The Spleen . . . . • . 426 XLI. — The Abdomen 4.>1 XLII. — The Hekni.e of the Abdomen . 436 VIII. THE RESPIRATORY ORGANS. XLIII. — The Nose: The Nasal Foss.e; The Antkum . . 4.>5 XLIV. — The Lakynx 470 XLV. — The Thachea; The Thyroid Body; The Bhonchi . 483 XLVI. — The Lungs 490 IX. THE URINARY ORGANS. XLVII. — The Kidneys 497 XLVIII. — The Urinary Bladder 502 XLIX. —The Urethra 527 X. THE GENERATIVE ORGANS. THE MALE ORGANS. L. — The Testicles . LI. — The Prostate Gland LI I. — The Penis . 545 552 555 THE FEMALE ORGANS, Lin. —The Ovaries LIV. — The Utet.us LV. — The Vagina LVL — The Vulva . LVII. — The Mammary Glands 559 506 571 576 585 viii CONTENTS. XL THE EXTREMITIES. LVIII. — Amputation 590 LIX. — Deformities 633 LX. — Compensative Appliances 649 INDEX 663 OPERATIVE SURGERY. I. THE PRINCIPLES. CHAPTER I. THE OBLIGATION.! The Principles of an art are those general truths and maxims which competent authority has established. If an art is progressive, like operative surgery, the principles cannot all be fixed and perma- nent, but must change with the advance of scientific improvements. These changes take place gradually, for alleged new truths do not obtain the weight and importance of principles until they have re- ceived the sanction of recognized authority. In order to determine, therefore, the principles of an art suscei)tible of constant improve- ment, it is necessary to consult the o|)inions of its acknowledged exponents at the particular period under review. An adequate knowledge of the principles of operative surgery, as thus estab- lished, is a part of the civil obligation of the surgeon, for the stand- ard of judicial estimation of his responsibilities, in any case, is an in- telligent application of those i)rinciples in practice. ^ And the same criterion is required by the professional obligation. But this meas- ure of success implies special qualifications, for though capital opera- tions are attended with a certain degree of risk to life, and the minor or insignificant may have a fatal issue from causes which are not always easily determined, » it is nevertheless true that the results of operations depend largely upon the capacity and qualifications of the surgeon.* Whoever undertakes to practice any art or pro fession assumes an obli'j;ation, both civil and professional, whicli. though implied, has all the force and validity of a formal contract. ^ In legal construction, this obligation retpiires that every practitioner of operative surgery shall, (1) possess that decree of knowledge, skill. and experience which is ordinarily possessed by the professors of the 1 Hon. M R. Waitk, Chief-.Iiistice. U. S. - Espinasse. 3 S. D. Gross. * C. St'-dillot. 5 Justice Tvndall. 2 OPERATIVE SURGERY. same art or science; and which is regarded by those conversant with that employment as necessary and sufficient to qualify bim to engage in its practice ; (2) that he use reasonable and ordinary care in the exercise of his skill and the application of his knowledge to accom- plish the purpose for which he was employed ; (3) that he use his best iudgment.^ I. QUALIFICATIONS. The measure of qualifications which the surgeon must bring to the discharge of his duties is defined to be competent knowledge of the principles of the art and adequate skill in the application of that knowledge. But there can be no fixed limit to these qualifications, for the required knowledge and skill rise in proportion to the value and delicacy of the operation.''^ Every case necessarily has its own peculiarities, and, therefore, there can be no universal standard of treatment established. ^ Even the most trivial operation is liable to serious complications, requiring for its successful management a wide range of knowledge, a high order of skill, and the largest experi- ence. Recent judicial decisions and legal opinions have more dis- tinctly defined these qualifications. 1. The knowledge required is that reasonable degree of learning which is ordinarily possessed by others of the profession ;* or the req- uisite knowledge to enable the surgeon to treat such cases as he un- dertakes with reasonable success, or understandingly and safely ;5 or, again, he must have that degree and amount of knowledge of the science which the leading authorities have pronounced as the result of their researches and experience up to the time, or Avithin a rea- sonable time, before the issue or question to be determined is made.^ It follows from those decisions that the surgeon who fully complies with the obligation must have adequate knowledge of the medical sciences, anatomy, physiolog}-, and pathology, and of the practical branches, medicine, surgery, obstetrics, and therapeutics. He must also be familiar with the current opinions of the leading authorities, for as surgery is a progressive science his patient is entitled to the benefits of new discoveries. '^ "Without such knowledge no case can be treated understandingly and safely. 2. The skill implied in the contract is the ordinary skill of the profession ^ or a reasonable, fair, and competent degree of skill. ^ Tlie lowest grade of qualification which is now regarded as admissible is the least amount of skill compatible with a scientific knowledge of the healing art.^ But skill in operative surgery requires ifianual dexterity. The success of the operation may depend upon the dex- 1 Leighton v. Sar^ceant. 2 Bonvier. 3 j. Ordronaux. * Rranner i: Stormont. 5 Patten v. Wtgc'in. 6 J. J. Elweli. ' McCandless v. McWha. 8 Justice Story. 9 Justice Tvndall. THE OBLIGATION. 3 terity of the surjieon alone, when he must employ the skill reqnis^ite to aecomplish it;^ but if the operation is a part of the general treat- ment of the ease, the deite qualifications, and failure to employ them sedulously for the benefit of the patient, is nefflifcnce, and negligence is as much a fraud upon the employer as want of skill, for it is upon the diligent application of skill that the problem of success must rest.'' It is held that whenever any im- portant step in the treatment of disease is neglected, or any impor- tant staije of it is overlooked which might have been used for the benefit of the patient, then it may be averred that the surgeon has been guilty of negligence.'' III. GOOD JUDGMENT. In everv case, good judgment must characterize the professional acts of the surgeon. By good judgment is understood judgment bast-d upon a knowledge of the medical sciences.* There are few diseases where a single course of treatment can be adopted; in general, ue of diseases, and operative procedures undertaken for their cure. The chances of recovery after operations are so largely in- fiuenceil by the jjrevious state of the patient's constitution, ^ that special inquiry ^^hould be made as to former diseases and their effects, and the existing organic and functional integrity of every inijiortant organ. Due attention should also be given to mental and physical peculiarities, and to those surrounding conditions which more or less directly modify the ordinary course of the malady under observation. The following considerations have a relative importance, and should have projx-r weight in deciding the probable issue of an operation : 1 . The native bears operations better than the immigi-ant. 2. The sex which has the greatest endurance is the female. ^ 3. The age is not in itself a barrier to any necessary operation,^ but witli it we connect the most regular average difference in capac- ity to bear operations;* the most favorable period is between five and fifteen; the next, between fifteen and thirty; after tlu'rty the risk to life is more than twice as great as it was at the same period after birth.5 Young and healthy children ■* are in danger through shock, ag- gravated by pain, but bear very well the loss of blood, and are little liable to pyajuiia after wounds. Old ])ersons * are likely to have or- ganic diseases and degeneracies, and feeble circulation, inducing congestions, due to sinking of the blood in the lungs, liver, intes- tines, and other dependent parts; are liable to die of shock, or mere exliaustion, and do not bear losses of blood, lowering of tempera- ture, or want of food; they convalesce slowly, or after partial re- covery fade, waste, and die; but the thin, dry, tough, clear- voiced, and bright-eyed, with good stomachs and strong wills, muscular and active, bear very well all but the largest operations. 4. Constitutional Diseases * influence operations as follows : Scrofula oive-s a considerable mortality, but its ill eflfects are seen chiefly in the imperfect healing of wounds, the swollen cellular tissue, the thin and lowly organized cicatrix, or indolent ulcers and sinuses; in the large majority of chronic cases the removal of a scrofulous part is followcil by improved health, but the patient remains scrofulous, and, if old, may not bear confinement well ; sypliilis is liable to delay reparative action, and the operation in those who have tertiary sores may be followed by renewed tertiary symptoms; rheumatism 1 N. Chevers. 2 \\\ g. Savory. 3 s. D. Gross. * Siu J. Pagkt. 5 T. Holmes. 8 OPERATIVE SURGERY. and gout predispose to structural changes of arteries and kidneys, and to organic diseases of the lieart; cancer contra-indicates opera- tions only in its later stages, when the general health is failing ; anffiuiia is not a bad condition in which to operate, wounds heal slowly and soundly, but if erysipelas or like casualties supervene patients are less likely to recover. 5. Habits and Temperament ^ should be duly considered ; in- temperance increases the dangers of operations in proportion as it is habitual; slight intemjDcrance is much worse than occasional great excesses; avoid operating on confirmed drunkards, unless com- pelled by the necessity of the case ; operations are hazardous on all persons who require stimulants before they eat or work; over-eating is closely allied to intemperance in increasing the dangers of oper- ations, esj^jccially if the over-eating is of meat and other nitrogen- ous foods ; the over-fat are a bad class, when their fatness is not hereditary, but due to over-eating, soaking, indolence, and defective excretions, their pendulous bellies indicating omental fat, and defi- cient portal circulation ; persons in whom the vital processes are weak, but without morbid action, repair wounds feebly, and are es- pecially liable to real diseases of the blood and tissues, and ojjer- ations should be deferred, if practicable, to some period of better health, for fear of local failure, rather than of incurring any unusual risk of life ; allied to this class are the cold-blooded, with cold, damp hands and feet, dusky appearance of vascular parts, feeble circula- tion, small pulse, slow digestion, constipation ; nervous persons, who are exceedingly mobile and excitable, whether in their sensitive or motor organs, their whole cerebro-spinal system being altogether too alert and vivacious, pass through the consequences of oper- ations with as great impunity as any other class; malarial affections do not contra-indicate operations, but in the course of convalescence ague fits, resembling those which precede pyjemia, may occiu*. 6. Deranged or diseased conditions ^ of organs variously affect the results of operations; of the digestive organs, gastric dyspepsia is followed only by flatulence, unless vomiting is a symptom when anaesthetics are liable to excite emesis, with dangerous prostration ; great caution is required with those whose biliary secretions are ha- bitually unhealthy, or who have been often jaundiced, or who have a sallow, dusky complexion, dr}' skin, dilated small blood-vessels of the face, sallow and blooilshot conjunctivae, symptoms which indicate deranged functions and al)doiiiinal plethora; enlargement of the liver, whether amyloid or fatty, is often coincident with chronic diseases of the bones in children, and eitliei* tends to cause death by exhaustion, or secondary hemorrhage; of the organs of circulation, ' 1 Sir J. P.voi-.T. THE EXAMINATION. 9 affections of the heart are not serious hindrances to recovery from operations; shock and loss of blood are attended with more than ordinary risk in persons whose hearts are feeble or embarrassed by valvular obstruction, but a rapid or irrejfular pulse, witliout organic disease of the heart, and with respiration not exceeding twenty or twenty-five, does not contra-indicate an operation; degeneracies of the arteries are only serious when general in the extremities, espe- cially the lower, rendering primary hemorrhage diflicidt of control, and secondary hemorrhage more fre(pient and dangerous after ampu- tation, and so interfering with nutrition that destructive supj)uration is liable' to occur, with slow and imperfect healing of the wound; diseased veins complicate operations only when varicose, and cut through, as in amputations, thus exciting inflammation; of the dis- eases of the respiratory organs, chronic bronchitis and emphysema, especially in old people, render operations extremely hazardous, owing to imperfect respiration, cough, and loss of sleep; phthisis, when progressive, adds greatly to the dangers of operations, from the consequent fever, loss of food, and pain, but, when chronic, operations are advisable, which relieve the system of painful and wasting local cliseases; persons suffering from long-standing strumous affections, with the appearance only of tubercular disease, may be greatly benefited by the removal of the diseased part ; menstruation and prciinancy are conditions rendering operations undesirable. 7. Various other affections ^ modify the prognosis as follows: se- vere operations during the staWGund is completely finished ; as in the extremities, so the supply of blood to the male genital organs can be entirely cut off by the In- 1 F. ESMARCH. THE II^EMOnnilAGE. 19 (lia-rubbcr tubing ; to remove a testicle or amputate the penis, apply a thin India-rubber tubing from behind round the root of the scro- tum and penis, cross the ends in front on the mons veneris, and tie them on the loins ; the tubing may perhnps be found useful in operations on the trunk, neck, and head, by shutting off the blood of all or some of the extrennties, from the general circulation, by strappinii, and thus forming reserve stores from which we could admit the blood successively again into the general circulation, if the patient were in danger of bleeding to death ; the dangers which may arise from this method are not determined, but we must not ig- nore the possibility that the firm strapping of a limb for any consid- erable time may be followed by serious derangements of the circula- tion and innervation, such as thrombosis, inflammation, paralysis, etc.; when operatin.; upon parts infiltrated with ichorous matters, it would be a wise precaution not to apply the bandage, but to raise the limb, and empty the vessels as completely as pos.-ible before ap- plying the tubing.^ 2. Elastic rings^ of proper size, rolled upwards from the extremity of the limb etlectually suppress all circulation. Tlie advantages are complete control of the circulation, and simplicity and facility of application. A set of rings contains nine sizes, the smallest being of solid rubber cord, and one half an inch in diameter, the largest being of rubber tubing, and four and a half inches in diameter. Select a ring suited to the limb to be operated upon, and roll it slowly from the extremity upwards, sufficiently above the point of operation ; the rings for the arm and forearm should fit the wrist firmly, and those for the thigh and leg the ankle ; in applying the rings, one side may be raised to pass ~ painful or diseased parts, or the ring may be stretched and placed above the seat of injury or disease, thereby avoiding the forcing of septic fluids into the circulation. II. ARTERIAL COMPRESSIOX. The control of the circulation may be effectefl by compression of the artery which supplies the part. As this method, however cai'cfully ap- plied, permits of the loss of the blood contained in the limb, the amount should be diminished, as far as pos- Fig 3. sible, by elevating the limb, and rubbing towards the heart. > F. EsMAKCH. ' A. E. Spoiin. 20 OPERATIVE SURGERY. 1. The Fingers afford ready and available means of arterial compression when the artery is accessible, iind lies upon a bone. (Fig. 3.) If the thumb is used, it must be laid flat upon the vessel; in either case the pressure must not be relaxed; if the vessel slips from the grasp it should be instantly compressed again upon the bone by the fingers or thumb, but not by grasping the limb ; the fingers are best employed in compression of the brachial, the radial, and the ulnar arteries; the thumb in compressing the abdominal Fig. 4. against the vertebras, the external iliac against the brim of the pelvis, the femoral against the pubes, or in the upper part of the thigh. 2. The key, the ring being so padded as to make a hard mass, is used to compress deep-seated arteries, as the subclavian. 3. The tourniquet has several modifications (Fig. 4, a, b, c), but the most important difference is in the effect upon the venous cir- culation ; they may compress the limb only at opposite points (a) ; or the entire limb, the pad being placed over the artery (6, c). The most useful instrument is that in com- mon use {by. In its application it is usual to put several turns of a roller aroimd the limb at the point j where it is applied, terminating with placing the cylinder of the roller over the artery as a compress; the tourniquet should now be applied, but the screw should not be placed over the cylinder, lest the ball roll from the artery when the screw is 1 J. L. Petit. Fig. THE U HEMORRHAGE. 21 Fk;. worked. The screw beint; placed at one side of the limb (Fig. .5), tlie strap should be buckled tightly, and the screw gradually turned to the necessary tightness; if there is a liability of the slipping of the compress, put the cylinder of the roller between the pad and the strap, and apply it to the artery. The tournitpiet may be specially adapted to compress the abdominal aorta, ^ or it may be devised to compress ciilicr the femoral, the aorta, or other large arteries. 4. The ligature is sometimes usefully applied to the main artery of the limb or part to be operated, as to the common carotid artery in operations on the face and mouth. ^ III. LIGATION. The application of the ligature to cut vessels is the favorite method of controlling bleeding during and after the operation. The material employed may be irritating or non-irritating ; the former induces suppuration, and must be removed from the wound when the vessel is closed ; the latter causes no suppuration, and may be inclosed in the wound. In applying the ligature the coats of the artery should, as far as possible, be isolated from surrounding tis- sues with the tenaculum (Fig. 6), or the ten- aculum forcejis (Fig. 7), or the dog-tooth forceps. Draw the artery well out, and press the knot down with the index fingers (Fig. 9); to ap|)ly the ligature accurately the forceps should have a slide (Fig. 8) which, drawn up while the ligature is cast around the points of the forceps, may then be forced down, and will carry the ligature directly upon the artery as the first knot is being tightened. If necessary, seize several bleeding vessels before the ligatures are applied to restrain immediate ha?morrhage, as when assistants are not at hand, and employ any form of catch or claw forceps that may be at hand. (Fig. 10.) 1 . The silk ligature, though irritating, is still generally prcferreil. It should have three threads and be so firm as to resist the utmost strain of the fingers. In its application make the surgeon's knot » J. E. Erichsen; J. Lister. " V. Mott. 3 i). Prince. < n. J. Bigklow. Fig. 8.4 22 OPERATIVE SURGERY. (Fig. 11; or the sailor's knot (Fig. 12). To tic the latter knot, hold the ligature between the thumb and finger of the right hand ; throw the end round the forceps, and seize the body of the liga- ture between the mid- dle and ring finger of the left hand, in a Fig. 10. prone position, the end being grasped between the thumb and index finger; draw the thread Fig. 11. Fig. 12. in the right hand over the end of the left index finger and the ex- tremity of the ligature, and pass it between the ends of the index and middle fingers; now taking the end of the ligature from the grasp of the left index finger and thumb with the right index finger and thumb, the knot is completed by drawing out the portion passed between the left index and middle finger; in tying the second knot the action of the hands must be reversed. Cut one end near the knot and draw the other out of the most depending part of the wound. In some cases the bleeding vessels can not be isolated, and it becomes neces- sary to enclose a small area with a ligature (Fig. 13) passed around it with a needle. 2. The hemp ligature differs from the silk only in its want of pliabilitv, being much more inflex- ible. 3. The catgut, carbolized, is a non-irritating liga- ture, and seems to fulfill all the conditions of a perfect ha?mostatic, combining the security and universal applicability of the ligature with the absence of a foreign body in the wound. ^ After the knot is tied, both ends of the ligature should be cut off and the wound per- manently closed. IV. TORSION. The twisting of an artery upon its axis is designed to cause lacera- tion of the internal coats of an artery; they then roll into the calibre 1 J. Lister. Fig. 13. THE ILEMOmUlA GE. 23 of the vessel and form a mesh, within which a blood clot forms and becomes organized; the external twisted coat remains as a protection and support. Torsion is a reliable method,* especially when applied to small arteries, bnt is not generally approved for large arteries. I. Free torsion is applicable to small arteries, and consists in seiz- ing the extremity of the vessel with firmly uniteil forceps, drawing it out from its connections, and rotating it several times. 2. Limited torsion is apijlied to large arteries, as fol- lows: — Seize tlie extremit}- of the artery with strong catch forceps, liaving blunt serration s ; draw it well out of its sheath; grasp it firmly with a second forceps about one inch from the end; now rotate the first forceps three or four times, or until all resistance ceases. (Fig- 14.) y. ACUPRESSURE.-! Compression of the artery in the wound by means of a needle is reliable in the arrest of bleeding, ^ prevents secondary hajmorrhajre even when the condition of the blood or artery predisposes to such accidents, is adapted to cases in which the artery cannot be seized or is friable, admits of the ready closure at the same time of the veins, and protects the interior of the wound from forei'jrn matters on Avithdrawal of the needles in twenty four to forty-ei <^ invagination of the internal coats; an internal coagulum now ' nn 1 forms, while the integrity of the external coat and the con- tinuity of the vessel are preserved (Fig. 18). The advantages of this method are that it is efficient, safe, and easily ap- plied; no internal coagulum is necessary, as the invagination of the internal and middle coats is sufficient to arrest hiemor- rhage ; no foreign body is left in the wound; tliei'e is no risk of secondary liEomorrhage, pyaemia, or phlebitis ; it is appli- FiG. 17. cable to all sizes and conditions of arteries where the external coat is perfect; it has a uniform effect, and requires but little skill or practice in its application, and the management of details. I I I The instrument consists of a flattened metal tube, six Vj(JJ inches (more or less) in length, open at both ends, with a sliding steel tongue running its entire length, and having a Qf^\ vice arrangement at the upper extremity, by which it can be III made to protrude from or retract within the tube or sheath ; ^m the lower end of the tongue is hook-shaped, so as to be T adapted to the artery to be constricted ; it is so shnpod that having grasped an artery, it can be made to contract upon it bv means of /r Fig. 18 the si the vice at the upper end, which forces it witliin leath (Fig. 19); Fig. I'J the hook of th'e tongue is so shaped and grooved as to form only 1 G. A. Peters. 2 s. F. Si'IER. THE HEMORRHAGE. 25 a compressing surface, by which means the artery, when acted upon bv tlie force of the vice, is compelled to assume the form of the curve of the tonjj;ue, and the artery is constricted in such a way that its internal ami middle coats give way, but the ex- ternal coat is j)reserved intact. It is applied as follows: Seize the artery with a teiiac- I ■' iiltiin, or forceps ; pass the tongue of the constrictor arounil the vessel and draw it tightly upon the artery by means of the vice arrangement at the end (Fig. 20); when the screw turns with considerable resistaiice, or Fig. 20. the internal coats are seen to be invaginaled by no- ticing tlieir movements in the end of the artery, detach the tongue, and the operation is completed. VII. AERTIVERSION.' This method is desij:ned to reinforce the cut extremity of the artery by duplicature of its walls, and thus secure such an amount of muscular structure around the cut end as will effectually close its calibre against the impulse of the heart's action. The advantage of the method is, that it leaves nothing but living tissues in the wound. There is a tendency, by the alternating distention and contraction of the vessel, to force the reflections back. The operation is readily made with an instrument (Fig. 21) hav- 7^ Fig. 21. ing a tenaculum point; this is easily introduced within the artery, and holding the margin with the forceps, traction on the hook in- verts the coats, as the cuff of a sleeve is rolled backward. VIII. CAUTEItIZ.\TIOX. The cautery, once the only method of arresting blecdin. Squiuu. THE EMERGENCIES. 35 symptom to watch is tlie rcsj)iration, for if obstructed breatliinij con- tiniK' Idiiir it loads to fatal paralysis of the nervous centres.^ Death may also commence at the heart, and hence the pulse must also be frecpiently examined.^ 1. Slight narcosis, as irrcirular respiration, without failure of the pulse, will neiurally yield to any shock, as a slap on the face with a towel wet in cold water, or forcible compression of the chest, pressure under the ribs of the left side in the direction of the dia- jjhragm, ammonia apjilicd to the nostrils, or nitrite of anivl.^ 2 Profound narcosis is announced by stertor, impeded respira- tion, pallor, or lividity of face; such symptoms demand immediate treatment. Two methods of resuscitation are stronirly recommended, iiotli of which can always be instantly aj)plied. The first ^ is based on the theory that respiration ceases from laryngeal paralysis, which is indicated by stertor, and may be relieved by very forcible with- drawal of the tongue ; artery forceps, or a tenaculum, are the best instruments: in order that it may be effectual, firm traction is essen- tial ; the end of the organ may be withdrawn consideraljly beyond the lijis without any good effect, but if an additional pull be given, the nervous system is aroused and respiration reestablished. The second method * consists in inversion of the body, with a view to overcome supposed cerebral anaemia, as follows : suspend the body with the head downward by elevatiug the thighs or hips, or by al- lowing the body to hang from the side of the table ; separate the jaws, and draw the tongue forcibly forward ; agitate the body, and practice artificial respiration ; persevere in maintaining the patient ill this position for thirty minutes or more, if necessary. ^ 3. Apncea from regurgitation of the contents of the stomach into the lungs occasionally occurs,*' and requires prompt treatment by the direct method^ of treating persons suffering from drownin<^. To relieve the liinj^s of the fluids, proceed as follows: — Face (lownv.ards ; a hard roll of clothing beneath the epigastrium, making that the highest point, the mouth the lowest ; forehead resting upon forearm or wrist, keeping mouth from the ground; place the left hand well spread upon base of thorax to left of spine, the right hand upon the spine a little below the left, and over lower part of stomach; throw upon them with a forward motion all the Aveight and force the age and sex of patient will justify, ending this pressure of two or three seconend it in the middle at a .'^harp angle over the probe, tie a piece of carbolized silk around it close to the probe, on withdrawal of which the drain is left with a rounded end which j)asses readily into the interior of the wound.* ;j. The position of the wound must be such as to favor the escape of all secretions, to ])romote the free circulation of blood, and to re- lieve the wound of all sources of irritation. The wound will thus be so ])laced as to secure perfect rest, the necessary antecedent to the healthy accomplishment of both repair and growth.* III. ANTISEPTIC DRESSING. This method is designed to exclude from wounds all putrefactive or.Mnisms.* Though the antiseptic treatment of surgical diseases is infinite in variety, extending from the sim|>le protection of wounds from contact of catalytic germs, to the purification of hospital wards, water-closets, and grounds," but two principal methods of employing antiseptic dressings are in use; first, by dis-infecting the wound and 1 ,'. LisTi:i«. 2 li. Cliassaifrnac. 8 J. Chiene. < L. W. Marshall 6 J. Hilton. « J. H. Hodgen. 42 OPERATIVE SURGERY. the air about the wound with antiseptic agents; second, by intercepting septic niattei's around an already disinfected wound. The antiseptic agents are very numerous, embracing the haloid salts, the tar creo- sotes, the antiperiodics, yet they are not all equally applicable for general use. I. Carbolic acid^ has proved, thus far, the most available antisep- tic agent, as it may at once be used for disinfecting the wound and the air, and for storage in the dressings. Though useful, however superficially but judiciously used, its full benefit is secured only when it is employed iu a systematic manner, with an intelligent apprecia- tion of the objects sought to be accomplished at each step in the dressing. The following are the details when the dressing is applied according to the foi'mula : Provide a vessel containing carbolic acid dissolved in water, 1 to 40, for the immersion of the hands of the operator, the sponges and instruments used in the wound ; a steam spray apparatus, capable of giving a cloud of vapor (make the solu- tion of carbolic acid to be atomized 1 to 30, which diluted by the steam will give a 1 to 40 spray) ; antiseptic gauze, oi)en cotton cloth impregnated with carbolic acid 1 part, common resin 5 parts, and parafline 7 parts ; Mackintosh (fine cotton hat lining), or gutta per- cha tissue of good quality will also answer, but is liable to wear into holes ; drainage tubes (India rubber, with a silk ligature attached, or horse-hair ;) oiled silk protective (oiled silk coated on both sides with copal varnish, and afterward brushed over with dextrine; when the copal varnish has dried, a mixture of one part of dextrine, two parts of starch, and sixteen parts of carbolic acid is brushed over; the acid soon evaporates ; common oiled silk, smeared with the oily solution, will answer the purpose pretty well, especially if used in two layers;) carbolized catgut ligatures. Proceed as follows: Shave the part, if there is much hair, in order that the antiseptic may not be prevented from acting upon the skin ; wash the part witli a watery solution, 1 to 20, to purify the skin; direct the spray upon the part and maintain its action and position during the entire operation and dressing, without a moment's interval; immerse the hands, instruments, and sponges in the 1 to 20 solution before operating, and at every interval when not envelojjed by the spray in the 1 to 40 solution; tie all vessels with antiseptic catgut and cut the ligatures at the knot ; if the finger is to be introduced into the wound, take s])ecial care that it is an aseptic finger, and this is ilone by cleansing it with an antiseptic solution, making sure that it passes well into the folds about the nail; instruments must remain in the antiseptic lotion sufficiently long to penetrate any dirt or grease which may be concealed on them, as between the teeth of forceps; sponges, though used in suppurating wounds, but thoroughly treated 1 J. LiSTKK. THE DRESSING. 43 with carbolic acid solution, are antiseptically clean. First, wash the cut surface thoroughly with a strong watery solution, 1 to 20; jilace the drainage tube or tubes so deeply in the wounds as to drain all accuimdaliiig fluids. The effusion of plasma which occurs during the first few hours after the infliction of a wound is greater when the cut surface has been treated with a stimulating wash than it is under ordinary management, and unless provi.-ion be made for its escape, it will be pretty sure, in a wound of considerable deptli, to accumulate in suflicicnt (juantity to cause inflammatory disturbance from tension. When the antiseptic has left the wound the discharge will be trifling in amount, unless the irritation is continued by blood or serum pent up in sufficient (pantity to cause disturbance, or by some other accidental circumstance exciting the nerves of the part. If the tube enters obliquely, cut the outer extremity obliquely; lay the retaining threads on the surface; if the wound is to be closed as after amputation, use carbolized silk for sutures,^ as it is very superior to wire, not only on account of its perfect suppleness, but because its actively antiseptic character insures absence of putrefaction in the track of the wound ; the spray is never more useful than in the in- troduction of the sutures; if it be not employed the wound must be injected with lotion after the insertion of the last stitch, to destroy any mischief that may have entered through regurgitation of blood that oozes into the cavity during the sewing; if strap[)ing is re(juired common adhesive plaster may be rendered antiseptic by dipjjing it for a second or two in a watery solution of the acid, and it is most convenient to have the lotion hot ; tlie ends should be overlapped by the gauze; apply to the cicatrizing part a layer of the oiled silk pro- tective, wet with the watery solution, and having a hole for tlie drain- age-tube, for cicatrization is retarded when the acid is allowed to act immediately on the margins of the wound, and it is therefore necessary to protect the part by interposing between it and the gauze a layer of some impermeable material; apply eii^ht layers of the gauze, of such size as to cover all the wound and the adjacent parts; in situations where there is not as much extent of skin for the gauze to overlap as is desirable, as in the vicinity of the pubes, the deficiency of surface may be compensated by using the gauze in a thicker mass, say in sixteen or thirty-two layers; dip the first layer in the solution, for if the gauze were applied dry, some active septic particle adhering to its surface might enter the blood or serum at the outlet of the wound, and propagate putrefaction to the interior; be- tween the last two layers ])lace a piece of Mackintosh of smaller size 1 Sillv tliread willi tlic interstices among the fifires fiiied up with wax con- taining at)niit a tenth part of earbolic acid; mix the acid with molted beeswax; iinmerse the sill<, and wlien tlioroughly steeped draw it out through a cloili to remove superfluous wax. 44 OPERATIVE SURGERY. than the layers of gauze ; apply the last layer so as to cover in com- pletely the JMackintosh ; this impermeable cloth is used to prevent the discharge from going directly through the dressing, because, if a considerable (quantity went through, the acid might all be washed out within twenty-four hours, and then putrefaction would spread inwards to the wound ; the Mackintosh having no antiseptic prop- erty, except mechanically by its impermeability, but, on the con- trary, being like other indifferent materials covered more or less with septic matter, it is necessary when the dressing consists of more pieces than one, that the Mackintosh be well covered in at the place of junction of the two pieces, for if it were allowed to j^roject uncovered in the vicinity of the wound it might com- municate septic mischief ; retain the dressings by bandages of the antiseptic gauze, over which elastic webbing may be applied when the bandage is not sufficient, as in wounds or abscesses in the groin ; inspect the wound on the day after its infliction, whether it be accidental or the result of operation, and change the dressing only in case the discharge is liable to extend beyond the edge of the folded o-auze; during the subsequent progress of the case leave the gauze undisturbed for periods varying from two days to a week, ac- cording to the diminution of the effusion; in re-dressing continue the spray uninterruptedly on the part ; while the bandage is being cut or removed, the patient, or an assistant, keeps his hand over the site of the wound, to prevent the dressing from rising en masse, and pumping in septic air; in raising the folded gauze take care that the spray jiasses into the angle between it and the skin ; remove the drainage-tubes, cleanse them in the carbolic-acid solution, and before re-introducing them cut off such portions as the granulations in the wound render necessary to bring the external extremity flush with the surface of the skin; lay aside the gauze which is soaked, but use the Mackintosh again after cleaning it with carbolic-acid solution.! 2. Cotton-wool 2 is used to intercept germs in the air. Apply it as follows to open wounds, as after amputation: Select three or four pounds of wool of good quality, white and clear of foreign matters; strip off any glazed surface ; tear the sheets into strips about one foot wide, and roll them up; prepare several rolled bandages of un- washed linen or cotton, two inches wide and eight to ten yards long; remove the patient from a septic atmosphere, as that of a ward, during; the dressing; apply ligatures to all bleeding points; wash the wound with a solution of carbolic acid (one per cent) ; the wound being held open, fill it completely with little wads of loose cotton- wool evenly superposed; now apply the rollers of cotton-wool over and around the limb evenly and methodically, so as to surround it with a homogeneous mass of even thickness, which must in all eases 1 J. Lister. "- A. Gueriu; T. B. Ccuris. THE DRESSING. 45 extend beyond the first joint above the seat of the wound. Apply roller after roller of the wool so long as strong pressure throufdi the mass gives any pain; next ap|)ly the common bandage fur the pur- pose of seenrin;^ the wool, the turns being up and down the limb, circular, oblique, or s])iral, as will best mould the mass into shape; wherever there is any bulging the bandage should be applied, the end being ecjually compressed with the sides ; thus oraduallv cover the wool at every point by successive over-laj)ping of the bandafre, making each roller firmer and firmer as the ap"^)licati()n pro'_'resses, the last being applied with all the power of the strongest hands; place the patient in bed; lay the limb on a folded sheet and cover with a cradle. If the case progress favorably, the dressings should not be disturbed for two or three weeks, except they become loos- ened, when additional layers of bandage should be applied to secure anew the firm consistency and elastic compression of the fre.-hly applied dressing. On the fifteenth or twentieth day remove the bandages, and tear open the cotton-wool, layer by layer, along the anterior aspect of the wound. The wound will be found granulating in a healthy manner, the bone being well covered, and the limb as natural as at the time of the operation. The further treatment is that of an open granulating sore. Throughout the treatment the dressings must be watched to detect signs of hipmorrhage, and the temperature must be taken for evidences of imjjending or existing erysipelas, septicivmia, and pyaemia. lY. ORDINARY DRESSINGS. The special form of dressing must be determined by the nature, con- ditions, and peculiarities of each individual wound, and the method of repair which is sought to be obtained. In treatment, wounds are either closed or open; the former tend to primary union, the latter to secondary union, or union by granulation. Although the mor- phological changes in the tissues are the same in both cases,* the method of closing wounds immediately after an operation is to be preferred whenever the conditions are favorable to primary union, as the wound heals more rapidly, with less inflammation, and gives more perfect results, especially Avhen immediate union is secured, which is the best imaginable process of healing.^ The subcutaneous wound must be carefully protected from the admission of air to the interior, as follows: On the withdrawal of the knife, press the end of the finger firmly upon the cut, then apply an adhesive strip over the wound, upon this place a mass of cotton batting anil retain it with adhesive j)laster ; re-dressinf is not re- quired until the union is complete, unless suppuration occur. Incised 1 T. Billroth. 2 Sir J. Paget. 46 OPERATIVE SURGERY. wounds repair by primary union, when their surfaces are accurately maintained in apposition without the intervention of any unorganiza- ble matter, and should be treated with a view to such union, unless the conditions make it desirable that repair should be by granulation. 1. Collodion is the best application if the wound is very superficial and does not gape ; or gauze may be added to give more support, as follows : Cut strips one or two inches wide, and three or four inches long, and with a camel's-hair brush moisten one end of the strip, which quickly dries and adheres ; then treat the other in the same manner; when the wound is covered with the gauze, apply the col- lodion freely over the whole material, thus hermetically sealing the wound with a dressing impervious to water. Collodion dressings rarely require removal until the repair is complete. 2. Adhesive plaster must be used when the wound involves the entire skin and gapes freely; it answers best Avhen bone underlies the wound, as in wounds of the scalp. Cut the plaster in the direc- tion of the length of the roll, and of sufficient length to extend two or three inches upon either side of the wound ; compress the lips of the wound firmly when the strip is applied, as there is always a slight yielding of the margins, which may amount to a complete separation; the strips may be parallel across the woimd, or so obli(iue as to cross each other. When adhesive plaster is removed, great care is neces- sary^ to avoid disturbing the apposed surfaces ; raise each strip equally from both ends to the margin of the wound, and turn it gently over on its axis, while extending each extremit}'. 3. The interrupted suture must be a])plied when the wound is of such extent or so situated that the adhesive strip does not sufficiently support its margins. Various materials are used for sutures, as catgut and horse- hair, silk and hemp, silver, iron, and lead. Catgut, carbolized, is entirely unirritating, but may be ab- sorbed too soon; horse-hair is unirritating and reli- able, but it is not very flexible where the knot is foruied ; silk is irritating, but is generally preferred, the best being that used by dentists, three-thread ; hemp resembles silk, but is not flexible; the best is Fig. 31. three-pl}^ nianilla, hardash.^ The metallic sutures are unirritating and entirely reliable ; the silver is more generally used. If the non-metallic are used, needles of various shapes are re- quired (Fig. 31). The needle with curved extremity (c) is more generally used ; a needle curved throughout its entire length (h) is useful when the wound is deeply seated ; the straight needle («), with sharp point and three cutting edges, is serviceable in 1 C. J. Cleborne, U. S. N. THE DRESSING. 47 Fig. 32. Fig. 33. wounds on a slightly elevated surface; in deeply seated wounds needle foreeps are useful (Fig. 32). If metallic su- tures are used, they may be inserted with the or- dinary suture needle, held by forceps. The suture- ])in conductor (Fig. 33) is very useful ; it con- sists of a slightly-curved needle fixed in a handle, somewhat enlarged for half an inch near its point, and perforated on the con- cave side. Proceed as follows: Pass the needle, armed with the lij^atiire, from without inwards thi-ough one lip of the wound, at a distance fioni its niary;in varyinj^ from a line to one third of an inch, according to the tension of the parts, at a depth siitfi- cient to support the deep parts of the wound, and continue it through the op- posite lip from witliin outwards at a point exactly corresponding to the inser- tion ; tie with the reef-knot, and twist wire with suHicient firmness to press the surfaces well together without causing pouting or wrinkling of the lips. (Fig. 34.) The distance between the sutures should not exceed lialf an inch, and it is better, when silver wire is used, not to exceed one fourth of an inch. Between wide su- tures apply adhesive strips. 4. The twisted suture (Fig. 34) must be used when the wound involves deeper tissues and the surfaces are approximated with difKculty. Pass a needle of steel, silver, or other unirritating metal I sides of a wound, as in the interrupted suture, and tlien twist the thread around the ends in the form of a ligure-of-eight (Fig. 35); when several needles are re- quired they should all he introduced he- fore the thread is applied, which should ^^ then also take a diagonal direction be- tween the pins (Fig. 35) to protect the intervening spaces. t-_^ 5. The quilled suture (Fig. 36) is to be preferred when the wound involves the perineum; pass a double thread or wire as in the interrupted suture, but at greater distances, and tie the ends over (pulls or pieces of bougie ^ Fig. 35. 48 OPERATIVE SURGERY. laid on the sides of the wound ; fine interrupted sutures should also be inserted in the intervals to sustain the lips in apposition. V. OPEN TREATMENT. The open method is adapted to those wounds which heal by second- ary union. This process involves the separation of the dead par- ticles and the formation of granulation tissue. From the infliction of the wound and the covering of the surfaces with granulations there is a constant liability to absorption of septic matters from the wound into the blooil, but when the granulations are complete this danger no longer exists.^ Though suppuration generally accom- panies the process, it is not necessary to the organization and devel- opment of granulations. If the wound is maintained in a condition of perfect freedom from irritating matters arising from filth and decomposition, granulations will form and cast off the stratum of dead tissues without suppuration.^ In the treatment of an open wound, therefore, it is important both to preserve the surfaces from every source of defilement from filth, and to thoroughly disinfect them, the air, and the dressings, so that active septic ferments can- not gain access to the wound, or, if present, will be rendered inert. In dressing a granulating wound, avoid breaking the granulations; for if they bleed, septic poisons may enter the circulation.' 1. Incised wounds may be treated by the open method, as fol- lows : 2 Place the part in an easy position, support it by a pillow of oakum, cover with gauze, and protect from the contact of bedclothes with a cradle; use no sutures except at the angle of the wound, nor adhesive plasters, oiled silk, compress, or bandage; wash the wound at frequent intervals with earbolized water by means of a douche, and pour over it balsam of Peru ; receive the drainage in a disin- fected vessel, and remove it frequently; when suppuration has nearly subsided approximate and mould the flaps with adhesive plaster. 2. Contused wounds are made with blunt instruments, which so lacerate the tissues that the dead particles pi'event immediate union. One of two methods of treatment must be adopted: (1.) When the contusion is slight, convert the lacerated into an incised surface by cutting away the lacerated tissue with a sharp knife and then treating it as an incised wound. (2.) If the contusion is severe, secure the separation of dead matters by warm moist application containing a sufficient quantity of carbolic solution to disinfect sloughs; union will be by granulation. 3. Punctured wounds made with blunt-pointed instruments tend to unite by granulation. Cleanse the wound of all foreign matters and disinfect it with carbolic solution ; if superficial, a>ttempt to se- 1 J. Lister. ^ j. R. Wood. THE DRESSING. 49 cure union by compresses so adjusted as to bring the surfaces of the entire track in apposition; if the contusion is severe, denoted by duskiness of the uiarj^ins, apply warm moist dressinj;s to promote granulation ; if the surface wound unites and pus forms det-ply, the external wound must be reopened. VI. HOT- WATER TKEATxMENT.i This method is adapted to wounds much lacerated or in lin, saturated with warm water, the whole bring enclosed in oiled silk or vulcanized rubber; this is to be changed about once in fotir or six hours. The lower extremities can only be completelv and perma- nently submerged to a point three or four inches below tlie knee, ami the upper extremities to a point a few inches above the elbow, con- sequently, submersion is limited to those portions of the extremities which are below the f)oints mentioned. A vessel, in which tlie part can be immersed, maybe obtained in any household; but a more covenient receptacle is made as follows : — Construct an oblong zinc bath, twenfj'-three inches long by eight inches wide and eight in ^ ^ \*^— —- — "^ "^ n:?F;:^ Fig. 44. Fig. 45. 8. The recurrent bandage should be five yards long and two inches wide; it is applied to the head as follows: — The roller is first passed two or tliree times around the head in a line running just above the eyebrows and the ears, and below the occipital protuberance; next, at tlie centre of the forehead, the cylinder is reversed and carried directly over the liead to the circular turns behind, where it is again reversed, and carried back to the forehead, overla|)ping the former about one third, as usual; these reverses to be continued until first one and then the other side of the head is covered; and the whole is completed by two or three firm circular turns as at the commencement; the reverses are to be held by the fingers of an assistant. II. PLASTIC APPARATUS.i This form of appliance is required when operation-wounds are of such nature and location as to require absolute protection of the part from all motion. It must be a|)plicd with great care, and with due regard to the liability to strangulation of parts recently submitted to operation. By way of caution, it should be stated that all starch, chalk, and plaster of Paris sjjlints contract on drying, and hence are lial)le to be followed by harm.- But though unfavorable results have followed its injudicious use, this dressing is invaluable when prop- erly used.^ The best safeguard against accidents is careful padding of the limb and parts adjacent to the wound with cotton wool.* There must be constant watchfulness of the toes or fintrcrs involved: if these parts become l)luish, red, cold, or even insensii)le, the dress- ini: should at once be removed, or if the patient complains of severe pain under the dressing it is well to remove it.* 1 S. B. St. John. 2 T. Bryant. 8 T. Billroth. * Burggraeve. 54 OPERATIVE SURGERY. 1. The starch bandage is made with starch or dextrine as fol- lows : — Take common starch, a sufficient quantity, and boil it in water a few minutes. Dextrine is very readily prepared by thoroughly mixing with it spirits of cam- phor or brandy, 100 parts of the former to GO of the latter, and adding about 40 parts of warm water. Envelop the limb with cotton wadding, so thickly ap- plied as to cover all the prominences and fill the cavities; over this apply a roller well saturated with the starch; along the sides of the limb apply paste- board splints of proper thickness, soaked in hot water, and nicely shaped to the limb; repeat the bandage twice, and saturate the whole with starch, rubbed in with the hands or a brush. When the starch is completeh' Avy, cut out a piece, and bring the edges together with strong tapes, or leather straps with buckles; hasten the drying, by suspending the limb, or by applying hot bricks or bottles of hot water. 2. The gypsum splint is in many respects preferable to starch, and chiefly owing to the rapidity of its consolidation. It may be ap- plied to a part of the circumference of a limb, or to the entire limb. When applied to a part of the limb as a splint, proceed as follows:^ — First shave or slightly oil the limb; next select a piece of old coarse washed muslin of a size so that when folded about four thicknesses it is wide enough to envelop more than half of the circumference of the limb, and long enough to extend from a little below the under surface of the knee to about five inches below the heel; select fine, well dried white plaster, and, before using, mix a small portion with water in a spoon and allow it to set, to ascertain tlie length of time requisite for that process; if it is over five minutes, dissolve a small quantity of common salt in the water before adding the plaster; the more salt is added, the sooner the plaster will set; if delay be necessary, the addition of a few drops of carpenter's glue or mucilage will subserve that end; equal parts of water and plaster are the best proportions; sprinkle the plaster in the water, and gradually mix with it; immerse the cloth, unfolded, in the solution and saturate well: fold quickly, as before arranged, and lay it on a flat surface, such as a board or a table, and smooth once or twice with the hand in order to remove any irregu- larities of its surface, and then, with the help of an assistant, apply it to the pos- terior surface of the limb; turn np the portion extending below the heel on the sole of the foot, and fold the sides over the dorsum, and make a fold at the ankle on either side; apply a roller bandage pretty firmly over all; hold the limb in a proper position, extension being made, if necessary', by the surgeon, until the plaster becomes hard; the time required in preparing the cloth, mixing the plaster, and applying the casing to the limb need not be more than fifteen minutes. When the dressing is to enclose the limb completely, all the de- tails of preparation and application must be carefully attended to in order to insure safety and success. The following method ^ secures a neat and serviceable dressing : — Select clean cotton batting, smooth and fresh plaster of Paris, and the flimsi- est cotton cloth, as crinoline, which tear into strips of two and a half or three inches in width, make one strip nine to twelve yards long, and the remainder three yards long; lay the latter on a kitchen table or board, and have the 1 J. L. Little. 2 D. w. Yandell. THE APPLIANCES. 55 plaster well rul)l)C(l into the cloth; roll them into cylimiers; into an onlinarv wash basin one third full of water a little warm, put two heaping tablespoon- fuls of powilered alum ; have the whites of half a dozen fresh ef;f;;s beaten into a froth; unfold the batting carefully, that it may be in a sheet rather than a roll, and envelop the whole limb, coverinjjf well the bony prominences; secure the cotton with the lon;^ roller, into which no plaster has been rubbed; put the plaster rollers into the basin of water; squeeze antl press them willi your hand until well wetted; apply them to the limb, one after another, until the dressing Ls suHiciently firm; three layers are usually required; the rollers maybe put on lonj;ituive ; the tongue is generally clean, often red at the tip and edges, or smooth and glossy ; the appetite is good, often voracious, and though digestion continues, assimilation fails; there is coldness of the limbs, but the hands and feet are dry, hot, and burning; as the disease progresses, emaciation increases, the pulse daily loses power, sweating is more profuse; bowels often loose; 1 E. W'agiiur. 2 j. UiUroth. 70 OPERATIVE SURGERY. evening exacerbation, with chilliness, is more severe, and morn- ing remission more max'ked ; still later, all the symptoms are ag- gravated, the appetite begins to fail, aphthous spots occur on the tono-ue, oedema appears about the ankles and feet, chills and sweats which are colliquative succeed each other at shorter intervals, emaci- ation reaches an extreme degree, bed sores foini, the mind continues clear until near the close, Avhen unconsciousness supervenes.^ The first requisite =n treatment is to relieve the system of the exciting cause, as by uisinfecting and destroying the internal surface of open abscesses; or by their removal with the knife, as the exsec- tion of a carious joint, or the amputation of a limb affected with an incurable source of suppuration ; the second indication is to sustain the patient with tonics, as quinine and suli)h. acid, given in antici- pation of the evening exacerbation, muriated tincture of iron, or other form, with wine, brandy, wine whey, ale, or porter; give easily di(»-ested and assimilated foods, as milk, eggs, meat-juice ; finally, secure fresh air and perfect cleanliness.^ VII. NERVOUS AFFECTIONS. Affections of the nerves and of the nervous system following ■wounds are frequently troublesome and even dangerous complica- tions of operation Avounds. 1. Pain,^ other than that which is excited by inflammation, foreign bodies, improper dressings, and wrong posture, may complicate wounds. It may appear (1) only as an exaggeration of the ordinary pain of wounds, severe and abiding long, through personal sensi- bility and so-called nervousness, and is usually continuous with the immediate pain of the wound, or commences not more than an hour or two after it; (2) in some cases a wound is the beginning of a long- continuing neuralgia in or near the injured part; or (3) it is due to partial division of a nerve, or (4) the confinement of effusions under dense fasciae. For the first form, hypodermic injection of morphia, or ice bladders, or opium, in full doses, are proper rem- edies; the second generally resists all treatment, even section of the nerve; the third requires complete division of the nerve; the fourth is relieved by enlargement of the Avound. 2. Spasms of the muscles ^ are frequent complications, especially of amputation and resection wounds ; the startings of the limb are often among the most distressing symptoms; they occur as the patient falls asleep and the influence of the will on the muscles ceases, and the pain remains until the muscles are at rest ; at any time, uncon- trollable quiverings and tremblinrrs'of the muscles may ensue, and lead to painful spasms. The remedy is posture and rest of the 1 S. D. Gross : J. Croft. 2 Sir J. Paget. THE lUCPA/Il. 71 wouiuk'il part, sustaineil by splints, or otliL-r appliances, and as- sisted liy opium or oilier ano(l\iies. 3. Delirium tremens, followini^ injuries, and surgical operations on drunkards, or on persons of intenij>erate liabits, is due to shock and its reaction, and the deprivation or stinting of stimulants which induce a peculiar iuipairuicnt of the essential elements of the nervous structures.^ The symptoms usually apjjcar within two or three days after the opei'ation; at first the patient is restless, sleepless, and talkative; then he has hallucinations and illusions of siglit and hear- ing, which lead to attempts to get out of bed and escape reptiles and vermin, and to answer imaginary calls; next there is trembling of the tongue, hands, and liuibs; the skin is moist and cool; the tem- perature normal; the tongue coated; the breath olfensive; the eyes suffused. As the condition is one of debility, the great object of treatment is to enable the patient to take and to assimilate a sulhcient quantity of proper nourishment.'^ The aim should be to fortity and stimulate the functions of the brain ; mild preparatory purgatives may be required for the young and robust, but the debilitated must be sustained from the first; the typical stimulant is easily digested food, 3 and it is imperative that it be given regularly and continuously; the most desirable foods are milk with lime-water, soup or broth with bread in it, raw eggs beaten up, concentrated meats: irritation of the stomach requires ice, soda water, and other aerated drinks; the narcotic stimulants are useful, of which opium and cannabis indica arc most valual)le ; opiates may always be administered in the form of morphia hypodermically injected in the dose of Jj^ to ^, or ^ a grain ; if the circulation is enfeebled, ext. cannabis indica should be uiven in doses of ^ to ^ a grain; alcohol should not be given to young subjects, nor in any case where it can be dispensed ■with.3 In some cases it may be found necessary to give "-ood ale, porter, or wine, with solid food.^ Bromide of potassium condiined with the hydrate of chloral, the former twenty to thirty o-rains and the latter fen to fifteen grains at a dose, is a valuable remedv in quieting nervous ater morphia liyj)odermically. 5. Tetaiius is a spasmodic affection of the muscles, (hie to irrita- tion of the spinal medulla and portio minor of the fifth pair.^ The chief causes are cold and damp, and the injury of the ojjeration.^ The muscles of the jaw alone may be affected, trismus, or other groups may be involved. The symptoms appear as late as the third or fourth day after the injury, often later. In a well-marked case they develop in the following order: (1) there is a sense of suf- fering from a cold, with sore throat and stiff neck, an uneasy sensa- tion and stiffness of the muscles of the lower jaw and tongue, rigid- ity of the back of the neck ; (2) difficulty and pain in masticating and swallowing food, fixed and closed state of the lower jaw, severe pain with every effort to open the mouth; (3) convulsive cramp in all the affected muscles on any attempt to swallow; (4) sudden, violent, and continued jiain, increased at short intervals by spasm extending from the ensiform cartilage to spine in the situation of the dia- phrao-m ; (5) constricted and hardened state of the abdominal mus- cles, friving the sensation of a board to the hand; (6) all of the volun- tary muscles become involved, the head is thrown back and fixed, the extremities become fixed and rigid, the shoulders are drawn forward, the countenance is pale, anxious, and contracted, and dis- figured with the tetanic grin; (7) the spasms become more and more frequent and violent, with hurried and laborious respiration, and quick, small, and irregular pulse; (8) the spasms may not be sudden, but may gradually draw parts into the form of a bow ; (9) at the close the whole face becomes distorted and disfigured, the larynx forcibly drawn up, and in the majority of instances the case termi- nates in a paroxysm of spasm ; (10) the intellectual faculties remain unimpaired.* The bodily temperature varies greatly in different cases. The treatment can be only symptomatic, owing to the un- certainty as to its etiology; the most marked indication is to allevi- ate the acute course, and make it more chronic: narcotics with opium and chloroform are most often employed, the former in large doses as by hypodermic injections of morphia, and the latter during the spasm;'' the opium never removes the cause, though it will prevent 1 S. D. Gross. - T. BiUroth. 3 c. B. RadclifEe. * Morgan. THE CICATIUZATIOX. 73 the effects, and does fjood by not allowing the symptoms to do harm.^ The Calabar bean has proved more useful, perhaps, than other rem- edies, when given in such do.-es as to paralyze the voluntary muscles.* Almost every other internal remedy has been successively tried, but no one individual medicine has proved an appropriate means of cure ; they have been useful oidy as they have rendered the i)ar- oxysms less severe, and enabled the patient to lesist the exhaustion caused by spasmodic action. It must be remembered that the disease will run a certain course, having its period of accession, its height of intense activity, and its gradual decline; nothing seems to check its progress, or control its unvarying and too often fatal career; all that can be done is to give the patient as much strength as pos- sible, to avoid ;ill useless applications and internal reineive plaster, and cut it into two strips three or four inches wide, but narrower for children : one should / L, be of length to encircle the arm and the body, and the other to reach from the sound shoulder around the elbow of fiie fractured side and back to the place of starting. Pass the first piece around the arm just below the a.xillary margin, and Fig. 5'2. stitch in the form of a loop sulficiently large to prevent strangulation, leaving a 1 E. nart>hurne. - F. H. Hamilton. 3 BtUevue Hospital Reportt. * L. A. Sayre. 84 OPERATIVE SURGERY. large portion on the back of the arm uncased by the plaster; draw the arm down- ward and backward until the clavicular portion of tlie pectoralis-niajor muscle is put suHBciently on the stretch to overcome the sterno-deidomastoid, and thus pull the inner portion of the clavicle down to its level: carry the plaster smoothly and completely around the body, and pin to itself on the batk to pre- vent slipping. This first strip of plaster fultills a double purpose: first, by put- ting the clavicular portion of the pectoralis-major muscle on the stretch, it prevents the clavicle from riding upward; and, secondly, acting as a fulcrum at the centre of the arm, when* the elbow is pressed downward, forward, and in- ward, it necessarily forces the other extremity of the humerus (and with it the shoulder) upward, outward, and backward And it is kept in this position by the second strip of plaster, which is applied as follows : Commencing on the front of the shoulder of the sound side, draw it smoothly and diagonal!}- across the back to the elbow of the fractured side, where a slit is made in its middle to receive the projecting olecranon. Before applying this plaster to the elbow, an assistant siiould press the elbow well forward and inward and retain it there, while the plaster is continued over the elbow and fore arm, pressing the latter close to the ches^, and securing the hand near the opposite nipple; crossing the shoulder at the place of beginning, it is there secured by two or three pins. Union occiir.s with great rapidity, sometimes as early as the sev- enth or tenth day, but the arm should be kept quiet two or three weeks. ^ 4. The humerus.^ fractured at any point above the elbow, should be uiaintaineil in po.sition as follows: Select a piece of leather, gutta- percha, or felt, long enough to extend from above the acromion pro- cess to the elbow-joint, and wide enougli to inclo.se about one half of the circumference of the limb; mould it while wet to the outside of the arm, and allow it to become dry; prepare a short sj)lint for the inside of the arm; cover each splint with a sack of woolen cloth; re- duce the fracture and apply the splints to the arm with a roller bandage, and secure the arm to the body with a second roller bandage passed around the lat- ter; flex the fore-arm, and sus- pend by a sling. Xo bandage is required for the fore-arm; slight overlapping may be anticipated. If the fracture is at or near the elbow-joint, the fore-arm must be placed and maintained at a riiiht angle with the hutnerus by means of a thick piece of gutta- FiG. .53. percha, moulded to fit the shoul- der, arm, and fore-arm, and well padded; place the fore-arm at a 1 F. H. Hamilton. Till-: lyjL'lUES OF BOXES. 85 right allele wiili the humerus, and maintain it in this position by a right-angled splint; cover the gutta-percha si)lint with a woolen or cotton sack, and secure it to the fore-arm by a roller. In a case of fracture of the humerus above the condyles, while extension is made secure the upper portion of the splint to the arm in a similar man- ner. The front or bend of the elbow should always be well cov- ered with cotton batting before inclosing the elbow-juint in the turns of the roller, to prevent strangulation. ^ Passive motion must be conunenced very early by loosening the dressing, supporting the parts at the joint, and making flexion and extension. If the frag- ments are not disturbed, repeat this manoeuvre daily. ^ 5. The radius fractured above the attachment of the pronator (piadratus must be so adjusted that the proper axis of the bone is maintained, to secure the restoration of its normal movements.^ The elbuw should be semiflexed, the fore-arm and hand, excepting the fingers, supported between a dorsal and a palmar s[>lint secured by adhesive plaster; the limb should be accurately fixed in supination at an angle of 1"20° by means of angular pads; the thumb in this position is brought nearly into a line with the outer fleshy border of the supinator radii longus.^ Fracture of tlie radius within an inch of the wrist-joint'' has re- ceived the following elucidation :^ The fracture is caused by forced extension of the hand on the fore-arm, the bones of which constitute two levers, A and B (Fig. 54), held together by the anterior and posterior radio-carpal ligaments C and D. Wlien B is forcibly carried backwards, as in extension of the hand, liie band U is made tense; the opposite bor- der of tlie lever, having slipped forward as far as the band will permit, now abuts aj^ainst the lower sur- face of A, wliich becomes a fulcrum for tlie further ac- tion of the lever. Tlie mechanical arranicjement is such / i / tliat an innnense power maybe exerted; if the back- / \/\ ward force continues to act, either the band D must rup- '^^ " ' ture, or a lever be fractured; the projecting lip upon the v upper lever puts it at a disadvantage; the band continues to sustain the strain, and the lever li^ives way (Fij;. 5-5). The point of fracture is necessarily just above that por- Fig. 54. lion of the lever controlled by the band; the strain upon the lever is nearly transverse. Ry the powerful leverage which the extended hand and carpus obtain tlirough the strong anterior ligament upon the lower end of the radius, that portion of the bone is literally torn from it. A second force, other than that of extension, is also present, as an important and independent 1 F. H. Hamilton. 2 j. Packard. 3 (;. \\\ Cullender. * A. Colles. S L. S. I'lLCHEU. 86 PER A TIVE S UR GER Y factor in the production of the results, namel}-, the forward and downward im- pulse of the lower end of the radius. A force compounded of the weight of the body and the velocity of the fall is received upon the anterior ligament, and converted b^' it into a force of avulsion. The new and tinal relation of parts (Fig. 55) is lixed by the peri- osteum covering the back and lower portion of the radius, reinforced by tibres from tlie poste- rior ligament and posterior annular ligament of the wrist. The force having expended it- self, and the injured member being relieved from the weight, entirely new forces begin to act upon it. The hand recovering from the condition of forced extension, as it straightens or becomes flexed to the extent of its weight, tends to bring back with it the lower fragment of the radius; this fragment, abutting against the projecting posterior margin of the upper fragment y (Fig. 56), is supported as a fulcrum, and the result of the weight of the hand is simply to make still fmore tense the aponeurosis which is ) attached to it behind. Thus the char- ( / yj I maintained, while immobilit}' ' ,{^J' I fragments and absence of cref /V\.A/''A>A cpnnverl (Fio-_ .^i? ^ Whpn tliP Fig. 5G. acteristic deformity is produced and of the repitus is secured (Fig. 57). When the radius has given way, and the force of exten- sion is no longer arrested by the inser- tion of the anterior ligament into its broad margin, this force is felt strong- ly by that portion of the ligament whicli is inserted into the ulna ; the whole hand, with the lower radial fragment, is caused to move backward and outward, as in supination ; a strong fasciculus of the anterior ligament, passing ob- liquely from cuneiform bone to an- terior border and base of the styloid process of the ulna, bears the most of the strain ; through it, the tend- ency to supination is increased, the rounded head of the ulna is made to project strongly upon the front and e. Dorsal periosteal pseudo-liga- inside of tlie wrist, its styloid process y. Point of entanglement, g- becomes approximated to the radius Fig. 57. ment. Flexor tendons. upon tlie back of the wrist, and in some cases is completely torn off. In this position the parts are firmly held, all rotation in either direction being pre- vented, as long as the backward displacement of the lower radial fragment remains unreduced. In the treatment, 1 two classes of fractures must be recognized, I 1 L. S. PiLCHER. THE INJURIES OF BONES. 87 namely, those witliuut and those with disphiccment. The first is likely to be called a sprain and to be treated as such; for immediately upon the recovery of the hand fi-om the over-extension which it had sustained, the correspondinj^ surfaces of the fragnicnts fall together, where they are hehl by the weight of the hand when j)rone ; there is no tendency to displacement. The indications are: (1.) That the wrist should be supported in the prone position, with the hand hau'- ing loosely, and thus maintain the fragments in apposition. (J.) That movements of extension of the hand shoidd be limited, lest separa- tion of the fragments again occur. The first indication in the treat- ment of the second form is to overcome the displacement, which is ef- fected as follows: Hend the hand and wrist backward, approximatino- the position in whirh the parts were when the displacement took place, and relax the tense jjeriosteum. Slight extension now in the line of the fore-arm is suflicient to disentangle the rough surfaces of the frag- ments from each other, and moderate pressure ujjon the dorsum of the lower fragment causes it to fall into line ; the weight of the hand is now sufficient to secure perfect apposition of the fragments; the periosteum again envelo[)S closely the whole leni^th of the radius; the tense inner fasciculus of the anterior ligament is completely relaxed; the radio-ulnar movements are free; the head of the ulna has ceased to project as if subliixated; all the parts have resumed their natural relations; the fracture has become one of the first class, with this difference simply, that the sj)rain of the soft parts is much more ag- gravated. Splints are not always necessary in the treatment, but all the measures inrlicated as of value in overcoming the results of sprained wrist are now of importance; as compression and support by means of a bandage encircling the joint; the snug application of a strip of strong adhesive plaster, two inches wide, so as to grasp firmly the lower extremities of both radius and ulna, to restrict effu- sion, and reinforce the radio-ulnar ligaments, and render more toler- able efforts at motion of the wrist-joint; massage, early, persistently, and skillfully applied; motion, early, regular, and decided in charac- ter; use of the hand after the third day. As a rule, it would not be wise to discard splints altogether in this fracture, but they may in general be limited to a single well-padded splint on the dorsal or palmar surface. ^ There are instances of great displacement and contusion, in which two light-pailded splints, care- fully applied with adhesive strips, are useful. 6. The olecranon process separated from the ulna requires the straight position of the fore-arm. Apply a light but firm splint, ex- tending from about four inches below the shoulder to the wrist, wide as the arm at its widest part, thickly padded with cotton batting to 1 F. H. Hamilton. 88 OPERATIVE SURGERY. meet the irregularities of the arm, and having a notch cut about three inches below the olecranon; place it on the palmar surface, and apply a strip of adhesive plaster, the centre being on the process and the ends drawn firmly through the notches and fastened to the splint ; retain the splint in position by a bandage or strips of plaster passed circularly around the limb and splint. The plaster of I'aris is applied as follows: Place the limb in extreme exten- sion; cover it with cotton bat- ting or flannel ; apply three layers of bandage, and when it is hard cut out a large fenes- „ „„ trum over the olecranon: now Fig. 58. i . • f n • i apply strips of adhesive plas- ter, the centres being over the upper surface of the olecranon, and fasten the ends, drawn down firmly, to the sides of the splint (Fig. 58). 7. The radius and ulna fractin-ed must be maintained in paral- lelism. Take two wooden splints of the length of the fore-arm, nearly or quite the width of the limb at its widest part, properly padded; apply them evenly to the palmar and dorsal surfaces, and retain them with two adhesive strips applied directly around the limb and splints. 8. The femur ^ is liable to be fractm-ed through the neck, within and without the capsule, below the trochanter minor, in the central portions of the shaft, just above the condyles, through the condyles, and at the points of epiphyseal connections. Fracture of the neck, including even cases of suspected fracture, should be treated as if in a condition favorable to bony union, in order both to save the patient from the pain and suffering caused by the irregular contractions of the muscles, due to the pressure of the broken fragments against in- flamed tissues, and to insure a longer limb and less eversion if bony union does not take place. Fractures of the shaft are generallj' ob- lique, and the fragments override from half an inch to two inches, owing to the contraction of the muscles ; fractures just above the condyles are in most cases oblique from above downwards, and from behind forwards. All of these forms of fracture can be treated more successfully in the straight than in the flexed position, and in nearly all cases extension is more effectually made by the weight and pulley than by any other method. The sooner the limb is put up and subjected to this methoil of treatment after the fracture, the better; suffering is prevented, and the sufferer made comfortable from the outset.^ Precisely the same form of apparatus is not suited to all fractures of the femur, but certain modifications are required to meet all of the indications present. In an ordinary case, provide a firm 1 F. H. H.\MlLTON. THE INJURIES OF BONES. 89 bed with a suitahle mattress (Fijx. 61); apply a roller banda2;e from the toes to the ankles; next apply strips of strong adhesive plaster two and a half inches broad, and well warmed, 'i /-y to both sides of the leg, extending from the frac- ture some iiichrs below the sole of the foot (Fig. 59); warm the ends and lap them over each otjier so as to make a loop of two thicknesses four inches lu'low the sole of the foot ; in this loop put a foot-piece of wood four inches long and three inches wide; continue the roller bandage over the limb to the groin; pass a strong India-rubber band around the foot-piece in the depres- sions cut on either side, and attach to it a rope, or make a hole in the centre of the block, through which a cord is passed and a knot tied so that it cannot escape ; at the foot-board arrange a pulley on a level with the long axis of the leg; this pulley may be iron or wood, or even a large spool, and may be fastened on the foot-board of the bed, or in an iron or wood upright (Fig. 60); the weights may be obtained in sets and neatly adjusted to the rope, or they may lie made to ^-lide down one upon the other as the weights of the common scales. Xow apply co- aptating splints, which may consist of ^-, several narrow strips of thin board A\ jiroperly padded and of such length as ,aijj to e.xtend well above and below the fracture; or four sole-leather splints may be used which do not quite touch at their margins, the external and in- ternal embracing the condyles; main- tain these splints by four to six strips of bandage knotted over the front splint, or by straps with buckles. The amount of weight to be employed must be determined by the resistance to be overcome, and the toleration of the patient; the maximum is about twen- ty-two pounds, and generally not over twenty pounds can be long endured. Counter extension is made by the wei'jht of the body, in- creased, if necessary, by raising ihe foot of the bed on blocks, or by Fio. 60. 1 A. Crosby. 90 OPERATIVE SURGERY. a perineal band attached to the head of the bed (Fig. 61). Pre- vent eversion of the foot, espeoial'y in fractures of the neck, by long sand bags at the si;istant presses down the upper fragment of the patella, secure it in place with bands of adhesive plaster; each band should be two or two and a half inches wide, and sufficiently long to enclose the limb and splint obliquely; la}' the centre of the first band upon the compress, partly above and partly upon the upper fragment, and bring its extremities down so as to pass through the two notches on the side of the splint, and close upon each other underneath; let the second band, imbricating the first, descend a little lower upon the patella, and secure it below in the same manner; the third, and so on successively until the whole is covered, after which apply a roller from the foot to the groin. The lei; should not be fle.xed freely, under three months.^ 10. The tibia is very little displaeed, when broken alone, and re- quires only a leather splint,- or a properly adjusted plastic dressing. A very neat and simple plastic dressing may be made with flannel, plaster of Paris, and shellac,^ prepared and applied as follows : After replacing the fragments as accurately as possible, extension being maintained by assistants, bandage the limb smooth'y with cot- ton wadding, prepared in the form of an ordinary roller; now soak a flannel bandage spread with dry plaster of Paris and rolled, in warm water, adding about two fluid-ounces of saturated solution of sulpliate of potassium, and apply to the limb, over the wadding, by circular and reversed turns; one layer of the (iannel applied in this way is amply sufficient for supjjort; the splints should be varnished with shellac. To inspect the point of fracture, the dressing, which is only about an eightli of an inch thick, is easiiy cut through. To avoid die difficulty in removing plaster of Paris dressings when applied by the roller bandage to the leg, the following method of dressing is very con- venient : 3 Take a woolen or cotton stocking suffi- ciently long to reach to the knee-joint, and cut from it as a pattern six layers of coarse red flan- nel, one quarter of an inch larger, to allow for shrinkage; soak the flan- nel in water, press and lay over the back of a chair, ready for use ; sew a one quarter inch cotton rope to the posterior median line of the stocking (Fig. 64); 1 T. Brvant. ^ F. H. Hamilton. 3 g. Wackerhagen. Fig. 64. THE IXJiRIKS OF BOXES. 93 the plaster of Paris lieiiig in process of preparation; cut the stocking in the an- terior median line, apply it to the fractured linili, lace up in front, including the rope, extension and counter-extension being kept up by assistants; adjust the fracture; saturate each layer of the fiannel now separately in the plaster paste, suid apply three layers to each side of the limb, being careful to avoid covering the ri)i)e; after this is done, apply a layer of planter paste to the flan- nel, and, when tliis has become sulHciently dry, a coating of shellac varnish, which produces an elegant finish, and also gives lirmncss to the splints; the varnish will dry in about lifteen minutes. Remove by loosening the rope from the plaster and cutting tlie thread which binds it to the stocking; cut the plain Stocking surface with an ordinary pair of scissors. 11. The fibula is most frequently fractured two or three inches al)()ve the lower end ; the most convenient dressing is the o;yj)sum, which must include the foot, except the toes; the fracture must he reduced and the foot held firmly in position until the limb is dressed and the material has har J. J. Chisholm. - F. II. Hamilton. 3 G. A. Otis. < B. Beck. 6 T. Longmore. "^ F. Stromeyer. 7 98 OPERATIVE SURGERY. nerves, or extensive comminution in the vicinity of joints, with fis- sures extending into the articulations.* After extractino; loose frajr- FiG. 69.2 ments, if no considerable dcfornuty exists, only simple splints and bandages are required; if there is great tendency to displacement, the fenestrated g}'psum dressing, applied when the arm is midway between pronation and supination, with a slightly bent elbow, is most useful.^ If but a single bone is fractured, the most simple splint dressing is required. Suspension of the fore-arm in the early stages of treat- ment is very important, and mav be effected by simple apparatus, as follows (Fig. 70):* Select iron tubing, or other material, fasten its upright portion by clamps at the head of the bedstead, while its lower portion over- hangs the bed and holds sus- pended at its extremity a flattened strip of hard wood, on the upper edge of which a row of screw heads serves for fastening the ends of the canvas bands that suspend the limb; the strip of wood that supports the limb should play horizontally on a swivel joint at the e.Ktrem- ity of the iron tubing. 6. The metacarpal and phalangeal bones should, as far as .practicable, be preserved, wdiatever the nature of the injury, though their functions may subsequently be greatly limited. Their wounds 1 F. Schwartz. 2 F. Esmarch. 3 H. Fischer. < G. Buck. Fig. 70. THE INJURIES OF BONES. 99 are extremely painful and troublesome in manaf^ement, but are not specially liable to induce tetanus.^ In the treatment, splinters and foreign bodies should first be removed; free incisions' through the aponeurotic layers are important in preventing accumnlations of matter under fasciaj and tendons, or relieving tension caused by such collections. Carljolized oil ilressings j)ressed into the wounds in or- dinary cases, and the hot water in those liable to extensive sloughs, should be early resorted to and persistently used; the hand may be 8uj)ported upon ])r()perly adapted splints. 7. The femur,- fractured by a modern rifle-ball, is generally exten- sively comminuted, and often fissured for long distances along the shaft; an attempt to conserve the injured limb, however free from complications, and however favorable the case may appear to be, will unavoiilably subject the patient to a wide variety of hazardous circumstances, owing to the prolonged treatment and attendant dilR- culties which must necessarily occur before a cure can be completed. If the femoral artery and vein have been divided, any attempt to save the limb will certainly prove fatal. In shot fractures of the upper third of the femur, especially if it be doubtful whether the hip-joint is implicated or not, the question is still open whether ex- cision of the injured portion, or removal of the detached fragments and relying on the natural efforts for union, or amputation, which is very dangerous, is best for the safety of the patient. The decision must depend upon the extent of the injury to the surrounding struc- tures, the condition of the patient, and other circumstances in each individual case. As a general rule, in fractures in the middle and lower third of the thigh, amputation is held to be a necessary meas- ure. When it is deter- mined to attempt to save the limb, the wound may be enlarged to remove spicula of bone, and oc- casionally counter open- ings should be made to prevent the accumula- tions and burrowing of Fig. 71. pus; carbolic solutions should be injected into all the recesses, and carbolized oil on lint be introduced with forceps to avoid creating additional irritation ; cold water or ice dressings may at first be applied, to be discon- tinued if suppuration occurs. The part should finally be perfectly immobilized by ap])aratus; for this purpose the splint should allow the limb to be swung so as to admit of dressing without change of 1 G. A. Otis. 2 T. Longmore. 100 OPERATIVE SURGERY Fig. 72. position. The gypsum splints or the fenestrated gypsum bandage may be employed (Fig. 71), or the cradle with a light weight at the foot (Fig. 73). A wire suspending apparatus ^ (Fig. 72) has given good results: — Tlie frame is stout wire; strips of cloth are laid across the splint from side to side, and upon these the limb is laid; the centre and upper extremity of the splint are kept asun- der by strong bows of iron wire, so arranged that they can be put on or taken off with- out disturbing the dressings; when applied, the inside wire must be bent upwards at its upper extremity, so as to make room for the pubes; extension is made bj' adhesive 4\ plasters, and the whole apparatus is finally suspended to the ceiling or to some point above by a rope or pulley. 8. The tibia and fibula, fractured without implication of the knee or ankle joints, are very amenable to conservative measui-es, and hence, as a general rule, or- dinary fractures below the knee, fi'om rifle balls, should never cause primary am- putation. ^ The treatment should consist in freeing the wound of all foreign matters and splinters, the local use of carbolized oil on lint, and Fig. 73. tlie application of the gyp- sum splint noticed in the treatment of ordinary compound fractures in this region. A very simple apparatus* may be made, consisting of a wooden frame formed of four square bars of the length of the lower extremity, two on either side of the leg, united by a crescent-shaped piece of wood situated at the back of the knee, and by a foot-board below; the lower two serve the purpose of hold- ing the apparatus together, and making an inclined plane; the upper bars serve as points of attachment for a number of linen straps or rollers to suspend the limb, which pass from side to side and are fastened with pins; they constitute a per- fect bed, having the advantage of adapting themselves to the differences in the conformation of the limb; the foot is retained to the foot-board by long adhesive plaster strips, passed around the foot-board and carried upwards and secured to both sides of the leg with roller bandage, leaving a sort of loop beneath the foot-board, through which a rope is passed and attached to a little l)ag weighted with sand, for the purpose of keeping up extension; counter-extension is made by a perineal band, the end of which is secured to the head of tiie bed; a long cross-bar under the foot-board, resting on the bed, prevents the apparatus from 1 J. T. Hodgen. 2 T. Longniore. 3 G. Tiemann & Co. THE DISEASES OF BOXES. 101 tilting; bricks may be placed under the legs of tlie bed at tlie foot, to give the apparatus an incliiiatiun towards flie pelvis; one of the advantages of this in- strument is that each of the bands of linen may be removed separately, any wound dressed, and the band reapplied without displacing the others. CHAPTER XIII. DISEASES OF BONE AND SPECIAL OPERATIONS. Morbid anatomy illustrates physiological processes very mark- edly in the osseous system; in every case some analogy at least may be discovered between the morbid phenomena and a normal proto- type; in many cases there is a simple excess or deficiency of normal growth, but in the larger niunber there is a predominant activity of single anatomical factors whose part in normal growth is more subordinate.^ In the examination as to the condition of bone, much useful information may be obtained in obscure cases, both as to the seat and nature of the disease, by percussion ; '^ the instrument used should be a metallic hammer with a whalebone handle, and the bone should be firmly compressed on two sides; of the more notice- able sounds elicited by percussion of diseased bone are a high pitch when the bone is very compact, as in osteo-sclerosis, and a hollow sound when the bone is very porous, as in osteo-porosis. I. RICKETS. The swellings and distortions of rickets depend on a morbid ac- celeration of those changes which usher in and prepare the way for the transformation of cartilage into bone, and the development of bone from periosteum; ossification follows at a slower pace, and hence the substance which should undergo immediate conversion into bone- tissue accumulates, forms swellings, and allows the bones to be bent and broken. 1 In its various forms rickets ^ is a very common affection in children from six months to two years of age, who live in damp, dark, ill-ventilated apartments and have insufficient or improper food. Faulty digestion results in the de- velopment of acids, mainly lactic, in the blood, and the rapid elimination of the phosphates by the kidneys. The child grows feeble, peevish, nielancholv. has perspiration of the head; the ends of the long bones, radius, tibia, and ribs, enlarge, and those bones subjected to pressure bend. The general treatment is (1) fresh air and sunlight; (2) cod-livor oil, and syrup of iodide of iron, or the compound syrup of the phos- phates. The mechanical treatment consists in supporting the bones 1 E. Rindfleisch. 2 a. Liicke. 3 j. L. .Smith. 102 OPERATIVE SURGERY. which are inclined to curve during the period of softening ; the great- est care and discretion are required to avoid doing harm by undue pressure on yielding bones; as far as possible the weight of the body should be taken from the long bones, and when curvature occurs gentle lateral support shoukl be given by well- padded splints, making such points of pressure as will not involve other bones. Plastic appara- tus may be applied to support a weak spinal column and the lower extremities. The curva- ture of the lower limbs maj' be very firmly sup- ported by apparatus which protects the bones without other pressure. If curvature exists, -c much may be accom])lished in straightening the limb of the child that does not walk, by firm pressure and extension with the hands, repeated several times daily. When the child is walking an apparatus may be adjusted to the tibia. (Fig. Fig. 74. ^'^"^ Two upright steel stems are fastened below to a shoe and terminated above in the calf-band; a leather bandage is passed around the stems and tightly laced in front over the arc of the curvature {a), or a strap is passed over t'le arc of the curvature and fastened to a spur suspended from the calf-band behind (c) ; the points of resistance being in either case the heel of the shoe (6) and the posterior trough of the calf-band (c). When the bones of the leg and thigh are both bent, the apparatus must be so constructed as to overcome the deformity which takes different directions. The support is given by double stems of steel, secured to a shoe, carried up as high as the thigh and jointed at the ankle and knee to allow the patient perfect freedom of motion; they are kept in place by calf and thigh bauds. The bow is corrected by pads being placed respectively against the ankle and knee on the concave side of the limb, whilst a strap passed around on the highest point of the arc, inside of the outer stem, tightly buttoned to the steel bar on the con- cave side, gradually compels the leg to become parallel with it; in slight cases, or when the bow is greatest below the calf, an instrument carried up to the knee is sufficient. When the bones have become consoliilated in deformed positions which impair function, they must be straightened by osteoclasis or osteotomy. ir. TUMORS OF BONE. Osseous tumors are distinguished from other ossifying tumors by the uniform production of true "bone as an essential element in their development. 1 They are never formed altogether of bone, but there is always present an ossifying matrix, derived generally from the perios- 1 R. Virchow. THE DISEASES OF BONE. 103 tcuin and cartihujc; the amount of periosteum, eartilage, and bone present varies indefinitely in different cases. * In the diagnosis, ^ gen- eral smoothness of surface is usually significant of a tumor growing witliin a bone and expanding it, unless in the case of cartilaginous tumors, which, after growing within bones, have protruded through some of their expanded walls; pulsation in a non-cancerous tumor connected with bone is a nearly certain sign of growth within bone, exce|)t in the case of luyeloiii ej)ulis; if these means of diagnosis are insuflicient, resort to puncture or an exploratory incision. In operations for the removal of tumors of bone, the following general rules'^ should be borne in mind : (1) Simply removing a tumor from the place in which it lies is as sufficient for tlie cure of one growing in a bone as for tliat of one growing in connective tissue ; (2) it is rarely necessary to disturb the continuity of a bone in order to re- move from it any innocent tumor; (3) the safety of removing a tumor from within a bone is greater than that of any resection or amputation that might have been performed as an alternative opera- tion; (4) innocent tumors growing on bones slionld be removed by excision, and growing in bones iiy enucleation ; (fj) cancerous and recurrent tumors should generally be removed by amputation or wide excision. 1. Chondromata, cartilage tumors, are usually seated in the bones; the phalanges of tlie fingers and toes are more often af- fected; next, the humerus, femur, and tibia; next, the jaws, pelvic bones, and scapula; they may spring from the periosteum and from the medulla; new bone may form, layer after layer, producing a bony capsule which may continue for a long time.^ They are of slow growth, painless, rounded, nodular, and when very large prone to ulcerate. The treatment is removal when life is not endangered by the operation. Enucleation ^ is a method to be oreferred when it can be effected, as in the bones of the hand, the elastic bandage being first applied to the liml); amputation is necessary wlien the growths are multi[)le or very large, or when the limb would be use- less after their removal;'* if the tumor is in the femur, disarticulation is ad\ isnlilf.^ 2. Exostoses are manifestations of an increased jihysiologicnl activity of the periosteum ; in the majority of cases some general disease, as syphilis, rheinnatism, or rickets, has a part in their causation, though an injury is often the assigned cause. ^ They frequently occur in the nuiltiple or diffuse form. They may con- sist of (1) spongy bone-substance, which occurs almost exclusively on the epiphyses of the long bones, outgrowths from the epiphyseal 1 R. Moxnn. 2 Sir J. Paget. 3 e. KiiulHeisch. ^ T. Holmes. 6 T. Billroth. 104 OPERATIVE SURGERY. cartilages, but from the first being intimately connected with the spongy substance of the epiphyses; (2) compact bony substance, ivory-like, which develops on tlie bones of the face, skull, pelvis, scapula, great toe; (3) ossification of tendons, fascia, and muscles, where they are attached to bone. These tumors form withou: pain, and are inconvenient when in the vicinity of joints or on the toe, and unsightly when on the face or head. The only treatment is ex- cision, which is neither advisable nor necessary, unless the impair- ment of function be so great as to balance an operation dangerous to the joint and to life, for these tumors in time cease to grow. On epiphyseal exostoses mucous bursa3 are often found, usually com- municating with the joint, which are liable to be opened and lead to unfortunate results.^ These gi'ovvths do not return when removed.^ When they appear on the great toe the phalanx should be ampu- tated. The ivory exostoses of the skull owing to their hardness are generally excised with extreme difficulty by means of saw and chisel, and the violence involves very great danger. As they may exist without other inconvenience than the deformity whicli they cause, the risk of excision should not be lightly incurred. An ex- ception must be made in the case of ivory exostoses of the orbit, as the gradual growth of such tumors displaces the eye, causing blind- ness, by stretching the optic nerve, and a hideous squint; the base, usually attached to the inner or outer angle of the root of the orbit, is often small, and when fully exposed can be partially cut with a fine saw, and then bi'oken with the chisel and mallet.^ Exostoses of the antrum often have very small bases and are removed without difficulty on opening the front wall of the cavity. 3. Sarcomata comprise two groups, namely, the external and the internal, the former springing from the periosteum and the latter from the medulla. The periosteal growths embrace for the most part the hard forms, namely, the fibro, chondro, and osteoid sar- comata; they take their origin from the layer of the periosteum next to the bone, while the external layer often remains as a fibrous in- vestment which, by its unyielding character, retards the growth; the cortical portion of the bone is not at first involved, and if very thick, as in the diaphysis of long bones, it may become only super- ficially affected, but if the tumor appear where spongy bone is near the surface, as in the epiphyses of long bones, the growth spreads into the medullary spaces and it is difficult to distinsjuish periosteal from medullary sarcomata.* They are quite malignant ^ and usually con- tain all the varieties of sarcoma tissue, but the spindle cell-tissue predominates in most cases, especially in those enormous tumors which are developed on the ends of the great bones of the extremi- 1 T. Billroth. 2 e. Rindfieisch. 3 t. Holmes. ^ R. Virchow. THE DISEASES OF BONE. 105 ties.^ The meilullary form, myeloid tumor, ^ myelogenic osteo-par- comata,^ appear especially in the jaws, as ejmlis; * next in the tibia, radius, and ulna; these tumors often contain mucous cysts and spherical or branched osseous formations, circumscribetl nodules mostly forming in the medullary cavity, which gradually destroy the bone; but new bone is constantly developed from the periosteum, so that the tumor, if very large, often remains covered, eiitirelv or partially, by a shell of bone, which appears j)uffed uj) like a blad- der; in the lower extremity they beiome very vascular; small trau- matic ancurisn)s develop in them with the true aneurismal murmur; cysts also develop in them; they are usually solitary, rarely generally infectious; they appear in the jaws at the second dentition, and in the long bones at middle age." ^\^^en the growth is periosteal the fibrous tumor resembles it, but the sarcoma is softer, more elastic, and vascular; when within bone it is dillicult to distinguish sarcoma from other innocent tumors; it differs from cancer chieliy in that it is of slower growth, has a broadly rounded shape, and its seat is in the articular end rather than in tlie shaft of a bone; in the absence of glandular disease and of all cachexia, though three or four years may have elapsed.- Excision is the only available remedj-, and should be resorted to without delay, the base being thoroughly re- moved.2 4. Fibromata^ springing from the periosteum are quite frequent, and are generally conqiosed of fibres and spindle-shaped cells; the latter m.ay preponderate, giving the growth the character of a fibro- sarcoma ; the periosteiuu of the bones of the skull and face, especi- ally the inferior turlnnated bones, is particularly liable to this dis- ease ; in the latter position the tumors appear as naso-phaiyngeal polypi ; these tumors may form in the interior of bone, especially in the upper jaw ; they are most common in the young, but after puberty. They are hard, round, of slow growth, and without jiain. The treatment is removal by enucleation. 5. Carcinomata occurring in bone may originate by a propagation of the iiidltratioM from cutaneous, mucous, or glandular cancers; but cancer api)an'Mtly also appears originally in bone, thouLrh it may have an epithelial origin, as in case of those soft and (piickly grow- ing cancers which spring from the upper end of the humerus and femur, at one time from the medulla and at another from the periosteum.^ It may assume various forms, namely, encephaloid, which is most common, scirrhus, and e|»ithelial. The diagnosis'^ in obscure cases must be made in favor of cancer (1) when the tumor commences growth before puberty or after middle age, unless 1 E. Riiidfleisch. 2 Sir J. Paget. 3 r. Virchow. * E. Nelaton- 6 T. Billroth. 106 OPERATIVE SURGERY. it is a cartilaginous or bony tumor on a finger or toe, or near an ar- ticulation ; (2) when the tumor on or in a bone has doubled, or more than doubled, its size in six months, and is not inflamed; (3) if, in ad- dition to rapid growth, the veins over the tumor have much enlarged, or .the tumor has protruded far through ulcerated openings, bleeds, and discharges matters; (4) if, though the tumor is not inflamed, the neighboring lymph glands are also enlarged ; (5) if the patient has lost weio-ht and strength out of proportion to the damage to health by pain or fever or other accident of the tumor; (G) if situated on the shaft of any bone but a phalanx. The treatment of all forms of cancer of bone nmst be by amputation when the disease is local; the point selected must be as far as it may be safe to operate from the seat of the malignant growth.^ III. INFLAMMATION OF BONE. The morbid changes included under the term inflammation of bone are remarkable for their clinical diversity and singular ana- tomical uniformity; there is no deviation from the physiological type, except where pus forms, which introduces infinite complica- tions into the whole course of the inflammatory process, as repair can be brought about only by circuitous methods."^ 1. Periostitis, acute, occurs chiefly in young persons, and in its tvpical forms almost exclusively in the long bones, as the femur and tibia ; at first there is high fever, not unfrequently a chill, severe pain in the affected part; swelling without redness; skin tense and usually cedematous ; every touch or jar is very painful. The inflam- mation may resolve at this stage, or progress to suppuration, when additional svmptoms appear: the swelling now increases, the skin becomes reddish, then brownish red, the cedema extends, the neigh- boring joint becomes painful and swells, and towards the twelfth day fluctuation is detected.^ The inflammation often occurs in the periosteum of the third phalanx, felon, causing great suffering, and terminating in necrosis. In the early stage of the disease in the long bones apply the strong tinct. iodine, and repeat when the vesicles dry up;^ add ice, if, when applied until the deeper parts are cold, it is afrreeable and the pain subsides. When effusion takes place and is confined beneath the dense fibrous periosteal layer, free incision down to the bone gives immense relief; as the object is to relieve ten- sion, the incision should be made as soon as this condition clearly exists, though pus may not have formed ; this practice is especially important when the upper part of the shaft or the articular end of a bone is affected.* The local applications should now be soothing, as fomentations, and carbolized solutions should be freely used in 1 Sir J. Paget. 2 £. Rindfleisch. « T. Billroth. < T. Bryant. THE DISEASES OF BONE. 107 the wound to arrest septic changes. Pus should be freely evacuated wherever it may be found, and free drainage secured by position or drains. The general treatment should consist of anodynes, with laxatives and low diet, to relieve pain and inllammation; and tonics and nutritious food when suppuration is established. 2. Osteo-myelitis, acute, is an inllaunnation of the medulla of bones; it occurs in the young and is generally caused l)y injury ; the symptoms are, intense aching pain at the scat of inllaiuniation which is relii'ved only by perforation of the bone ; swelling, which begins as a pulHness but has a peculiarly aln-upt margin and as the disease spreads advances up the limb; red and hcpalized apjtcarance of the marrow, seen in the bone of a stump; globules of oil mixed with the pus discharged; irritative fever with great restlessness, and in bad cases delirium.^ The symptoms so closely resemble those of suppurative periostitis that in many cases it cannot be discovered whether only the jjeriosteum is affected or the medulla also; but if while there is great pain and fever, or complete inability to move the limb on account of pain, swelling does not occur for several days, it is to be inferred that the seat of the inllammation is the inedidlary cavity.'^ The inflammation may induce acute periosteal abscess, thrombosis, pvit^mia, necrosis, and the separation of the epiphysis l)y the suppuration of the epiphyseal cartilage. The indications of treatment are : removal to the open air; elevation of the part, but with depending opening for free discharge of pus; local applications of ice when agreeable to the patient; free use of disinfectants; ap- plication of the strong tincture of iodine; tonics, as quinine and iron. If antiphlogistic remedies fail and the pain increases to a violent degree, nuUce free incision and trephine the bone to relieve the ten- sion ;8 if the integrity of the bone is destroyed, resect, or amputate. Amputation in the continuity of the affected bone is injurious, but disarticulation of the bone at an early j)eriod, before pyjBmia occurs, has given good results.^ It is inaiiitained that extensive wounds are bad in feverish patient?, and pre- dispose to pyaemia, and that disarticulation is erroneous because, first, the tliag- nosis is not certain, second, the resuhs obtained are uncertain, and, tliird. the proi^nosis in exarticulation of large limbs, for acute disease of the bone, is always doubtful.- IV. CARIES OF BONE. Periof^titis and osteo-myelitis may terminate in circumscribed sup- puration, which results in ulceration or caries of bone. 1. Superficial caries corresponds to an indolent ulcer of the skin; the surface of bone exhibits a loss of substance which gradu- 1 J. A. Lidell. 2 T. Billroth. 8 l. Bauer. 108 OPERATIVE SURGERY. ally increases in depth, but remains shallow, and continually throws off small quantities of pus and shreds of decaying structures, de- rived from the denuded medullary tissue, which at a certain depth is in a state of hyperajuiic proliferation, passing near the surface into an exceedingly dense corpuscular infiltration; the cells occupy all the pores of the bone tissue and leave no room for blood or blood-vessels, which are finally converted, with the cells, into molec- ular debris.^ The symptoms are tenderness, oedema, severe boring and tearing pains at night."'^ The process of cure consists in the de- tachment and removal of the necrosed portions or particles of bone, cessation of the process of proliferation, shrinking together of the interstitial granulation tissue, and its transformation into cicatricial tissue.*^ The indications as to general treatment are the impi'ove- ment of the health by tonics and hygienic measures; the local treat- ment is: (1) Removal of the purulent debris; (2) arrest of the ca- rious process; (3) healing of the surface. If the caries affects the shaft of a long bone, easily accessible, as the tibia, expose the carious bone by a free incision, whether the pus is still contained in an ab- scess or is escaping from a sinus; cleanse the exposed surface of all foreign matters; very gently remove, with forceps or periosteal knife or gouge, every particle of dead bone, without injury to the living bone; apply the strong solution of carbolic acid, 1 in 20, to the surface of bone; complete the dressing by packing the wound with carbolized oil, 1 in 10; place the part in a condition of perfect rest, using plastic apparatus if necessary; renew these dressings only when required for cleanliness, and change the application to bals. Peru when granulations cover the bone. 2. Central caries usually begins in a hollow bone as an osteo- myelitis; the inflammation extends to the inner surface of the cor- tical substance, which is dissolved, and pus may form quite early in the centre of the new formation, creating what is known as a bone abscess; the periosteum is thickened, new bony deposits form from the surface of the bone, and the hollow bone is thus enlarged exter- nally at the point where the abscess forms, giving it the appearance of inflation; the central caries may be accompanied by partial necrosis of portions of bone on the internal surface of the cortical substance.* These bone abscesses more often form in the spongy portion of long bones, especially of the tibia. The sym])toms are very often uncer- tain, as the chronic inflammation may exist deep in the bone; there may be only a dull pain, with but slight impairment of function; it is only when there is severe pain on pressure and oedema of the skin, showing that the periosteum is involved, that the case becomes more apparent; but it may happen that the true state of the disease can 1 E. Rindfleisch. 2 T. Billroth. THE DISEASES OF DONE. 109 be determined only when perforation has taken place and the probe may be passed into the cavity.^ The most reliable symptoms, when present, are severe, lonji continued, and paroxysmal pain and local swelling:, often at a single point, wliere there is extreme tender- ness on pressure.'- The treatment is trci)biniMg; mark on the skin the precise spot where the tenderness and pain are located ; give an anaesthetic and make a crucial incision down to tlie bone, raise the periosteum to the re(lui^ite extent, and with the trephine open the cavity. 2 If no pus is found, puilcture the surrounding bone with a strong awl or drill, for the pus has been found just beside the track of the trephine.^ The abscess cavity should be cleansed and filled with pledgets of lint saturated with bals. Peru. A less severe operation is at times of equal value, namely, puncture with a drill, especially when the seat of the abscess is not well delhied.-* 3. Internal and external caries may be accompanied by necrosis and by suppuration or osteo- plastic periostitis in the same hollow bone; abscesses appear at different points; rotten bone and a seques- trum may, at the same time, be felt with a probe; at one point the surface is exposed, and at another the interior; the whole bone is thickened, as is the periosteum; thin pus escapes from the fistulous openings; the surface is thickly covered with porous osteophytes; necrosed portions lie here and there; the medullary cavity is j)artly filled with porous bony substance, and round holes are found con- taining necrosed bone.^ The proper treatment of a bone in this condition is usually extirpation or amputation, as recovery cannot be expected by any method of treatment.^ V. NECROSIS OF BONE. The complete arrest of nutrition in a certain portion of bone, which results in its death, is usually due to suppurative periostitis as a prox- imate cause, even in traumatic cases, though not an invariable con- sequence; the pus excites a sequestrating inflammation both in the periosteum and the bone; the former being converted into a pyogenic membrane, is separated from the bone, while a fungating ostitis, fed by the medulla, is set up in the bone, which shuts of? the organism by granulation tissue; the dead bone is called the secpiestrum, and the fungating ostitis which separates it, demarcation ; the detached periosteum develops a layer of new bone immediately under the pyogenic surface, forming a capsule, the involucrum, which incloses the se(juestra.^ 1. Partial necrosis of the diaphysis occurs when the outermost 1 T. Billroth. 2 C. Jacksou. « T. Holmes. * T. Bryant. 6 E. liindtleisch. 110 OPERATIVE SURGERY. layers of the compact substance of bone have been too long cut off from the circulation and nutrition to allow their vitality being re- stored from the medulla; the fungating ostitis does the work of a sequestrating inflammation, detaching the lamellae of dead bone and mingling them with the pus which fills the abscess cavity.^ The presence of dead tissue is recognized when it is exposed by its white appearance, with dark places if it is situated deeply. Only the probe introduced through sinuses can exactly determine its presence; in addition, there is increased thickness due to the new formation of bone. The treatment at fii'st should be limited to keeping the fistulae clean; chemical solution of the sequestrum is liable to affect injuri- ously the new-formed bone, and thus do harm; mechanical removal of the dead bone is the only proper method; but it is important not to attempt removal until the dead is completely separated from the living bone, for the dead bone can rarely be detached without re- moving a good deal of the healthy and of the newly-formed bone; nor is the involucrum firm enough before complete detachment.2 The complete separation of a superficial sequestrum is generally easily made out with a probe. 2. Total necrosis of the diaphysis results from suppuration of the periosteum and medulla: the pus from the periosteum perforates the soft tissues and escapes, but that from the medulla falls to detri- tus or putrefies within the bone; the process of detachment is effected by an interstitial proliferation of granulations in the edges of the living bone by which a slight amount of bone is consumed; the se- questrum now lies loose in a pus cavity; this detachment of thick hollow bones requires months and sometimes more than a year; meantime the periosteum has formed a shell of new bone which in time becomes very thick, and finally compact.^ The probe is the guide to determine whether the bone is loose, but, it is difficult to decide on the mobility of a large sequestrum, especially when the bone is curved, as the lower jaw; the duration of the process and the thickness of the bony case are important aids ; most sequestra are usually detached in eight or ten months, and in a year, even an entire diaphysis usually becomes detached, completely separated from its connections. ^ The treatment is, in general, the same as in partial necrosis ; but this distinction must be made, namely, if the formation of bone be still weak, though the sequestrum be already detached, it is Avell to postpone the extraction in case of the humerus, tibia, and femur, so that the formation of bone may be firmer ;2 it may be necessary occasionally to resect when no new bone exists.^ 1 E. Rindfleisch. 3 T. Billroth. 3 j. Holmes. THE OPERATIONS ON BONES. Ill CHAPTER XIV. GENERAL OPERATIONS ON THE BONES. I. SEQUESTROTOMY. The removal of necrosed bone may bo effected by successive slight operations by which the periosteum is gradually separated from the dead mass, the indirect method, or by a single formal operation, the direct nut hoi I. 1. The indirect method i is to be preferred when the bone is superficial and it is desirable to preserve its contour, ^ as in the removal of lar^e sections of the tibia, the lower and upper jaw, the clavicle. This method consists in separating from time to time the diseased periosteum from the bone beneath with the handle of the scalpel or with a small spatula, the periosteum not being raised beyond the limits of the disease. By this means free escape for pus is constantly maintained, the new-formed bone becomes more per- fectly adapted to the space occupied by the old, and the tissue of the new structure is more firm. When at length the sequestrum is sep- arated it is readily raised from its bed with scarcely the appearance of blood, and the shape and function of the bone is largely pre- served. 2. The direct method is often tedious, and much complicated by the oozing of blood into the wound; to avoid bleeding, the ves- sels of the limb should, as far as jjraeticable, be emptied of their blooil; as the elastic bandage, so effectual in removing blood from the limb, would be liable to force infectious matters into the meshes of the cellular tissues, and the extremities of lymphatic vessels, it is better to empty the limb as completely as possible by causing it to be raised high in the air for a few moments, and then apply the elastic bandage or tubing above the point of operation.^ The operation is as follows: ^ If the opening in the bony case is large, and the se(iuestriun small, attempt the direct removal with strong forceps through this openiu'i; if this is impracticable, with a stout knife make an inei>ion through the soft parts down to the bony case from one fistulous oj)ening to another; with a pcriosteotoiue draw the thickened soft parts from the rough surface of the bony case to just sufficient extent ; remove this exposed portion with a saw, or a chisel and hammer, or gnawing forceps; the sequestrum being ex- posed, attempt its removal by elevators or strong forceps; first move it gently in its case in different directions until free from all spiculie; 1 J. R. Wood. 2 Von I.aiigenbeck. 8 F. Esmakch. •» T. Billroth. 112 OPERATIVE SURGERY. if the sequestrum is not detached, avoid forcing it out, but wait a few weeks or montlis until its separation is complete. After the operation the suppurating cavity is to be kept clean, and the parts maintained in a state of rest; the ossifying granulations fill the cav- ity slowly, and the fistulje may remain open for a long period, but the process of closure cannot be hastened unless the walls become sclerosed and cease to granulate, when the application of the hot iron to the cavity, or the chisel to the fistulas, may be beneficial. II. RESECTION. Extirpation of bone in part or whole is frequently required, as after injuries which have destroyed their vitality, or after diseases which have resulted in necrosis, or in the removal of tumors. But such an operation is justifiable only when it is evident that resection is preferable to every other remedial measure.^ When the opera- tion is undertaken it must be so planned and executed as to become the first step in a process of repair by which a part is restored to more or less complete usefulness that would otherwise have been sacrificed. 2 1. The indications for resection must be determined by the con- dition of the patient and of the diseased part. In general the opera- tion is indicated only when the general health admits; for if the patient is suffering from a progressively wasting disease, as tubercu- losis or marasmus, which will necessarily prove fatal, resection would be unwise, as repair would not follow.^ In injuries, as gunshot, only such fragments of bone should be removed as are nearly or quite detached from the periosteum. In caries of hollow bone the ulcer may be thoroughly cleaned out with the gouge and the cavity be allowed to close by granulation,* but if the bone is small, extirpation may be necessary to arrest the process at once.^ If a hollow bone is affected throughout, as with periostitis, external and internal caries, partial internal and external necrosis, extirpation of the entire bone may be required, as the only alternative of amputation. * Tumors of bone,'' if not malignant, must, be removed from their lo- cality, but if malignant, extirpation of the bone or wide resection is necessary. 2. The time of operating after an injury, as a gunshot, should, if possible, be within twenty-four hours of the accident, or pri- mary; if it is delayed beyond this period it should not be performed until the intermediary stage of inflammation is passed.^ If the bone is necrosed the invariable rule should be not to attempt removal before complete detachment, because the dead bone can rarely be 1 F. C. Skey. 2 a. AVagaer. 3 T. Billroth. ■* C Sedillot. 5 Sir J. Paget 8 G. A. Otis. THE OPERATIONS ON BONES. 113 sawed out without removing healthy and newly-formed bone; and the new bone is not firm enough before the sequestrum is detaehed.^ 3. The instruments required in resection may be few or many, both in number and variety, according to the nature of the case. (1.) The knife (Figs. 75 and 76) should be broad and firmly set in a ^ Fig. Fig. 78.3 Fig. 79.'* routrh handle, which may or may not terminate in a periosteotome. (2.) The retractor may consist of broad metal plates properly curved (Figs. 77, 78), or take the form of hooks (Fig. 70); the latter are less liable to slip out of the wound, but do not so effectually open it. Fig. 81. 'i (3.) The periosteotome takes many forms (Figs. 80, 81); it is al- ways a blunt instrument and in its use care must be taken not to contuse the periosteum when it is desirable to preserve its function. 1 T. Billroth. 6 H. B. Sands. 2 G. Buck, c L. A. Sayre. 8 W. Parker. * G. C. Blackmail. lU OPERATIVE SURGERY. (4.) The bone-cutting instruments are numerous and important. The straight bone forceps ^ (Fig. 82) is a most useful instrument Fig. 82. Fig. 83. Fig. 84. Fig. 85. Fig. 86. in the section of the small bones, wherever it can be brought to bear. But frequently it is quite difHcult to reach the part, which may be more readily divided with the forceps than the saw, unless the blades are curved at a considerable angle; in such cases a for- ceps curved (Fig. 83, or Fig. 84) will be found serviceable. The bone gnawing forceps (Figs. 85, 8fi), or rongeur, is indispensable in many resections, as it enables the operator to remove projecting parts not accessible to other instruments. The saw in one of its various forms is neces- sary. The chain saw (Fig. 87) consists of a number of pieces, with movable articula- tions, terminated at each extremity by han- dles with which it is woi'ked. To use this saw one handle is removed from hook, B, and a needle, c, armed with a strong thread, is C attached to this end; the needle is passed under the bone, and the saw drawn into its position, with the cutting edge upwards, and the handle is then reat- tached; the operator, grasping the handles, draws the saw alternately from side to side, until the bone is divided; there is great danger of breaking this saw if it is worked carelessly; it should be drawn from side to side steadily, at an angle of 45^ to the long axis of the bone. The sections mav consist of metallic beads strimg on a wire with handles; such a saw will act efficiently in whatever direction it is beld.i Other saws, of peculiar shape, are often useful in the removal of certain bones, though not absolutely essential; the saw (Fig. 88) with a movable back, 1 R. Listen. 2 TiEMANN & Co. THE OPERATIOXS OX BOXES. 115 may be used to advantajre in most resections of bones of the ex- tremities; in the removal of the superior maxilla, the right and left bone saws (Figs. 8Jt. 90) enable the operator to separate its superior attachments with great facility; a small straight saw (Fig. 91) is often required and when it is necessary to use a part of the edge, an India- rubber tube may be drawn over the part unused to prevent its in- juring the soft parts; occasionally a saw having a circular as well as a straight edge^ (Fig- 9-) is required in removing sharp points, or thin ^Q^SSC Fig. 91. Fig. 92. bones; finally, a saw^ is essential, whicli may be taken from its posi- tion (Fig. 93) where it is firmly held by a spring, connected with the (T ^ NH Fig. 93. handle, and passed under the bone, if required, and the ends, being reattached in the frame, the bone is as readily divided from beneath 1 R. Hey. R. Butcher; S^inanowsky. 116 OPERATIVE SURGERY. as from above; the saw may be turned laterally also, or be made to cut in a curve; the tension of the saw is regulated by a spring in- closed in the handle. The gouges, the chisel (Fig. 94), and the mallet (Fig. 95), are often required; to thoroughly clean out all Fig. 95. Fig. 94.1 forms of carious cavities, two or more gouges are necessary with different cutting edges ; the mallet may be of wood or metal with a firm handle. (5.) The seizing forceps may be the common dressing forceps (Fig. 96) for small fragments, and larger forceps for large Fig. 96. Fig. 97.2 Fig. 99. fragments (Fig. 97); they should also have straight and curved beaks (Figs. 98, 99) to seize fragments that are concealed. Other instru- ments may be used, as the conical screw, the terefond. 4. The operation is as follows: The anaesthetic having been ad- ministered, the elastic bandage should be applied unless there is in- 1 J. T. Darbv. 2 Sir W. Fergusson. THE OPERATIONS ON BONES. 117 filtration of the; oclliilar tissue witli Hiiids, in which case it should be omitted. 1 Tlie method of operating must be adapted to each partic- ular ease. In shot fractures the extirpation of fragments must be through openings extending from the wound; in necrosis the sinuses are guides for incisions; in tlie removal of the bone for morbid growths, the incisions must be largely in the direction of the tumor. The incision in general should be made as nearly as possible over the bone to be removed, and distant from important blood-vessels and nerves; the soft parts should not be destroyed, except so far as they have undergone degeneration, or interfere with the proper closure of the wound ; injuries to blood-vessels and nerves lvinwellinjj;, make a short lateral incision at eacli extremity of tlie longitudinal cut.^ The incision may also be made between the tendons of the long and short extensors on the doi-sum along the radial border. 3 In resection of the fifth metacarpal the cut may be a T or L- (/>.) The shaft is removed by a lon- gitudinal incision on the radial border of the first and second, on the ulnar border of the fifth, and the dorsal sur- face of the third and fourth; carefully avoid the extensor tendons, and with a chain saw divide at two points the denuded bones. (c.) The proximal portion of the bone is resected by a longitudinal incision over the upper extremity of the metacarpal bone; avoid the extensor tendon, separate the soft i)arts from the sides of the bone; divide the bone at the requisite point with bone for- ceps, or with the saw, after being isolated from the soft parts, and as far as possible from the perios- teum ; seize the fragment with the forceps ; raise it from its bed (Fig. 101), and disarticulate the joint with the point of the knife. ('/.) In complete resection the e.xtrendty of the metacarpal bone is removed and its corrcsjjonding carpal bone, by a single longitu- dinal incision made in the direc- tion of the superior extremity of Fir.. 101. the metacarpal bone, which is denuded of soft parts, and sawn 1 E. Chassaiguac. 2 C. Sedillot. 3 a. Gu^rin. 120 OPERATIVE SURGERY. at the proper point; remove this part at its articulation, and then extirpate the carpal bone. (e.) The phalangeal extremity of the metacarpal bone of the thumb is removed thus: Make an incision on its dorsal surface; draw aside the extensor tendons carefully ; divide -with a chain saw at the required point; seize the diseased portion with the forceps (Fig. 102), bring it forward, expose the articular extremity to the point of the 'knife, by which it is readily disarticu- lated. Or, make an oblique incision, commencing half an inch beyond the point at which you wish to apply the saw, from the middle of the dorsal surface of the metacarpal bone to the conimissure of the linger, then another from the same point to the next commissure on the other side ; thus circumscribing a V-shaped flap, with its base next the linger; turn aside the extensor tendon, detacli the iiiterossi from the sides of the bone, and open the joint, cut- ting its anterior and lateral ligaments carefully, not to wound the flexor tendons; then dislocate the phalanx backwards. Fig 102 '" total resection the incision should be dor- sal, except^ for the first, second, and fifth meta- carpo-phalangeal articulations ; in opening these the incision should be lateral, as the operator will thus avoid exposing the extensor tendons; the two articular surfaces being exposed, the ligaments ai'e incised, and the bone eilhei' sawn with the chain saw, or divided with the bone forceps (Fig. 103). Or, make two incisions, begiiniing at the middle of the dorsal face of the metacarpal bone, diverging on either side to the commissure of the finger, and forming a V-shaped flap, with its base towards the fin- ger. 3. The radius may be resected for necrosis with excellent results, the mortality being small, and the usefulness of the hand and wrist being well preserved.*^ In shot injuries operative in- terference increases the mortality.^ In the after treatment secure rest by a wire, tin, or sole-leather s])lint apjilied to the inner surface of the arm and forearm, and use carbolized oil dressings. («.) The lower extremity is broad, of a quadrilateral form, having two articular surfaces, one concave, on the lower part, for articula- tion with the scaphoid and semilunar bones ; the other on the inner 1 E. Cliassait:nac. ^ j. M. Carnochau. ^ G. A. Otis. THE OPE RATI OXS OX BOXES. 121 Fig. 104. side, narrow and concave, to articulate with the lower end of the ulna. The anterior and posterior ligaments are atlaclied to the margin of the joint, the lateral li^'unu'iit to the stvioid process; the posterior surface has grooves for the passage of the tendons of extensor muscles; the outer surface of the styloid process has grooves for tendons, and its base gives attaciimeiit to the supinator iongus muscle; the pronator quadratus muscle occupies the lower fourth of the anterior surface. Resect as follows : make a loiijritudinal incision aloir^ the radius on its external anterior border (Y\>^. 1U4), extending downwards to a point opposite, and a little behind, the styloid process (h) ; if neces- sary, add two terminal incisions at the extremities of the first one, extending transversely backwards, about three quarters of an inch; dissect so as to expose the bone on its different aspects; make sec- tion of bone by means of the chain saw; separate the diseaseil portion from the soft parts, and isolate the lower part of the radius from its attachments at the radio-carpal ar- ticulation, without injury to the artery («), nerves, or tendons. In many cases it will suffice to make a simple straight incision along the radial border, over the part parallel with its long axis. (6.) The shaft is resected thus: make a long strai;.dit incision on the external aspect of the bone, parallel with its shaft; separate the muscles, and, drawing the lips of the wound apart, denude the bone; pass the chain saw, divide the bone at the two j)oints selected, and raise the fragment from its bed. (f.) The head of the radius is quite superficial on its posterior part and surrounded by the orbicular liiraiuent, which retains it in the lesser sigmoid cavity of the ulna. Resect by making a strai'jht in- cision on the posterior and external part of the arm over the bone, divide the bone cautiously, and raise it from its articulation by cut- ting the ligaments with the point of the knife. ((/.) The entire radius may be excised; make an incision along the outer surface of the radius from the styloid process to the head of the bone at the elbow joint ; divide the fascia along the outer border of the supinator Iongus muscle, and separate the muscles along this line down to the bone; incise the periosteum the length of the wound, and separate it from the bone; divide the bone in the mid- dle and remove each extremity separately.^ 1 L. Oilier. 122 OPERATIVE SURGERY. 4. The ulna, like the radius, may be resected for necrosis with very favorable results, both in regard to mortality and usefulness of the limb; but for shot injuries the mortality is in the aggregate aug- mented by operative interference.^ The after treatment is the same as in rejections of the radius. (a.) The lower extremity articulates on its external surface with the radius, but is excluded from the wrist- joint; it has an anterioi* and posterior ligament uniting it to the radius, and a lateral lig;imeut connecting the styloid process to the carpus. Resection is as follows : the hand being carried outwards, make a longitudinal incision over the most superficial part of the extremity; dissect the periosteum from the bone to the re- quired height, and carry the chain saw under the bone (Fig. 105); having divided the bone, proceed to dissect it from its ar- ticular connections. Fig. 105. (b.) The shaft may be removed by a lon- gitudinal incision on its posterior part, parallel with the bone, and external to its border; sepai'ate the muscles, detach the periosteum, make a section of the bone at the two points selected, and remove the included portion. When a large portion of tlie bone is to be removed, make two or three sep- arate incisions instead of one and remove the bone in pieces. 2 If the skin is diseased or redundant, make two very long and slightly curved incisions, with their concavities facing each other, as in circumscribing an ellipse; then dissect in front and behind, as far as the radial border of the bone, and saw the bone. (c.) The upper extremity includes the olecranon which enters large- ly into the formation of the elbow-joint, but is subcutaneous. Resec- tion is as follows: 3 make a longitudinal incision, five inches in length, over the middle of the olecranon, extending three inches above and two below it, penetrating to the bone; divide the triceps tendon at its insertion towards either edge, care being taken to avoid cutting across the aponeurosis, which is continuous from the edges of the tendon over the muscles lying on the posterior part of the forearm, and inserted into the edges of the olecranon; dissect up these inser- tions of the fascia, as well as the origins of the muscles beneath it, from the bone to the extent of nearly two inches, which allows the olecranon to be exposed, when the edges of the incision may be drawn asunder over the condyles; broad, curved spatulas being used for this purjjose; with the amputating saw cut through one half the i G. A. Otis. 2 E. Chassaignac. 3 g. Buck. TTIE OPERATIONS ON BONES. 123 thickness of tlic bone; complete the section witli a fine saw, after which separate completely with a chisel and mallet.^ Ill some cases betler access is secured to the bone by a T; in others by a crucial incision. - (a.) The entire ulna may be removed by the following method: * rotate the limb inwards from the shoulder-joint, and carry the pro- nation of the forearm so far as to cause the palm of the hand to look directly outwards ; slightly flex the elbow-joint and elevate the hand; this twisted position places the ulna upon the posterior and outer as- pect of the forearm and renders it more easily accessible; the limb thus placed, the assistants maintaining the arm and forearm stead- ily, stand upon the right side of the patient, with a strong, straight, sharp- pointed bistoury make an incision along the posterior and inner aspect of the ulna, commencing at the lower part of its supe- rior third and extending downwards to a point over the extremity of the styloid process, dividing the tegumentary layer and fascia; pull back the tendon of the extensor carpi ulnaris and expose the bone; make a transverse incision, about an inch long, parting from the lower extremity of the first incision, across the back of the wrist; reflect the superficial tissues and detach the tendon of the extensor carpi ulnaris carefully from its groove on the lower part of the ulna; now carry the dissection along the anterior surface of the lower por- tion of the ulna, and detach the soft parts from the bone as far as the interosseous ligament, the ulnar artery and nerve being carefully avoided; detach the soft parts from the posterior surface of the ulna, avoiding injury to the extensor tendons; divide the bone at the lower part of the mitldle third, and separate the lower fragment from its articular connections; prolong the incision upwards, along the pos- terior surface of the ulna, terminating at the upper part of the olec- ranon, opposite its outer edge; to this join a terminal incision transversely across the back of the elbow-joint, as far as the inner margin of the ulna; now dissect the soft tissues from the bone, upon its posterior and anterior aspects, as far as the interosseous liga- ment, and as high up as the insertion of the brachialis internus muscle; pass a knife, curved flatwise, close upon its interoectiuii of the j)lialani:eal extremity of the metatarsal bones, make a straight incision on the dors^uin of the toe, over the part to be removed, avoiding the extensor temlons, divide the bone witli forceps or saw, and disarticulate; in operating upon the first and fifth, the incision may be upon the free lateral surface, and it may be straight, or curved.^ Resection of the extremity of the first metatarsal bone is made by an incision on the outside of the joint; denude the bone to the point at which it is to be cut, and saw it perpendicularly to its axis; then detach it from the soft parts, pro- ceeding from behind forwards and complete the resection by sepa- rating it from the phalanx. (6.) In resection of the shaft of meta- tarsal bones, the same incisions are practiced on this part of the metatarsal bones as at the exiremities; in removing the body of the first and fifth, a curved incision more completely exposes the bone (Fig. HI); the chain saw should be used to divide the shaft of the first metatarsal bone, (c.) The resection of the tarsal extremity of the metatarsal bones requires the same incisions as have been given for resections of the phalangeal extremities of the metatarsal bones. The chief obstacles in the disarticulation are the interosseous liga- ments which unite the metatarsal bones together. The incisicm should freely expose the articulation, and the bone being divided, it should be raised with the forceps, and disarticulation effected with the j)oint of the knife, (r/.) The y resection of entire first and fifth ^^'^ metatarsal bones requires a curved ^^ , ■'"/ ^ incision with its convexity down- ^^■— ^^^''^" /• ^•— •' wards a, />, c (Fig. Ill), and ex- ^^^^<^^^^<^^f;;^^^hy^ tending beyond the articulation; the \ ^''-^^j^ '"' bone being exposed, the middle of ^^ '^ the shaft should be divided with the ^■'*^- 1^^- saw, and the fragments separately disarticulateion; divide the Imne with the chain saw, raise the diseased |)art with tlu- forceps, and tffect the resection with the point of tlie knife. (<^/.) in resection of the entire (ibida make an incision parallel with the l)one its entire length, separate the soft parts with the periosteum, and divide the bone in the centre vvith the chain saw; now disarticu- late each fragment separately. (j. The tibia is siil)ji'Cted to resection more frccpiciitly than any other lon;^ hone, owing to its subcutaneous situation. The results are most favoral)le, as new bone is readily reproduced when the periosteum is well preserved. ^ The tiliia is l)omid to the fibula l)v tlie following ligaments: the anterior, a flat band of fibres; tlie posterior, soniewiiat triangular; the transverse, long and narrow, and below the posterior. The internal lateral ligament unites the lower border of the internal nialleolus to the astragalus, os calcis, and scaphoid. (a.) The lower extremity forms ihe upper and internal part of the ankle-joint ; it is closely invested with tendons, and upon its pos- tero-internal border the posterior tibial artery and nerve pass to the foot. Resection by the subperiosteal method of the entire diaphysis and lower epiphysis has resulted in reproduction of the bone removed and a useful limb.''^ Make a straight incision along the crest to the ankle-joint; saw the bone at the requisite height; raise the bone from its periosteal bed by carefully separating the periosteum ; dis- lodge the tendons from their grooves, divide the ligamentous struc- tures, and complete resection by detaching the bone from the articu- lation. (i.) The shaft of the tibia is subcutaneous on the anterior and inner part; exsection of this portion is a comparatively simple opera- tion ; on the posterior part it gives attachment to muscles, and along its external border is attached the interosseous ligament connecting it to the fibula. The operation will depend upon the extent of the disease, and the location of the sinuses if the disease is necrosis. The incision should be along the subcutaneous borders of the bone, and extend beyond the diseased portion; the periosteum should be thoi'- oughly separated from the shaft, and the bone divided with a chain saw at either extremity; the fragment is then easily separated. Or, make a long curved incision in the length of the bone, having its convex- ity backwards; dissect this flap up and turn it outwards; divide the bone at tlie proper points, and raise the fragment with forceps. As excision of the shaft of the tiliia is generally undertaken for necrosis, tlie gouge is found useful in separating dead bone, and the mallet maybe used freely; it is also frequently desiralile to use the trephine. (c.) The upper extremity of the tibia is broad, and presents upon 1 L. Oilier. 2 D. W. Cheevers. 136 OPERATIVE SURGERY. its upper surface two cup-sbaved cavities for articulation with the condyles of the femur. The ligaments which are attached to it are, anteriorly, the ligamentum pa- telhe, internally, the internal lateral, posteriorly, the posterior ligament, or the ligamentum posticum Winslovvii, and within, the anterior and posterior crucial ligaments. The operative process is entirely subordinated to the degree, actual situation, and form of the disease ; so that there may be occasion for the crucial, or the elliptical, or simple incision, and also for a va- riety of saws and bone-cutting instruments.^ When practicable, subperiosteal resection should always be performed. 7. The patella, though in immediate relation with the knee-joint, may be excised with good results. Make a crucial incision, the trans- verse branch being over the base of the bone, or a second transverse incision may be made near the ape.x; dissect the flaps off cautiously, and remove the bone or its fragments; the tendinous expansion sur- rounding the bone should be separated, and not divided, as far as possible. The antiseptic method should be strictly pursued. 7. The femur is the largest bone of the skeleton. Resections of different portions of the bone are very frequent and give satisfactory- results, especially when the periosteum is i^reserved, as new bone is reproduced.^ (a.) The lower extremity is rarely removed, except in exsections of the knee-joints. When it is necessary to operate for necrosis in this region, the sinuses are the safest guides to the dead bone. If, however, a formal operation is required, make a long straight or slightly curved incision on the external aspect of the knee, isolate the femur a little above the condyles, preserving the periosteum, and make section of the bone by the chain saw; the fragment is then made to protrude at the wound, seized with forceps, and disarticu- lated. (b.) The shaft of the femur gives attachment to muscles thi-ough- out nearly its entire extent, and to reach it without injury to the soft parts, the muscular septa must be followed, either along the antero- external region of the limb, or as indicated by the seat of the disease; the curved incision and the semilunar flap raised up from without inwards, and from behind forwards, m.ay sometimes be necessary to lay bare the bone to a sufficient extent. The limb must be well supported by the gypsum or other dressing during the after treatment. (c.) The trochanter major gives attachment to the gluteus niedius anil minimus, and by its fossa to the external rotators. In resection make a free crucial incision through the skin nnd tendon of the glu- teus maximus, and when the surface is sufficiently exposed, use the 1 A. Velpeau. 2 T. Holmes; J. Bell. THE OPERATIONS ON BONES. 137 gouge to ?coop away the affected parts; if the disease prove exten- sive, divide the attachments of the ghitei to the upper anil fore [t&ri of the process, and then remove the entire trochanter with saw and forcejjs. {d.) The upper extremity of the femur enters so largely into the exsections of the hip-joint that the methods of removal are essen- tially the same. BONES OF TIIK TRUNK. The bones of the trunk form the walls of cavities containing vital organs, and give support to the limbs; resections are, therefore, gen- erally partial, and must be performed with such care and by such methods as will not impair these functions. 1. The vertebrae have been subjected to frequent partial resec- tions. The removal of loose fragments after severe injuries, as from shot, are perfectly rational, and have resulted in a fair measure of success.^ Resections of the arches or trephining the spine, is one of the most diflicult'^ and fatal operations in surgery, and practically ■without benefit. Eighty-five per cent, of terminated cases have proved fatal, and there is no well authenticated case of complete re- covery.8 The conclusion is inevitable that without much more posi- tive favorable evidence, resection of the arch cannot be accepted as an established operation.^ If resection is attempted, proceed with the operation as follows : * make a long incision above tlie rid<;e of the spinous processes, tlie middle of which is opposite the displacement; divide all the attaciiments of the muscles to the ar- ticular processes; as one end of eacli muscular bundle is separated from its nttacimient, it retracts and needs little iioldiiig back; the saw or tlie nippers are generally sulHcient io divide tlie vertebral arch; in sawing or cutting out the arcli, grasp the spinous process, if it be not broken, with a pair of stout tooth forceps, which are to be preferred to the elevator for lifting the detached bone from its natural connections; a small crowned trephine may be used to cut through the vertebral arch, or IIe3''s saw. 2. The sacrum may bo partially resected for the relief of pressure upon nerves as follows: Make a crucial incision; remove the spinous process of the bone with forceps and Iley's saw; apply a trephine, and make an opening, through which introduce bone nippers, and re- move the bone.^ .3. The coccyx may be excised in whole or part for necrosis, fracture, and a painfid affection, coccydinia, thus: place the patient on the side, the thighs flexed, and the hips close to the edjje of the bed; the buttocks being separated, make an incision in the median line, extending from the extremity of the coccyx upwards to the 1 G. A. Otis. 2 p. F. Eve. » J. Ashurst, Jr. * J. F. South. 5 G. C. Blackmaa. 138 OPERATIVE SURGERY. requisite extent; remove the diseased bone either with the gouge, or the drill, or the bone may be divided with the cutting forceps. The forefinger in the rectum determines the progress and extent of the resection. 4. The ribs are closely invested on their internal surface by the pleura, and along the groove on the lower border runs the intercostal artery. The only admissible primary interference when the ribs are fractured by balls is the extraction of loose fragments, and the smoothing off of sharp- pointed ends.^ Resection for necrosis should be made by opening existing sinuses and carefully separating the thickened periosteum with the pleura. In the removal of mor- bid growths, portions of ribs may require resection; great care must be taken to separate the pleura with the periosteum without wound- ing the former. Proceed as follows : Place the patient upon the sound side, and expose the bone by an incision along the middle of the rib, or the incision may be curved downwards; divide the inter- costal muscles and disengage the intercostal artery from its groove in the inferior border of the bone; separate the pleura cautiously with the handle of the scalpel, or similar instrument, and pass a thin piece of pas-teboard or other substance behind; divide the bone with the chain saw. Section of the posterior part of the rib may be first made to avoid wounding the pleura; scrape carefully each border of the bone, and do not incline the point of the knife tow- ards the intercostal space. In removing the false ribs, support the free extremity while the rib is divided posteriorly. Or, make a curved incision having its convexity downwards, exposing the diseased bone, two ov tliree days before resection; after iiaving cut the flap pass two threads firmly united, by means of a curved needle along the internal face of the rib at the point where the bone is to be divided; replace these threads after twelve or twentv-four hours bj' a drainage tube; these tubes prepare the way for the passage of the chain saw; on the second or third day saw the bone and remove the fragment.'^ 5. The sternum has been frequently partially resected for shot injuries, and with very favorable results, the mortality being very slight.^ When subperiosteal resection has been made for necrosis, new bone has been reproduced.* The incision for resection may be crucial or vertical, according to extent of injury or disease, and the parts may be removed by the trephine, gouge, or forceps. BONKS OF THE FACE. In resection operations on the bones of the face it is important to avoid, as far as possible, incisions which will leave unsightly scars, and the removal of bones which destroy the symmetry of the fea- tures. When practicable, perform intra-buccal resections without 1 G. A. Otis. 2 E. Chassaignac. 3 Q. Heyfelder. * L. Oilier. THE OPKRATIOXS ON BOXES. 139 external ineiiiion; ^ make incisions along tlie natural folds of skin ami preserve the borders of the mouth from division ;2 in all cases that admit of ^ul)])* ri(jsteal resection, tliis method is to he preferred. 1. The inferior maxilla is very liable to injury and necrosis, and to be the seat of morbid growths. In comminuted fractures the frag- ments shoulil be preserved unless quite detachetl, as they have great vitality, and are important in the preservation of the contour of the jaw. For necrosis the resection should as far as possible be sub- periosteal and intra-buccal, and both objects may often l)e accom- plished by occasionally aiding the slow process of separation of the necrotic bone from its attachments to bone and periosteum with the elevator, or the handle of the scalpel, or a spatula.^ By de- grees the sequestrum is loosened, new bone forms around it from the periosteum, and eventually the dead bone may be lifted from its bed with perhaps slight incisions of the gum; by this method large portions of the jaw, and even the entire jaw, may be reproduced during the process of sequestration, and not only its contour but its funetion be preserved.^ This method is preferable to early resec- tion, which is liable to be followed by great contraction of the parts, even if the periosteum is preserved and new bone is produced. " In resection for tumors ample external incisions are often required, and large portions of the bone must be sacrificed. But small tu- mors, involving only the alveolus, may be removed with bone forceps without incision of the skin.'* A considerable portion of the central part of the jaw may be removed without incising the lip, if the mu- cous membrane is freely divided between it and the bone, and the lip is drawn well down.* (a.) When the entire central part is to be resected proceed as fol- lows : Pass a stout ligature through the tip of the tongue to hold it in position when the muscles are incised; an assistant standing behind the patient holds his head firmly, and compresses the two facial arteries at the points where they cross the lower jaw; standing in front, seize with the left hand one of the angles of the loAver lip, while an assistant holds the other angle from the bone, and the whole in a state of tension; divide the lip with a vertical incision through the median line down to the os hyoides; or, if practicable, make a single curveroc('ss, and prevent dislocation, cut oft" the tumor as liigh as possible with the bone forceps or saw, and then remove the remaining portion of the jaw only in case the disease Is malignant. i (f/.) The entire lower jaw is removed as follows: Pass a ligature through the anterior part of the tongue, and intrust to an assistant ; make an incision commencing opposite the left condyle downwards towards the angle of the jaw, ranging at about two lines in front of the posterior border of the ramus, thence along the base, to termi- nate at the median line a little ])ostcrior to the most prominent part of the l)order of the jaw. Dis.sect - upwards the tissues of the cheek, and reflect downwards, for a short distance, the lower edge of the incision; separate the tissues forming the floor of the mouth, situated upon the inner surface of the body of the bone, from their attach- ments from a point near the median line, as far back as the angle of the jaw; next divide the attachments of the buccinator ; secure by ligature the facial artery, the sub-mental and the sub-lingual; expose the external siu-face of one branch of the jaw, and of tlie temporo- maxillary articulation, by dissecting the masseter upwards as far as 1 C. Heath. 2 J. M. Carnochan. 142 OPERATIVE SURGERY. the zygomatic arcli; seize the ramus and pull the coronoid process downwards below the zygoma; divide the insertion of the ptery- goiileus internns, grazing the bone in doing so; carefully avoid the lingual nerve, here in close proximity; divide the dental artery and nerve; separate the tissues attached to the inner face of the bone, as high up as a point situated about a line below the sigmoid notch, between the condyle and the coronoid process; detach the tendon of the temporal muscle by means of blunt curved scissors, a probe- pointed bistoury keeping close to the bone; make use of the ramus, now movable, as a lever to aid in the disarticulation of the bone; to effect safely the disarticulation of the condyle, penetrate the joint by cutting the ligaments fi'om before backwards and from without in- wards; the articulation thus opens sufficiently to allow the condyle to be completely luxated; bliuit scissors may now be used to cut care- fully the internal part of the capsule, and the maxillary insertion of the external pterygoid muscle; by a slow movement of rotation of the ramus u])on its axis the cond\le is detached and the operation completed. To effect the removal of the other half, malce the same incision on the opposite side, so as to meet the first on the median line ; the dissection is similar. 2. The superior maxilla has the following important anatomical features : ^ — It is attaclied to other bones in but three principal points: first, by its as- cending process and articulations with the os unguis and ethmoid; second, by the orbital border of the malar, as far as the spheno-maxillary fissure; third, b\' the articulation of the two maxillary bones with each other and palate bone; there is a fourth point of contact behind with tiie pterygoid process and palate bone, whicii yields easily b}' simple depression of the maxillary bone into the interior of tlie mouth; in attacking these different points no large vessel is in- jured; the trunk of the internal maxillary artery maj' be easily avoided, or in any case tied after the removal of the bone; moreover, in case of imforeseen haemorrhage during the operation we have a resource in compression of the car- otid; only one important nerve trunk, the superior maxillary, need be divided. Resection of the bone is performed for the extirpation of malig- nant growths and to gain access to naso-pharyngeal tumors ; in the former case it is justifiable, only where the disease is limited to the upper jaw and its corresponding palate bone, owing to the certainty of recurrence if the disease extends beyond. ^ The methods of pro- cedure are numerous, and give great and desirable latitude ^ to the operator. ICarly operators cut boldly through the cheek, ^ 1 (Fig. 118), but, to avoid unsightly scars, the rule now obtains of making the incision in the course of natural folds of the skin, 2 (Fig. 118)^, and 2 5 and 4^ (Fig. 117). Subperiosteal resection may be made by 1 J. F. Malgaigne. 2 j. Bell. 8 Sir W. Fergusson. * Lizars. 6 E. Nelaton. 6 A. Guerin. THE OPERATIOXS ON BOXES. 143 these incisions, Ijut a more formal operation is made by dividiiur the cheek, 1 (Fig. 117).i Fig. 117. Fig. 118. Resect the superior maxilla below the floor of the orbit - (Fig. 119), bv the following operation : Make an incision slightly convex back- wards commencing at the ala of the nose, and terminating at the cor- responding conmiissure of the lip, following the naso-labial fold or fur- row, 4 (Fig. 117) ; dissect up the two flaps resulting from this incision until the nostril is exposed, and the malar process is completely denuded; with a small saw held in the right hand, a, saw through the malar process from above downwards, and a little from within outwards ; the soft palate hav- ing been detached from the posterior border of the i)alatine bone by a trans- verse incision made at the posterior border of the last great molar, and an incisor tooth having been extracted, divide the horizontal portion of the maxilla from before backwards with cutting forceps c, one branch being in the mouth, and the other in the nares; make a section of the bone from the ^'*^- ^'''• divided malar process to the nares by the forceps b ; seize the bone with strong forceps, and remove, fracturing the ptervsjoid process. The entire maxilla or portions may be resected as follows: ^ Ex- tract the incisor teeth of tliat side ; divide the upper lip in the median line to the nostril ; continue the incision around the ala and up the 1 L. OlUer. 2 a. Guerin. « Sir W. Ferirusson. 144 OPERATIVE SURGERY. side of the nose, towards the inner canthus of the eye, thence con- tinue it in a slight curve below the orbit, 2 (Fig. 117 i), or, to the malar bone, 2 (Fig. 118) ; reflect the skin from the bone, ami with a narrow saw passed into the nostril divide the alveolus and hard pal- ate ; incise the mucous membrane of the moulh as far back as the soft palate ; with a narrow saw passed into the nostril divide the alveolus and hard palate ; cut partially also the malar process of the maxillary bone, or, if necessary, the bone itself, and the nasal pro- cess of the superior maxilla, and complete the division of these bones with the forceps: grasp the bone with the lion forceps, and detach it forcibly from the pterygoid process and palate bone; when the bone is loose, raise the fascia of the orbital palate, separate the infra- orbital nerve, the soft palate, and any adhering tissues. The haem- orrhage must be suppressed by ligatures and the actual cautery, and the wound adjusted at the lips by hare lip-pins and in other parts by the wire suture. Resection may be necessary by an incision through the cheek 2; Make an in- cision with its convexity downward, 1 (Fig. 118) from the commissure of the lips to the temiioral fossa; dissect this large flap from below upwards, and turn it back upon tiie forehead; cut through with the forceps the external or- bital process at its juncture with the malar bone, the zygomatic arch, the os unguis, and the ascending nasal process of the upper jaw; divide the soft parts which connect the ala of the nose to the maxillary bone, and separate the max- illae in front with a chisel and mallet, or a small saw; detach the soft parts from the floor of the orbit, divide at once the superior maxillary nerve, and the con- nections of the bone with the ptervgoid process; conclude the operation by cut- ting through with the bistoury, or curved scissors, the velum of the palate, and the remaining soft parts which still adhere to and retain the bone. The chain saw may be used to divide the processes. Resection without external incision may be made as follows^: The head being thrown back in position, and the mouth kept open by the gag placed between the back teeth of the opposite side, place a sponge cut so as to completely fill up the passage to the throat, and hold it in position on the soft palate by a sponge-holder to prevent the blood passing into the throat during the first part of the opera- tion, the patient being allowed to breathe only through the nose ; make two internal incisions from behind, half an inch on each side of the fangs of the molars forward to the central incisor of the op- posite side ; denude the periosteum with the elevator by commen- cing externally at the central incisor, and passing backward to the internal pterygoid process, and upward to the malar bone; then in- ternally from the same point to and a little past the centre of .the palate ; the sponge now being of no further use, remove it; denude the tensor-palati muscle from its attachment to the posterior part of 1 E. Nelaton. 2 a. Velpeau, J. Syme, R. Listen. 3 D. H. Goodwillie. THE OPERATIONS ON BONES. 14.3 the lianl palate ; care being taken not to injure the posterior pala- tine vessels and (lescending palatiiu^ nerve that pass at this j)oint for- ward on to the hard [);datc through the posterior foramen and along H groove ; now extraet the lateral incisor of that side, and by its socket thongli a little to the ri'_dit of the centre of the hard palate, so as to save the vomer, make a section with a saw, dividing the superior maxillary bones; change this saw for one much shorter, the teeth of which have a different angle and the cheek falls into a U shank which allows the saw to play freely; make a section up between the tumor and the internal pterygoid process to the malar bone, then forward through the canine fossa, dividing also the inferior tubinated bone, to meet the other section at the ala nasi ; after the saw has entered the antrum in this last section, the handle shoidd be advanced more rajjidly than the point; this pre- vents tlie j)oint from piercing the vomer. By these two sections a tumor with adjacent bone may be removed clean. 3. The superior maxillae may be removed at a single operation liy an incision. .'3 (Fig. 1 1 7), along the centre of the nose and through the upper lip ; adilitional incisions may be made, if required, under the orbit laterally. Or, a four-cornered flap may be made by an in- cision on either side from the angles of the mouth to the external angles of the eye, 1 (Fig. 117). III. TKEPHINING. This operation is required for the removal of a circular piece of bone, as in opening into cavities in bone. The instrnmtnts neces- sary are the trephine and elevator (Fig. 1-20). The trephine, h, c, d, i- a cylindrical saw, witli a cross handK like a gimlet, a, and a centre-pin, the perforator, around which it re- volves until the saw has cut a groove sufficient to hold it ; the centre-pin is then retired. The handle is fast- ened to the shaft by a screw, with a button affixed to the end of the shaft; or the screw may be on one end ; when the handle is placed on the shaft this screw is tightened. Fig. 120. and its extrenuty reaches the shaft and fastens it firmly in its place; the advantaire of this arrangement is that the upper surface of the handle is smooth, and the palm of the hand is not bruised as it is by the handle of the old instrument. The conical trephine, c, has the peculiar advantage of dividing the osseous walls without any 10 146 OPERATIVE SURGERY. danijer of wounding the structures within. It is a truncated cone, with spiral peripheral teeth, and oblique crown teeth; when applied, the peripheral teeth act as wedges so long as counteracting pressure exists on the crown teeth; upon removal of that pressure of the Viony walls its tendency is to act on the priiu'iple of a screw; but owing to its conical form and the spiral direction of its peripheral teeth its action ceases. In the construction the trephine is made of different sizes to meet the various conditions in which it is used, as on the cranium, b, c, or for opening the antrum, d. Trephiniug is performed as follows: Make an incision down to the bone, having the form of a V, T, or -|-, or of a semicircle; the bone being scraped, take the handle of the trephine in the right hand, and fixing the perforator by its screw so that it protrudes slightly beyond the teeth, place the perforator in the centre of the bone to be removed; woi'k the instrument alternately backwards and for- wards, until the teeth liave cut a groove sufficiently deep to receive them; then loosen the perforator and fix it in the shaft, to avoid wounding the membranes; great care should be taken to maintain the instrument in a position perpendicular to the part operated upon, in order to avoid its penetrating more deeply on one side than the other, and thus suddenly and unawares wound the cerebral membranes. It is important to examine the depth of the groove frequently with a probe, to ascertain how nearly the instrument has completed the section of the bone; the teeth of the trephine may occasionally re- quire cleaning with a small brush or wet sponge. The disc of bone should be raised with the point of the elevator e, and the edges smoothed with the lenticular knife at its other end. IV. OSTEOPLASTY. The transplantation of bone consists in raising bone, covered with its periosteum, and placing it in a new position for the ])urpose of filling gaps created by disease or operations. The superior maxilla has been resected so far as to permit the removal of naso-pharyngeal polypi, and been replaced with perfect restoration of its integrity;^ portions of the hard palate have been cut away and placed in appo- sition with similar sections from the opposite in staphyloraphy ; ^ the chasm between the fragments of ununited bone has been success- fully filled by dividing the long axis, and turning it down so that it filled the space. The requisite to success is the preservation of the fibrous and periosteal attachments of the fragment removed to the bone from which it is separated. 1 Von Langenbeck. 2 gir "w_ Fergusson. INJURIES OF JOINTS. 147 CHAPTER XV. INJURIES OF JOINTS AND SPECIAL OPERATIONS. Joints are composed of the two ends of bones covered with car- tihige; of a sac frequently contahiing many appendages, pockets, and bulgings; of a synovial membrane, a fibrous capsule, and the strength- ening hganients.i It is owing to the intimate relations of these com- plicated structures that the injuries and diseases of joints are pe- culiarly serious. I. WOUNDS. On account of their exposed positions joints are specially liable to wounds of various forms and degrees of severity. 1. Contused •wounds may be so severe as to be followed bv ex- travasation of blood into the tissue around it, or even into its cavity. Examine first for a fracture, then apply apparatus to secure perfect rest, and the ice-bag to prevent inflammation; the gypsum dressing with a suitable fenestrum at the joint is the best apparatus for the injury of joints of the lower extremity. 2. A punctured wound is dangerous, owing to the tendency to suppurative inllammatiou and the retention of the pus. That the joint is involved is known by the escai)e of synovia. Pursue the fol- lowing treatment : Place the patient in belaeed raise the head firmly by the chin and occiput, and if reduction does not follow, add slight rotation in the direction of dislocation to disengage the process, or place the patient on the back and make extension in the same manner. 3. The sterno-clavicular joint may be dislocated by the displace- ment of the end of the clavicle forward, upwards, or backwards. Reduction is eft'ected by elevating the shoulder in pushing upward at the elbow, or by drawing the shoulders backward and upward with the knee pressing aixainst the spine between the scapula. Though frequently it is difficult to retain the davitle in position, the function of the arm is ranly impaired. For the first and second forms, the pad in the axilla, the sling for the elbow, and a pad upon the displaced bone, retained by adhesive straps, are most useful ; for the third form, rest on the back, or such appliance as will retain the shoulder upwards and outwards, are required. 4. The acromico-clavicular joint may be luxated by the upward or downward displacement of the end of the clavicle : reduction is ef- fected by drawing the shoulder outward and backward. The retain- ing apparatus for the upward luxation should be applied as follows:^ Place a compress over the articulation, and retain it by two strips of adhesive plaster, the ed'.'es being glued to the skin by collodion ; bandage the hand and forearm with a flannel roller ; npplv a loop of elastic bandage'^ five feet long and one inch and a half wide, passe1 tii'nt being soatcd, carry the arm ami forearm dirt'Ctly backwards, the scapula being ])resse(l forwards ;i extension of tlie forearm from the hand or wrist (h>wnwards ; '^ extension of the forearm from its middle bv an assistant, while the surgeon seizes upon the olecranon process with the fingers of one hand and placing the palm of the otlier against the front and upper part of the forearm pulls forcibly back- wanls.8 The second form may be reduced by forced flexion aided by pressure; the lateral displacements are restored by moderate extension combined with lateral pressure.* The head of the radius may be dis- placed separately forwards, outwards, and backwards, the first being far the most frecpient ; reduction is effected in all forms by extension aided by pressure upon the head of the radius made in the right direc- tion.'* In compound dislocations in healthy jjatients, reduce the bones and close the wound antiseptically, unless there is much comminu- tion, when excision of the bones involved should be performed; in general, a useful limb results from these excisions of the joint surfaces. 7. The wrist joint is luxated by displacement of the carpus for- wards or backwards; reduction is made by extension in a straight line with slii;lit rocking or lateral motions if necessary.* 8. The phalangeal joints may be dislocated and are generally easily reduced. The dis])lacement of the first phalanx of the thumb upon its metacarpal bone is an exception; the difficulty of reduction is due to the escape of the head of the metacarpal bone between the two tendons of the flexor brevis, where it is lodged as in a button- hole.^ Reduction is effected by first pressing the metacarpal bone firmly to the centre of the palm to relax the short flexor, then put- ting the displaced phalanx in a state of extreme extension to relax the tissues of the button-hole and to push up those which form its distal part over the projecting head of the metacarpal bone; this is done by dragging the hyper-extended thumb downwards or away from the wrist, and then acute flexion will restore it to its place.* If this method fail, with a very narrow bladed tenotome divide the insertions of the flexor tendon and repeat the manoeuvre. 9. The hip joint ^ is protected and strengthened by the ilio-fem- oral, or inverted Y ligament, which is inserted al)ove into the front and outside of the inferior spinous process of the ilium, and below into the anterior inter-trochanteric line ; it has two main branches, extend- ing, the outer to the trochanter major, and the inner to the trochan- ter minor; in regular dislocations this ligament is unbroken and controls largely the movements of the head of the fenun-. The several positions of the lu-ad of the bone with reference to the socket may be reduced to the following, namely, (1.) The dorsal, including 1 R. Listen, J. Miller. 2 F. C. Skey. » J. Pirre. •• F. H. Hamilton. 6 Fal)l)ri. *» T. Holmes. ' H. J. Bigelow. 152 OPERATIVE SURGERY. tliat on the tuberosity, the dorsal, the everted dorsal, the anterior oblique, and the supra-sjnnoiis. (2.) The thj-roid, including that on the perineum and on the thyroid foramen. (3.) The pubic, the pubic and sub-sj)iiious. Though the head of the bone may be jjriniaril}' luxated in various directions, yet the downward dislocation is by far the most common, as the capsule is thin and weak at this part, and flexion, by which the ligament is relaxed, with adduction or abduc- tion, is the habitual attitude of the thigh in action and self-defense. From this jjosition the head of the bone readily passes to the dorsal, or thyroid, or pubic regions; thus all regular dislocations may be sec- ondary. These several positions are sufficiently well recognized for reduction by the following sign, namely: the head of the femur al- ways faces the same way as the internal condyle. As a preliminary to reduction, etherize the patient to relaxation, and place him re- cumbent on the floor. The best general rule for reducing a recent dislocation is to get the head of the femur directly below the socket by flexing the thigh at about a right angle, and then to lift or jerk it forcibly up into its place. This rule applies to all dislocations except the ])ubic, and even to that when secondary from below the socket ; the reduction by the lifting method is usually instantaneous, and flexion is the basis of its success (Fig. 124). If after one or two trials it appears that the bone cannot be jerked into place, enlarge the rent in the capsule a little by moving the flexed thigh from one side to the other so as to sweep ^the head of the femur across below the socket; and again repeat the act of lifting. The following rules for reduction of the Fig. 124. femur from its several ])ositions, should be observed : (1-) In dorsal dislocations, flex and forcibly lift; if this effort fnil, flex and lift while abducting. If this fail it will be found that abduction has carried the head of tlie bone from the dorsum nearly or quite to the thyroid foramen, and that the capsular rent has been so enlarged that the first method may now prove successful. (2.) In thyroid dislocations, adduction of the flexed thigh reverses this movement and carries the head from the thyroid foramen to the dorsum, ami also enlarges the opening, making the first rule effective. (3.) The pubic dislocations may generally be brought down without difficulty from above the socket, after flexion, especially if they are secondary, and may then be reduced from that i)osition like the thy- roid. A fulcrum marie by rolling one or more sheets into a firm band, two or three inches in diameter, maj' aid the manipulator. Plkce the centre of the band in the groin, and while assistants raise the ends by pressure at tiie knees, the head INJURIES OF JOINTS. 153 is lifted into the socket. l Tlie same result is secured by requiriiifj; an assistant to lift the head of the bone by means of a stout sheet in the t(roin and o%-er his shoulders. 10. The patella may bo displaced outwards, inwards, or on its own axis ; rrdiiction is made by layiiijjj the patient on tlie floor, lifting the limb with the heel upon the shoulder so as to rela.\ completely the (piadriceps muscle, ami pushing the patella into position ; if this eiTort fails in the last form ile.\ the thi;^h and straighten the leg while pressure is made on the patella.^ 11. The knee joint is dislocated by displacement of the til)ia backwards, forwards, outwards, and inwards, but in general the lux- ation is incomplete. Reduction is generally effected without nuich difficulty. If backward, use forced and extreme flexion ; if forward, reverse the movement ; if lateral, make extension anlying these dressings the parts may be thor- ou'dily painted with tr. iodine. Opium and quinine should be given in such measure as will secure relief from the effects of pain and fever. If the disease subsides months may elapse before the inflam- mation entirely disap[)ears, and great care is necessary to avoid a renewal of the disease by cold or injury. If the disease continues to progress abscesses form, the joint becomes more swollen, the fever is high, and inter-current chills occur, emaciation follows, with sleep- lessness and prostration; in the joint there is a collection of thick yellow pus mixed with fibrinous flocculi, the synovial membrane is covered with dense purulent rinds under which it is very red and puffy, partly ulcerated; the cartilage is partly broken down into pulp, partly necrosed and peels off, the bone is very red or infiltrated. The limb being secureil in immovable apparatus, with ami)lefenestr8e, open the absces.-^es and the joint anti>epticaily, thorouuhly cleanse with carbolic solutions, secure free drainage, and give opium, qui- nine, and nourishing diet liberally. The patient may recover under this treatment with anchylosis, or metastatic abscess may form in the lungs, liver, or other organs, and death ensue from pyjemia. Occasionally the inflammation extends uncontrollably in and around the joint, the suppuration involving the thigh and leg, followed by great exhaustion, fever, and chills. Recovery is still possible, but openings must be made to evacuate the pus, and strengthen- ing remedies given.^ The antiseptic treatment is most service- able in such cases; every collection of pus must be evacuated; all septic matters removed and cavities cleansed with carbolic solutions, and antiseptic dressings applied.^ The question of exsection or amputation may arise in severe cases and must be determined by the special conditions of each case. 3. Chronic synovitis may result from the acute form, or it may be chronic from the start and remain so. The joint is much swollen, without heat or pain, and fluctuates all over; the fluid collects chiefly in tlie mucous bursas adjacent, especially at the knee, where the bursae under the tendons of the extensors at both sides of the patella and in the popliteal space are greatly distended, while the capsule is less distinctly marked than in acute synovitis; the patient can often walk 1 T. Billrotfi. 2 J. Lister. 156 ' OPERATIVE SURGERY. easily, but nuidi exercise is fatiguing and followed by increased effu- sion.^ The cure requires rest to the joint, and change in the syno- vial surfaces. Rest may generally be best secured by plastic dress- ing, both in the upper and lower extremity. To effect a change in the synovial membrane apply blisters or iodine; if it still remains filled with fluid, it may be tapped with a fine trocar, and the fluid withdrawn ; or, if the fluid return, to tapping add an injection of io- dine. The arrest of secretion in the latter case is due to the shrink- age of the serous membrane caused by the action of the iodine, with the new formation of endothelium.^ Tap the joint carefully with a fine trocar, and after the escape of the fluid, without admitting air, inject by means of a well-made syringe officinal tincture of iodine and distilled water, ecjual parts, or, if it is desired to be more cautious, take one of the former to two of the latter; be careful that no air enter the joint; allow the litjuid to remain from three to five minutes, according to the pain induced, then let it escape slowly, close the wound, and envelop tlie joint with wet bandages; the opera- tion is not free from danger and may terminate in purulent syno- vitis.^ II. CARIES. Two forms of destructive ulceration occur in the articular extrem- ities of bones, which'are liable to seriously compromise joints. 1. Simple caries ^ attacks tlie articular ends of bones as a sequel of inflammation of other tissues of the joint; it sets in as soon as the cartilafi^e which coats tlie articular surfaces is finally destroyed, and the bare bone is left projecting into the cavity of the joint; by me- chanical violence minute portions of bone tissue are successively de- tached with the debris which surrounds them; the ulcer is invariably superficial, sharply circumscribed, and relatively smooth; it is com- monly situated where the opposed surfaces are in contact with each other; though slow in its progress it causes extensive losses of sub- stance followed by marked shortening and distortion of the limb. The first symptoms may be slight heat, pain, and swelling, followed in a few weeks by gnawing pains and starting of the limb at night from spasms of the muscles, great pain on rubbing the joint surfaces together, contraction of the limb; finally pus forms and abscesses ap- pear with their attendant symptoms.^ The indications of treatment are, (1) tonics, as syr. ferri iodid, and cod liver oil; (2) complete relief of the carious bone from pressure and friction by extension, with apparatus adapted to the special joint involved. If the caries extends, exsection or amputation may be required. 2. Fungating caries, fungous or scrofulous inflammation of a joint 1 T. Billroth. 2 £. Rinddeiscli. DISEASES OF THE JOL\TS. 157 may orit;inate in the synovial nii'inhrane, or lh«TL' may be a cen- tral or more rarely a peripheral caries in the spon'jry epiphysis of a hollow bone or in one of the sponjiy bones of the wrist or ankle which niav perforate from within outward and excite synovitis; sometimes in the hip, knee, and ankle with the fungous ])roliferation of the synovial membrane, there is an independent proliferation under the cartilage and between it and the bone, wliich subsequently unites Avith that above, so that the cartilage lies partly movable between the two granular layers. ^ More commonly the disease connnences as a non-suppurative inflammation of the adjoining epipliyses of two bones where they unite to form a joint; the hypera'mie medulla grows towards the joint, the bony trabecula? melt away, the cortical portion becomes thin, the exuberant granulations protrude between the cartilage and bone; meantime, the synovial membrane and its connective tissue, the ligaments, and finally, all of the neighbor- ing connective tissue inflames; a diffuse congestion occurs in the deli- cate, overlapping fringe of the synovial membrane, from which a membrane of young connective tissue overspreads the cartilage from its edges; the superficial layer of cartilage cells now take part in the inflanmiation, cells multiply, the capsules open, the young connective tissue forces its way in ; finally, the ascending growth meets that which is advancing downwards, the two coalesce, and the cartilage is perforate<1.2 The disease may terminate in resolution, and the parts recover, or pus may form in the joint or in the tissues around it, creating abscesses with sinuses; or the connective tissue may en- lai'ge and degenerate into a firm, white, fibroid mass of colossal di- mensions, stretching the skin allaroun. be so adjusted that the patient sits lirnily and comfortably upon tlieni; when the apparatus is adjusted apply the key to the rachet and extend the splint until the patieat gives evidence that the strain is sufficient. 1 C. F. Taylor. Fig. 125.1 160 OPERATIVE SURGERY. Fig. 127. THE KNEE-JOINT. At the knee the disease causes at first but slight symptoms for months, as dragging of the leg or limping, pain after exercise, or on pressure; then there is swelling, the joint is evenly rounded, quite sensitive to pressure; gradually the joint becomes more and more an- gular and painful, so as to pre- vent walking; certain points be- come more painful and red with fever, fluctuation is detected, and soon after a thin pus, mixed „^ with fibrinous cheesy flocculi, I escapes; the symptoms at first improve, but soon another ab- scess forms with fever; these symptoms are repeated, attended by gradual emaciation, wasting and flexion of the limb; the dis- ease may teri|iinate fatally by extension, or recovery may fol- low with anchylosis of the affected joint. The knee- joint may be very firmly fixed, and still allow of exercise by the gypsum bandage applied from the middle of the leg to the middle F^g- 128. of the thigh. An eificient brace ^ may be made of steel band and (Fig. 127) piece connected by ex- tension rods, with rack and pinion (Fig. 12ions confined to the carpus, three retained valuable mobility of the hand, and five had anchylosis with much deformit}' ; from this record it seems probable that recovery unattended by an- chylosis is seldom to be anticipated, yet that this result is not disastrous provided the hand is in good position, and the functions of the fingers are in some degree preserved. But these imperfect extremities are far more useful, especially when supported by suitable apparatus, than stumps after amputation. ^ Excision for caries has hitherto been unsuccessful chiefly owing to the I'ecur- rence of the disease, and the impaired functions of the hand; but these results are largelv due to partial excisions, and hence the necessity of complete removal of the wrist when affected with caries. Even bones which appear sound in a carious joint seem apt to be affected in an insidious, incipient degree, and if left behind may lead to recurrence of the complaint. 2 The indications for excision are; for shot injuries, if there is com- minution of the bones of the carpus, or of the carpus and epiphy- ses of the bones of the fore-arm, especially if the missile is lodged, and cannot be removed otherwise; if subsequently infiltration cannot be controlled by incision and threatens to spread to the fore-arm ;3 in injuries, as compound dislocations, all displaceil and fractured bones which must eventually become detached should be at once re- moved ; in crushing injuries when vessels, nerves, and soft parts are not so much involved as to render amputation necessary ; in sec- ondary excisions for injuries to the carpus the entire wrist should be removed; in caries involving the carpus extensively, and which has resisted other treatment, excision becomes necessary. Excision of the entire wrist consists of a series of operations each of which must be executed with scrupulous care, as follows:- Break down adhesions of tendons by freely moving all the articulations of the hand ; commence the first incision at the middle of the dorsal as- pect of the radius, 2 (Fig. 140), on a level with the styloid process ; carry it towards the inner side of the metacarpo-phalangeal articula- tion of the thumb, running parallel in this course to the extensor secundi internodii ; on reaching the line of the radial border of the second metacarpal bone, carry it downwards longitudinally half the length of the bone, the radial artery lying farther to the outer side of the liinb; detach the soft parts from the bone at the radial side of the incision, the knife being guided by the thumb nail; divide the tendon of the extensor carpi radialis longior at its insertion into the base of the second metacarpal bone, and raise it along with that of the extensor carpi radialis brevior previously cut across, and the ex- 1 E. D. Hudson. 2 j. Lister. 3 Von Langenbeck. OPERATIONS OX THE JOINTS. 171 tensor secundi internodii while the radial i.< thrust somewhat out- wards ; separate the trapezium from the rest of tl»e carpus by cutting forceps applied in the line with the longitudinal part of the incision; leaving the trapezium in po- sition until the rest of the carpus is taken away, dissect the soft parts on the ulnar side of the incision from the carj)us as far as convenient, the hand being bent back to relax the extensor tendons of the fi niters; commence the second incision, 3 (Fig. 140), at least two inches above the end of the ulna, immediately anterior to the bone, and carry it downwards between the bone and flexor carpi ul- naris, and on in a straight line as far as the middle of the fifth metacarpal bone on its palmar aspect ; raise the dorsal lip, cut the extensor carpi nlnaris at its insertion into the fifth metacarpal Fig. 140. bone, and dissect it from its groove in the ulna wiihout isolating it from ;he integuments ; separate the extensors of the fingers from the carpus, and divide the dorsal and internal lateral ligaments of the wrist-joint ; leave the connections of the tendons with the radius undisturbed; now clear the anterior surface of the ulna by cutting towards the bone, avoiding the artery and nerve; open the articulation of the pisiform bone, and separate the flexor tendons from the carpus, the hand being depressed to relax them ; clip through the base of the process of the unciform bone with pliers, but avoid carrying the knife farther down the hand than the bases of the metacarpal bones; divide the anterior ligament of the wrist-joint, separate the carpus from the n\et;>carpus with cutting pliers, and extract the carpus with sequestrum force[)s through the ulnar incision, dividing any ligament- ous attachments; the articular ends of the radius and ulna may be protruded at the ulnar incision and excised; divide the ulna obliquely with a small saw so as to take away the cartilage-covered roundeil part over which the radius sweeps while the base of the styloid pro- cess is retained ; clear the radius sufficiently to remove the articular surface; if the caries is sli;iht remove a thin slice without disturbing 172 OPERATIVE SURGERY. the tendons in their grooves on the back of the bone ; clip away the articular facet of the ulna with bone forceps applied 'longitudinally; if the caries is extensive remove freely all the diseased bone with pliers and gouge ; examine the metacarpal bones and excise the artic- ular SLU-faces only if they are sound, and more extensively if diseased; next seize the trapezium with strong forceps, and dis. per cent, useful limbs; for injuries, 12. .5 percent, had perfect results, and 02.5 usefid limbs; for shot injuries, 2.7 per cent, had perfect results, and 22.2 per cent, useful limbs.'- The amount of motion is generally very satisfactory, but is not greater than that after recovery with anchylosis; the arm cannot be elevated beyond the horizontal line, and in many cases hangs down without any power in the deltoid; but the movements of flexion, exten- sion, anions along the extensor tendons, which must be preserved and drawn aside; the treatment is extension and passive flexion. The metatarso-phalangeal joint of the great toe may be removed by a lateral >oini-liiiiar imision over the j(jint. 3. The metacarpo-tarsal joints have been exsected with good results thus, 3 make a semilunar incision on the dorsum of the foot and dissect the flap upwards ; expose the first row of tarsal bones and exsect their surfaces with a saw; now expose the articular surfaces of the metacarpal bones and excise them. 4. The tarsal joints generally become carious in connection with such extensive caries of the tarsal bones as necessitates the extirpa- tion of entire bones. Single joints may, however, be excised when the disease is limited, as the astragalo-scaphoid, the calcaneo-sca- [•boid, the calcaneo-astragaloid. The incision should be made over the affected joint and curved, and the artiiular surfaces should be removed with a fine saw or gouge. .5. The ankle joint is a hinge joint; the inferior extremities of the iil)ia and lihuia united form a kind of arch which embraces trans- versely the superior articular surface of the astragalus so as to render lateral moven)ents impossible when the ligaments are tense.* The mortality 5 in the total excisions at the ankle-joint is 12.9 per cent., and for each class as follows: for disease, 8.5 per cent.; for injuries, 12.5 per cent. ; for shot injuries, 12. G jiercent. ; between the ages of land 15 there were no deaths; the mortality was greatest in the following order of age periods, 20-25, 15-20, 2.')-20, :iO-tO, 50-60, ami greatest from 40-50 years. In excision for disease *the largest number of deaths are found at the period 30-40, and in excision for injuries the least number; the cause of deatli attributable to the operation is 1 Von Langenbeck. 2 Fig. gg. 3 T. Holmes. * Quain's Anatomy. 5 H. Culbertson. 180 OPERATIVE SURGERY. 9.7 per cent., and to the disease or injury, or other diseases, 58.8 per cent.; the mortality increased in proportion to tlie extent of bone excised as fol- lows : excision of the tibia gave 4.7 per cent. ; of the fibula 8.6 per cent. ; of the astragalus, 13 per cent.; of the tibia and fibida 18.4 per cent.; of tiie tibia, fibula, and astragalus, 24.4 per cent. ; no deaths occurred when excision for disease and injuries was not practiced until after eight months from the attack, from which it is inferred that other joints gradiiall}' became involved, rendering the operation more and more dangerous by delay. The usefulness of the limb was recorded as follows: in excision for disease, 5 5 per cent, were perfect, 60.1 per cent, useful, and in 12 per cent, the extremities were amputated; for injuries, 6 per cent, were perfect, and 59.3 per cent, were useful, for shot injuries 6 per cent, were perfect, 42 per cent useful, and 6 per cent, were amputated, from which it is concluded that a large proportion of these excisions result in more or less usefulness of the limbs. The indications for tlie operation are as follows : (o.) In compound fractures and dislocations of the ankle-joint, with large, lacerated ■wounds, and protrusion of the bones, immediate excision greatly in- creases the chances of saving life and limb;^ (bJ) in neglected com- pound fractures at the joint, originally produced by severe destruc- tion, combined with extensive laceration of the ligaments, attended with suppuration, formation of fistulae, partial dislocation, excision is the only remedy to produce rapid healing, and to gain a useful limb;^ (c.) in acute suppuration, due to osteo-myelitis, with abun- dant fetid discharge, and destruction of ligaments; (f/.) in cases which have recovered with so much deformity that the foot cannot be made useful with mechanical appliances ; ^ (e.) in chronic caries limited to the articulation of the tibia, fibula, and astragalus. ^ The indications against the operations are: («.) marked constitutional cachexia; 3 (i.) chronic caries of the ankle-joint, especially in chil- dren, which is curable by drainage, removal of carious portions of bone with the gouge, and immobile a])paratus,* and in persons ad- vanced in years, in whom amputation at the ankle-joint is more speedy and safe;^ (e.) extension of the caries to the ankle-joints and bones, or upward along the shaft of the tibia.^ The operation which best preserves vessels, nerves, and tendons, as well as the periosteum, is by two longitudinal incisions, one over the external and the other over the internal malleolus, and extended above and below sufficiently to give free access to all of the diseased bone.^ All transverse incisions involving the vessels, nerves, and tendons should be avoided.^ Excise as follows i^ The limb being turned on the inner side upon a firm pillow, make an incision two or three inches long on the middle of the fibula (hnvn to tlie point of the malleolus, and sufficiently deep- to divide the periosteum; from the extremity of the malleolus con- 1 R. Volkman. 2 l. Oilier. 3 T. Holmes. ■* L. A. Sayre. 5 Von Langenbeck. 6 H. Hancock. OPERATIONS ON THE JOINTS. 181 tiniie the iixii^ioii ahoiit a third of an incli, but inercly through the skin, so as not to injure the tendons, but to permit of their being raised from behind the malleohis; at the point where tlie l>one is to be divided, separate the periosteum with the raspatoriuin, and turn down as much as eircumstanees will permit ; introduce the point of the index finger, or a spatula, into the interosseous space to jjroteet the soft parts during the act of sawing; incline the saw slightly to- wards the joint, so that the part to be removed will be external at the point of division; seizing the upper extremity of the fragment witli very strong forceps, separate its connections with the raspa- torium and knife when necessary; now turn the foot upon the ex- ternal surface, and make the same incision as ujjon the fibula; the periosteum is more easily separated than from the libida; saw the tibia in place with a nne-l)laded saw, when the parts are unyielding from chronic inflammatory infiltration ; in recent injuries, and acute sui)puralions, it may be j)ossible, after the periosteum has been sepa- rated and the liiiaments incised, to gradually dislocate the foot out- wards with the aid of the knife, and remove the tibia with the saw.^ To gain more complete access in many cases, the incisions made along the centre of the malleoli may be extended laterally along the margins of the extremities of these bones, 3 (Fig. 148). Or, the Fig. 147. Fig. 148. same result may be attained by extending the incisions m.ade along the posterior margins of the tibia and fibula, around tlie lower and anterior margins of the malleoli, 3 (Fig. 117). Remove the carious parts of the astragalus with a gouge in chronic disease; resect only traumatic cases. Modilieations of the loiipitiidinal incisions are as follows : Continue the ex- ternal incision from tlie point of the nialluolus downwards and forwards to within lialf an incli of the base of tlie outer metatarsal bone, making a tiap: re- flect this flap forward, expose and divide tlie flbiila, and dissect out the frag- ment; now reverse llie foot, and continue in like maimer the internal longitu- dinal incision from the point of the nnilleoius to tlie projection of tlie inner cuneiform bone; reflect the flap, divide the internal lateral ligament close to the bone, and by twisting the foot outward the tibia and astragalus will appear at the wound; introduce a narrow-bladed saw between the tendons through to the external wound; saw off the end of the tibia and top of the astragalus. ^ 1 11. Volkman. - II. Hancock. 182 OPERATIVE SURGERY. Fig. 149. Fig. 150. A convenient method of suspending the Hmb is as follows:^ Make a splint of wood or metal fitted to the anterior surface of the leg and ankle (Fig. 149), with rings in- serted at three points for suspension: in its application, the splint is well padded and laid on the front part of the leg and the hmb fixed by the ordinary bandage, the ankle being free (Fig. 150); or the gypsum bandage may be applied over the splint and around the leg, a layer of old flannel being first adapted to the leg, and the ankle left ex- posed. 6. The knee-joint may be regarded as consisting of three articulations conjoined; namely, that between the patella and femur, and two others, one between each condyle of the femur and the tibia; the ligamentura mucosuin is an indication of the original distinctness of the synovial membranes of the inner and outer joint; the crucial ligaments may be regarded as the external and internal lateral ligaments of those two joints respectively; each portion of the articular surface of the femur belongs either to one or other of the three component joints of the knee, and no part is common to any two of them.^ The knee is a hinge-joint, having free motion in but two directions; it is sup- ported principally by the lateral, the internal, and the posterior lig- aments, and in front by the patella, and its ligamentous attachments; it has also a capsular ligament; the articular face of the tibia has a semilunar fibro-cartiiage, which deepens the articular surface for the condyles of the femur. The mortality 3 following excision is, for disease, in 603 cases, 29.8 per cent.; for injuries, in 28 cases, 39.2 per cent., and for shot injurie.«, in 01 cases, 75 per cent. The modifying conditions are as follows: the age most favorable for excis- ion is for disease and injuries, 5-10; for shot injuries, 15-20; the period of the disease most favorahle, is 3-6 months, and the most unfavorable 15-18 months, for shot and other injuries, secondary operations are most favorable; traumatic influences greatly increase the mortality in excisions for disease; complete ex- cisions for disease give a higher per cent, of mortality (29) than partial (25), but for shot injuries it is the same (75); in general the mortalitv increases in propor- tion as less than 2| inches are removed; from2| to 4 inches the mortalityis least; above 4 inches it reaches its highest rate; removal of the patella increases the mortality from 2.34 percent., not removed, to 27.3 per cent.; in excision for disease the greatest per cent, died from the operation (37), a less per cent, from 1 R. Volkmau. 2 Quain's Anatomy. 3 H. Culbertson. OPERATIONS ON THE JOINTS. 183 other diseases (28.0), and the least per cent, from tlie orif;inal disease (20.2); in excision for siiot injuries an etjual number die from tiie injury and the operation ; in excision for shot injuries tiie mortality is mainly attril)utal)le to the character of the injuries sustained, 42.2 percent., and to the supervention of other diseases, 15.5 per cent., the deaths traceable to the operation being l)ut 4.4 per cent. It is noticeable that exsectioiis at the knee-joint for disease are becoming more and more succes.^ful; for example, before 18.50 the mortality was o'.iAH jier cent.; 1850-60 it was 30.73 per cent.; 1800-70 it was 21.0; 1870-4, 10.9 per cent. The usefulness of the limb is thus recorded: In excisions for disease in 420 cases, 14.3 per cent, were perfect, 42.4 per cent, were useful, 4.0 per cent, not useful, and 17.8 were amputated; for injuries, in 17 cases, 17.6 percent, were perfect, 04.7 per cent, were useful, and 11 7 per cent, were amputated; for shot injuries, in 17 cases, 58.8 per cent, were useful, and 23.5 per cent, amputated; in 46 cases of e.xcision for deformity, 19.5 per cent, had perfect, and 07.8 per cent, had useful limbs; the amount of bone lemoved varied from | an inch to over 4 inches, but the usefulness did not depend upon the extent removed; the removal of the patella secures a greater degree of usefulness than its re- tention ill the proportion of 76.9 per cent, of the former to 31.4 per cent, of the latter. From these facts it would appear that this e.xcision gives a large percentage of useful liLubs; but those who believe that the value of the limb depends upon a permanently firm, unyielding, osseous union of the femur and tibia, will conclude that the recorded results must be taken with some allowance, for too often the union proves to be librous and has been followed by amputation, ^ or the limb bends under constant use, or bows outward or inwards, or disease recurs.- 15ut great progress has recently been made in perfecting excision at this joint, and limited motion is no longer regarded as impairing its function. 3 The results that have followed the efforts that have been made to preserve the natural relations of the librous structures and muscles,'* give gratifying j)roofs that the knee-joint will be no exception to the rule that excision should, as far as practicable, restore the functions of joints. Present experience indicates that excision should b.- had recourse to only in those cases where the disease begins to endanger life, where hectic fever has set in, the patient loses flesh, the existence of an intra-articular suppuration luaiiifests itself, and a long-con- tinued rational treatment has failed;^ the number of fistulaj or ab- scesses in the neighborhood of the joint is of little importance in deciding the question, as they may exist without grave implication of the joint itself, and atonic caries may exist with cheesy-like matter, in the joint, and destruction of ligaments, with little dis- cliarge.^ On the other hand, as a general rule, excision is not indicated, (1) when the patient is under five or over foriy-five years of age; for in the first case there is a possibility of recovery without an operation, and a risk that excision would check the growth of the limb, and in the second case, the advantage of excision over amputa- tion is not stifBcient, in the most favorable cases, to balance the in- 1 R. Volkmau. 2 X. Holmes. 8 (j. Iliiter. ■• Von Langenbeck. 184 OPERATIVE SURGERY. creased risk;^ (2) when the disease is of recent origin, or limited to the synovial membrane, as in simple hydrarthrosis, however lonw it may have continue 1, for a natural cure may still often be obtained by position, rest, extension, and constitutional and local treatment; ^ (3) when there is satisfactory evidence of the presence of organic vis- ceral disease, as phthisis; (4) when there is caries of the articular ends of the bones in a healthy patient, for the disease may often be brought to a successful termination by incision and the removal of the dead bone,^ and the passage of setons of oakum or perforated rubber tubing through the joint to secure complete drainage and the escape of carious particles;* (5) when the disease has lasted many years and the process of natural cure is well advanced, for by placing the part in proper position, securing rest and aiding the natural efforts, recovery with anchylosis may be obtained ; ^ (6) when shot injuries involve the joint, for if not severe, expectant treatment will give the best results, but if severe, amputation of the thigh should be per- formed ; even in traumatic suppurations in consequence of pene- trating wounds or severe contusions, well-managed, conservative treatment, with the plaster of Paris bandage, ice, incisions at the proper time, injections of concentrated nitrate of silver, extension if necessary, will save more patients than secondary excision.^ The following suggestions as to the extent of the excision are im- portant: The patella should not be removed, unless diseased, as the preceding facts show a large per centage of recoveries when it is .un- disturbed; it is also essential to the formation of a firm, well applied flap; ^ if carious, the diseased part may be removed with the gouge or forceps; in excision of the knee-joint in children, remove at first a thin slice of bone, and, in case this should not suffice, with the gouge scrape out carefully the softened and brokon-down osseous tis- sue, leaving the much thinned cortical substance with the periosteum, behind; the epiphyseal cartilage is often by this means laid entirely bare from the side of the joint; if perforated with fistulous openings a small spoon must be introduced and every particle of diseased tissue removed ; in very young children it will often even not be necessary to remove any part of the tibia with the saw, it being practicable to remove the diseased part with the spoon; if the epiphyseal cartilage can be saved only in part, no more should be sacrificed than is actually necessary.^ Tiie method of operation will depend upon the kind of joint sought to be ol)tained; if union of the excised bones is necessary, the U- sha[)ed infi>ion is in general preferable to others, as it permits the removal of any necessary amount of bone without injuring the soft ' T. Ilolnit's; J. Asluubt, Jr. - J. A^l^l^st, Jr. 3 T. Bryant. 4 L. A. Sayre. 5 j. Ashurst, Jr.; T. Bryant, o It. Volkman. OPERATIONS ON THE JOINTS. 185 ^J parts, and both corni-rs of the wouml are situated as low as the ana- tomical conditions will allow. ^ If an attempt is made to retain mo- tion, a lateral incision ^ is to be preferred, which admits of oxsection with the least destruction of the ligamentous tissues of the joint. In exsectioM designed to secure union, the articular surfaces should be so divided as to give a forward angle at the point of union; this is secured by saw- ing the bones in the lines h, k, and /, j (Fig. 151); the amount of bone removed must of course depend upon the extent of the disease. Exsect as follows: ^ The leg being slightly flexed on the thigh, make a curved •' incision, commencing at the insertion of the internal lateral ligament into the inner con- dyle of the fvmur, and passing just below h the lower extremity of the patella, terminate ' it at the same point on the external aspect of the joint; the lateral inci.-ions should not be made lower than the insertion of the lateral ligaments, to avoid division of the articular arteries; carefully remove all diseased and degenerated tissues ; reflect this flap upwards (Fig. 152); re- move the patella, if diseased, if not, leave it un- disturbed and divide the lateral and in- terarticular ligaments; pass a fold of cloth through the joint, and draw it firmly under the extremity of the bone to be sawn, thus completely isolating the soft parts behind; apply the saw first to the extremity of the femur, and then to the articular head of the tibia; cleanse the wound, and wire the bones together. The wire selected should be the an- nealed iron-wire, and it shouhl be inserted Fig. 152. at two points corresponding to the inser- tion of the lateral ligaments. Subperiosteal resection, with lateral curved incision, is made as follows :2 Fig. 151. 1 R. Volkniaii. 2 Vou Langeubeck. 8 J. K. Wuou. 186 OPERATIVE SURGERY. Fig. 163. 2, 2 (Fig. 15-3) Extend the knee and make a curved incision five to six inches long on the inner side, beginning two inches above the patella, at the inner bor- der of the rectus fenioris muscle, its convexity looking back- wards, passing over the posterior edge of the internal con- (\y\e and ending on the inner side of the crest of the tibia, two or three inches below the patella. In the upper part of the wound is the vastus internus, beneath which the tendon of the adductor niaginis presents itself; in the lower portion the tendon of the sartorius muscle is seen; these tendons must not be injured; cut through the internal lateral ligament in the line of the joint; separate the internal insertion of the capsule from the anterior surface of the internal condyle as high as the vastus internus : detach the internal alar liga- ment from the anterior border of the tibia to the middle line; flex the knee, and, as it is again slowly extended, by a powerful effort luxate the patella outwards; divide the cni- cial ligaments, and to separate the posterior crucial ligament from the spine of the tibia rotate the internal condyle of the tibia forwards; divide the external lateral ligament together with the adjoining portion of the capsule, by a free cres- cent-shaped incision, carried several lines below the tip of the external epicondyle ; the joint now gaps widely ; cut the posterior wall of the capsule; push the articular heads of the femur and tibia successively forward, and saw them off; if it is necessary to remove the patella, cut around it wiih the knife at the border of its cartilaginous surface, and then, by means of the periosteal knife, peel it out of its peri<)>teum, so that the latter continues in connection with the ligamentum patella; and the extensor tendons. Before the wound is closed, a strong drainage-tube is inserted, and allowed to protrude at the most depending part. It is also useful to make a counter-opening out of which the other end of the drainage-tube is allowed to hang, as also one through the upper attachment of the capsule of the joint. ih^; after-treatment is generally very prolonged and tedious, for the average time in excision for disease in recovered cases is one hun- dred and seventy-eight da3'S, and in fatal cases fifty-eight days. The conditions to be seciu'ed and maintained, of the greatest importance for success, are, (1) proper coaptation of the cut surfaces, and (2) complete immobility of the parts. These conditions are secured by apparatus which fixes the limb immovably, and yet leaves the excised purts so exposed that dressings may be renewed without disturbance of the bones. The gypsum splint and bandage, when judiciously applied, give the most satisfactory results. Of several forms the following meets all the indications most perfectly; ^ provide a compress by folding a strip of firm cloth, or lint, extending from just below the tuber i.schii nearly to the heel, twelve times together, and of such width as not to touch the angles of the incision; dip it in a solution of plaster of Paris, and apply it to the posterior sur- face; retain it by <2y})sum bandages, so applied as to leave the front part of the knee uncovered; an iron brace may be added over the 1 P. H. Watson; F. Esmarch. OPERATIONS ON THE JOINTS. 187 knee for strength. ^ Or, make a wooden concave splint to the calf of the leg and back of the thigh, but naiTow at the knee; also an iron rod for suspin<;ion, apply the dressing thus: Pad the posterior splint with lint or cotton-wool, and cover that part corresponding to the site of the wound with gutta-percha cloth, or hot paraffine; I>Iace the liuib in poj^itiun and carefully adjust it; place the iron rod on the front and lay folded lint between it and the limb at the groin, at the u[)per part of the tibia, and at the bend of the ankle; apply an open woven roller bandage around the whole dressing from the toes upwards F"^- ^5^- excei)t at the site of the wound ; over this apply the gypsum band- age in two or three layers ; when the dressing is firm, suspend the limb by the hook; the wounds may now be dressed without disturb- ing the part. 6. The hip-joint is a large ball-and-socket joint, in which the globular head nf the femur is received into the acetabulum or coty- loid cavity of the innominate bone; tlie articulating surface of the acetabulum is formed by a broad, ribbon-shaped cartilage occupying the upper and outer part, and folded round a depression which, ex- tending from the notch, is hollowed out in the bottom of the cavity, and is occupied by delicate adipose tissue covered with synovial mem- brane ; the articulating surface of the femur presents a little beneath its centre a pit in which the round ligament is attached; movement is allowed in every diiection, extension being limited by the anterior fibres of the capsular ligament, and flexion by the contact of the neck of the femur with the acetabulum. ^ The results of excision are as follows: For shot injuries the mortality is 89 per cent, in a total of 121 cases; at the different periods it is as follows : pri- mary, .36.7 per cent; iiiterinetliate, 48.1 percent.; secondary, 15.2 per cent.,* giviiit; a larj^e preponderance iu favor of tlie secondary operation. For disease, the mortality is 45 per cent, in a total of 426 cases; the most favorable age is 1 to 10 years; the most favorable period is when the disease has existed 12 to 15 months; the <;enera! mortality is greater in complete than in partial excisions. There is but little difference in the mortality when the head and neck, or the head, neck, trochanters, or the head, trochanters, and upper part of the shaft are removed, provided the amount of pelvic bone excised is limited; the mortality centre is the head of the femur, the rate diminishing as the bone is removed outwards to the shaft and increasing as it advances upwards upon the pelvis.' The usefulness of the limb after excision for disease is equivalent to 93.8 per cent, of the recovered cases; complete excision gives a better result in re- 1 R. Volkman. 2 Quain's Anatomy. 3 H. Culbertson. 188 OPERATIVE SURGERY. covered eases than partial, the former having 45.8 per cent, and the latter 35.8 per cent, perfect limbs, and the former having 48.6 per cent, and the latter 56.6 useful limbs; after excision for shot injuries 3.9 more or less useful limbs and 5 imperfectly' useful limbs are recorded in 119 cases. i The indications for exsection are as follows: In compound disloca- tions ^ in shot injuries when the head is shattered by the ball, or the ball is impacted in the head ; ^ in disease, when suppuration and dis- oro-anization of the textures of the joint continue unrelieved hy or- dinary treatment, and the patient's health is in fair condition.* Superficial or limited acetabular disease does not interfere with the performance and good results of excision of the head of the femur ; even when the acetabulum is much involved, or pelvic suppuration ex- ists, it is important to afford a free escape to the pus by the removal of the head, neck, and great trochanter of the femur.^ It should not be attempted in cases in which abscesses form with little or no fever, the nutrition of the patient remaining satisfactory; nor when anchylosis is complete, though free suppuration is present. ^ In gen- eral, the following conditions should guide in deciding to exsect for disease: (1) in chronic coxitis with formation of abscesses and fistu- lous openings, the suppuration being abundant, with lever at night, and progressive weakness ; (2) when an acute suppurating coxitis, with high increase of temperature, supervenes upon a chronic one in which dry granulations without suppuration have filled the acetabu- lum ; (3) when an iliac abscess which is forming shows that pus has perforated the acetabulum and entered the pelvic cavity; (4) when during suppuration, the head of the femur has separated and left the acetabulum.^ The period of operating should be primary in compound disloca- tions and shot fractures. In disease it has not yet been accurately decided what is the earliest stage of its course in which, the opera- tion is justifiable, but the evidence strongly corroborates the opinion that usually it is delayed too long.^ The surgeon cannot commit a greater error than by delaying excision too long in severe cases, and operating only when the patient is excessively debilitated.^ Though the mortality would seem to diminish in proportion as the shaft is removed, yet there can be no doul)t that, as a rule, the extent of the incision should depend upon the amount of disease ; if limited to the head, that part alone should be removed ; ^ if the neck is carious, the trochanter may still be preserved ; but if the latter is involved, the bone must be divided at the trochanter minor. The methods of operation are numerous, but the single incision along the axis of the trochanter, with subperiosteal removal of the 1 H. Culbertson. 2 p. H. Hamilton. 3 r. Volkman. ■• L. A. Sayre; T. Annandale ; L. Verneuil; C. Hiiter. 5 T. Annandale. 6 Von Langenbeck ; Sheede ; C. Hiiter. OPERATIONS OX THE JOINTS. 189 bone, most marly mei-ts the anatomical indication of the part. Of the several arteiics distributed to this region, namely, the gluteal, sciatic, obturator, external and internal circumflex, and the superior perforating i)y anastomosis, the only one which approaches the line of this incision near enough to be incised before dividing into branches of distrllnition too small to give rise to noticeable hiemor- rhage, is a twig of the internal circumflex, which, at one eighth to one fourth of an inch from the insertion of the obturator externus, breaks up into its terminal divisions ; this branch may be avoided by keeping the point of the knife well against the bone, and dividing the tendon of the obturator externus muscle in the digital fossa.^ Exsect as follows ^ ; (Fig. 155) The pa- tient lying on the sound side, with a strong knife commence an incision, 1, 1 (Fig. 155), at a point midway between the anterior in- ferior spinous process of the ilium and the top of the great trochanter; carry it in a curved line over the ilium, in contact with the bone, across to the top of the great tro- cbanter; extend it not directly over the cen- tre of the trochanter, but midway between the centre and its posterior border; com- plete it by carrying the knife forward and inward, making the whole length of the in- cision four to six or eight inches, according to the size of the thigh; if the periosteum has not been divided by the first incision, carry the point of the knife along the same line a second or third time; an assistant sep- arating the wound with the fingers or retract- ors, the great trochanter (Fig. 157), is exposed ; with a narrow thick knife make a second incision through the periosteum only at right angles with the first at a point an inch or an inch and a half l)clow the top of the great trochanter, opposite or a little above the lesser trochanter, and extend it as far as possible around the bone, making sure that the periosteum is freely divided; at the junction of the two incisions of the periosteum introduce the blade of the periosteal elevator, and gradually peel up the periosteum from either side with its fibrous attachments until the digital fossa has been reached; with the point of the knife applied to the bone divide the attachments of the rotator muscle, and continue to elevate the peri- osteiun, carefully avoiding rupturing it at any point; when the perios- teum is removed as far as necessary, adduct the limb slightly, de- 1 J. A. Wyeth. 2 l. A. Sayre. Fig. 155. 190 OPERATIVE SURGERY. Fig. 156. press the lower end of the femur sufficient to allow the head of bone to be lifted out only so far as is requisite to permit its re- moval with the taw g : divide the bone just above the trochanter minor, and remove the fmgment; if the head of the bone cannot be raised before division on ac- count of the involucrum, saw the bone first and then remove the head ; if the shaft at the point of section is necrosed, expose and exsect more; examine the acetab- ulum and if found diseased re- move all dead bone; if perforated, the internal periosteum will be found peeled off, making a kind of cavity behind the acetabulum, and all diseased bone must be very carefully chipped off down to the point where the periosteum is reflected from sound bone; all sinuses must be thoroughly cleaned of particles of bone and false meiubrane ; cleanse the wound thoroughly, fill it with Peruvian bal- sam, and stuff it with oakum, always avoiding cotton or lint, and close only the extremities with stitches.^ Or, make an incision 2, 2 (Fig. 155), 2 commencing about three inches below the crest of the ilium, and the same distance posterior to the anterior superior spine, downwards to the trochanter major, and then along the centre of the shaft of the bone. An exploratorj' incision may be made by entering the knife immediately above and in a line with the posterior margin of the great trochanter, and making an incision sutficiently long and deep to allow the finger to explore the joint; extension of this in- cision upward or downward two inches will admit of excision of the head of the feniur.^ The following method * is approved : Make a longitudinal incision over the great trochanter 2^ to 4 inches in length, in a line Fro. 157. with the axis of the femur, and directed to the posterior superior spine of the iliac bone; two thirds of the incision is made in the glutei muscles above the trochanter, and one third on the trochanter; 1 L. A. Savre. ^ l. Oilier. 3 X. Annandale. ^ Von Langenbeck. OPERATIONS ON THE JOISTS. 191 separate the muscles down lo tlie neck of the femur, in the direction of the longitudinal incision until the neck of the femur and the margin of the ace- tahulum are entirely free; incise the capsule in a longitudinal direction, and notch it slightly on both sides at the margins of the acetabulum; while the fin- ger is passed into the wound, cause rotation of the femur, which enables the operator to separate all the muscular attachments on either side of the incision; the head may be di.-located and sawn off, or the bone may be divided in place and the fragment removed (Kig- 157). The operation ^ by a horizontal incision at the front part of the joint has been advised; the incision commences external to the crural nerve, and involves the sarlorius, rectus, and tensor vaginsc femoris muscles. It is not well ada|)ted for real e.\cision of the joint, as it admits only of an operation on the neck of tlie femur, unless the incision is very large; as the wound is in front of the joint it does not favor free discharge of matter; the incision is, however, well adapted for simply dilating tistubv; situated in front of the joint, or for gouging out the joint by means of sharp spoons, or for the extraction of the head of the femur when separated. - The after trtatmont requires fjreat care and unwearied patience; in order that the exeised joint may be kept at rest, the wound must be so placed and exposed that the dress- in;^ and cleansinj; may be accomplished without moving the part ; daring the first weeks it is necessary to keep the acetabulum and the surface of the fe- mur well apart, and the soft parts well j/ stretched, as in excision of the elbow, \\ shoulder, and the ankle-joints; by this means healthy granulations make a |i^ more rapid progress, and the pelvis ami femur come into close contact by the contraction of the granulations and their formation into cicatricial tissue. - The wire cuirass is the best apparatus to meet these indications, especially when the patient is a child (Fig. 158). Apply it as follows : The cuirass being properly padded, place the patient in it so that the anus is opposite the opening and free from any obstruction; dress the well leg as follows: make it perfectly straight, tlu-u screw up the foot-rest until it is brought firmly against the heel; place a pad between the rest and the foot to absorb perspiration; cover the instep with cotton or blanket, and carrj' a roller (irmly rotmd it and the foot- Fig. 158. ^ rest, and thence up over the limb; before applying it, place a piece of paste- board, leather, or several folds of paper, over the leg, knee, and thigh to pre- 1 Kozer. 2 R. Volkmaii. 8 C. II. & Co.; W. F. Ford. 192 OPERATIVE SURGERY. vent the slightest bending of the knee; carry the roller around the perineum, and over tlie outer arm of the instrument, and several times back through the perineum, and then across the pelvis, by which means the well limb is made a firm counter-extending force; dress the operated leg as follows: apply two strips of adhesive plaster, two to four inches in width, according to the size of the leg, one upon either side, extending above to the sinuses, and below suffi- ciently to admit of their attachment to the foot-rest where extension is made; screw up the foot-rest to meet the heel, and bring down the ends of the plaster and fasten them securely around it; then extend the foot-rest slowly and grad- ually by means of the screw, until the limb is brought down to its full extent; if, by long contraction, the adductors and tensor vaginaB femoris do not yield, divide their tendons and fascitB subcutaneously; now apply a bandage from the toes over the entire limb to the wound; place a mass of oakum aroiuid the wound to absorb the discharge, and continue the roller firmly over it to the body; this dressing will probably not require to be changed for from forty-eight to sixty hours, or until the dressings are moistened with the discharges, when the oakum must be removed, the wound cleansed with carbolic solution, and again filled with Peruvian balsam, and dressed as before; after this, change the dress- ings once or twice daily according to the discharge, and remove the patient from the entire instrument as often as may be necessary; the well leg should be removed at least once a week, and free movement given to all the joints; the cuirass should be used for a month or two, when a long or short hip splint may be substituted, and the patient allowed to exercise. i 111 the absence of tliis apparatus, the limb may be placed in ex- tension, supported by sand-bags or pillows, ^ or it maybe encased in piaster of Paris, with suitable openings for the discharges. The gypsum bandage is best adapted to adults, and is most ser- viceable when applied with a strip of iron spanning the joint, and maintaining the thigh and pelvic portions in position (Fig. 159);^ this stirrup of steel may be movable by means of a bracket, making extension j)os- sible ; its construction and application are apparent. With chil- dren, extension by the application of weights and projjcr positions of the limb are the best means ; the patient Fig- 159. uiay be placed on a divided mattress, of which the two different parts, exactly corre- sponding to the spot where the excision was made, are separated by an interstice of several inches.^ 1 L. A. Sayre. 2 t. Annandale. 3 c. F. Stillman- * R. Volkman. III. THE MUSCULAR SYSTEM. THE MUSCLES; THE TENDONS; THE FASCIiE; THE BURS.E. CHAPTER XVIII. INJURIES OF THE MUSCULAR SYSTEM, AND SPECIAL OPERATIONS. I. MUSCLES. 1. Ruptures of muscles may be partial or complete. The former are sprains, and occur in severe wrenches of the limbs or back; they are restored l)y rest and soothing applications, and when the soreness is relieved, by gentle movements, massage and galvanism. A muscle may be com[)letely ruptured subcutaneously when the whole force is thrown in a violent and unexpected manner upon one or two muscles, or in violent paroxysms of muscular spasms, as in tetanus ; the point of separation is commonly at the junction of the muscle with the tendon ; the accident is attended with extreme pain, resembling that occasioned by a smart blow from a stick, and often by a distinct sound like the snapping of a cord; all motion of the part is either impossible, or is accompanied by such severe pain, with spasmodic twitching, as to cause the patient to desist; deep in- dentations are found at the seat of rupture by retraction of the di- videil ends, and often considerable swellings; there is always extrav- asation of blood with discoloration of the skin. Simple subcuta- neous ru[>tures of muscles are not serious injuries.^ Place the part in a position most favorable for relaxing the muscles, and bringing the surfaces in apposition, and support it with splints and other appli- ances; maintain the extremitiL's of the separated nuiscle in contact by evenly applied flannel bandages or laced belts, aided in some 1 T. Billroth. 13 194 OPERATIVE SURGERY. cases by a strip of leather or gutta percha. At first there is a con- nective tissue interinediate substance whicli soon undergoes such shortening and atrophy tliat a firm tendinous cicatrix forms ; func- tional disturbances rarely remain of any considerable amount, though there may be some weakness of the extremity and loss of delicate nioveuient.^ If the rupture involve the skin also, the injury is grave in proportion to the extent of the laceration; if the muscle protrudes at the wound, it must not be cut away but reduced to position; if necessary, enlarge the wound of the skin, and after replacement close the wound with antiseptic dressing and treat it with a view to secure union without suppuration. 2. Incised wounds cf muscles are followed by i-etraction of the cut ends. There is always observed a peculiar inversion, subsid- ence, or tucking in of the muscular fibres at the divided parts, so that nearly all the fasciculi direct their cut ends towards the subja- cent bone or fascia; in repair, new muscular fibres are never formed, but the retracted portions become inclosed in a tough, fibrous bond of union; in some cases the cut ends of the muscle are imperfectly united, but the action of the muscle is not lost, for one or both of its ends, acquiring new attachments to the subjacent parts, still act, though with diminished range.- Whether the wound is open or sub- cutaneous, approximate the cut extremities of the muscle as perfectly as possible both by position and dressings, and retain them in this condition by absolute rest; if the wound is open, employ deep su- tures to muscles and skin, with bandages above and below fastened over the wound so as to give uniform sujiport and prevent separa- tion. II. TEXDOXS. 1. Rupture of a tendon is caused by a sudden action of its mus- cles, as of the tendo-Achillis in springing upon the toes; or violence from accidents, as in dislocations; the tendon yields more frequently than the nniscle, the point of separation being at the junction of the tendon to the muscle, or at the attachment to the bone ; the itipture occurs with a snap and a shock as if the part had received a sharp blow, with sudden and comp'ete loss of function. In treatment, the divided ends must be as accurately approximated as possible, and retained until firm union is established; though close adaptation can not be hoped for, yet a perfect union, with recovery of the action of the muscle, usually takes place, for the severed ends are brought closer and closer together by the contraction of the new material as it becomes perfected, and the remaining deficiency is fully compen- sated by the accommodating nature of the muscle. The appliances 1 T. Billroth. 2 gjr j. Paget. INJURIES OF THE MUSCULAR SYSTEM. 195 in the troattiiunt of ruptured muscles ami tendons are I lie same, 'i'lie following muscles and tendons are more frecjuentlv ruj)tured : — (n.) The triceps extensor cubiti usually rui)tures at tlie insertion into the olecranon; bamlaj;!' tliL- aim from aliove dowiiwanls, with a splint in front to keep it extended; or apply adhesive strips over the body of the museles, and allowiiif^ them to eross over the ohcranon, make firm traction and fasten tlie ends over the splint (»n the anterior surface. {b.) The biceps flexor cubiti is liable to have the tendon of its long head rupturetl, the other usually ruptures at a later date;i bandage the arm up- wards, and lix the limb with the hand upon the opposite shoulder; union rarely occurs. (c. ) The quadriceps extensor cruris may be ruptured near the patella; place the limb on a straight splint, the foot elevated; fix the patella with ad- liesive strips so that it cannot descend ; ai>ply adhesive strips over the eiUire compound nuiscle, each commencing at the upper limits of the thigh; but all converging to the i>atella ; to the combined strips united, attach a rope passing over a pulley, and add a weight sul^ieient to maintain the parts in apposition. ((/.) The tendo-Achillis may riijiture, or be detached from its insertion into the OS caleis; inunediately ajiply a bandage to the leg from above downwards, over the calf, but stop short of the point of separation, lest the tendon be forced down to the bone and form attachments. Extend the foot on the leg, fliex the leg on the thigh, and fix the parts in this position by attaching a belt placed above the knee to the heel of a stout slipper on the foot, if detached from its insertion. 2. Incised -wounds of tendons are followed by contraction of the muscle or the (iisplacement of the attached part. They are rec- ognized by loss of function, and the depression at the point of separa- tion. This is one of the few structures of the body capable of com- plete reproduction, and the extent of the new part varies within given limits, according to the separation of the cut tendon.'^ The obstacles to perfect union of tendon are : failure to maintain the parts in apposition, too early use of the limb, division in dense fibrous sheaths, the extremities becoming adherent to the inner sur- face of the sheath. Place ami niaint;iin the limb in such position as to secure easy apposition of the cut extremities ; if the wound is open, first unite the cut extremities of the tendon by suture, as car- bolized catgut, and then close the external wound; avoid putting the tendon on the stretch for several weeks. III. BURS^. Wounds of bursa? are liable to lead to inflammation and suppura- tion; and secondarily, involve the neighboring joints. Cleanse and disinfect the wound, and endeavor to secure immediate union ; if pus form, open the abscess under carbolized spray, and apply antiseptic dressings. 1 T. Brvant. 2 w. Adams. 196 OPERATIVE SURGERY. CHAPTER XIX. DISEASES OF THE MUSCULAR SYSTEM AND SPECIAL OPERATIONS. L MUSCLES. 1. Inflammation of muscles, myositis, is rarely an idiopathic dis- ease ; it may occur, however, in the tongue, psoas, pectoral, and gluteal muscles, and in those of the thigh and calf of the leg; the acute form usually terminates in abscess, although resolution has been observed.^ After an injury, the symptoms usually appear sev- eral weeks later, and result from some lack of repair in the injured part, due to the want of the necessary rest which an injured muscle so much requires in the process of healing. ^ It begins with parenchy- matous swelling of the muscular fibres, and passes raj)idly into sup- puration and abscess; the bellies of entire muscles, as the psoas, may be converted into pus; but more commonly the abscess is limited to a spot varying in size from a pea to a walnut, according to the cause in each particular case ; the most trifling inflammation affecting the striped muscles of the trunk and limbs occasions the most violent dis- turbance of function; the muscle rests in a state of contraction, and any attempt to extend it is most strenuously opposed by the patient on account of the intense pain to which it gives rise.^ In large ab- scesses which are compressed by strong fasciae there is contraction of the muscles in the substance of which the abscess develops, as in psoitis; but in small and not very painful abscesses, and in traum;)tic inflammations of the muscles, there is usually no contraction.^ Reso- lution of the inflammation should be attempted by rest and the ap- plication of ice-bags. When pus forms, warm moist applications must be made, and as soon as abscess is detected it should be opened, and with antiseptic dressings if a large muscle is involved. II. TENDONS. 1. Inflammation of tendons, and their sheaths, is liable to follow sprains, or other injuries. The sheaths may inflame, with exudation of fibrinous serum, which often induces temporary or permanent ad- hesions of the sheath to the tendon; or suppuration may occur with necrosis of the tendons; there is now fever beginning with a chill; if the inflammation and suppuration extend, the fever becomes con- tinued and remittent in form ; if intermittent chills occur, there is great danger. Inflammation of the sheaths, arising from unknown 1 T. Billroth. 2 T. Bryant. 3 e. Rindfleisch. DISEASES OF THE MUSCULAR SYSTEM. 197 causes, begins as an acute phleo;mon, the cellular tissue participates, and the limb swells greatly. The symptoms at the first are pain on motion, and slight swelling; sometimes a friction sound is present, or grating in the sheath perceptible to the ear or hand. Resolution may occur without suppuration, the limb remaining stiff a long time, as the adhesions between the sheath and tendon do not break down until after months of use; if e.xtcnsive suppuration follow, the ten- dons usually become necrosed and escape from the abscesses as white threads or shreds, followed by permanent stiffness of the fingers. The treatment of slight inflammation of the tendons, with crepitation, is rest on a splint and local application of tincture of iodine, or add a blister.^ If the symptoms are more severe, elevate the limb and apply ice ; if this is painful, use hot fomentations over a lar^^e sur- face ; if the inflammation extend, with throbbing, and hardness, make a free ii^cision along the centre of the sheath, to relieve the tensely strangi-lated tissues, even though no pus is present. "-^ If pus is detected, make numerous openings, and secure free drainage from position or tubes; if the disease still progresses, and the patient sinks, amputation of limb may be necessary to save life.^ In the more chronic states, where abscesses burrow, though free openinofg have been made, resort to pressure with pads of lint soaked in liquor plumbi acetat., and combine tonics and good diet.- The synovial sheaths suffering chronic inflammation mav be- come distended with a fluid, jelly-like and containing white bodies. The sheaths in the hand are most frequently affected; there is a gradual formation of a swelling in the hollow of the hand and the lower end of the volar side of the forearm, and the fluid mav be felt passing in the sheath to the forearm under the ligament of the wrist; the fingers are generally flexed and cannot be fullv extended; the movements of the hand and fingers are somewhat limited, but there is no pain; the fluid is jelly-like, with white bodies. In other cases there is a partial hernia of the sheath, with dropsy, a ganend upon the prominence of the tendon; by carefully passing the tenotome alonir the tendon, the plantar ar- teries will esca[)e injiny. 3. The extensor longus digitorum may fix the toes in a state of extension, or, by contraction, may elevate the anterior part of the foot. In the former case, section of separate tendons should be made on the dorsum of the metatarsus where there are neither important arteries nor nerves; the extensor of the great toe often requires sec- tion also; the skin may be pinched up and the tenotome passed be- tween it and the tendon, and division made towards the bone. In the latter case section shoubl be made where the tendons pass over the ankle; enter the tenotome close to the inner border of the tendon made tense, pass it outwards, and when the point is at the extremest border turn the edge upwards. 1 J. Syme. 208 OPERATIVE SURGERY. 4. The extensor proprius poUicis has upon its internal bor- der below, the anterior tibial vessels and nerves and dorsalis pedis artery. Section may be made through the same puncture as that used for section of the long flexor of the toes, the point of the knife being turned inwards, and carried no farther than the internal bor- der of the tendon to avoid the vessels and nerve. Or, being made tense, the knife may be inserted on its inner margin and passed out- wardly. 5. The tibialis anticus passes from the annular ligament of the ankle over the internal surface of the tarsus, and is inserted into the inner and under surface of the internal cuneiform bone and base of the metatarsal of the great toe. In talipes varus it is placed very much to the inner side, and passes obliquely downwards across the inner malleolus, inclined backwards towards the internal cunei- form bone, Avhich occupies a lateral position, owing to the altered position of the scaphoid bone. The tendon can generally be easily felt, except in fat infants; it should be divided a Httle above its in- sertion as it crosses the ankle joint. C. The tibialis posticus passes through a groove behind the in- ner malleolus with the tendon of the flexor longus digitorum, but in a sepirate sheath, then through another sheath over the internal lateral ligament, beneath the calcaneo-scaphoid articulation, and is inserted into the tuberosity of the scaphoid and internal cuneiform bone.i The posterior tibial artery lies behind it. In talipes varus the tendon at the point of division, just above the inner malleolus, is relatively more forward than in the healthy foot, and in the sec- ond part of its coui'se, between the malleolus and its insertion into the scaphoid, the tendon does not pass beneath the inner malleolus, and then obliquely downwards and forwards to its insertion; but on the contrary, passes directly downwards to the scaphoid bone.^ If the tendon is normal, divide it half an inch above the inner ankle; the posterior tibial artery lies posteriorly; make a puncture between the artery and tendon, turn the foot outwards, and cut towards the skin; the artery may often be pressed one side by the finger, — by the nail of the left index finger. If the tendon is displaced, as in varus, the following is important: If neither the tendon nor the inner edge of the tibia can be felt, as is commonly the case in fat infants, a puncture made in the inner aspect of the leg exactly midway be- tween the anterior and posterior borders, is a true guide to the posi- tion of the tendon at the point of section. Thrust the tenotome or a sharp-pointed knife straight down to the tendon, and open the sheath by a movement of its point; now insert a blunt-pointed knife beneath the tendon, which will at once be so fixed that it cannot be 1 H. Gray. 2 W. Adams. OPERATIONS OX THE MUSCULAR SYSTEM. 209 moved from side to side if it is between tbe tendon ami bone; make a complete section of it. 7. The peroneus tertius is a part of the lonir extensor, and branches oft" to be inserteil into the base of the fifth metatarsal. Section is readily made when the long extensor is tense !>}• insertinif the tenotome on its external margin and passing it inwards; or it may lie divided at the same time with the long extensor. 8. The peroneus longus aud brevis pass through the same groove behind the external malleolus, and are invested by a common fibrous and synovial sheath; the long peroneus then passes across the outer side of the os calcis, in a separate sheath, over the margin of the cuboid, across the foot to the base of the first metatarsal; the short peioneus j)asses on the outer side of the os calcis to the base of the fifth metatarsal bone. Section of these tendons may be made: (1.) An inch al)ove the base of the external malleolus, the tenotome entering fiom before backwards between the fibula and the tendons; or, (2.) half an inch in front of the apex of the malleolus, where they may be niade prominent and divided by a single puncture; or, (3.) the long tendon could be divided at a point midway lietween the end of the malleolus and the tubercle of the cuboid, and the short tendon at the external border of the extensor brevis digitoruin. 9. The tendo-Achillis is about six inches long, commencinor about the middle of the leg, and is inserted into the lower part of the tuberosity of the os calcis; it is separated from the deep vessels by a considerable interval; the external saphenous vein runs along its outer side; section is made as follows: Place the patient on his stomach with the foot hanging over the table or bed; an assistant shoidd put the tendon on the stretch by attempting to fle.x the foot; introduce the tenotomy knife obliquely downward with its flat surface parallel witli the tendon, close to its inner or outer edore, as most convenient, when the tendon is prominent; but when the tendon is deep, enter the knife on the fibular side to avoid the possi- bility of puncturing the posterior tii)ial artery; carry the knife to the opposite side, depressing the handle to a horizontal direction ; now turn the cutting edge towards the tendon and divide it trans- vei'sely from the internal to its external surface; close the wound with a compress fixed by adhesive strip and bandage. If the foot is immediately restored, it must be retained in position by a proper shoe or by adhesive strips passed around the anterior part of the foot, and fastened to the upper part of the leg. If reduction is to be gradual, these appliances should not be resorted to in three or four (lavs. 10. The biceps flexor cruris is inserted into the head of the fibula, and forms the external hamstring; the external popliteal 14 210 OPERATIVE SURGERY. nerve lies close to its internal border. Place the patient in a prone position, extend the leg firmly, and recognize the tendon; enter the tenotome an inch above the head of the fibula, on its inner border, inclining it at first outwards, until its point passes under the tendon; then depress the handle to the horizontal, and when its point is felt on the opposite side, turn the edge upwards towards the tendon and divide. 11. The semi-tendinosus, semi-membranosus, gracilis, and sartorius, form the inner hamstring, and are inserted upon the inner and anterior surface of the tibia; the nerves and vessels of this re- gion lie quite external. The patient being in a prone position, enter the probe-pointed knife close to the outer side of the tense hamstring to avoid the vessels and nerves of the ham, incline it inwards towards the median line of the body as it passes under the mus- cles, and until its point is felt on the inner side; now depress the han- dle and divide the structures towards the skin; the section may be limited to tlie semi-tendinosus and membranosus, or by deeper pene- tration all the tendons and muscles forming this group may be safely divided. 12. The quadriceps extensor cruris is composed of the rectus, vastus externus and internus, and crureus; the tendon is inserted into the tubercle of the tibia through the medium of the patella and the ligamentum patella ; a large bursa lies under the conjoined ten- dons above the patella. Section above the patella is made as fol- lows: pinch up a fold of skin parallel with the ligament; pass the tenotome through to the tendon, but do not penetrate too deeply; carry the blade along the anterior surface under the skin; turn it towards the tendon, and with a sawing motion cut until all resist- ance ceases; effectually close the wound, and do not attempt flexion until the repair has begun. 13. The pectineus is situated at the anterior part of the upper and inner aspect of the thigh, extending from the ilio-pectineal line of the pelvis to the rough line below the trochanter minor; it is an adductor of the thigh and may be divided as follows: ^ While one assistant fixes the pelvis, and a second straightens the contracted thigh, recognize the tense and elevated tendon of the muscle and pass a long blunt tenotome blade under it from the external side, an inch and a half below its origin; with a few passes of the blade the entire muscle is divided towards the skin, or the section may be made from the skin. 14. The adductor longus lies on the same plane as the pectineus; it arises by a flat narrow tendon from the angle of junction of the crest with the symphisis, where it may be readily severed. Abduct 1 F. Stroniever. OPERATIONS ON THE MUSCULAR SYSTEM. 211 the tliij^li and make the muscle prominent near its insertion. Pass the tenotome from without downward and inward, until the muscle is passed; then cut with a sawing motion towards the skin until the contracted tissue is divided. 15. The tensor vagiiice femoris is a short, flat muscle arisinor from the anterior part of the outer lip of the crest of the ilium, and from the outer surface of the anterior superior spinous process, and terminates in the fascia lata of the thigh, one fourth down the ex- ternal aspect of the thigh. It is easily divided hy making it tense anart, recourse should be had to an operation, by which both ends of the wounded artery may be secured by ligature; and the inipraclicability of doing this should be ascertained only by the failure of the attempt; if the lower end of the artery cannot be found at the time, the upper only having bled, a gentle compression maintained njwn the track of the lower may prevent mischief; but if dark-colored blood should flow from the wound, which may be expected to come from the lower end of the artery, and compression does not suffice to suppress the luemorrhage, the bleed- ing end of the vessel must be exposed, and secured near to its extremity; (5.) wounds of the branches of the internal iliac require that a ligature should be applied to both cut extremities, and not to the arteries at their origin. III. THE VEINS. The vt'ins are liable to traumatic lesions, but owin,' to tlie quiet flow of the blood-current, and the coni|)res.sion of surrounding tis- sues, the effusion is rarely serious. When, however, injuries of dee[>-seated veins, especially those communicating with cavities, oc- cur, the haemorrhage may be dangerous. 1. Contusion ^ causes the rupture of a greater or less number of superficial veins, followed by the extravasation of blood into the sur- rounding tissues, or into cavities. The more vascular and yielding a part, and the more severely contused, the greater the extravasation; if the blood escapes slowly it forms a passage-way between the con- nective-tissue bundles, especially subcutaneous connective-tissue and muscles, the wounds being rough and ra.rged, obstacles are pre- sented to the free escape of blood, and fibrinous clots form, extend- ing into the calil)re of the vessel, causing mechanical closure by tlironibnses. The escaped blood undergoes various chanires, namely: the filirine coagulates, the serum enters the connective tissue and is ve-absori)ed, the coloring matter leaves the blood- corpuscles and is distributed in solution among the tissues, passing through various metamorphoses, with change of color till it is transformed into hema- toidin; tlie fibrine and blood corpuscles for the most part undergo disorjijanization and are re-absorbed. The effused blood assumes different conditions : (1.) Sug<_dllation is a diffuse, subcutaneous hajmorrhage, of a dark blue color, which chau'jes into a {jreen, and then into a brighty ellow, which remains for a iou'^ period. Re-ab- sorption usually takes place, owing to the diffusion of the blood, and the good condition of the vessels; apply cold to prevent further ex- travasation, and spirit or stimulating lotions to promote absor|)tion. (2.) Ecchymosis is the accumulation of blood into a circumscribed 1 T. Billroth. 218 OPERATIVE SURGERY. space of connective tissues, and may be superficial with a dark blue color, or deep without discoloration ; fluctuation is often very dis- tinct. The blood will have the same fate as the contused tissues; if they return to their normal state, re-absorption will follow; but if they are broken down and pass into disintegration or decomposition, the blood collection will under<;o the same change. Innncdiately after the accident apply compression as accurately as jjossible to the rup- tured vessel to prevent further effusion; apply ice, or cold lotions, to prevent inflammation; employ uniform compression, with moist dressings to promote absorption; if there is no marked change in two weeks, to compression add painting with tr. iodine daily; if it become hot, red, and painful, apply warm, moist dressings, as poul- tices, and wait for thinning of the skin over the forming abscess before opening it; if the tension and swelling rapidly increase, with chills and fever, the blood and pus are decomposing, and the contents must be evacuated by free incision, and the cavity cleansed and dressed with carbolic solution. 2. Wounds of veins are of frequent occurrence, and generally of slight importance. They are recognized by the flow of dark blood without jet or impulse. They heal readily, owing to the easy ap- proximation of the cut surfaces, and the prompt formation of the blood clot in the wound and vessel. The danger is three-fold, namely, haemorrhage; the entrance of air; inflanmiation in the con- nective tissue with the formation of thrombus. Ligate the vein, if exposed and accessible, or use torsion or acupressure; elevate the limb or j)art, and remove all constriction above the wound; apply firm compression over the wound; prevent inflammation by the use of cold. V. THE LYMPHATICS. Wounds 1 of the lymphatic vessels occur in every considerable wound of the soft tissues, but their injury is concealed by the flow of blood, and the lesions of other vessels. It is only by the subse- quent inflammation that their lesions become important. From the margins of the wound fine red strise run longitudinally towards the glands, which swell and become very sensitive, accompanied by fever, loss of appetite, and general depression. The inflammation may terminate in resolution, or the limb may become red and cedem- atous, with high fever, and even chills, and fluctuation soon after an- nounces the formation of pus in the glands or cellular tissue. The early treatment should be cleansing and disinfection of the wound to prevent the further absorption of septic fluids; rest; active purga- tion; local applications of lead and opium lotions, or inunctions of mercurial ointment; wrapping the limb in cotton, the limb mean- 1 C. H. Moore; T. Billroth. INJURIES OF THE CIRCULATORY SYSTEM. 219 time being elevated and wrapped so as to maintain an even tem- perature. If pus forms it must be evaeuated early ; if it is in a •rland, and healing does not progress satisfactorily, use hot, moist applications, lest the poison again extend from the gland. VI. ARTERY AND VEIN. Wounds may penetrate an artery and adjacent vein, or the lesion of the two vessels may occur spontaneously, ansi(in on the cardiac side for an hour or n)ore. 3. The elastic bandage has been successfully employed, the object being to completely conlnji the circulation of the limb and tumor for a time. Apjily the elastic bandage from the extremity upward above the tumor, but lightly over the aneurism; apply the elastic tubing around the limb over the highest turn of tlie bandage, and remove the bandage; the limb is now pallid and the tumor pulseless; after fifty minutes, aj)|ily compression to the main trunk, and remove the tubing; continue pressure, if necessary, in an iijtermittent manner for a day or two, when the cure will be found complete. ^ 4. Flexion- has been successful in aneurism at the bend of the elbow, knee, anil hip, and is indicated in small aneurisms, so situated that the pulsa- tion and bruit are suspended by bending the joint: it need not be extreme nor painful, nor neeil the limb be bandaged or confined in any way in many cases, as voluntary flexion, the patient being allowed to change the position of the limb slightly, will sometimes succeed when forced flexion would not be tolerated; as flexion acts by retarding the blood-stream and displacing dot, pressure n)ay be combined in the treatment; forced flexion may cause ru|)ture of the sac* IJandage the limb from the extremity nearly to tlie joint, then flex the limb firmly and turn the roller around the part above, thus fixing the forearm or leg in a fle.xed position. 5. Foreign bodies have been introduced into the cavity' of the aneurism for the purpose of iiulucing coagulation by whipping the blood; the cases selected were most unfavorable, and all were fatal, but not from the effect of the opera- tion. Iron wire,'* horse hair,^ carbolized catgut,'' are the agents which have been used; they were introduced through a fine canula. a. Electrolysis is designed to secure a gradual deposit of the layers of fibrin, and has proved successful in forty-eight out of ninety cases," for the most part of the extremities ; abdominal and thoracic aneurisms have rarely been benefited ; in the latter case, if the disease tends certainly to death and other methods have failed, electro-puncture would be justified.* Give an aniesthetic; begin with one or two cells; introduce into the aneurism two or three needles connected with the negative pole, while a sponge electrode connected with the positive pole is applied to the adjacent surface; the length of the application may be five to forty-five minutes; from one to four or five operations are usually sufficient.'' Operations upon the arteries are perforined for the purpose of ar- resting the flow of blood into the aneurism, and thus promoting co- agulation. 1. Xiigation of the arterial trunk has long been the approved method of ob- structing the circulation in an aneurism. The ligature has generally been some irritating, indestructible material, as silk, which, in its application, ruptured the internal coats, and then by slow degrees divided the external coat, and was cast off from the w(uind. The cure of the divided artery was effected by the organ- ization of a clot, and the final repair of the cut ends; but this process is al- ways lialile to be interrupted; the clot may not organize and the cut ends of the artery may not repair, owing to the inflammation whiili the ligature creates. This result is followed by hivmorrhage from the wound, always a dangerous 1 W. Reid. 2 E. Hart. 8 T. Holmes. * C. H. Moore. 5 K. j. Levis. « Murray. 7 A. M. Hamilton. 8 H. I. Bowditch. » Beard & Rockwell. 224 OPERATIVE SURGERY. complication. These dangers are ver}' materially diminished by the use of an uiiirritating ligature, as silver or iron wire, which may remain long in the wound without causing inflammation. But the most perfect results are ob- tained when an uiiirritating and absorbable ligature is used, as carbolized cat- gut. The ligature need not be so tightly applied as to sever the coats of the artery, and the wound may at once be pernutnently closed. The course of re- pair consi^ts in the union of the exteinal wound without suppuration, the union of the opposed surfaces of the internal coat of the artery, the replacement of the old ligature bj' a new ligature of living tissue which strengthens the artery at the point of ligation. It follows that such a ligature may be applied where silk would ordinarily prove fatal, as in the vicinity of large trunks, and where a resulting intiammation would dangerously complicate the operation, as in prox- imity with serous cavities. The only defect in the method of applying absorb- able ligatures is the liability of their absorption before the cure is completed; but this has been remedied b}' preparing the catgut so that it will remain firmly applied for a sutHciently long time and then undergo absorption without irrita- tion, 'i'he rule, therefore, shouUl be to select a ligature which is unirritating, and will be absorbed, and to apply it with antiseptic dressings. But if such a ligature is not at hand, the silk should be carbolized, and applied antiseptically. The several points of ligation are as follows: (1) On the cardiac side, near the tumor,! or near the first collateral branch, above the aneurism;'^ the latter point is alwaj's to be preferred when the artery is readily accessible, as the femoral, for popliteal aneurism; (2) on the distal side ^ when the artery cannot safely be reached on the cardiac side, as the subclavian or common carotid in innomi- nate aneurism; (3) At its entrance into, and exit from, the aneurism, the old operation,* as in carotid aneurism at the base of the neck, or traumatic aneu- risms. 2. Compression consists in the application of pressure to the artery, on the cardiac side, with a view to cause stagnation of a mass of blood in the aneu- rism until it coagulates. This method is capable of curing the majority of surgical aneurisms, and when it fails, in no marked manner militates against the adoption of other measures. ° Pressure may be digital or instrumental; the former, when successful, is more rapid and less painful, and should be preferred if all the conditions are favorable. To be successful, pressure must be regular, efficient, and equable. ^ Commence the treatment by preparing the patient with several days of rest and low diet to reduce the circulation; select three or four reliable assistants, who must be employed for four or five hours consecutively, each in rotation applying pressure for ten minutes at a time; the pressure must be steady and equal by the finger or thumb placed directly over the vessel, with just suf- ficient force to arrest the flow of blood and no more;^ if the patient becomes restive, give anodynes; or it may be necessary to intermit to give the patient rest. The pressure of the fingers may be reinforced by placing a weight, as a bag of shot, upon the ends. The cure may be verj' rapid, even occurring in one and a half, two and a half, and three hours,'' or it may be prolonged; pressure should not be given up unless after several days no impression is made, or the surface ulcerates. Instrimiental compression ma}' be made in a variety of ways, but in all cases the point used for pressure should, as far as possible, be small, like the finger ends, in order to make accurate pressure on the artery and avoid compression of the vein. A simple appliance is a bag 1 Anel. 2 J. Hunter. 3 Brasdor. 4 j. Syme. 5 T. Bryant. 6 T. Holmes. • J. Knight. DISEASES OF THE CIRCULATORY SYSTEM. 225 sac of sand or small shot, made tapering at one end, and suspended by an elastic band; tourniquet pads may be adapted to various forms of apparatus so as to make (iressiire at a single point {¥\g. 1G8), or at several points allowing intermittent ])ressure. 3. Acupressure can be practiced with safety upon arierifs which are so much dis- eased that I hey aie too brittle and friable to bear I lie strain of a ligature; in cases of aneu- rism where the artery is diseased for some dis- tance above llie sack, the vessel may be closed by an acupressure-needle at a point where it would be inexpedient to apply a ligature; thus, an aneurism of the lower femoral may be treated by acupressure at the upper portion of the femoral, whereas, if treated by deligation, the ligature would have to be placed upon the external iliac artery, a much more serious operation. 1 Pass the needle under the artery and make a tigiire of 8 with the thread. 4. Constriction- is made by the artery constrictor (Fig. 169); expose the artery at the point for constriction, and apply the constrictor (Fig- 170) as di- FiG. 168. E-;= oc^ Fig. 169. Fig. 170. rected (p. 25); the internal coats being ruptured, remove the instrument and accurately' close the wound; a clot forms, the current of blood is permanently interrupted, and the consolidation of the aneurism takes place. III. THE VEINS. 1. Venous thrombosis is due to the same conditions which caus^ thrombus of an artery, namely, retardation of the circulation, or irrogiilarities in the coats of the vessels. More frequently they are caused by acute inflammation of cellular tissues, especially under fascia, tense skin, or boiie.^ The thrombus forminp; at one point often extends by the deposition of fibrin to other branches until a largje number, or a plexus of veins, is filled. The clot may be re- absorbed, or organized into connective tissue, or suppurate, forming an abscess, or undergo disintegration, giving rise to embolism.^ The treatment is absolute rest, with applications of ice ; friction with mercurial ointment to prevent embolism; early evacuation of purulent collections.-' 2. Varices are veins in a state of permanent dilatation. Veins in certain localities, as in the plexuses of the true pelvis and its outlet, 1 J. C. Hutchison. 15 2 S. F. Spier. 8 T. Billroth. 226 OPERATIVE SURGERY. and in the superficies of the leg, undergo permanent dilatation, causino- varix, jjhlebectaj^y. This change is the result of a local rise in the blood-pressure; the disorder is never restricted to a sin- o-le and very marked dilatation of a vein, but always involves the moderate dilatation of an entire j)lexus, or of all of the branches of a single trunk; the distention begins just above the valves, -which, having to support a greater weight than usual, become incompetent, and the vein is stretched longitudinally; the fixed condition of both ends of the vein compels the elongated vessel to bend, forming zig- zags, or become spirally twisted.^ The tendency to varices is indi- vidual, or inherited; hence the ordinary causes act u2)on existing predispositions.^ Dilatation may affect alike both the suj)erficial and deep veins ; ^ in the former case the disease is ajjparent, in the latter it is recognized by the enlargement of parts, the unusual weight, achinf, and sense of weariness. In general, varices are merely causes of discomfort and inconvenience; but they may create disa- bilities so serious as to necessitate operations designed for their radical cure. The general plan of treatment is as follows : Remove the causes of local blood-pressure; support the distended veins and restore their tonicity; operate only upon such varices as cause serious inconvenience or permanently disable the patient. The special treatment must vary with the particular class of veins affected, their condition, and the causes which created and maintain the varicose state. The veins which more frequently become varicose and require radical treatment by o[)erations are as follows: — 1. The internal saphena vein, varicose, forms soft nodular masses, or tortuous elevations of the skin on the anterior and inner aspect of the leg; the disease may involve a few branches or the entire plexus and the trunk above the knee. It occurs more often in persons who stand much; in women Avho have borne many chil- dren; and in those who have undue pressure upon some part of the main trunk. Palliative treatment, in the forui of the elastic stock- ing, can be most satisfactorily employed. Operations are very rarely required; those most approved are as follows: (1) Acupressure; raise the vein so as not to puncture it, pass two pins under it an inch npart, and twist a figureof-8 silk ligature around the ])ins, or use India-rubber, or wire; now pass a tenotome under the included vein and divide it subcutaneously; support the limb with a bandage; re- move the pins in three to five days; excision should be delayed several days;* (2) injections of coagulating fluids; use persulphate of iron with hypodermic syringe thus : apply a compress and roller on ithe vein above, the patient first standing until the vein is well dis- 1 E. Kiiidfleisdi. 2 t. Billroth. 3 Verneuil. 4 H. Lee. DISEASES OF THE CIRCULATORY SYSTEM. 227 tended; fill the syringe and then force out a drop or two to expel the air, point in<^ upwards; select several of the most jirominent nod- ules and inject into each three or four drops; apply adhesive plaster over the ])unctures; retain the compress over the vein two or three days and enjoin perfect rest. 2. The heemorrhoidal veius, varicose, constitute Iiicniorrhoids; they have their orij^in in con:^'estion of the venous radical^^ in the lax submucous tissue of the rectum close to the anus; mucous ca- tarrh and overgrowth of the mucous follicles follow; at a later stage the phlehcctasy proceeds to the development of large plexuses of varicose veins which pu.^h the mucous membrane before them and form a ring of transverse ruga; round the anal aperture; the dilata- tion finally concentrates at one or more points of these rugae, which develop into rounded protuberances, and ultimately into fungoid tu- mors of considerable size ; the chief part of the texture of a lucmor- rhoid is spongy, being atrophied connective tissue, caused bv the pressure of the distended veins kept up by the persistently increased tension in their interior; infiammation often occurs about tliese venous plexuses, resulting in induration or suppuration, and blood may co- agulate in their interior.^ Veins may rupture into the connective tissue around the anus, and by subsequent infiammation and con- densation of connective tissue give rise to tumors of various size, color, and density, external piles. In general, patients c>omplain of fullness and weight in the rectum, pain in the loins and thighs, bleeding after defecation. Every case should be thoroughly exam- ined before the plan of treatment is settled. Place the patient on the side, on the edge of a sofa, with the knees drawn up; separate the nates gently; external piles will appear as tabs, or bluish more or less inflamed masses covered by skin ; internal piles may protrude from the anus as large grape-like tumors, often very sensitive, or, if not protruding, the finger well-oiled, introduced into the rectum, will detect the growths. In early sta'.'cs luemorrhoids may be cured by the removal of those conditions which cause congestion of the veins of the rectum, and the free use of cold water to the anus when the bowels move. If the piles are inflamed, direct rest in the recumbent j)osiiion; hot or cold applications, as may be most agreeable; mild cathartics, as the following: mag. sulphate, mag. carb., sulphuris precipitati, sacch. lactis, aa 5^^- ! p"lv. anisi, 3ii-; ^I-; take one or two teaspoonfuls at bed-time.- If external piles suppurate, apply anodyne poultices; when the inflammation subsides use astringents, as lead water, oint. nut-galls. If internal piles become prolapsed and painful, with fin- gers well oiled, or with a cloth wet with cold water, reduce them by 1 E. Rindfleisch. a G. T. Elliot. 228 OPERATIVE SURGERY. gentle pressure, the patient reclining with the hips raised, or resting on his knees and elbows. External piles should be removed by excision: place the patient on the side with the thighs flexed ; subdue sensation by local anses- thesia ; seize the pile with firm forceps and excis^e with curved scis- sors by incisions radiating from the anus. Internal piles may be removed by ligature or cautery. Strangulation by the ligature is the safest, surest, and most manageable procedure; ^ give a full dose of castor oil twelve hours before the operation; secure the protrusion of the piles as far as possible by the efforts of the patient, after an enema of warm water, straining over a vessel containing hot water; place the patient on the side and separate widely the buttocks; if an ansesthetic is used, the position with the upper part of the body prone, the hips elevated, and the thighs flexed on the abdomen is preferable, and in this case commence the operation by forcible dilatation of the sphincter ani, by which the interior of the lower part of the rectum is fully exposed.^ Seize the tumor with forceps or a tenaculum ; avoid the skin or make a light incision around its base where the covering is integument ; transfix with a curved needle armed with a double ligature of stout silk (Fig. 170); divide the ligature at the eye of the needle and tie each half around its portion of the tumor with such firmness as to thoroughly strangulate the part (Fig. 171); cut off the ends of Fig. 170. the ligature and half of the protruding mass of the tumor, if it is very large; ligate all the liEemorrhoidal tumors in the same manner, and return the mass within the sphincter. The cautery, galvanic or iron, is preferred by many surgeons; prepare the patient as for ligation; on seizing the pile with forceps apply a clamp (Fig. 172) on its base; the blades of the clamp, the surfaces of which are faced with ivory to prevent the communication of heat to sensitive parts, close per- „ ,_^ - fectiv parallel bv means of a screw so as to compress the mass equally; cut off with scissors half of each mass, dry the surface, and apply the cautery at a white heat until the remaining portion is burned to an eschar down to the clamp; remove the clamp carefully, and with well-oiled fingers return the eschars within the sphincter; apply cold to prevent infiannnation and give opiate suppositories or morphine to relieve pain and quiet the bowels; confine the patient to bed with a light diet; at the end of four or five days move the bowels witli oil. 1 W. H. Van Buren. 2 h. Smith. Fig. 171. DISEASES OF THE CIRCULATORY SYSTEM. 229 If the tumor is small, sessile, strawberry-like in appearance, fre- quently emitting bright red blood, it is composed larj^ely of congested mucous iiienil)rane, and may be treated with nitric acid. Prepare the patient as for ligature; while the lucniorrhoid is protruded, wipe the surface with lint and touch it with the end of a flat piece of wood dip|)ed in nitric acid; smear the parts well with oil, and return the whole within the anus. It is not necessary to confine the patient to bed ; if hieniorriiage occur, examine the part, and apply a styptic to the bleeding sin-facc. 3. The urethral veins of the female become varicose, and appear as small vascular tumors of the meatus urinarius;^ they may be sin- gle or multiple, pedunculated or sessile; their most frequent site is the floor of the meatus at its extremity, but they may extend deepily. The more marked symptoms are proneness to bleed, great sensitive- ness, liability to become extruded and inflamed, pain during mic- turition. An examination, which should always be made when a patient complains of pain in urination, with occasional bleeding, re- veals the nature of the disease. The ligature and caustic are the only effective agents. Administer an anaesthetic and place the pa- tient in the position for lithotomy; if the ligature is used, transfix the mass from behind forwards with a fine tenaculum and apply the thread beneath the instrument so as to inclose the base of the tu- mor; if caustic is preferred, it must be boldly used; the actual cau- tery, especially the galvanic, is most manageable. Chromic acid may be used as follows : surround the growths with cotton wool soaked in solution of carbonate of soda; make a swab of cotton wool on a stick, with which apply the acid solution; repeat in five or six 4. The spermatic veins, when varicose, constitute varicocele; these veins are subject to turgescence, the chief factor in its produc- tion being ungratified sexual desire, or abuse of the sexual organs, by which the veins are kept constantly engorged;^ dilatation, serious enough to constitute a disease, is an exaggeration of this condition; it occurs in early manhood, on the left side, rarely on the right; the vessels are elongated, the valves broken down, and the walls thick- ened and affected with fatty atrophy ; the mass fills up one side of the scrotum, is of a pyriform shape, and has the feeling of a bunch of earth worms; in the recumbent position the tumor disappears, proving that it is not hydrocele, and if a finger is pressed on the external ring, when the patient rises, the tumor will return, showing that it is not hernia. The slighter grades are cured by the removal of the conditions inducing congestion of the veins, and the free use of cold water; the severe forms may be palliated by the use of the 1 J. Ilutchiusou. 2 X. W. Kllis. 8 Van Burcu and Keves. 230 OPERATIVE SURGERY. suspension apparatus, and a compress or truss so placed over the external ring as to prevent the distention of the veins by exertion. As all procedures for the radical cure are more or less dangerous, an operation should be undertaken only in those cases where the pa- tient is kept in a state of constant unrest, and worried into bad health by morbidly dwelling on his troubles; or, in neuralgia with liabilitv to atrophy of testicle, or when the suspensory bandage fails, or the patient is not satisfied with it.^ When operative ])rocedures are required two methods are advocated: (1.) Excision of the scro- tum is regarded as the only method which offers a fair prospect of relief without serious accompanying risks ; it is curative only in the sense of preventing further disease, arresting atrophy of the testis, and usually relieving pain, and the result is nearly uniformly satis- factory.^ Place the patient in the recumbent position, the testis be- inof raised to the external ring by an assistant; draw a sufficient portion of the relaxed scrotum between the fingers; excise with the knife or large scissors and tie all bleeding arteries ; bring the edges of the incised skin together by raising the lower portion towards the upper, and apply the requisite number of sutures.^ (2.) Oblitera- tion of the large veins by subcutaneous ligature is as follows : ^ — (o.) With the left thumb and index-finger separate the vas defer- ens, which feels hard and cordlike, from the veins; carry a needle armed with a double ligature behind the veins and leave it in place; now drop the veins and grasp only the skin and through the same ori6ces, but in the reverse direction, carry a second loop in front of the veins; the bundle of veins (Fig. 173) is included between the two loops; pass the free extremities of each thread through the loops of the other, and tighten them (Fig. 174), thus effectually strangulating the veins under the skin ; fasten the extremities by tying over a small roll or compress. Sub- cutaneous section may be performed as follows:* (/;.) Pass a needle between the vas deferens and the veins at two points, separated one inch, apply a ligature over each needle suffi- ciently firm to stop all circulation in the veins; two days after divide subcutaneously the veins which feel like soft cords between the two pins; two days later withdraw the pins; Aviihin the next three or four days the cure will be complete by the consolidation of the veins. 5. Venous neevi, cavernous angiomata,^ consist chiefly of dis- FiG. 173. Fig. 174. 1 Van Buren and Keyes. i H. Lee. ^ Sir A. Cooper. 5 T. Billroth. 3 M. Ricord. DISEASES OF THE CIRCULATORY SYSTEM. 231 tended vt'iii.*, in a white, firm, tou'^h network, liavia.^ an indistinct bouniiary; or a sort of capsule; these tumors are rarely conirinital, but generally appear in cliildhood or youtli ; their seat is chiefly in the subcutaneous cellular tissue, more frccjuently in the face; they often occur in large numbers, but in such a way tliat a certain vas- cular district is to be regarded as the seat of disease, as the face, arm, foot, or leg; they cause weakness of muscles, some pain, and disfigurement; they may attain considerable size and prove danger- ous, especially by their destruction of bone; they are recognized by fluctuation, want of pulsation, compressibility, and swelling on forced expiration. The tumor must be destroyed by (1) excision, when the growth is large, the line of incision being quite external to the capsule; (2) injection of persulphate of iron, in small quantities, when the tumor is small, and not amenable to other remedies, as on the face, great care being taken to compress the vessels around the tumor to prevent the escape of the fluid into the general circulation. III. THE CAI'ILLARIES. The capillaries may form vascular or erectile tumors, consisting almost exclusively of vessels held together by connective tissues. The plexiform angioma, telangiectasis, cutaneous naevus, is com- posed entirely of dilated and tortuous capillaries and anastomosing vessels, and occurs almost exclusively in the cutis ; they may be of a dark cherry, or a steel-blue color, according as the superficial or deep-seated vessels of the cutis are involved ; they are sometimes as large as a pin's-head, and again as a henip.seed; some are moderately thick, others scarcely rise above the level of the skin; as a rule, this proliferation of vessels does not extend beyond the subcutaneous cellular tissue, their growth is always slow and painless;* they fre- quently not only cease to enlarge, but undergo a gradual contraction and obliteration; hence the propriety of treating them at first with mild remedies, as pressure, applications of collodion, vaccination. If more radical measures become necessary, inject persulphate of iron, using precautions by pressure around the growth ..-;^-. to prevent the entrance of coagula into the cir- .••;•' culation; or pass red-hot needles under it at ^ several points and secure a slough. Strangu- '^ lation of the mass by subcutaneous ligatuif, ^'-^'^ when the growth is accessible, is adapted to the larger najvi, and may be applied in many ways, as follows: (1) The single ligature; strong whip ^'*"'- ^~^' cord (Fig. 175), is carried around the tumor by entering it at one point and carrying it as far as possible round the l»a>;e. then emerwin" 1 T. Billroth. 2 x. Holmes. 232 OPERATIVE SURGERY. Fig. 176. round the half (Fie Fig. 177. 176). For a large nae- and reentering at the same puncture and carried around another por- tion, until it reaches the point of first entrance, where the two ends are firmly tied; (2) or, if the growth is too large, the ligature may be carried, double, under the tumor, and then each section may be carried as before, and tied vus the following knot may be made : ^ Pass the needle under the centre of the tumor (Fig. 177), divide one thread near "^\___^^_,a8!^«rTX. the needle; pass the other end of the ligature into the needle's eye; now enter the needle at a Fig. 179. quarter of the circumference and pass it under the base at right angles to its former direction (Fig. 177;) before tying the ends make a lunated in- cision between each puncture into which the lig- W^^i^ ature sinks; finally, tie the opposed ends (Fig. 179). If the tumor is elongated in form the ligature may be applied as follows (Fig. 180): Pass a double ligature under its base from side to side; color the end of one ligature white and the other black; leave each loop long, the whole ligature being of great length; divide the white loops on one side and the blnck on the other, and tie the pairs of white and black strings tightly; the skin Fig. 178 is destroyed by this method.^ CHAPTER XXIII. GENERAL OPERATIONS ON THE CIRCULATORY SYSTEM. I. THE HE.\RT. The only general operation on the heart and pericardium is un- dertaken for the relief of dropsy. In order to perform any opera- tion upon this organ it is important to be able to define its normal position. 1 Sh- W. Fergusson. 2 T. Holmes. OPERATIONS ON THE CIRCULATORY SYSTEM. 233 That part of the heart which lies immediately behind the wall of the chest, and is not covered by lung, is sulliciently defined for all practical purposes by a circle two inches in diameter round a point midway between the nipple and the end of sternum; the apex pulsates between the fifth and sixth ribs, two inches below the ni[)ple, and one inch to its sternal side, this point varying sli{;htly witli the position of the body, and with inspiration and expiration. i Paracentesis of the pericardium is practiced as follows: The most prominent point beinjr carefully determined, select the left fifth intercostal space, from two fifths of an inch to two inches from the sternum, accordinir to the prominence of the sac;^ make an incision a Httle more than an inch long parallel to the ribs in the centre of the space commencing about two fifths of an inch to the left of the sternum; carefully divide the layers of muscle until an elastic dila- tation is felt which resists under pressure with an indistinct impulse of the apex of the heart ; make a slight puncture and introduce a small trocar ^ or the aspirating needle. II. THE ARTERIES. The general operations upon the arteries are arteriotomy and iiga- tion. The arteries possess considerable strength and a high degree of elasticity, being both extensible and retractile in width and length; they are inclosed in a sheath of connective tissue and have three independent coats, namely, inter- nal, middle, and external; the internal coat consists of epithelium and elastic tissue; the middle of muscular fibres disposed circularly round the vessel, and the external of elastic and connective tissue; arteries are accompanied by one or more veins, and nerves.* Arteriotomy, very rarely practiced, is performed to secure sud- den loss of blood and thus make a profound impression on the sys- tem or relieve sudden congestion. The temporal artery is prefeiTed, and the anterior branch selected. Incise its coats obliquely with a sharp-pointed lancet or bistoury, and when suflScient blood has flowed, divide it completely, and apply a compress and bandage. The ligation of an artery is still the more conmion method of radically treating aneurisms. Before the operation the following facts should receive due consideration: — 1. The instruments rerpiired are a scal|)el, forceps, aneurismal neepar;itus should be used during the operation, or a carbolic solution should be thoroughly applied to the wound after the ligature is a[)p]ii'd. 3. The precise location of the artery is determined, (1) By its pulsations; (2) l)y given anatomical points in the vicinity. To ren- Fig. 184. der the former distinct, ihe limb should be placed in a position fa- vorable to arterial circulation ; to render muscles and tendons most distinct the limb should be forcibly extended at the comniencenient of the operation. When the dissection has proceeded so far as to reach the vicinity of the artery, the operator is aided in detecting its position by fle.xing the limb so as to relax the muscles and tis- sues. The point of application of the ligature, when it is applied for anein-ism, will depend uj)on the situation and condition of the aneurism. It should be applied (1) on the cardiac side at a dis- tance from the tumor, 2 (Fig. 185), ^ when the artery can be tied with comparative ease and safety, as the femoral for popliteal aneurism; (2) on the cardiac side, near the tumor, 1 (Fig. 185),- when the space between the tumor and important parts on the proximal side is slight, and the artery in this space is sound, as the ex- ternal iliac for aneurism of the femoral near Pou- part's ligament; (3) on the distal side, 3 (Fig. 185), 8 when the proximal ligature is impossible, as the axillarv for subclavian aneurism; (4) on a distal branch, 4 (Fig. 185),* when the cardiac and distal ligature of the main trunk is impracticable, as in the subclavian for innominate aneurism; (5) at the aneurism, the old operation, when the tumor is so situated that it is inadmis- sible or impracticable to ligate the trunk on the cardiac or distal side. 4. It is important, before the first incision is made, to ^uard ag.ainst wounding; superficial veins. Their position is readily defined by compressing the parts above the point of the proposed operation. 5. The operation involves several consecutive steps: When the first incision is about to be made, the skin should be rendered tense by the thumb and fingers of the left hand applied on either side of the vessel, or the fingers applied at the extremity of the proposed incision, parallel to its course ; if the first method is chosen, care 1 J. IIiMiter. 2 Anel. * Brasdor. ■» Wardrop. 236 OPERATIVE SURGERY. Fig. 186. must be taken not to make more traction on one side than on the other. The second method answers where the skin is naturally tense and but slight traction is necessary. Hold the scalpel in the second or third position (Figs. 27, 28); make the incision directly over and parallel to the artery, through the skin only if the artery is superficial, but also through the cellular tissues if it is deep, its length varying with the depth of the vessel and the adipose tissue. The incision is sometimes made in the direction of the fibres of the muscle covering the arter\', as where the great pectoral overlies the axil- lary ; at other times it should be curved, so as to raise a flap. The length of the incision cannot be prescribed, but it should always be ample. Pinch up the fascia carefully with the forceps (Fig. 186), nick it with the scalpel applied horizontally; incise freely on a director introduced beneath. In dissect- ing among muscular structures enter the muscular interstices, and not wound the substance. These inter-muscular spaces are marked by deposits of fat, especially towards the ter- minal extremity of the muscles, and hence we should commence the separation of muscles as nearly as possible at their terminal ex- tremity. If there is doubt as to the line of separation, a puncture will disclose adipose or muscu- lar tissue, according to the na- ture of the underlying struc- ture. If the dissection is made through the body of the mus- cle, the fibres separate more readily in an inverse direction, namely, from their origin to their attachments. The mus- cles mny be separated with the handle of the scalpel or the finger nail. The larger arte- FiG. 187. ries have firm sheaths, which require to be opened by dissection; the smaller vessels have but slight fibrous investments, and are readily exposed with the point of a director, or the aneurism needle. The sheath opens by jjinching up a small portion with the forceps, and nicking it slightly with the scalpel ; into the opening thus made, introduce the director or the needle, and by slight movements of its point, first upon one side and then upon the other, separate the sheath completely around the vessel, to an extent sufficient to allow simply the passage of the lig- OPERATIONS ON THE CIRCULATORY SYSTEM. 237 ature ; as the extremity of tlie instrument emerges on the opposite side, with the fiiigir of the left hand, or the thumb and fort-finger pressed together, steady its point as it penetrates the last portion of the sheath. If the artery is small and very superficial, a director may be passed under, and along its groove, a blunt needle carrying the ligature. If more deeply situated, the common aneurism needle (Fig. 182), or the double-eye needle (Fig. 183), shoul -■ • Sternal attachments of tlie \^ -.VIL sterno-deido mastoid mus- X^ cle; this interval is marked by a depression above the clavicle, at the articulation f .1 1-1 If Fig. 190. or the clavicle and sternum ; fle.\ the head ; slightly sej)arate the internal portion of the muscle, «, from the external, I) ; divide the sterno-hyoid and tliyroid on the di- rector; the innominate, h: the common carotid, e: the pneumogas- tric, (I, and its branch, the recurrent laryngeal; the origin of tlie subclavian, r/, and its branches, the vertebral, c, and inferior thyroid, are now readily seen. 3. The common carotid arteries extend on the right side from the innominate, and on the left from the highest jioint of the arch of the aorta, to the upper border of the thyroid cartilage ; the direction is obliquely from before backwards, and from within outwards, along the external side of the trachea and larynx, in a line drawn from the sternal end of the clavicle, below, to a pcjint midway between the mastoid process and angle of the jaw above. Its sheath is derived from the deep fascia, and contains the internal jugular vein and the pneumogastric nerve, the vein being external, and the nerve between. (a.) At the base of the neck the artery is deeply seated, and a ligature should be applied at this point only from necessity. In front is the platysma, superficial and deep fasciip, the sterno-mastoid, sterno-hyoid, and sterno thyroid muscles; externally it is in relation with the pneumoga-^tric nerve and internal jugular vein; internally with the trachea; posteriorly with the longus colli and rectus aaticu^s major muscle; the internal 240 OPERATIVE SURGERY. jugular of the right side recedes from the artery, but on the left approaches and often overlaps it. The carotid tubercle is a guide to the position of the ar- terj';! this tubercle is the anterior projection of the transverse process of the sixth cervical vertebra, which is two inches above the clavicle, and is a precise guide to the artery when the neck is straight; it corresponds in front and a little inside to the artery. Operate as follows (Fig. 191) : ^ Place the patient on the back, the Fig. 191. head extended and inclined to the opposite side ; recofjnize the in- terval between the two attachments of the sterno-mastoid muscle, and make an incision from the clavicle, two and a half inches, obliquely, along this interspace; divide the skin, platysma, and deep fascia; draw the internal portion of the muscle, c, inwards, and the external, a, outwards, by means of spatulas ; this exposes the internal jugu- lar vein, bs and the pneuniogastric nerve, e, lying between the vein, b, and the artery, f, and the onio-hyoid muscle, d, crossing the upper part of the wound ; open the sheath and pass the needle from with- out inwards, carefully avoidincr the internal jugular vein and par vagum ; a finger pressed upon the vein at the upper part of the wound will cause it to collapse. (6.) Below the omo-hyoid the artery is much more accessible. It is covered by the integument, the platysma, the superficial and deep fascite, the sternal part of the sterno-mastoid, the sterno-hyoid and thyroid muscles; it is crossed obliquely, from within outwards, by the sterno-mastoid artery, also by the superior and middle thyroid veins, and lower down by the anterior jugu- lar; on the outer side are the pneuniogastric nerve and internal jugular vein, and on the inside are the inferior thyroid arter}- and recurrent laryngeal nerve, which separates it from the trachea and thyroid gland; the descendens noni nerve lies on the sheath of the artery. Operate thus (Fig. 192) : Place the patient on the back, with the head thrown back ; make an incision three inches in length along the inner border of the sterno-mastoid muscle, in the line above given ; 1 Chassaignac 2 Sedillot. OPERATIONS ON THE CIRCULATORY'' SYSTEM. 241 commencing on a level with the ericoiil cartilage, pucce.s^ivcly divide the skin, superficial fascia, phiiysnia, and deep fascia, and expose the inner l)or(icr of the stcrno-mastoid, e ; carefully avoid the sterno-mas- toid artery and midiUe thyroid vein; throw the licad forward and draw the sterno-mastoid muscle outward, and the sterno-liyoid and thyroid muscles inwards; expose the anterior belly of the omo-hyoid muscle, a, which should be drawn upwards; divide the deep fascia; Fig. 192. expose the sluath of the vessel; open it directly over the artery, avoiding carefully the descendens noni, which runs along the tracheal side; press the pneumogastric nerve, d, and internal jugular vein, c, outward, and pass the needle from without inwards, carefully isolating the vessel from tlie inferior thyroid artery, and recurrent laryngeal nerve which lies behind it. The thyroid body may be so large as ti> mislead as to the marj^in of the mus- cle, and then requires careful dissection; if the onio-hyoid muscle interferes with the operation it maj' be turned aside, or even divided by dissection. (c.) Above the omo-hyoid the artery is still more superficial, being covered only by the skin, the two fascia?, platysma, and the border of the sterno-mastoid; it is in relation internally with the larynx and pharynx, and externally with the pneumogastric nerve and internal jugular vein. Operate as follows: Place the patient on the back, the shoulders raised, and the liead turned to the oppo- site side; make an incision from a little l)elow the angle of tlie jaw, in the line given, along the internal border of the sterno-mastoid, three inches in lengili: divide the integuments, superficial fascia, and platysma; raise the deep fascia carefully on a director; avoid the small imderlying veins; flex the head to relax the muscles, and draw the wound apart by spatulas; avoid the descendens noni nerve and superior thyroid arteries, and open the sheath over the artery ; if the internal jugular vein swell up into the wound, compress it in the upper and lower part of the wound, and draw it outwards; pass 16 242 OPERATIVE SURGERY. the ligature from without inwards, the point of the needle being kept close upon the artery, to avoid wounding the vein or including the pneumogastric nerve. 3. The external and internal carotids arise from the common trunk at the upper border of the thyroid cartilage, the external being more superficial and internal at their origins. They occupj' the triangle formed by the stenio-mastoid beliind, the omo-hyoid below, and the posterior belh^ of the digastric and stylo-hyoid above; and are crossed by the hypo-glossal nerve, and the lingual and facial veins. Operate as follows: Make an incision along the inner margin of the sterno-mastoid, three inches in length, from the angle of the jaw to the cricoid cartilage, through the skin, platysma, superficial and deep fascia ; the internal margin of the sterno-mastoid now appears; cautiously separate the cellular tissue, and the wound being drawn apart, the artery is exposed ; draw the digastric muscle and hj'po- glossal nerve upwards, and the internal jugular outwards; both ar- teries mny now be ligated or either artery separately. The carbol- ized catgut ligature should be used and the wound closed to avoid all suppuration. 4. The external carotid artery ascends from its origin at first, slightly forwards, then backwards, to the space between the condyle of the lower jaw and the meatus auditorius; above the digastric the artery lies more deeply and is crossed by the stylo-hyoid muscle. Operate thus : Make an incision from the lobe of the ear to the great cornii of the hyoid bone, along the inner margin of the sterno-mas- toid ; divide the skin, platysma, and fascia; seisarate the posterior belly of the digastric and stylo-hyoid from the parotid gland, by depressing the muscles, and the artery will be exposed. 5. The superior thyroid artery arises from the external carotid, just below the greater cornu of the hyoid bone, and passes inwards to the thyroid gland in a tortuous course ; it is at first sujierficial, lying in the triangle formed by the sterno-mastoid, digastric, and omo-hyoid muscles. It is ligated thus: Place the head in an extended position ; make an incision an inch and a half along the internal bor- der of the sterno-mastoid, the centre of which corresponds to the great cornu of the thyroid cartilage; incise the skin and platysma; draw the sterno-mastoid outwards and expose the omo-hyoid muscle, internal jugular vein, and primitive carotid artery; the artery lies between these vessels and the lobe of the thyroid body, and is read- ily ligated. 6. The lingual artery is the second branch of the external ca- rotid ; it arises just above the superior thyroid, ascends to the great • cornu of the hyoid bone, rinis parallel with it and passes directly to the base of the tongue (Fig. 193). Turn the head to the opposite OPERATIONS ON THE CIRCULATORY SYSTEM. 243 side; make an oblique incision an inch and a half in Icni^th, a little above the body of the hyoid bone, and parallel with it, near the median line, and curved backwards, outwards, and downwards, par- allel with the superior border of the great cornu of the thyroid car- tilage; divide the superficial parts and with the finger recognize the direction of the great cornu : divide upon it the aponeurosis which covers the deep parts ; this exposes the digastric muscle, the sub- maxillary gland, hypoglossal nerve, and stylo hyoid muscle, a; now isolate the great cornu of the hyoid bone, and the fibres of the hyo- glossus muscle, which are attached at this point, come into view; Fig. 193. divide this muscle at the superior border of the great cornu ; draw it upwards and backwards, and the artery is found behind it; the needle should pass from below upwards. Or, having recognized the position of one of the greater cornua of the hyoid bone, make an incision about an inch in length, parallel with, and about two line« above it, through the skin, cellular tissue, and platysma; this incision will expose the lower border of the submaxillar}' gland, on lifting which slightly, the shining tendon of the digastric will be recognized; less than a line below this lies the hypoglossal nerve, and at the distance of a line below the nerve, a transverse incision through the fibres of the genio-hyo-glossus muscle will certainly expose the artery, which, in this situation, is accompanied by neither vein nor nerves. l 7. The facial artery (Fig. 194) passes over the lower jaw, at the anterior border of the masseter muscle, a; it lies on the periosteum, and in a groove which is recognized at the junction of the jiosterior third with the anterior two thirds of the body of the bone; the facial vein lies on the outer side. The pulsation of the artery being recog- nized, make an incision an inch in length, along the course of the vessel, as already given, through the skin, fascia, and platysma; the wound being separated, and the fibrous tissue divided, the artery, c, 1 J. F. Malgaigne. 244 OPERATIVE SURGERY. is exposed, and the vein, &, and masseter muscle, a, are drawn out- wards, and the needle passed. 8. The temporal artery (Fig. 194) runs upwards towards the temporal region from its origin at the condyle of the jaw, in front of the concha; two inches above the zygoma it divides into the anterior and posterior branches. Recognizing the position of the artery by its pulsation, at a point above the zygomatic arch, and in front of Fig. 194. the ear, make an incision through the skin, an inch in length; di- vide the dense cellular tissue on a director, and the artery, a, will be exposed ; pass the needle from behind forwards to avoid the tem- poral vein, h, and the auriculo-temporal nerve. 9. The occipital artery arises from the external carotid, opposite the facial, ascends to the space between the transverse process of the atlas and the mastoid process, and passes up upon the occiput. (a.) At its origin the artery is covered by the stylo-hyoid and di- gastric muscles, and the hypoglossal nerve winds around it from behind forwards. Make an incision along the inner border of the sterno-mastoid muscle, two inches in length, at the angle formed by this muscle and the digastric ; the deep fascia being carefully divided, expose and isolate the artery, the nerve being carefully protected. (ft.) Behind the mastoid process (Fig. 195) the artery passes up- wards, in a tortuous direction, and divides into branches, upon the occiput ; it is covered by the sterno-mastoid and splenius muscles. Make ;in incision one inch long, half an inch behind and a little beneath the mastoid process, obliquely upwards and backwards ; di- OPERATIONS ON THE CIRCULATORY SYSTEM. 245 :.J....t vide the skin and aponeurosis of the sterno-mastoid muscle, c, as also tlie splenius muscle, through the whole length of the wound ; the pulsations of the artery, a, are recognized by the finger a little \ above the oblique muscle, />, and it is isolated from its veins. 10. The internal mammary artery ari-es from the subcla- vian, and descends behind the clavicle on the inner surface of the costal cartilages near the sternum. The internal jugular and subcla- vian veins and the phrenic ner\'e cross the upper part; in the chest it at tirst Hes on the costal cartilages and intercostal muscles, covered by the pleura behind ; but lower it is cov- ered also bv the triangularis sterni Fig. 195. muscle; it may be tied in the second, third, or fourth intercostal spaces. Make an incision along the upper edge of the rib, commencing at the sternum, in either space, slightly upwards, and outwards, an inch and a half in length; divide the skin, cellular tissue, pectorahs major muscle, fa.«cia, and intercostal muscle successively ; a thin layer of cellular tissue is expo.<5ed, which conceals the artery; j)ass the needle cautiously from within outwards. 11. The vertebral artery arises from the subclavian artery in the first part of its course, and passes directly along the spinal colimin, to the foramen in the transverse process of the sixth cervical verte- bra, and along the canal to the brain. («.) Before entering the vertebral canal the artery passes behind the internal jugular vein and inferior thyroid artery, to the spine, where it lies between the scalenus anticus and the longus colli, and in a line drawn from the posterior part of the mastoid process to the junction of the internal fourth with the external three fourths of the clavicle. Place the patient on the back, the shoulder depressed, and the head turned to the opposite side; make an incision three inches in length along the inner border of the sterno-mastoid mus- cle, between it and the sterno-hyoid, terminating at the middle of the upper extremity of the sternum; divide the skin, cellular tissue, and the aponeurosis uniting the sterno-mastoid muscle and sterno- hyoid ; bring into view the common sheath of the carotid, the in- ternal jugular, and the pneumogastric nerve; separate with the finger the cellular connection of the sheath with the sterno-thyroid muscle, and finally with the longus colli; the head is now raised, though still 246 OPERATIVE SURGERY. turnt'd to the opposite side, and the sides of the wound forcibly sep- arated; divide tlie cellular tissue at the bottom, and expose an apo- neurosis which passes from the scalenus anticus to the lougus colli, and the anterior part of the transverse process of the sixth cervical vertebra, the carotid tubercle; then open the aponeurosis an inch below this point, at the external border of the lonj^us colli muscle; the artery is exposed very deeply. (6.) Between the atlas and axis the artery lies in a triangular space formed by the rectus posticus minor and superior and inferior oblique muscles, and is covered by the rectus posticus major and com- plexus. Turn the head to the opposite side, and incline it forwards; make an incision two inches long on the posterior edge of the sterno- mastoid, commencing half an inch above the mastoid process; make a second incision, an inch in length, from the upper fourth of the first incision backwards and obliquely downwards; divide the skin and cellular tissue; then the splenius muscle with its fibrous expan- sion; a fibrous layer now appears, which must be cautiously divided to arrive at the small arteries which lie beneath it; the edges of the wound being separated, a layer of fat appears, which is cautiously opened with the finger or handle of the scalpel, and the artery is found within; the two branches of the occipital artery are to be drawn aside, as also branches of the second cervical nerve; the ar- tery is isolated, and the needle passed from without inwards to avoid the internal carotid artery. (c.) Between the atlas and occiput the anatomical relations are as given above. The incisions are the same as in the last operation, except that the first commences one fourth of an inch above the mastoid process; divide the skin, fascia, and splenitis muscle; the occipital artery appears at the upper angle of the first wound, and is held aside; divide the underlying aponeurosis, with the cellular tis- sue; separate the edges of the wound, and in a triangle formed by the muscles of the part, the cellular tissue, loaded with fat, covers the artery; divide this and the artery is exposed; pass the needle from behind forwards. 12. The inferior thyroid artery is a branch of the thyroid axis; it ascends the neck obliquely, passing behind the internal jugular, the pneumogastric nerve, the carotid artery, and omohyoid muscle, to the thyroid body. It may be ligated through the same incision as is made for the ligatui'e of the common carotid (Fig. 190). ARTERIES OF THE UPPER LIMB. The following general rules should guide in the ligation of arteries of the upper extremity for aneurism : — Aneurism of the subclaviaa is usually fatal if left to itself,i and surgical treat- 1 T. Holmes. OPERATIONS ON THE CIRCULATORY SYSTEM. 247 Itient ff»;ni'rally only liustens death; if it occurs in tiic first or second part of the artery the ligature can only be applied to the innominate, if in the third part of the rijjht, it must he applied to the first part of the same vessel, but botli operations have proved so uniformly fatal that tiiey do not warrant the trial. The carbolized eatgut ligature, used with all necessary antiseptic precautions, may prove entirely successful, as it does not involve the danjjers of the division of the coats of the artery, nor of suppuration in the wound. i Axillary aneu- rism should lirst be treated by compression of the subclavian in its third part with the fingers or an instrument; if this fail, liyatui'e of the subclavian in its third iiart may be resorted to. Or, especially in traumatic aneurism, the sac may be laid open, and the vessel found and tied,- |)ressiire being made upon the sub- clavian over the lirst rib, an incision being- made if necessary to reach the artery; the relation of the artery to the sac and the nerves is very variable. ^ Aneu- risms of the vessels of the arm and forearm, if spontaneous, are commonly asso- ciated with disca.se of the heart or general arterial degeneration, and ought not to be actively treated ;3 if traumatic, they should be laid open and the vessel tied at the point where it is torn. 1. The subclavian artery arises from the iimominate on the right side, and from the arch of the aorta on the left; it extends in a curved direction from its origin to the lower border of the first rib. (rt.) Within the scaleni, on the right sidi-, the artery passes up- wards and outwards from its origin from the innominate across the neck to the internal border of the scalenus anticus muscle. It is very deeply situated, and lies upon the pleura; its anatomical relations are, in front, the skin, fascia', platysma, origin of sterno-mastoid, sterno-hyoid, and thyroid muscles ; it is also crossed by the pneumogastric, cardiac, and phrenic nerves, and by the internal jugular and vertebral veins; behind, it is in relation with the recurrent laryngeal and .sympathetic nerves. On the left side the artery extends from the left portion of tlie arch of the aorta to the scalenus anticus, situated very deeply, and passing upwards, almost vertically; in addition to the anatomical relations of the light, the left has in front the plein-a, the lung, and the carotid, and internally the a>sophagus, trachea, and thoracic duct. (6.) The right subclavian is ligated thus: Place the patient on his back, the shoulders raised, and the head turned to the opposite side; make two incisions, one parallel with the inner part of tlie clavicle, and the other along the miw.v border of the sterno-mastoid; pass a director behind the sternal attachment of the sterno-mastoid, and divide the cellular tissue; avoid small arteries and veins in this part, and especially the anterior jugular; divide the sterno-hvoid and thy- roid muscles on a director; open the deep fascia with the finger-nail, or end of tlie director, and expose the internal jugular, which being pressed aside, pass the needle around the artery from below upwards to avoid the pleura. The left subclavian is ligated thus: Place the patient in the position above descril)ed; make an incision three and a half inches long on the inner edge of the sterno-mastoid, ter- 1 J. Li.-.tu-. 2 J. Svnie. 3 X. llclmes. 248 OPERATIVE SURGERY. minating at the sternum, thi-ongh the skin and platysma; this is met by another incision along the sternal extremity of the clavicle, two and a half inches; dissect the flap and divide the sternal and half the clavicular origin of the sterno-mastoid on a director, and raise the flap ; divide the deep fascia with the handle of the scalpel and the fin- gers ; continue the dissection along the outer side of the deep jugular vein to the inner edge of the scalenus anticus muscle, half an inch above the rib, to avoid the thoracic duct; the phrenic nerve is de- tected and avoided, and the fingers pressed to the bottom of the wound discover the rib, and then the artery; pass the needle from below upwards.! (c.) Between the scaleni the artery is very short; it is covered bv the integuments, platysma, sterno-mastoid, and the scalenus an- ticus, upon which lies the phrenic nerve; below is the pleura and above the brachial plexus. The ligature has seldom been applied at this point. Make a deep incision; the tubercle of the rib being recog- nized, and the insertion of the muscle into it, pass the director behind it and between the muscle and the artery, and with a bistoury, divide the muscle; its retraction exposes the artery, which is readily ligated; pass the needle from without inwards. Or, divide the muscle from without inwards, commencing some distance from the rib. The phrenic nerve is liable to be divided, unless this proceeding is adopted; the internal mammary artery may be wounded if the in- cision is too near the rib. (J.) Outside of the scaleni muscles (Fig. 196) the artery, h, passes downwards and outwards, lying in a groove on the first rib. It first passes through the supra-clavicular triangle, and is then covered only by the deep fascia, the platysma, and skin; lower in its course it is covered by the clavicle and subclavian muscle; the subclavian vein, h, lies lower and in front of the artery, separated from it by the insertion of the scalenus anticus muscle, c; the external jugular vein crosses in front of the artery; the brachial plexus of nerves lies above and behind the artery. The depth of the artery may vary from one to three inches, according to the depth of fat. Search for the artery (Fig. 196) in the supra-clavicular triangle, which is bounded externally by the omo-hyoid muscle, internally by the scalenus anticus, and below by the first rib; place the patient on his back, tlie shoulders depressed, and the head turned to the opposite side; the skin over the parts being drawn down upon the clavicle, make an incision nlong the bone, from the anterior border of the tra- pezius to the posterior border of the sterno-mastoid, e : divide the platysma and superficial fascia, care being taken to draw the exter- nal jugular outward, or, if cut, to tie the ends; with the director and finder separate the cellular and fatty tissue, and draw the omo-hyoid 1 J. K. Rodgers. OPERATIONS ON THE CIRCULATORY SYSTEM. 249 inusL-le aside; divide the deep fascia and the border of the scalenus, d, being defined, pass the finger along its margin down to the first rib, recoiinize the tubercle for the attachment of that muscle, just external to which the artery, 6, will be felt pulsating; separate the attachments of the artery with the finger nail, and gently insinuate the aneurism needle beneath it, from before backwards and slightly Fig. 196. from within outwards, avoiding the vein, c ; guide the point of the needle bv the end of the finger, and prevent it, when it emerges upon the opposite side, from engaging a branch of the brachial plexus, a. It must be remembered that the stevno-mastoid may have an unusually ex- tended insertion upon tlie clavicle, as also the trapezius, in which case the in- cision must involve the clavicular attachments of the former; the external jui^ular may run so near to the sterno-mastfiid as to be involved in the in- cision, unless it is carefully isolated and drawn to the outer or inner side; the transverse cervical and supra-scapular arteries may be met with in tliis dissec- tion, and if wounded should be immediately lii]C''>ted; the tubercle of the rib is sometimes not well defined, in which case the attachment of the scalenus to the rib is the y;uide to the artery, which is found just posterior to its insertion. 2. The axillary artery extends from the lower border of the first rib to the l(jwer margin of the tendon of the latissimus dorsi, or the inferior l)i)undary of the axilla, in a line dividing the anterior and middle third of the axilla. It may be liorated in two places. (a.) Below the clavicle (Fig. 197) in its upper part, the axillary artery is covered successively by the insertion of the pectoralis minor, / .• higher up by the pectoralis major muscle, j, from which it is separated by a layer of adipose tissue, containing numerous small veins and arteries; and finallv by the fascise and the skin. The suprascapular artery, n, crosses the base of the neck just above the clav- icle; the a.\illary vein, /(, in front and to the inner side of the artery, is not in immediate contact with it; the ceplialie vein passes upwards in the interspace between the deltoid and pectoralis major muscles, crosses the axillary arterv above the pectoralis minor, and empties into the axillary vein: the nerves, b, of the brachial plexus, c, lie behind and above; a thoracic branch often crosses the artery, sometimes in front, and sometimes behind it. 250 OPERATIVE SURGERY. Place the patient on his back, with his shoulders slightly raised, the elbow a little separated from the body, and the head inclined to the opposite side ; make an incision three inches in length, three quarters of an inch below the clavicle, and commencing about two Fig. 197. inches outside of the sterno-clavicular articulation, through the skin, platysnia, and subcutaneous cellular tissue; separate the fibres of the pectoralis major gradually until the posterior investment of this muscle, like an aponeurosis, appears; now depress the shoulder and tear this fascia with the point of the director; press downwards and outwards with the finger the upper- border of the pectoralis minor, Fig. 198. when the axillary vein is brought to view; draw this gently forward with a blunt hook, and behind it the artery is found, with the nerves of the brachial plexus still further behind and above ; pass the needle from within outwards. Or (Fig. 198), make a transverse incision three inches in length, through the skin and platysma, along and upon the lower edge of the clavicle, three lingers' OPERATIONS ON THE CIRCULATORY SYSTEM. 251 breadth from the sternal extremity of that bone, and terminatinf^ an inch from the acromion process of tiie sca[)ula; make a second incision, three inciies in lengtli, obiiqueiy througli tlie integuments, over tlie deltoid and pectoral mus- cles, meeting the first nearly in the centre; remove the cellular membrane and fat ; detach the clavicul/ir portion of the pectoralis major, r/, b, and remove the cellular tissue overlying the subclavian vessels; the artery now appears and its pulsations are detected ; the pectoralis minor, c, and the margin of the del- toid, d, are brought to view, and the artery, e, is isolated from the vein, a, lying in front, and the brachial plexus behind. (J).) Ik-low the i)t'ftoralis minor, in its lower half, the artery is superfieial, covered only by the integuments and deep fascia. The coraco-brachialis muscle is in h contact with the artery, which may be found at its internal anil jjosterior bor- der; the brandies of the brachial plexus of nerves surround the artery, the mus- culo-cutaneous lies along the outer side ; the two roots of the median meet in front, at the lower border of the pecto- ralis minor; the nerve then lies in front and to the outer side of the artery; the internal cutaneous lies in front and to its inner side; the ulnar anil radial are still further within and behind ; the axilhiry vein is in front of the artery and nerves, which it partly conceals. Place the patient (Fig. 199) on the back, the arm rotated out- wards : stand on the outside if Fig. 199. it is the right arm, and on the inner side if the left, and recognizing the inner border of the coraco-brachialis muscle, g, and the pulsa- tions, make an incision two or three inches in length in the line in- dicated, h, dividing only the skin ; incise the fascia on a director; with the end of the director, the axillary vein, n, is first pushed back- wards, then the brachial ple.xus; the median nerve, c, is now recog- nized, and being brought forward, while the internal cutaneous, e, and ulnar, d, are pushed backwards, the artery, f, is exposed; sepa- rate the artery carefully from the vein, which is pushed backwards, and the nerves which surround it, and pass the needle from behind forwards. 3. The brachial artery extends from the lower margin of the ax- illa to an inch Iji'low the bend of the elbow, in a line drawn from the junction of the anterior with the middle third of the axilla to the middle of the bend of the elbow. (rt.) In the upper third, the arm being extended as before, make an incision two and a half inches in length along the inner border of the coraco-brachialis; the artery is readily exposed, lying between 252 OPERATIVE SURGERY. and behind the median and ulnar nerves, the former to the outside, and the latter to the inside. (6.) In the middle of the arm the brachial descends on the inner side, first of the coraco-brachialis, and afterwards of the biceps. It is covered by the fascia and integuments, and overlapped slight!}' by the biceps; its sheath contains the two venaj comites; the internal cutaneous nerve lies superficial to it; the median is superficial to it above, and rather to its outer side; about the middle of the arm, it crosses the arter^', and interiorly it is to its ulnar side: the ulnar nerve is internal to the artery, and at some distance from it inferiorl}'; the spiral nerve is posterior, and separates it above from the triceps. (Fig. 200.) The arm being extended and carried at right angles to the body, and held supine, the course of the artery may be recog- nized, by its pulsation; by the internal margin of the biceps and d c coraco-brachialis; by the median nerve, to the in- ner side of which it lies; by the line above given. Make an incision two or three inches in length, along the inner border of the biceps, down to the fascia, which incise on a director; the position of the median nerve, b, is de- tected in the wound ; push Fig. 200. it aside with the biceps, d; the artery, c, is found immediately behind and inside, accompanied by its vena; comites, a. The arm is now flexed, the vessel isolated, and the ligature passed from without inwards. If the incision is made a little too far back the ulnar nerve is exposed, and is liable to be mistaken for the median ; and this error may be confirmed by the presence of the vein, occupying the same relative position as the brachial to the median, which niaj' be mistaken for the artery. If it is remem- bered that the ulnar nerve here passes down- wards and backwards, the error will be rec- tified. The brachial may have a high divis- ion into the radial and ulnar; or it may have a high division, and the branches again unite in the arm. a he d ef Fig. 201. (c.) At the elbow the brachial artery lies in the centre of a trian- OPERATIONS ON THE CIRCULATORY SYSTEM. 253 gular space, foriiu-d by the supinator longus, externally, and the pronator radii teres, internally. It rests on the brachialis anticus; the median nerve lies to the inner side half an inch; the tendon of the biceps lies on the outer side; its coveriiij^s are the skin, superficial fascia, and the median basilic vein, which is separated by the bicipital fascia. The arm extended and held in a supine position (Fig. 201), make an oblique incision, two inches and a lialf in length, along the inter- nal edge of the tendon of the biceps, within the median basilic vein, dividing only the skin; push aside the vein and divide the aponeu- rosis, which is the deep fascia, e, on a director; the tendon of the biceps, c, is now seen, and on its inside the artery, a, with its two veins, and still farther in- ward the median nerve, h; slightly flex the forearm, and pass the needle from within outward, carefully avoiding the veins. 4. The radial artery, though the smaller liranch of the brachial, lie? in the direct course of the latter like a continuation ; its course is marked by a line drawn from tlie centre of the elbow to the inner side of the styloid process of the radius; is superficial throughout nearly its entire course; the needle may be passed in either direction. (a.) In the upper third the artery lies between the supinator longus and the pronator radii teres; it has vena? comites; the radial nerve lies immediately on its external side (Fig. 202). The limb being ex- tended supine, the superficial veins maile prominent bv pressure of the thumb above, make an incision two to three inches in length, on the internal border of the supinator longus, if recognized by the depression, or on a line drawn from the middle of the bend of the elbow to the inner side of the styloid process of the radius, dividing the skin and superficial fascia; divide the deep fascia on a director; flex the arm slightly to relax the muscles; the supinator lono^us, a, being drawn aside, the sheath of the artery, b, is exposed; pass the needle from without inwards. (ft.) In the lower third of the arm the artery is situated super- ficially, lying between the tendons of the supinator longus and the flexor carpi radialis ; it is accompanied by venae comites, and by the radial nerve which lies external; its pulsation is easily detected 254 OPERATIVE SURGERY. Fig. 203. (Fig. 203). The arm held supine, the hand forcibly extended to make prominent the flexors, and the operator standinjj on the external side of the limb, make a liiiht incision, two inches in length, from half an inch above the articulation of the radius, on the exter- nal border of the flexor carpi radialis, or on a line joining the external with the three internal fourths of the arm; the deep fascia, a, is raised on a director, exposing the ar- tery, c, with its two veins, b, and the nerve, d, external and posterior; the needle may be passed in either direction. (c.) On the dorsum of the wrist (Fig. 204), the artery passes in the groove be- tween the upper extremities of the first metacarpal bones; a fibrous band separates it from the tendons of the thumb. It may be tied, just as it is about to form the palmar arch, or, as it passes under the extensor muscle of the thumb, between the extensor primi internodii and the extensor secundi internodii pollicis, a little below and pos- terior to the extremity of the styloid process of the radius. At the commencement of the palmar arch, make an incision of an inch in length along the outer borders of the extensor secundi and metacarpi pollicis, at the angle formed by the two first metacarpal bones, care ^ f) c a being taken not to wound the superficial veins ; the artery is readily ex- posed. At the higher point, place the hand between pronation and supination, the thumb strongly abducted so as to render prominent the extensors, and make an incision an inch in length, _ between the tendons of Fig. 204. ^Ijg j^q extensors, com- mencing at the lower extremity of the radius, and in the line of the axis of the first metacarpal bone; make these incisions lightly, to avoid the superficial vein of the thumb; draw the e.xtensor ossis metacarpi j)ollii-is, a, inwards, and the extensor secundi internodii pollicis, d, outwards, expose the artery, c, and its accompanying veins, b. 5. The ulnar artery, the larger terminal division of the brachial, passes to the inner side of the forearm, at the lower part of its up- OPERATIONS ON THE CIRCULATORY SYSTEM. 2o5 per tliird, continues alon<; the ulnar side to the wrist, passes over the annuhir ligament, on the outer side of the pisiform bone, and terminates in the snperficial palmar arch. Its course is marked by a line drawn from the internal tuberosity of the os brachii to the ex- ternal side of the pisiform bone. (a.) In its upper third, the ulnar artery, arising from the brach- ial, curves inwards deeply beneath the flexor muscles, and passes along the ulnar side of the forearm, between and covered by the Hexor carpi ulnaris and flexor sublimis digitorum; it is accompanied by two veins, and by the ulnar nerve, which is more superficial and internal, and on the radial side (Fig. 205). The forearm being su- pine, the hand strongly extended and inclined to the radial side, make an incision on the imaginary line given, three inches in length, and bi-ginning three fingers' breadth below the internal condyle through the skin and superficial fascise, and recognize tlie aponeurotic connection — of tln! flexor carpi ulnaris and flexor sublimis, which is of a yellowish- white color; divide it on the director from below, where it is the most deli- cate, carefully avoiding the division of nuiscular substance; the flexor sublimis, a, is drawn outwards, and the deep a])oneurosis exposeil, under which lies the artery; if the vessel is not seen, press the flexor carpi ulnaris, c, inwards, and expose the ulnar nerve, b, a little external to which lies the artery, e, with its two veins, d ; isolate the artery by flexing the arm slightly and the hand strongly; pass the needle from within outwards. (b.) In the lower third the artery is covered by deep fascia?, hav- ing upon its inner side the flexor carpi ul- naris and ulnar nerve, and upon its external side the flexor sublimis digitorum. Place the arm supine, and extend the hand so as to make prominent the tendon of the flexor carpi ulnaris; then along the radial border of this nuiscle, a (Fig. 20G), or at the union of the external four fifths of the arm with the internal fifth, or on a line drawn from the in- ternal condyle to the i)isiform bone, make an incision about two inches in length, through Fig. 206. the skin, c, and subcutaneous cellular tissue, c; raise tiie deep fascia on a director, or with the forceps, and incise it, exposing the tendon 256 OPERATIVE SURGERY. aba Fig. 207. of the flexor carpi ulnaris; this should be pressed inwards, and im- mediately behind it the artery, d, will be found with its two accom- panying veins, b, and the nerve upon the inside. (c.) At the wrist (Fig. 207) the artery lies immediately to the radial side of the pisiform bone, and is ac- companied by its veins, I), and the ulnar nerve, c, which lies on its in- ternal and posterior aspect. The hand being held back, make a slight- ly curved incision on the radial side of the pisiform bone, through the skin and adipose tissue, about three inches in length, its concavity look- ing inwards; the artery, a, is deeply seated in a groove, and the dissec- tion should be continued along tlie side of the pisiform bone until it is exposed; the latter part of the dissection will be facilitated by flex- ing the hand upon the forearm; pass the needle beneath from within outwards. ARTERIES OP THE LOWER EXTREMITY. Aneurisms of the arteries of the lower portion of the body, for which the ligature has been applied, now give the following indica- tions as to treatment :^ — 1. Abdominal aneurism, if of the aorta, must, as a general rule, be re- stricted to rest and medical measures only ; some of the aneurisms affecting the lowest part of the vessel may be under the influence of pressure applied to the artery as it lies on the spine just above the origin of the mesenteric; the artery has been successful!}' compressed where it lies between the pillars of the dia- phragm; 2 pressure is now a recognized surgical proceeding very far superior to the ligature of the aorta, but is dangerous from protracted aiiassthesia, contu- sion of the viscera, and injury to the great sympathetic ganglia and nerves ; when employed, the patient's bowels should be freed, the walls relaxed by bending, full but not deep anresthesia produced, and the tourniquet applied. 2. Gluteal aneurism, if traumatic and approffching the character of a recent wound, should be laid freely open and the artery tied, the sac being plugged with the finger, 3 or the tourniquet being applied to the aorta; compression of the aorta or common iliac, galvano-puncture, or injection of coagulating fluids, are justifiable measures; if the aneurism extend into the pelvis the internal iliac may be ligated. Pressure upon the trunk of that artery might possibly be effected by tln^ fingers, the hand being introduced into the rectum.* 3. Ilio-femoral aneurism should first be treated by instrumental pressure, under an anaisthetic, of the common iliac or the aorta; if pressure fail, resort to ligature of the common iliac. In aneurism of the common femoral the external iliac artery must be tied. 1 T. Holmes. ^ Murray. 3 j. Syme. * W. H. Van Buren. OPERATIONS ON THE CIRCrLATOIiV SYSTEM. 2')7 4. Popliteal aneurisms formini,' on tliu anterior face of tlie vessel, known l>v the distinct line of pulsation in the course of the artery lying over the tumor, are rarely cured by any otiier measure tlian the ligature, and this often fails, rendering amputation necessary. In treatment of the more comnion form, grow- ing from the back, or partly from the siile of the artery, marked by absence of an_v distinct line of pulsation, early implication of the nerve, and swelling of the foot and leg, digital or instrumental pressure on the femoral should be made; if it is very small, flexion may lirst be tried; if these methods fail, or if the aneurism is extending, and in all the severe forms not demanding amputa- tion, the ligation is the safest course. 1. The abdominal aorta lies in front, and a little to the left side of the bodies of the vertehnv, liavinij; the vena cava on its right side, the sj'nipathetic nerve on its left, and the left lumbar veins behind, it may be ligated about one ineh above its bifureation. It can be ex- posed and successfully ligated by the operation for the common iliac; the artery being separated from the vein with the linger or a direc- Fig. 208. tor; pass the needle from left to right. Or, make an incision along the linea alba, three inches in length, the middle of it on a level with the uml)ilicus, but a little to the left; open the peritoneum; push the intestines aside; detect the artery by its pulsations, separate the peritoneal covering with the finger nail on the left side, carry the finger under the vessel, and pass the needle from left to right; ^ or, make an incision from the extremity of the tenth rib downwards six inches, curving backwards to within an inch of the anterior spine of the ilium, q, and reach the aorta from the side by raising the peri- toneum."^ 2. The common iliac artery (Fig. 208) varies from three quarters of an inch to three inches in length, averaging about two;^ it passes from the bifurcation of the abdominal aorta, on the left side of the 1 Sir A. Cooper. 2 Murray. 3 L. Holden. 17 258 OPERATIVE SURGERY. body of the fourth hunbar vertebra, a point corresponding with the left side of the umbilicus, on a level with a line drawn from one crista ilii to the other, downwards and outwards along the mai'gin of the pelvis to the sacro-iliac synchondrosis; the artery upon the right side is on an average the same length as ^ that upon the left, and has in front, the peritoneum, and at its point of division, the ureter. Behind, the accompanying vein, J, is partly external above, but below it lies behind and slightly internal; on the outer side, the common iliac vein above, and the psoas muscle, >i, below. The left common iliac has the rectum and superior ha^morrhoidal artery in front, the left common iliac vein internal and partly beneath, and the psoas magnus external. The patient being placed on the back (Fig. 208), inclining to the opposite side : make an incision, R, commencing just anterior to the ex- ti'emity of the eleventh rib, downwards, one and a half inches within the anterior superior spine, and terminating just above the internal ring by a sharp curve upwards and inwards of an inch; the entire length is about seven inches ; divide the integuments and superficial fascia; then the three abdominal muscles; cautiously raise the fascia trans- versalis from the peritoneum, first at the upper part of the wound where the union is slightest ; now gently elevate the peritoneum and press it inwards from the iliac fossa towards the pelvis ; the pulsa- tions of the external iliac, f, are first recognized, and the finger car- ried upwards along this vessel reaches the common trunk ; the ureter, H, in front, is carefully pushed aside, and the needle passed from within outwards. There is great danger of lacerating the peritoneum, both in the act of separ- ating it from the transversalis fascia, and in raising it from the iliac fossa; to avoid the tirst accident the transversalis fascia should be lirst raised high up in the wound, where the attachments are the slightest; to avoid the second, the peritoneum, with the inclosed bowels, o, should be raised on the palms of an assistant standing upon the opposite side of the patient, while the surgeon gently separates with his lingers its attachments. Other methods are indicated by the incisions B, A, C, 1. 3. The internal iliac artery (Fig. 208), e, is an inch and a half in length, extending from the bifurcation of the common iliac down- wards and forwards to the upper margin of the gi'eat sacro-sciatic foramen ; it is in relation anteriorly with the ureter, H, which separ- ates it from tlie peritoneum ; posteriorly, wiih the internal iliac vein; it rests on the sacral plexus of nerves and the pyriformis muscle; on the left the rectum lies p:\rtially over it. The artery may be readily exposed and ligated by the method described in the operation on the primitive iliac ; ^ or, make an incision five inches long, half an inch outside of and parallel to the epigastric artery ;3 or, make an incis- ion in a semicircular form, commencing two inches to the left of the 1 L. Holden. 2 Stevens. 3 White. OPERATIONS ON THE CIRCULATORY SYSTEM. 2.39 Fig. 209. unibilii'us, and eiuling near the external ring, seven inches in length, with the convexity towards the ilium. 4. The gluteal artery emerges from the pelvis, at the upper part of the great isi lii:itic notch, above the upper border of the pyriformis muscles. It is covered by tlie gluteus inaximus muscles, and is accompanied by two veins; a line drawn from the posterior superior ?p\v.e of the ilium to the top of the great trocliantcr marks the course of the ar- tery. (Fig. 209.) Place the patient upon his belly, the thigh extended ; make an incision on the line above indicated, four or five inches long; the cut is parallel with the fibres of the gluteus niaximus, which should be separated, and the finger introduced to detect the pulsa- tit)ns of the artery; separate the pyriformis and gluteus niedius muscles, the borders of which cover the vessel, and isolate the artery from its veins and pass the needle. 5. The sciatic artery escapes from the pelvis between the pyri- formis and coccygeus muscles, and descends in the interval between the trochanter major and tuberosity of the ischium. It is covered bj' the gluteus maximus, and is accompanied by the sciatic nerve, and the vein which lies to its posterior and inner side; the centre of a line drawn from the posterior superior spinous process of the ilium to the tuber- osity of the ischium, marks the point of exit of the artery from the pelvic cavit}'. (Fig. 210.) Place the patient upon the belly; make a vertical in- cision, two inches in length, the centre of which falls upon the point of emergence of the artery, as given above; divide the skin, cellidar tissue, and the fibres of the gluteus maximus; the artery is found to the inside of the nerve, and must be carefully isolated from the vein. 6. The internal pudic artery, the smaller of the two terminal branches of the internal iliac, passes out of the pelvis through the great saero sciatic foramen, internal to the sciatic artery; ^ Fig. 210 it again enters the pelvis through the lesser sacro-sciatic foramen, runs along the ramus of the ischium and pubis, and divides into the arteries of the jicnis. ((/.) At the greater sacro-sciatic foramen make the same incision 260 OPERATIVE SURGERY. as in the ligature of the sciatic artery; the pudic is found a little in- ternal, accompanied by its veins and the pudic nerve. (h.) In the perineum (Fig. 211) the artery may be ligated as it descends the ramus of the ischium; draw a line from the middle of the pubes to the internal border of the tuber ischii. The patient being placed in the posi- tion for lithotomy, make an incision two inches in length along the ramus of the pubis, near the arch; by care- ful dissection the vessel is found along the inner border of the ramus, where it may be isolated and the ligature applied; care shoidd be taken not to incise the corpus cavernosum. 7. The dorsalis penis artery reaches the dorsum of the penis by Fig. 211. passing between the crura, and runs forward, through the suspensory ligament, in the groove of the cor- pus cavernosum, to the glans, distributing branches in its course to the body of the organ, skin, and prepuce. It is enveloped in the subcutaneous layer, and is accompanied by the dorsalis penis nerve and vein ; the latter structures should be remembered in ligating the artery. Make an incision three fourths of an inch in length, com- mencing two inches in front of the pubes directly in the median line; carry the incision through the skin and superficial lamina of the sub- cutaneous layer, when the artery is fully exposed; pass a small artery needle, carefully avoiding the nerve.^ 3. The external iliac artery, about four inches in length, passes obliquely downwards and outwards, from the sacro-iliac symphysis to Poupart's ligament, in a line drawn from the left side of the um- bilicus to a point midway between the anterior superior spine of the ilium and the symphysis pubis; it may be ligated in any -pnvl of its course, except near its upper and lower extremities. In its upper portion it has in front the peritoneum and intestines, and near Poupart's ligament the spermatic vessels, genito-crura! nerve, circumflex iliac vein, lymphatic vessels and glands; externally, the psoas magnus, m, from which it is separated by the iliac fascia; internally, the external iliac vein; below, and curving along its side, the vas deferens; behind, it rests above upon the external iliac vein, which gradually passes to its internal side. Place the patient in a recumbent position, the abdominal muscles relaxed; make an incision three or four inches in length (Fig. 212), 1 J. C. Hutchison. OPERATIONS ON THE CIRCULATORY SYSTEM. 2G1 comniencinc!: ahoiil an inch and a half within the antL-rior superior spine of the ilium ami on a level with this process, ami extendin!;^ in a curved directiDU down- j wards ami inwards, near- ^ I ly parallel with Poupart's " J ^^^^ \ ligament, and tenninat- /T^^jj^v \ inf]f an inch and a half l> ^./CT^^M^ \ above it, just outside of J^^^^ ^ \ the external abdominal [h^^J^^ y/ I ring; on the left side it ^■^)~^'~y'^ \ will be found convenient 1 1 I ( / to commence the incision 1 I I I ' internally, at the exter- Fi<^- 212. nal ring and carry it upwards and outwards to the point indicated within the anterior sujjerior spine; incise the integuments and fascia, and tie the superficial epigastric artery, if divided; the aponeurosis, c, of the external oblique muscle is now exposed and divided on a director; in the same manner divide the fibres of the internal oblique and transvcrsalis muscles, a, until the transversalis fascia, recognized by its white, opaque appearance, is exposed ; cautiously open this membrane and incise on the director; the peritoneum, (/, is now exposed and carefully detached from the iliac fossa, and pushed towards the pelvis ; the artery, 6, is readily felt pulsating at the bottom of the wound, along the inner border of the psoas muscle, the vein being on the inner aspect, the genito crural nerve external; open the sheath and insinuate the needle beneath it, from within outwards, to avoid the vein. Or, the finger may be passed into the internal ring along the spermatic cord and the iliac fascia raised in this manner. Other incisions i are made in the course of the artery (Fig. 208, a), three inches in leufjfth; a curved incision (Fig. 208, c),2 commencing a little above the spine of the ilium, and terminating a little above the internal edge of the inguinal ring; an incision (Fig. 208, b),3 in the centre of the space between the anterior superior spine, and tlie sjmphysis pubis. 9. The epigastric artery (Fig. 208, o). arises from the anterior face of the exteni:il iliac above Poupart's ligament. It at first descends and (hen passes obliquely upwards and inwards between the peritoneum an.) In its middle third the artery lies superficial, running parallel with the inner border of the tibia, from which it is separated by the 266 OPERATIVE SURGERY. Fig. 218. flexor longiis digitorum ; it is covered by the internal border of the soleus, it has vense comites, and the posterior tibial nerve is on its inner side (Fig. 218). The limb is placed as in the last position, and an incision made tliree inches in length, three fourtlis of an inch pos- terior to the internal border of the tibia; the integument and deep fascia being divided, the fore border of the gastrocnemius, d, is seen and drawn backwards, exposing the soleus; the fibres of this muscle should be di- vided on a director; the artery is now felt pulsating about an inch from the margin of the tibia; the peai'l-colored deep aponeurosis which overlies is divided, and then the muscles relaxed by the position of the limb; the artery, c, is isolated from its veins, h, the nerve being pressed to the outside; the needle is jjassed from without inwards. c. In its lower third, the artery passes down behind the internal malleolus, running at first parallel with the tendo-Achillis, and then midway between the internal malleolus and the tuberosity of the os calcis ; it is very superficial, and is in relation anteriorly with the tendons of the tibialis posticus and flexor longus digitorum, and pos- teriorly with the posterior tibial nerve; it has vente comites. (Fig. 219.) The leg being placed on its external aspect, the foot flexed, make an incision two inches in length, a finger's breadth posterior to the inner edge of the tibia, and parallel with it ; the integuments are divided, the deep fas- cia, a, raised on a director, and a small mass of fat opened, which will expose the artery, d, and the venae comites, c, and the poste- rior tibial nerve, 6 ; the sheaths of tendons should be carefully avoided; it should be noticed that the artery sometimes lies anterior to the incision here given. The artery may be ligated a little lower by making a cin-ved incision one third of an inch behind the external malleolus. At this part of the leg the anastomosis of large branches of the internal saphenous vein are numerous, and generally run transversely; these may be brought out Ijy com])ressing the trunk of the vein above, and thus be avoided, at least in part. Fig. 219. OPERATIONS ON THE CIRCULATORY SYSTEM. 207 13. The anterior tibial artery emerges ui)on the anterior part of the leg, at its upper part, through the interosseous uiembiMne, and passes down to the ankle, in a line drawn from the inner side of the fibula to a point midway between the two malleoU; it may be ligated at any point in its course. (a.) In its upper third the artery Hes deeply between the tibialis antieus and extensor longus digitorum ; those museles having their origin in part from the deep fascia, the intermuscular septum is not easily recognized, nor are the muscles readily se[)aratcd. The limb being turned inwards, the foot extended, take as a guide the line already given, or a point ten lines to the outer side of the spine of the tibia, and make an incision about four inches in length through the integument; divide the deep fascia with a crucial in- cision to allow of its complete separation ; the intermuscular septum is now sought for, and may be recognized, (1.) As the first intermus- cular space from the tibia ; (2.) on pressure from within outwards the resistance of the other muscles; (3.) at the lower part of the ■wound the white line of the muscular interspace is more marked. Tlie foot being Hexed, separate the muscles with the index finger, and, the wound being held apart, expose the artery with its two veins and nerve, the latter being outside; pass the needle from with- out inwards. (h.) In its middle third the artery is covered by the skin, super- ficial and deep fascia ; on the inner side it has the tibialis antieus muscle, and on the external the extensor longus digitorum and ex- tensor proprius pollicis (Fig. 220). The limb being placed as iu the former position, make an incision three inches or more in length, in the course of the artery, through the integument; the septum iu the deep fascia uniting the two muscles is recognized by a ti ■white line ; divide it longitudinally, and also by a crucial incision; flex the foot to relax the muscles, and the wound being separated by drawing the tibialis antieus, b, internally, and the extensor longus digitorum and exten- sor proprius pollicis, externally, the nerve is met with more superficially F^^- 220. than the artery, d, with its veins, c ; pass the needle from within outwards. (f. ) In its lower third tlu- artery is covered by the integuments and fascia, and is crossed by the extensor pro|)rius jiollicis ; it lies at first between the tibialis antieus muscle and the extensor proprius 268 OPERATIVE SURGERY. pollicis, the latter muscle crossing to the inner side ; the artery lies between tlie tendon of this muscle and that of ^the extensor longus dip-itorum ; it is accompanied by venas comites, and the anterior tibial nerve, which here lies to the outer side. The leg being placed in a horizontal position, the foot extended, and the tibialis anticus muscle recognized, make an incision along the external border of that muscle, on the line already indicated, three inches in length, but not extending to the annular ligament ; carefully incise the deep fascia on a director, and find the space be- tween the tibialis anticus and extensor proprius pollicis, and sepa- rate the two muscles with the index finger; now flex the foot, and expose the artery, resting on the tibia with the nerve superficial to it; isolate it from the two veins, and pass the needle from within outwards, the nerve being drawn inwards. If the incision falls be- tween the extensor ])roprius pollicis muscle and the extensor com- munis digitorum, the ligature may still be applied. 14. The dorsalis pedis artery terminates the anterior tibial, and runs in a line drawn from the middle of the intermalleolar space, measured from the extremities of the malleoli to the space between the first metatarsal bones. It is covered by the integuments, fascia, and innermost tendon of the exten- sor brevis digitorum ; on its inner side is the extensor proprius pollicis, and exter- nally, the inner tendon of the extensor longus digitorum ; it has two veins, and on its external aspect is the anterior tibial nerve. Make an incision (Fig. 221) two inches in length on the line indi- cated, l>eing parallel to the external border of the tendon of the extensor projirius pollicis muscle, c ; divide the skin and deep fascia, on a direc- tor, and draw the internal division of the extensor brevis digitorum, a, outwards, exposing the artery, d, and its accompanying veins, h; the nerve is on the outside; pass the needle from within outwards. 1.5. The peroneal artery arises from the posterior tiliial, and runs along the inner border of the fibula to the outer side of the os calcis; its course is marked by a line drawn from the posterior part of the head of the fibula to the external border of the tendo-Achillis, at the malleolus ; it may be ligated just below the middle of the leg. The Fig. 221. OPERATIONS ON THE CIRCULATORY SYSTEM. 2G9 foot bein;^; extended, make an incision two or three inches long, one or two lines behind the external ees of contusion. 3. Wounds of nerves ^ may be incised or punctured. The incised wound is causeil by severe cuts, as with a knife, or glass. It is of great importance to make out first the extent of injury, and this may be done by examining as to the local paralysis. If the nerve is par- tially divided, cleanse the wound of all foreign matter with carbolic solutions; close it with sutures or adhesive strip; place the limb in a position to relax the tissues and approximate the cut ends ; enjoin perfect rest; apply cold. Where it is plain that the nerve trunk has been altogether divided, the silver wire suture may be used to ai)prox- imate the extremities; it should be inserted near the cut surfaces, or through the loose tissue related to its sheath; the wound should then be accurately closed; the restoration of function takes place only after long periods. Punctured wounds of small branches are more serious than of large trunks; they follow the use of the lancet as in venesection and vaccination, or other penetrating instrunnnts. The symptoms are acute pain in the track of the nerve immediately or very soon, gradually increasing in severity until spasms or convul- sions occur; slight injinies of the digital nerves seem especially prone to occasion distressing.' symptoms, and wide-spread reflex sympathies. The treatment is complete division if practicable; rest and cold to prevent inflammation; hypod«>rmic injections of morphia to relieve pain. CHAPTER XXV. DISEASES OF THE NERVOUS SYSTEM AND SPECIAL OPERATIONS. I. THE HRAIN. 1. Inflammation ^ w^ithin the cranium may follow any injury to the head; tin- brain alniu- may l)e invDlved, or the membranes, and even the bone. Inflammatory softening is rarely met with in tlie central white portions of the brain, but tlie cortical substance is fre- quently inflamed, as the result of injury to the bone, and meningitis, 1 S. W. Mitchell. 2 P. Hewett. 284 OPERATIVE SURGERY. Avbich supervenes after concussion ; the intlamed gray matter becomes of a dark-red hue, is swollen and soft; effusion takes place in the pia mater, and the gray matter becomes of a darker color and dif- fluent; this softening is frequently very extensive, the white matter remaining unaffected. There are two kinds of traumatic inflamma- tion of the membranes; one commences in the dura mater and almost always reaches the free surfaces of the arachnoid; the other, com- mencing in the pia mater, seldom passes beyond this membrane un- less the inflammation is very severe. When the inflammation spreads inwards from an injury of bone or of its coverings, its progress may be traced, as it were, layer by layer, from the outer parts down to the brain, involving fires protracted suifering; the surrounding parts are often en- larged, the skin increases in thickness, the muscles and tendons ulcerate. The treatment is, ointment of well-powdered opium, or opium in water; if remedies fail, excise the nerves as far as pos- sible from the ulcer; it is also advisable to divide the nerve as near the upper part of the wound as possiljle. 3. Painful subcutaneous tubercles ^ are spherical, or oval, or fusiform tumors, generally white, always firm, sometimes hard, hav- ing a fibrous or fibro-cartilaginous structure; the size varies from that of a millet seed to that of a pea; they are situated in the sub- cutaneous areolar tissue, embedded between the fibres of nerves which are separated and stretched over them; they cause the most acute pains, which dart like electric shocks along the course of the nerve. Pain recurs very irregularly, and lasts from ten minutes to two hours or more; it begins gradually, increases in intensity, and gradually decreases, leaving the tubercle and parts around more or less tender; in all cases of obstinate neuralgia of the extremities, search should be made for these tubercles. The only treatment is extirpation. 4. Neuromata ^ are larger than subcutaneous tubercles, but mav be of every size, from a small grain of wheat to a larije melon; thev are round, oblong, oval, or fusiform, and when superficial, movable only laterally; they are situated between the neurilemma and nerves, or in the connective tissue between the bundles of nerves; they con- 1 J. L. Clarke. 19 290 OPERATIVE SURGERY. sist for the mo«t part of tough and wavy fibrous tissue with a varia- ble number of nuclei and small cells. When they are numerous there is little or no pain, but a solitary neuroma is a source of the most violent agony, which shoots along the nerve like electric shocks. Thev frequently occur in stumps after amputation, rendering the limb both painful and intolerant of pressure. The only successful treatment is removal, either by excision of the tumor and a portion of the nerve, or by amputation of the limb. 5. Neuralgia^ from nerve injury may depend upon pressure or the presence of foreign bodies, but more often it is a question as to whether the nerve is in a state of inflammation or sclerosis. If the former conditions exist, relief may be easy, as by removing the local cause. If the nerve is inflamed, repeated leeching and the steady application of dry cold for a week or two are the best remedies; if cold cannot be borne hot poultices should be applied. The pains of traumatic neuralgia can only be satisfactorily relieved by narcotic hypodermic injections; the salts of morphia are to be preferred to all others; the fourth of a grain may be given and increased if neces- sary ; if it is desired to maintain the anresthetic power of morphia without the hypnotic effect, add atropia, thus: to half a grain of sulph. of morphia add one thirtieth of a grain of sul[)h. of atropia. The alveolar processes sometimes undergo thickening and condensation after the removal of the permanent teeth, which causes such com- pression of the dental nerves that severe and persistent neuralgia results. The relief from this affection is most readily and effectually secured by removing the diseased process.^ Make an incision along the ridge of the process ; separate the periosteum from the bone by means of the elevator; with rectangular gnawing forceps remove the process to its entii'e depth ; allow the parts to heal by the falling together of the surfaces of the wound. Dissection of nerve from the condensed cicatricial tissue following a gunshot wound has been performed^ with success, as follows: the median nerve was enclosed in a dense cicatrix at the middle of the arm, involving the biceps muscle, resulting from a gunshot wound ; the nerve was gradually laid bare and dissticted out, so that it lay perfecth^ loose in the wound for an inch and a half or two inches of its length; the wound was lightly dressed, and allowed to heal; neuralgia returned slightly, with cicatrization, but eventually disappeared altogether. In ex- treme cases, amputation of parts is occasionally practiced. Now that it is possible to prevent the reunion of nerves, amputation offers no advantages over resection of the nerve at some higher point; it can, therefore, never be justified, except where more than one nerve is involved, or where the limb has been rendered altogether useless by grave injury.^ 1 S. W. Mitchell. •-! .J. M. Warren ; S. D. Gross. 3 j. M. Warren. OPERATIONS ON THE NERVOUS SYSTEM. 291 III. THE NERVOUS CONSTITUTION. Neuromimesis,! nervous mimicry, should be duly considered in the dia<;nosis of sur<;ieal affections, for there is scarcely a local or- cranic disease of invisible structures which may not be mimicked by nervous disorder. Examples are freciuent in the more or less acute inllammalions of the joints, especially of the knee and hip; it im- itates diseases of the spine, paraplegia, tetanus, aphonia, deform- ities, aneurism, and tumors. It may be regarded as a localized manifestation of a certain constitution, but as to what is the pe- culiarity of the nervous constitution there is no positive knowledge; it may be stated that the nervolis centres are too alert, too highly charged with nerve force, two swift in mutual influence, too deli- cately adjusted or defectively balanced, but these expressions may be misguiding, and it is better to study the nervous constitution in clinical facts. In the great majority of cases there is either history or present evidence of a characteristic nervous constitution; some have been or are truly hysterical, but very many have never been hysterical. The means for diagnosis are to be sought (I) in the general condition of the nervous system on which, as on a predis- posing constitution, the nervous mimicry is founded; (2) in the events by which, as by exciting causes, the mimicrj' may be evoked or localized; (3) in the local symptoms of each case. The treat- ment is too varied to notice in detail, but must be directed against (1) the local symptoms; (2) the constitutional condition which may co-exist or be combined with the nervous; (3) the nervous constitu- tion itself. CHAPTER XXVI. GENERAL OPERATIONS ON THE NERVOUS SYSTEM. I. THE BRAIN. Trephining the cranium should be regarded as an operation always fraught with danger,'- and only to be performed from clear necessity. The following general rules* should guide in deciding the question: (1) In diffused injiuies to the cranium and its contents all operative interference is unjustifiable; (2) in simple fractures, with or without depression, and in compound fractures that are not comminuted, with or without dej)ression, operative interference is only called for when marked and persistent symptoms of local com- pression of the brain exist; (3) in compound comminuted fractures, with or without brain symptoms, depressed bone should be elevated 1 Sir J. Paget. 2 j. Le G. Clarke. 3 T. Bryaut. 292 OPERATIVE SURGERY. and fragments removed, witli the oliject of taking away known sources of irritation to tlie membranes and common causes of enceph- alitis; (4) in all cases of local injury to the cranium, of fracture or other injury, followed by clear clinical evidence of local inflammation of the bone, and persistent symptoms of brain irritation, or subosteal suppuration, the operation should be undertaken. Proceed as fol- lows: Shave the scalp at the point where the oi)eration is to be per- formed; place the head upon a firm pillow; give an anaesthetic when the patient is fully conscious; select the point of application of the crown of the trephine so as to avoid the main branc.-hes of the middle meningeal artery (Fig. 235), and the longitudinal and other sinuses; make an incision down to the bone, having the form V, -\--i or other shape, as may be necessary to expose the bone; care- fully raise the pericranium over a s])ace just sufficient to admit the trephine; if at any point the ele- vator can be introdut-ed sufficiently to raise the fragment without using the trephine, elevate the depressed bone very cautiously, until its mar- gin is on a level with the sound Fig. 235. bone; if this is impracticable, place the pin upon the margin of the sound bone, and taking the handle in the right hand move it alternately to the right and left, until the teeth have cut a groove sufficiently deep to re- ceive them ; the perforator is then loosened and slid up in the shaft and fixed, to avoid wounding the membranes ; great care should be taken to maintain the instrument in a position perpendicu- lar to the part operated upon (Fig. 23 G), in order to avoid its penetrating more deeply on one side than the other, and thus sud- denly wounding the cere- FiG. 236. bral membranes; examine the depth of the groove frequently to ascertain how nearly the in- strument has completed the section of the bone, \//^^^y^~-^3^ occasionally cleaning the teeth with a small brush or wet sponge; raise the disc of bone with the elevator (Fig. 237). In fractures with depression there are frequently projecting points of bone which it is desirable to remove; this may be done with the bone nippers (Fig. 238). If there is a blood clot, remove Fig. 237. Fig. 238. OPERATIONS ON THE NERVOUS SYSTEM. 293 it with care, lost blccdiiifr recur; if the nienin;T(.al artory is exposed and Ijleods, compress it with a piece of spou'je, clotli, or wood in- serted under the niarixin of tlie Ijone ; if the blood or pus producing com])ression are lielow the dnra mater, open it sulHcientlv to remove these matters. The conical trephine is to be preferred in all cases where the bone is thin. ir. THE SPINAL CORD. Trephining the spinal column to relieve compression of the cord, whether froiii (K'pres^ed hone or extravasated blood, is now re- garded as a useless operation. ^ III. THE NERVES. Neurotomy, the section of a nerve; neurectomy, the resection of a portion of a nerve ; and stretching of a nerve, are operations un- dertaken for the relief of pain, and of spasm. These operations are justifiable only as a last resort, all other measures having failed. ^ Section of a nerve should always be made at a point which will in- volve as few terminal branches as possible, and yet the division must be sufHciently high to include all of the affected trunk, for if dis- eased tissue is left above the line of division the subacute neuritis and sclerosis may continue to ascend the nerve and render the op- eration useless; it is important that the area of the painful region should be accurately determined, and the trunk carefully examined for enlargements and hardness by rolling the nerve under the finder; as a rule the section should be a short distance above the point at which the nerve ceases to feel enlarged and hard; if it is practicable to find a spot, even a little farther up the limb, where the nerve is neither swollen nor tender, select that point; when the nerve lies too deep for examination, especially if the neuralgia is of long stand- ing and of traumatic origin, operate as near the body as possible; if the neuralgic cause is purely local, a healthy point is found.* But neurotomy, or simple division of a nerve, is at present scarcely ever practiced, owing to the certainty of prompt reunion ; resection is necessary and not less than two inches of its length ought to be re- moved, the object being to make reunion impossible, or very remote in point of time; in addition it is well to turn the peripheral extrem- ity back, and if necessary secure it with a loop of wire, or even in- terpose muscle or fascia to prevent the possibility of union. * Ex- posure and stretching of spinal nerves as a final resort for the relief of spasms* is now recognized as a justifiable operation. Tt orior- inated in the exposure, isolation, and rul)])ing of the sciatic nerve ^ 1 J. Ashmst, Jr. ■! S. AV. Mitchell; W. A. Ilammoiul; E. Brown-Sequard. 3 S. W. Mitchell. * Von Nussbauin. 6 x. Bilhoth. 294 OPERATIVE SURGERY. from a point below the gluteal fold, through the sciatic foramen, to the sacral foramen, for the purpose of relieving epilepsy supjjosed to be due to some irritating cause affecting the nerve. No such cause was found, but the stretching Avhich tlie nerve received relieved the spasms. It is beheved that the manipulation produces a favorable chano-e in the position of the nerve fibres in the trunk, whereby their nutrition is improved. The procedure is essentially the same as that of dissecting a similarly affected nerve out of cicatricial tissue ^ long since successfully practiced. The operation consists in exposing the nerve and stretching it with fingers, forceps, or blunt hooks, as if attempting to draw it from its connection to the spinal cord. NERVES OF THE HEAD, FACE, AND NECK. 1. The supra-orbital nerve (Fig. 239) is a terminal branch of the frontal, b, a portion of the first division of the fifth cranial nerve, a ; it runs along the roof of the or- bit, passes out through the supra- orbital foramen, and ascends upon the forehead. It should be di- vided as it emerges from the fo- ramen, and before branches are given off. Section is made as fol- lows, 1 (Fig. 239) : Recognize the supra-orbital notch, or foramen; pass the tenotome subcutaneously from a point two or three lines on the inner side of the notch outward beyond the notch; turn the blade backwards and cut down to the bone. Resection is made as follows: make an incision an inch in length down to the bone, just above the notch; seize the cut ends of the nerve in the Avound and remove it to the desired extent. Or the brow m;iy be raised and the lid depressed, and the incision be made along the edge of the border of the orbit; the nerve is seized in the wound and re- secteil; tlie wound will fall under the brow Avhen the skin is relaxed. 2. The infra-orbital nerves are the terminal branches of the su- perior maxillary nerve as it emerges from the infra-orbital foramen, beneath the elevator muscle of the upper lip, and consist of palpe- bral, nasal, and labial sets.^ The focus of pain is at the origin of these nerves.3 Section may be made through the mouth as follows: recognize the infra-orbital foramen, 2 (Fig. 239) above the second bi- cus[)id tooth and nearly half an inch below the margin of the orbit; 1 J. M. Warren. 2 Quaiu's Anatomy. " Valleix. Fig. 2.39. OPERATIONS ON THE NERVOUS SYSTEAf. 295 raising the upper lip, make an incision along the fold of junction of the lip and maxilla, ami (.onlinue the dissection to the upper limits of the fossa : now take straight scissors, and continue the dissection upwards to the infra-oibital foramen, which is four or five lines be- low the orl.it in the direction of the first molar tooth; the nerves are readilv divided as they emerge from the canal. Section through the skin is made thus : the patient's head being elevated and turned to the other side, recognize the exact position of the foramen by the guides given, and make an incision directly upon it through the skin and fascia. 3. The superior maxillary uerve, c (Fig 2ot)), is the second branch of the fifth; it passes through the foramen rotundum, across the spheno-maxillary fossa, and traverses the infra-orbital canal in the floor of the orbit and terminates at its foramen. Section is made with a strong tenotome carried along the floor of the orbit in the direction of the nerve ; at a depth of two thirds of an inch cut across the floor of tlie orbit, which is thin, severing the nerve at 3.^ Resection may at the same time be made by a transverse incision, one third of an inch below the border of the orbit, exposing the nerve, which may be seized and drawn out of the canal. ^ In the more formal operations the external incisions may take various forms, as V, -|-, U, H, the centre being the foramen; the object is to fully ex- pose the foramen, and the margin of the orbit; the canal may be entered by the trephine applied to the antrum, ^ or by raising the tissues covering the floor of the orbit, and entering the posterior part where the canal is covered by fibrous structures. The trephine is required when the nerve is removed at 4 (Fig. 239), the foramen ro- tundum ;3 the crown should be j^mall and be so placed as to open the antrum at the canal ; the lower wall of the canal is broken with the chisel to the sphenomaxillary fossa; the dissection may now be car- ried on, and the nerve divided at the foramen rotundum with scis- sors curved on the (lat. The canal may be opened by raising the soft parts from the floor of the orbit an inch or more from the orb- ital edge, and with a hook set at right angles with its shaft, the nerve may be raised and excised an inch.* The latter method is to be preferred when the resection is confined to the portion of nerve in the canal. 4. The Ungual, or gustatory, nerve, /(Fig. 239), one of the spe- cial nerves of the taste, su])plies the mucous membrane of the mouth, the gums, the sublingual gland, and the papilla; and mucous mem- brane of the tongue; it is one of the posterior branches of the inferior maxillary branch of the lifth nerve; it is deeply placed, lying first be- neath the external pterygoid muscle to the inner side of the inferior 1 J. V. MaL'aiiTue. '^ J. M. Carnotliau. 3 J. K. Wood. * T. G. Murton. 296 OPERATIVE SURGERY. dental, then between the internal pterygoid and the inner side of the ramus of the jae applied with reference to the separation of sloughs, and the most important is the carbolic acid dressing, as follows: carbolic acid, one ounce to a pint of olive or linseed oil, or an ointment made of carbolic acid 3iv., lard %\y., and caions, and dissect out from under the skin the h}pertro])hied tissue, care being taken to leave sufficient iiap to cover the cartilage; close the wounds wi.h fine silk suture. (Fig. 254.) II. THE NAIL. The nail consists of the flattened cells of the papillae •p nr-, of the posterior part of the matrix, and of the mucous layer of the beds of the matrix ; the former are pushed forwards along the beds in ridges, and the latter are added to the under surface of the nail.^ 1. Inflammation, acute, may follow injiu-ies, as blows, the pene- tration of sharp bodies ; the chronic is caused by syphilis, eczema, psoriasis; the result may be irregular growth of the nail, or its destruction by suppuration and ulceration; in unhealthy children the inflammation may be followed by the ulceration of the matrix. The treatment should be to relieve the inflammation by the removal of the cause, and such general and local remedies as the special conditions demand. 2. Atrophy and hypertrophy ^ depend upon the same condi- tions, namely, general diseases, as syphilis; local skin affections, as eczema, psoriasis; injuries, as pressure, blows, penetration of splin- ters, needles; trades, as hatters, gilders; fungi, as favus. In atrophy the function of the matrix is diminished, and the nail may become thin, small, narrow, soft, or be wholly lost. In hypertrophy, the functions of the matrix are increased, and as a consequence the nail may be of unusual length and width, appearing as if too small for its place ; or the substance of the nail may be thickened throughout, but most consiilerably in front, having the shape of a chisel, with its thick base forward; or the thickening may chiefly affect the middle portion, so that it is elevated in the form of a cone or wedge raised in a shapeless hump, often continued in a long, straight or curved, tap-shaped excrescence. The treatment of these affec- tions is the same so far as they depend upon the same conditions. All sources of local irritation should first be removed; syphilis re- quires the ordinary general treatment, and the local application of mercurial plaster wound round the ungual segment of the finger or toe, so that it compresses the fold of the nail. Non-syphilitic affec- tions require the same treatment as in other parts, but special effort iTOUst be made to secure the effect of the remedies upon the mati-ix 1 C. Wagner. 2 Virchow. ^ x. Anuandale. DISEASES OF THE TEGUMENT ARY SYSTEM. 323 and bed of the iiiiil. In li\ pcrtropliy, India rubber worn upon the part soon niaterates the ei)iderMiis ami diuiiiushes hyi»erjeniia of the papillary hiyer.^ The local treatment should aim to remove such excrescences as are deformities and annoyances, by means of scis- sors, the knife, bone-nippers, or a fine saw, care being taken not to extract the nail from its bed. 3. Ingrowing is a curvinjf downward of the niarixin of the nail, and in general is found on the external border of the nail of the great toe; it is due to the pressure of tight boots or shoes, and espe- cially when the nail is hypertrophicd; the fold of the nail becomes in- flamed, the skin ulcerates, red, spongy granulations ajipear, and the part becomes exquisitely tender; the ulcerative process may extend backward, and finally the matrix and the whole end of the toe may be involved in the iiillammation. The treatment at first should con- sist in attempts to heal the ulcerated point where the nail penetrates the skin. Of the various methods proposed, select the following: Cut dossils of charpie, having parallel threads, of the length of the lateral fold of the nail, or rather larger ; lay it on the nail ])arallel with the fold; by means of a flat probe push the mass down, thread by thread, between the swollen inflamed fold and the border of the nail, so as to completely separate the skin and the nail; pad around the furrow of the nail with charpie; apply long strips of adhesive plaster one and a half lines wide around the toe, from above downwards as reg.ards the inHamed fold ; repeat this dressing daily, if necessary.'* When the inflammation involves the whole fold and extremity of the toe, extirpate the portion of the nail involved, as follows: with sharp pointed scissors, slit up the nail, (Fig. 250) then seize the oflfendinw portion, and with a slight twist remove it from the matrix ^ (Fill- 251). When the inflammation extends completely around the nail, the entire nail should be removed and the matrix excised. 4. Onychia* is an inflammation of the matrix of the nail, causing ulceration, and gradunlly involving the soft textures around ; it is sometimes the effect of injury, but more frequently occurs as a result of some unhealthy state of the constitution; the sim- pler forms begin with the usual signs of in- flammation in the soft textures around the nail, which become red, painful, and swol- len ; the nail itself becomes affected, and its margins roughened and displaced; sup]>uratit)n and ulceration follow, and a sore is formed which is often kept in a state of irritation by the uneven margin of 1 Hebra. 2 Kaposi. 3 Dupuytren. * T. Annandale. Fig. 250. 324 OPERATIVE SURGERY. Fig. 257 the nail pressing against it; the nail is loosened, its edges and root roughened and raised up. In its most severe form, onychia maligna, it occurs in children, generally after slight injuries; the whole soft textures around the nail and at the extremity of the fingei's become red and swollen, giving it a bulbous ap])earance (Fig. 257) ; the dis- charge is thin and fetid, the nail is loosened, and the bone may be ex- panded. In the mild form use ni- trate of silver to arrest the ulcera- tion, and remove the nail if it keeps up the irritation. In the severe forms, remove the nail at once, and freely cauterize with caustic potassa, nitric acid, or ni- trate of silver. The nail is best removed as follows : The patient being under an anaesthetic, thrust the sharp point of strong scissors under the nail and through the matrix (Fig. 255) ; now seize one sec- tion of the nail with strong forceps (Fig. 256), and by sudden e ver- sion tear it from its position. 5. The claw-like nail, onychogryphosis, depends upon a hyper-plastic state of the entire matrix of the nail (Fig. 258); the long, horizontal papillte furnish nearly all the substance of the nail, which is no thick- er at the finger-tip than at the edge of the lunula ; this gives the nail its ridged appearance, each ridge corresponding to a papilla.^ The only reliable rem- edy is complete removal of the nail and its matrix, ^ with such general treatment as the case requires. 6. Horny growths (Fig. 259), resembling exos- toses, sometimes appear at the margin of the great toe, and create much suffering. The only treatment is excision. ^ 7. Psoriasis ^ appears as a thickened, rough, scabrous, and un- usually convex condition of the central portion of the nail ; the free edge is often split, and the cuticular fringe at the bottom of the nail is ragged and retracted; the whole nail resembles the concave shell of an oyster. If it is caused by syphilis, give mercury in small doses for a long period ; if not specific, give arsenic with a tonic. The appearance of the nail is improved by smoothing with glass or sand-paper; or by friction, with dilute acetic acid. 1 E. Riiulfleisch. 2 T. Brvant. 3 T. Smith. Fig. 259. OPERATIONS ON THE TEGUMENTARY SYSTEM. 32o CHAPTER XXIX. w y I I: GENERAL OPERATIONS ON THE TEGUMENTARY SYSTEM. THE SKIN. Thermometry^ is gem'rally practiced upon the skin to determine br\ with exactness tiie state and variations of /^^ bodily temperature, and is an important \ \ mechanical aid in diagnosis.'^ Two kinds of instruments are now employed, one, h, c. to be used in enclosed cavities, and the other, a, upon the surface of the in- tegument. Many varieties of the former in- strument are now in use, but the straight, self-registering, clinical thermometer (Fig. 2roject through the diaphragm to conduct the liquid from the cylinder ^1 and introduce it through the skin; the needles h, e, are stacked in the piston B, whose stem d is sleeved in the stem screw c,f. ^ Pig. 264. 6. The issue is a suppurating wound of the deeper structures of the skin. It may be made with a seton, incision, caustic, or moxa, and must be so limited as not to extend its action beyond the subcu- taneous areolar tissue. Apply them at points as free as possible from local irritation, and remote from large vessels and nerves, as the nape of the neck, the insertion of the deltoid on the arm, the external part of the thigh and internal part of the leg. The seton may consist of a few threads, a piece of linen, or of lamp-wicking, or, what is now more frequently used, on account of cleanliness, a 1 C. Rice. ' Fiermenich. 8 Klee. 330 OPERATIVE SURGERY. strip of In(lia-rul)ljer cloth. The instruments required for its intro- duction are either the seton needle (Fig. 260) or a straight bistoury, and a probe having an eye. Pinch up a fold of the skin corresponding with the direction of the muscles of the part, or vertical with the body, pass the needle, armed \> Fig. 265. Fig. 260. Fig. 207. with the seton, deeply through the parts, but without involving ten- dons or muscles; draw the seton through and tie loosely. If the bis- toury and eyed-probe are used, pinch up the integuments and trans- fix with the bistoury (Fig 266); pass the probe having the seton through the eye, or attached by a thread (Fig. 267), through the wound, and tie. The subsequent dressings consist of greased lint, and a bandage around the part to be exchanged for a poultice when suppuration commences. The seton must be drawn through daily, and the part saturated with pus cut off. When an issue is made with the knife, the incision must penetrate into the subcutaneous cellular tissue, and a foreign body, as a pen, or a small bead, is introduced and retained by adhesive straps until suppuration is es- tablished. The caustic may be the actual cautery, or Vienna paste, or other powerful escharotics. In shape, the iron cautery should have a more or less flattened surface, wheri it is required to produce a superficial slough, or conicnl when it is re- quired to penetrate more deeply (Fig. 268). If it is applied at a white heat, and firmly pressed upon the part until an eschar is formed, although not severely painful, local anaesthetics should be used; cold-water dressings should be ap])lied for several hours, followed by moist warm applications, as a poultice, until the slough se[)arates. Vienna paste is prepared by triturat- ing equal parts of quicklime and caustic potassa; it is applied to the part, of ilie re(|uired size, and allowed to remain ten or fifteen min- utes; when removed, wash the surface' with dihited vinegar, to coun- teract its action. Caustic potassa may be used in a similar manner, Fig. 268. OPERATIONS ON THE TEGUMENTARY SYSTEM. 331 the parts Iieinjj; circumscribed by a piece of adhesive plaster, through an opening in which the application is made. Strong sulphuric acitl also makes an issue of the piopcr depth, its effect being controlled by an alkali. The subsequent dressings are poultices. The moxa is a combustible substance, burned upon the surface; it may be com- posed of lint, carded cotton, hemp, agaric, etc., or the lint may be saturated with the nitrate of potassa. The substance selected should be firndy rolled into a pyramidal form, and held together by threads, or a solution of gum araltic, an inch or an inch aiul a half long, and of a diameter at the base corresponding with the size of the proposed eschar. Local anajsthesia being produced, the moxa is held in posi- tion with forceps or wire, and is ignited at the top; as it burns down, any desired degree of irritation can be obtained, from a sim- ple redness to a deep eschar, according to the time it is maintained in contact with the skin. 7. Hypodermic iujec'don is a method of inserting remedies into the subcutaneous areolar tissue. Its advantages are, rapidity of ac- tion ; intensity of effects; economy of material; certainty of action; facility of introduction in certain cases; with some drugs the avoid- ance of unpleasant symptoms.^ The apparatus required is a hypo- dermic syringe, needles, and solutions. The syringe consists of a barrel and rod, and a canula of silver or steel, which has a point for pene- tration and an opening for injection of the liq- uid (Fig. 269); n, b, c, is a form with a glass tube, a graduated rod, and deiaciiable points of two shapes; d, e, is a form of hypodermic syringe to be carried in a pocket-case; the point, inclosing the wire-cleaner, fits into lE^pt a hollow graduated ^ . £,„„ piston; the barrel is an ordinary silver tube, the size of No. 10 catheter, and is six inches long. There are numerous cases, varying in size to suit the convenience of practitioners. To meet the increasing necessities of this form of medication the case '^ should contain a double fenestrated hypodermic syringe ; three needles of different sizes, the smallest being the most delicate manufactureil, the second larger, and the third of the ordi- nary size ; extra leather washers and wires for keeping the tube open and clean; a small hone of the finest quality for sharpening the 1 Com. on Hypodermic Method. 2 \v. \, Greene. oQ^3= 332 OPERATIVE SURGERY. points; a twenty-four minim glass measure perfectly exact; five two- drachm vials filled as follows: (1) sol. sulpli. morphia, 16 grs. to the ounce, or ^ gr. to 15 m. ; (2) sol. sulph. morphia, 8 grs. to the ounce, for children, or delicate females; (3) sol. atrojiiiie, I gr. to the ounce; (4) strong alcohol for cleaning the points; (5) fluid ext. ergot. The case may contain other solutions, a thermometer, and thumb lancet. It is not necessary to confine the injection to the painful part, and thus a tendency to abscess from repeated injection may be avoided.^ As a rule, the least pain and irritation is caused when the injection is made at or near the insertion of the deltoid, or in front, between the ribs and hip bone, or from near the spine to the median line. Operate thus : On the first trial always use a minimum (juantity of the drug ; - draw the required amount into the syringe ; elevate the point of the needle and force out a di'op to ex- FiG. 270. pel the air; pinch up the skin at the point selected and thrust tlie needle into the sub- cutaneous connective tissue, avoiding any veins apparent; now gently force the fluid out drop by drop, watching its effects; if no effect is produced when the last drop is injected, withdraw the needle in- stantlv and press the finger on the puncture for a moment; if faint- ness or other unusual sym])tom appear, withdraw the needle and ap- ply such restoratives as may be required. (Fig. 270.) The needle^ may be little larprer than the proboscis of a fly, so delicate in fact that fluids as thin as water barely pass through it, and tliat quite slowly; it will penetrate the skin and reach the cellular tissue without pain, the little child and delicate female not being aware of its introduction in the cervical and lumbar spinal regions, or about the insertion of the deltoid. The needle should not screw on, but slide in, and thus avoid the wearing of the screw and the destruction of the thread. To keep the leather washer of the piston alwavs damp, draw a few drops of water into the barrel after using it, and let it remain; when about to use the syringe, draw this water out, and the piston will work well. Prepare the solution of morphia sulph. by putting four grains in the vial and tilling it with hot water; no acid is required to make and keep this a perfect solution; it is generally required in an emergency, and should always be in the case; it keeps indefinitely. To clean points draw the alcohol up and force it out of the tube several times; then detach the point and blow tiirough the tube ; finallv, pass the wire through, wiping it every time it is withdrawn, after which leave the wire in the point. 8. Vaccination destroys or diminishes susceptibilit}' to variola; every practitioner is under imperative obligation to exercise reason- i C Hunter. 2 ic. £. Anstie. 3 w. A. Greene. OPERATIONS OX THE TEGUMEXTARY SYSTEM. 333 able tare aiul ililii^eace in the protection by this means of all persons subject to his professional advice and eare.^ It may safely be per- formed at any period of life, and no age shotdd exempt a person from vaccination who has been exposed to sniall-j)Ox; the most suit- able period is six weeks from birth, and it should not be delayed be- yond the third month, unless conditions unfavorable arc unavoidably present, as acute febrile diseases or vesicular eruptions.^ The practitioner is responsible for the purity of the lymph which he uses, for pure virus can cause no otlier disease than variola; diseases are invaccinated only when the lynipli is contaminated with blood, pus, or otiier carriers of cou- tagia.- Lyniph is of two kinds, human or bovine, accordingly as it is taken frotn man or animal. Humanized virus must be selected from children of healthy parentage, and free from all hereditary taint, and cutaneous or other discoverable affections. In the collection of lymjdi, the following rules should be observed^ : — The vesicles should be perfect, having passed througli all the stages without complications. Lymph must be taken from the vesicle before the areola has formed, the most favorable period being the eighth day, or day week after vac- cination. Several fine punctures should be made in the top of the vesicle, when the lymph will exude from the cells and may be taken for immediate use, or for preservation. The vesicle should never be squeezed to obtain more lymph, but the surface may be gently wiped with a wet doih to remove any obstruction of the puncture. If any blood appear it must be allowed to coagulate, and then be removed, before lymph is again taken. The virus may be taken on points, pieces of ivory, or quill scraped smoothly, two coats being applied ; or in capillary glass tubes into which the lymph is drawn by capillary attraction, and which are then sealed at both ends by the flame of a caudle, to the exclusion of the air. The lymph is frequently preserved in the scab, or crust, which is the dried ves- icle. This falls between the twentieth and twenty-fifth days, is of a mahogany or amber color, and semi-transparent. If there is pus or blood in the scab, that portion, or the whole, should be rejected. The virus, in whatever form, must be preserved from the air, and in a cool place. Vaccination may be successfully performed on any part of the body; but for convenience and freedom from irritation, the arm near the insertion of the deltoid muscle is ordinarily selected. The left arm is preferred to the right, in first vaccination, as it is not so much used. Though the operation is extremely simple, it requires great care and delicacy in its performance. A variety of instruments have been used, but a common lancet, slightly dull, answers every indica- tion. It should be kept in a state of perfect cleanliness, as rust or filth are liable to poison the wound. After each vaccination it should be cleaned with a wet cloth. The operator should grasp the arm so as to make the skin tense at the i)oint of insertion of the virus, and either make several punctures with the point of the lan- 1 E. C. Seaton. 2 J. Simon. » J. B. Taylor. 334 OPERATIVE SURGERY. or several incisions (Fig. 271), thus 11|||, or abrasions, thus ^. The lancet should penetrate sufficiently to cause the appearance of blood. If the virus is taken from another arm, the point of the lancet should be charged by uncapping cautiously one of the cells of the vesicle. If the quill is used, first wet the charged extremity with a drop of water. If the scab is used, dissolve a small portion in a drop of water or glycerine on a piece of glass, and charge the point of the lancet. VV^hatever form of virus is used, be careful to rub the l3mpli well into the abrasions; the flow of blood, though considerable, does not interfere with the success of the operation. The following facts i in regard to the progress of successful vaccination, and the complications which may arise, are important: After the inoculation, a period of inaction, comprising three or four days, is followed b}' a papule-like elevation of the skin, due to swelling of the cells of the deep layers of the epi- dermis, accompanied by hypersBmia; these cells continue to enlarge, and, by the tifth or sixth day, the pock is found augmented in size, and, from inci'eased distention of the cells, presents the appearance of a vesicle, with a central de- pression, and is multilocular in structure. The contained fluid {vaccine lymph) is a colorless, adhesive liquid, containing leucocytes and minute granules, in which latter resides its virulent propert}'. The papillary layer of the derma is novv invaded by the morbid process; tlie free ends of the papillae become stran- gulated by cell-impaction, and, melting down, mingle with tiie fluid contents of the pock. Occasionally, the disease extends completely through the derma, and involves the subjacent cellular tissue, which then shares the fate of the destroyed papilliB. On the eighth day (inclusive) the pock has, if it have been produced by long-humanized virus, acquired its greatest size; if it have been produced by bovine virus, or by humanized virus of early removes, it continues to increase in size for several days longer. On the ninth day the pock has in- creased in plumpness, its central depression is more marked, a brown incrusta- tion has begun at the centre, the fluid contents are more decidedly purulent, and the whole is surrounded by a sharply-detined, bright redness of the skin, extending over a disk of from one to two inches in radius, and techiiicallj' called the areola. In the human subject the areola is usually accompanied by febrile reaction ; but in the calf there is no areola, and but little, if any, constitu- tional reaction. The further progress of the disease consists in the gradual fading of the areola, with the transformation of the entire pock into a hard, dry, translucent brown crust, which separates some time between the fifteenth and the thirty-second days, leaving a more or less depressed cicatrix, which is usuall}' permanent, and which shows numerous lesser depressions, which give it the ap- pearance termed foveolation. If the individual have previously had the disease, it usually runs a more rapid and less regular course, although the inflammation is apt to be more marked. Vaccinia usually runs its course without complica- tions, and does not call for treatment. Excessive erythema is best treated by the application of a liniment composed of Sij of ung. stramonii, 3j of liq. plumb, subacetat., and 3 viij of linseed-oil. True erysipelas is very rarely caused by vaccination, and does not require a moditied treatment. Axillary 1 F. R. Foster. OPERATIONS ON THE TEGUMENTARY SYSTEM. 335 adenitis is common, and should be treated on general principles. The same is true of cellulitis. Ulceration of the pock (generally caused by vioience) may be treated by sprinkling with eqiial parts of powdered starch and oxide of zinc, and the same may be used to check an immoderate flow of lymph, after open- ing the pock for the purpose of obtaining virus. The conveyance of syphilis in vaccination may be certainly prevented by complying with all of the following rules: (1) Use only bovine virus, or humanized virus which is known to be free from syphilitic virus; (2) after once applying the lancet, or other instrument, to the vaccinee, it should on no account be again applied to the vaccinifer, or any other |)erson, until it has been thoroughly cleansed; (3) after once using a quill slip, throw it away. Vaccination generally confers complete and lasting protection against small-pox; any person may, however, constitute an excep- tion. Hence, every individual should be revaccinated as often as once in five j'ears, and whenever small-pox is present as an epidemic, or upon setting out on a voyage, or when al)out to undertake military duty. As a rule, revaccina- tion succeeds. It should be carefully done, and repeated if unsuccessful. 9. Transplantation of skin is frequently required to repair de- fects either cuii-<' by a second assistant (Fig. 280) ; the older child should j,-,^^, .28o. recline with its head raised; (2) separate thoroughly all adhesions to the gums so that the two flaps move freely make section of the edges of the cleft with strong scissors (Fig. or with the knife (Fig. 282), and in such form as will most completely oblit- erate deformity when the flaps are placed in perfect apposition; (4) close the wound with hare-lip pins if the tension is great (Fig. 283), and with silver wire su- Fio. 282. ture if it is but slight ; introduce the suture so deeply as to reach, but not to penetrate, the mucous membrane: (5) support (\ the flaps with long adhesive strips, or with a well-adapted truss (Fig. 284). -^ 1. Single hare-lip may occin- on either side and mny I'ifi- 283. vary in extent from a slight indentation to a complete division into the nostril. The two sides of the cleft differ in their regularity, being on different levels, and variously beveled at the angles. If the knife is uset operation is a well-formed mouth. •2. The lower lip destroyed by a shell wound was restored as follows^ (Fig. 303): Two incisions were made dividing the under lip, one from d, and the other from b, converging to c, under the chin; this V-shaped flap was removed, including a notch upon the lip border, and the adherent portion; the re- maining left half of the lip and the adjacent cheek were detached from the jaw as low down as its inferior border, and as far back as the last molar tooth; this dissection permitted the parts to glide towards the right side and in part fill the chasm left by the removal of the V-flap. Fig. 303. The next step was to make a quadrilateral flap by the incisions d to (i, and a to e, which was glided forward edgewise till it met the left half of the under lip to which it was attached; new lip border was constructed on the upper edge of the transferred cheek-patch by excising a prism-shaped strip of tissue from between the skin and mucous membrane. The mouth was also lengthened on the right side, and a border made as just described ; a new angle was also made b^' securing the opposite edges of the divided cheek together at a point where the newlv constructed upper and lower lip borders ter- minated; the space in the right cheek was filled by extending the tranverse in- cision, loosening the skin and gliding it forward. At a second operation the left angle of the mouth was extended by the method given (Fig. 300), and the result was satisfactorv (Fig. 301). Fig. 304. Fig. 305. 3. The lower lip and chin destroyed by gunshot (Fig. 304) have been reconstructed hv a similar operation.'^ The lower jaw was carried awav from 1 G. Buck. 2 J. vv. S. Gouley. THE UPS. 347 the secontl bicuspid toolh on the left, to the second molar tooth on the right. The incisions, commencing at the margin of the cicatrix, in the cleft of the lip, extended on eitlier side to the angles of the jaw, and tiience upwards to c (Fig. 302) until both flaps became, on loosening their deep attachments, so free as to meet readily in the median line. .V useful lip resulted (Fig. 305). 4. The right half of both lips was restored as follows: i The right cheek was detached from the jaws above and below, and the dissection continued in every direction till the jaws could be separated far enough to admit the thumb edgewise between the front teeth; the thinned cicatricial edge of the right cheek, bordering on the region of the angle of the month, was pared afresh for adjustment to the new lip; both lips were now deiaciied from their connections, the upper by an incision from the ala nasi to the middle of the left cheek; the lower by an incision across the middle of the chin parallel with and as far into the left cheek as the former; this bifurcated quadrilateral flap was advanced towards the right side of the face, and its two extremities adjusted with the lip bordei-s in contact with each other, by pin and thread sutures; the result was a contracted mouth drawn to the right side. This defect was remedied as previously described (Fig. 300), and the mouth assumed sym- metrical proportions. 5. The upper lip and adjacent portion of the cheek may be recon- structed by material taken from the under lip i" (Fig. 30G), as follows: (1.) Divide the extremity of the upper lip where it joins the right cheek, through its entire thickness, at right angles to its border, to the extent of one inch from the border, a to 6; make a sec- ond incision from b to c, one and a half inches long, parallel to the bor- der of the lip; fold this quadrilateral flap edgewise upon itself and to en- able it to meet, and be adjusted to, the remaining half of the upper lip: . divide its base obliquely half across, c to ■'" ' Vs-, ■, <^crs of the palato-pharyngeus muscles have 4 / ff-o ^^ been pared and united, but the operation n -'i "' S .../X\.--- li;i*l the effect of compelling the patient to /\^ SL'^ ^"^""^ \ ^''^'''ithe entirely through the mouth, with- /ni W out improving speech. ^ (2.) The attach- l J^ — ^^-^-"^ N. \ ments of the palate to the sides of the // rr^ Vi fauces, to^'ether with the anterior and pos- / \ terior pillars may be divided as follows: ' ' pass a spatula behind the soft {)alate, 1, 2 (Fig. 325) both to steady and to draw it forward, then, transfix the soft palate by a sharp pointed bistoury by the side of the spatula and at the inner edge of the haniular pro- 1 G. Pollock. 2 T. Smith. 3 j. M. Warren. * W. R. Whitehead. 5 Passavant. TUE PALATE. 357 cess 1, 4, and cut tliroiifih the free margin of the palate to 2 {Y\<^. 325), dividing tiie tensor palati, palato glossus, and palatopharynger.s muscles; retraction fullows, 3; sutures are now passed througli the sides of the flap from before backwards, tlius hcniniing the mucous membrane, 5; this operation is extremely simple, conii)aratively painless, and has always resulted in some, and, in many instances marked, improvement of the voice. ^ (3.) Dissection of the palato- pharyngeus muscles to form flaps in connection with a raised portion of the mucous membrane of tlic prevertebral region was attempted but not completed. - III. TIIE UVULA. The special instruments adapted to operations on the uvula are (Fig. -328): forcei).s for holding the tongue, a; a vulsellimi, h; uvula scissors with claws, c; a uvulatonie, d ; double hook, e.-* 1. Elongated uvula is the result of* chronic inflammation ; the lengthening may be slight or so great as to fall into the laryn.x. Excision, a very simple op- eration,^ should be performed thus: the patient sitting upon a chair in front of a goofl light, seize the tongue with the broad spatula, a, or direct the patient to with- draw it from the mouth by seizing the tip enveloped in a handker- chief ; seize the apex of the uvula with the forceps, i, or double hook, e, and cut off ■with the serrated scissors slightly curved, c, or uvula- tome, d (Fig. 326), aliout two thirds of the organ. 2. Abscess occasionally forms in the soft palate as a result of in- flammation which often extends from the tonsils; when pus is recog- nized, puncture with a knife having a sharp point and a narrow blad(-'; pass this directly l)ackwards. 3. Tumors appear in the .soft palate, and arc either fibro-celliilar, cystic, or warty ; the former are usually pendulous, attached to the free border or upper surface of the palate, of slow growth ; remove them with forceps and scissors. Cysts result from obstructed ducts, commonly contain thin glairy fluid, and are treated by incision and the application of nitrate of silver. Warty growths springing from the mucous membrane should be removed with scissors. ^ Polypi may 1 F. :\[.i>^on. ^ W. K. Whitehead. » 11. Green. ^ S. D. Gross. 5 G. I'ollock. Fig. .320. 358 OPERATIVE SURGERY. appear on the posterior surface, and give rise to cough owing to their pendulous condition ; they may be easily removed with scissors.* CHAPTER XXXn. THE ALVEOLAR PROCESS; THE SALIVARY GLANDS; THE TONSILS. I. THE ALVEOLAR PROCESSES. These parts are the thick pyramidal ridges of the maxillae which arch from behind forward and inward ; the free margins present the orifices of a number of deep conical pits, the sockets for the insertion of the teeth; the outer surface is marked by alternating vertical rid"-es and depressions corresponding with the alveoli and their in- terval s.^ 1. Abscess is caused by inflammation of the alveolo-dental peri- osteum. A sac forms at the a])ex of the tooth which finally suppu- rates with absorption of the fluid; the gums swell and become pain- ful, the accumulated pus ultimately makes an opening through one side of the socket, opposite the extremity of the root, the pain mean- time is deep-seated and throbbing until the pus escapes. ^ The pointing? of the abscess upon the face appears to depend upon either an unusual length of fang or a superficial reflection of the mucous membrane from the jaw to the cheek.* In an early stage prevent suppin-ation by means of leeches or the extraction of the tooth or its filling; when pus is detected, punc- ture with a sharp-pointed knife ; if it threaten to open externally, remove the tooth and make an incision between the cheek and the jaw so as to cut aci'oss the pus-containing canal, and dress the wound with oiled lint to prevent union.* 2. Epulis is an innocent tumor, hard, and densely fibrous, com- posed of fibrous tissue and myeloid cells, and involving the perios- teum; it grows slowly and evenly from the edge of the alveolar proc- ess, usually between two standing teeth, more often on the external than internal surface, though it may spring from any part; it gener- ally makes its first appearance beneath and involving the little tongue of gum which exists between the necks of two contiguous teeth; finally it displaces the neighboring teeth, one usually more than the other, has a broad base, which increases more the projecting portion. The treatment is early and complete extirpation, not only of the tumor, but the teeth and all the gum from which it sprung; while any part of the gum remains it is likely to recur.* Excision is best 1 S. C. Bussy. 2 J. Leidy. 8 c. A. Harris. * J. A. Salter. THE ALVEOLAR PROCESS. 359 effected by strong cutting bone forceps. Extract tlie involved teeth, and then cut the process on both sides of the growth completely through the alveolar border, and remove the mass with a knife or bone nippers. 3. Hypertrophy appears as a congenital affection, and consists of an expanded and j)roIonged development of the alveolar borders of the maxilliu, immense thickening of the fibrous tissue of the gum, and exul)erant growth of the papillary surface. When fully devel- oped, the patient presents an extraordinary ajipearance — a large mass, deii?e, inelastic, insensitive, pink and smooth, jjrotrudes from the mouth. 1 Excision slioidd be j)erformed. 4. Vascular grow^ths,^ na;vi and aneurisms by anastomosis form in the tissues about the necks of the teeth, especially between the in- cisors or canines and lateral incisors of the upper jaw; they have a purplish color, are smooth and streaked, with many vessels, are easily compressed and become pale and reduced, but are elastic and resume their previous aspect on removal of pressure ; the whole gum is red, turgid, and swollen, and the little tongues of gum between the necks of the teeth are enlarged and spongy; troublesome haemorrhage oc- curs later in the disease. Excision should be performed with a scalpel, the bleeding being controlled by pressure and ice. 5. Warty gro^^rths ' are hypertrophied papillaj of the gum, which occasionally appear, sometimes in connection with warts on the lips and about the face. Excision should be practiced; and if there is a return caustics should be applied. 6. Tooth tumors.^ odontomes. spring from the hard tissues of the teeth, and arc rlassilied as follows: (1) enamel nodules, pearl-like tumors on the fangs; (2) exostoses, small rounded nodules near the apex of the fang; (3) hypertrophy of fangs; (4) dentine excres- cence, nodules of secondary dentine growing from the wall of the pulp-chamber ; (5) warty teeth, the tissues being hypertro|)hied and folded into an irregular and complicated mass. Extraction of the affected tooth is necessary when the symptom=. as severe neuralgia, or the degree of malformation, demand interference. 7. Dentigerous cysts ^ are collections of serum in the maxillary bones, depeniKnt upon impacted misplaced teeth ; they arise only when the tooth or teeth associated with them are imbedded in the substance of the jaw-bone and do not occur after the tooth has pierced the gum; they occur in connection with the permanent teeth which may fail to pierce the gum, either from the great depth of the sac, or growth in an oblique direction, or from arrest of development. The symptoms are, expansion of the jaw-bone, weight, and tension, and disfigurement of the features; the diagnosis depends on pressure, 1 J. A. Salter. 360 OPERATIVE SURGERY. ■which i-eveals fluid, expansion of bone, and crepitation Uke stiff parchment, and absence of a tooth or teeth which have never ap- peared. The treatment consists in opening tlie cyst freely with knife, gouge, or trephine, extraction of the imbedded tooth, and, if the expansion is hxrge, removal of the dilated bone; the result is always satisfactory. 8. The extraction of teeth,^ though not strictly belonging to the province of the medical practitioner, must frequently be performed by him. It is surprising that this operation should receive so little attention ; this neglect can only he accomited for by the too prevailing belief that little or no skill is required for its performance; but it is the duty of every physician, residing where the services of a skillful dentist cannot always be connnanded, to pro- vide liiuiself wiih the proper instruments and become acquaiutid with the man- ner of performing this operation. The indications for the extraction of the temporary and j)erma- nent teeth are as follows: — (1.) When a tooth of replacement is about to emerge from the gums, or has actually made its appearance, either before or behind the corresponding milk tooth. (2.) When the aperture formed by the loss of a temporary tooth is so narrow as to prevent the permanent tooth from acquiring its proper position without the removal of an adjuiuing temporary tooth. (3.) Alveolar abscess, necrosis of the walls of the alveolus and incurable pain in a temporary tooth. The indications for the extraction of the permanent teeth are: (1) when a molar has become partially displaced, or is a source of constant irritation; (2) when there is a constant discharge of fetid matter from the nerve cavit}' through a carious cavity in the crown, unless the discharge is slight, and the tooth is in tiie front part of the mouth and cannot be easily replaced; (3) when a tooth is the cause of an incurable alveolar abscess, unless the previous conditions exist ; (4) when there is irregularity of the tooth due to disproportion between the size of the teeth and the alveolar arch; (5) when dead teeth act as irritants, or have become very much loosened. Teeth may be extracted with the key or with forceps. The com- mon tooth-key is a wheel and axle, the hand of the operator acting on two spokes of the wheel to move it while the tooth is fixed to the axle by the claw.^ The straight shank, with a small round fnlcruni slightly flattened on each side, is preferable to any otlier; there should be several hooks of different sizes, the edges of which should resemble the eagle's claw;^ operate as follows : separate the gum from the neck of the tooth down to the alveolus, and round the entire tooth, with a straight, narrow-bladed knife, pointed at the end and with one cutting edge; attach the proper hook, and api)ly the fulcrum upon the inside of the edge of the alveolus, the extremity of the claw being pressed down upon the neck on the opposite side, grasp the handle with the right hand, and hy a firm, steady rotation of the wrist, raise the tooth from its socket.^ 1 C. S. Harris. 2 Arnot. THE ALVEOLAR PROCESS. 361 For the removal of a tootli on tlie left side of tlie lower jaw, or the right side of the upper, tlie palm t^hould be beneath the handle; for the other teeth it should be jibove; where the exter- nal surface of the tooth is decayed, the fulcrum must be placed on the outside (Fig 327). The forct'ps are to be preferred to the key, for in the niajority of cases they can be used with greater ease, and much less ])ain. ThouLjh there is a great variety of forms, but four are required for general use. These are arranged in two sets, one adapted for the incisors, o, below, and b, above (Fig. 328) and cuspids, and the other for Fig. 327. the bicuspids and molars, c. below, and d, above. Operate as follows: detach the gum from the neck of the tooth, un- FiG. 328.1 less the claw of the forceps is sharp and sufficiently separates it; grasp the tooth firmly at the alveolar edge, but do not compress the handles of the forceps too tightly; move the tooth outwards and inwards, in (piick succession, until it is loosened, and then draw it from its socket in a line with its normal axis. For the incisors, strong, straight forceps may be used (Fig. 329), and a slight rotary motion should be given to the tooth ; the cuspids reipiire greater force, due to the length of their roots: very little rotary mo- tion can be given to the bicus|)i(ls; the upper molars have three roots, are very firm, and must be grasped as high up as possible and pressed out and in uiuil it yields; the superior dentes 1 Geo. Tiemauii & Co. 362 OPERATIVE SURGERY. sapientise are usually less firmly articulated and are easily removed with the bicuspid forceps; the inferior molars have two roots, but are very firm, and the decayed tooth is liable to be overlapped by the crowns of the adjoining teeth, which mav require filing off to admit of removal; the dentes sapicntiiB of the lower jaw, when situated far back, are oftentimes exceedingly difficult to ex- tract, especially when the roots are turned posteriorly towards the coronoid pro- cess ; in this case the loosened tooth should be pushed backwards, describing the segment of a circle as it is raised. II. THE SALIVARY GLANDS. These form a series of conglomerate glands arranged in a curved manner, and following the circumference of the inferior maxiUa from the posterior border of one side to that of the other, and pouring their secretion into the moutli by means of excretory ducts.^ 1. The parotid, the largest in the series, is bounded above bv the zygoma; below by a line drawn backwards from the lower border of the jaw to the sterno-mastoid muscle; behind by the external meatus of the ear, tlie mastoid process, and sterno-mastoid muscle; its anterior border lies over the ramus of the lower jaw, and stretches forward to a variable extent on the masseter muscle ; the deeper parts extend far inwards between the mastoid process and the ramus of the jaw towards the base of tlie skull; the excretory ducf^ passes off from the anterior border of the gland, one finger's breadth below the zygoma, runs forwards over the masseter muscle to the anterior border, turns inwards through the fat of the cheek, pierces the buccinator muscle, runs a short distance ob- liquely forwards beneath the mucous membrane, and opens upon the inner sur- face of the cheek by a small orifice opposite the crown of the second molar tooth of the upper jaw; a line drawn from the middle of the upper lip to the meatus of the ear marks the course of the duct.^ 2. The submaxillary is situated immediately below the base and the inner surface of the lower jaw and above the digastric muscle; its duct, ^ two inches in length, passes off from the gland to the side of the fraenum lingua', where it terminates close to the duct of the opposite side bj' a narrow orifice which opens at the summit of a soft papilla beneatli the tongue. ^ 3. The sublingual, the smallest gland, is situated along the floor of the mouth, where it forms a ridge between the tongue and the gums of the lower jaw, covered only by the mucous membrane, and reaching from the fnenum in front, where it is in contact with the gland of the opposite side, obliquely back- wards and outwards rather more than an inch and a half; the ducts 5 are from eight to twenty in number and open along the ridge which indicates tiie position of the gland.** 1. "Wounds involving these glands are not liable to bo followed by fistula, for though saliva flows for a time through the incision the textures consolidate, and the wounded part is obliterated. If oozing of saliva prevent healing apply pressure, or touch the part with hot wire, when the fistulous opening will usually promptly close ; if the excretory duct is wounded, as of the parotid gland, it is important to complete the incision into the mouth, if it has not penetrated so 1 Cyclop. Anat. ^ Steno's. 3 Quain's Anat. * Wharton's. ^ Rivieri. THE SALIVARY GLAXDS. 363 deeply, to allow a free escape of the saliva in that direction, and close the external wound with silver suture.* 2. Abscess may form, especially in the parotid, and generally run-i an acute course with much excitement; the pain is excessive, the parts pit on pressure, there is inability to open the moutli, the fluctuation is obscure as the pus is Hrmly bound down by the fascia and capsule of the gland; the treatment is early and free incision, made vertically into the most prominent part.* Abscess may form in the course of the ducts from obstruction by concretions; in the parotid duct it appears as a soft, fluctuating swelling in the cheek, which may attain large size, but usually ulcerates w^hen quite small and opens externally; in the subma.xillary and sublingual ducts these abscesses open into the mouth; the obstruction should, if possible, be dislodged, and the abscess opened within the mouth; if the abscess of the cheek cannot be relieved it should be opened into the mouth, and the obstruction removed. 3. Calculi may form in any of the ducts- of the salivary glands, but the suljlingual and submaxillary are most frequently affected ; they are generally of an ovoid shape, whitish color, rough, conqjosed of phosphate and carbonate of lime with animal matter; when diag- nosed tiny should be removed within the mouth by incision.- 4. Fistulas may remain after wounils or abscesses involving either the glands or ducts which open externally. Fistula of the "_dand, fully establislied, is often very difhcult of cui-e. The means which may be adopted are, (1) injections of iodine; (2) cauterization: (3^ grad- uated compression ; (4) plastic operations. When the parotid duct is implicated, the first step in the process of cure is to establish a free opening into the mouth, from the oral end of the duct; pass a fine probe, armed with several threads of silk, into the fistula, through the duct, into the mouth either direct or through the natural open- ing; draw the end of the seton in the mouth out at the anoxic and tie it to the end on the cheek : after a week or ten days the artificial fis- tulous communication with the mouth will be established, and the fistula in the cheek will then probably contract and close; if it do not, cauterization of the edges of the fistula will tend to hasten cicatrization.' This operation failing, pass a thread of silk or metal through the fistula, into the mouth, from before backwards; remove the needle, leaving the thread in place ; thread the external end and reinsert the needle at the fistula and carry it forwards in a similar manner into the mouth; remove the needle and tie the two ends of the thread now within the mouth quite firmly; the loop cuts its way out, leaving a free internal opening of the duct ; tlie edges of the fistula may now be freshened and united by a suture.* Or, the fis- 1 J. Spence. - S. D. Gross. » Morand; T. Bryant. * J. Bell- 364 OPERATIVE SURGERY. tulous tract may be destroyed by placing a wooden spatula against the inside of the cheek and witli a large, sharp, saddler's punch re- moving it entire, and closing the external opening with a suture. ^ 5. Tumors of a cartilaginous nature appear by preference in the salivarv glands, especially in the sul:)maxillary and parotid. Pure examples of enchondroma are more often found in these glands than anywhere else.^ They may involve a single or several lobes, or the entire gland; the latter is rarely found in the pai-otid, but is the more frequent form in the submaxillary; other concomitant affections may also be present, especially myxoma, and sometimes cancer and can- croid. ^ In some cases the cartilage represents merely the acme of textural evolution, while the main bulk of the growth is made up of mucous tissue, with spindle-cell and round-cell sarcoma tissue.* Tumors of these glands are not only cartilaginous, but are mostly encvsted, and have a peculiar, hard, elastic feel, are generally em- bedded in the structure of the gland, varying much in depth, those Avhich appear movable and superficial too often dipping well down into the tissues; they may grow to a great size, and stretch the skin over them.^ The question of the removal of these growths must be determined by the conditions existing in each case; pure cartilag- inous tumors of small size may be very easily removed; mixed tu- mors of large size involve extensive dissection among important parts, but they are often removed very satisfactorily ; cancerous de- generation requires extirpation of the gland, which is always a for- midable operation, but may be safely accomplished and be followed by variable periods of comparative comfort^ A safe rule to follow may be thus stated : when it is evident that the part glides freely over the subjacent textures do not hesitate to undertake removal, whatever may be the bulk of the disease; but if the tumor seems fixed, its limits not clearly defined, and its movement causes jiain, hesitate about removal, however small the mass may be.'' Extirpation of the tumor requires a free division of the superim- posed parts as a condition essential to success; make first an incision down to the tumor and through its investments, and then add others so as to form two or more flaps; carry the dissection to the lower boundary of the growth where the vessels are known to enter, and divide, compress, or tie them, as may be necessary, and thus much less blood will be lost, and the time occupied lessened ; the utmost care must be taken to avoid, as far as possible, the branches of the cervical nerves and the portio dura by dissecting the posterior part of the tumor careftdly, and in the direction of their course, the edge of the knife being turned towards the tumor; in some cases 1 \V. E. Horner; S. D. Gross. 2 e. Riiulfleisch. 3 R. Virchow. 4 T. Billroth. « T. Bryant. 6 j. M. Warren. ' Sir W. Fergusson. THE SALIVARY GLANDS. 365 these nerves must be divided.^ Extirpation of the entire gland nin!