Kl}?>^ 1>A1 Columbia ^tnibct^ltp uitl)cCitpof2IrUigjjrfe Srpartmpnt of &«rgpra (Sift of Sr. 3lBBr;ilj A. llakr Digitized by the Internet Arciiive in 2010 witii funding from Columbia University Libraries http://www.archive.org/details/textbookofoperatOObick A TEXT-BOOK OPERATIVE SURGERY COVERING THE SURGICAL ANATOMY AND OPERATIVE TECHNIC INVOLVED IN THE OPERATIONS OF GENERAL SURGERY WRITTEN FOR STUDENTS AND PRACTITIONERS WARREN STONE BICKHAM, Phar.M., M.D. Assistant Instructor in Operative Surgery. College of Pliysicians and Surgeons. New Yurl< ; Late Visiting Surgeon to Cliarity Hospital, New Orleans ; Late Demonstrator of Operative Surgi-ry, Medical Department. Tulane University of Louisiana. New Orleans Wit^ 559 iflllufitrations; PHILADELPHIA. NtW YORK. LONDON W. B. SAUNDERS & COMPANY 1903 Copyright, kjo;, by W. B. Saunders & Company Registered at Stationers' Hall, London, England IN REVERED MEMORY OF MY FATHER Cbarles 5as>per Bichbam WHOSE DAILY LIFE EMBODIED THE HIGHEST IDEALS OF CHRISTIAN PHYSICIAN, I LOVINGLY DEDICATE THIS WORK PREFACE. The sub-title of the present volume sufficiently designates its intended scope — "The Surgical Anatomy and Operative Technic involved in the Operations of General Surgery." The work is planned to be a presentation to the Student and Practitioner of the best technic of modern Surgeons in the operations mentioned — accompanied by a brief summary of the descrip- tive and surgical anatomy of the structures involved. The clinical aspect of Operative Surgery has been less fully dealt with — and in generalizations in connection with groups of operations, rather than specifically in connection with individual operations. An apology for the amount of Anatomy given may seem, to some, neces- sary. From the standpoint of the pure technician. Operative Surgery is, largely, Applied Anatomy — the application of the facts of Surgical Anatomy during the progress of Surgical Manipulations — the resulting Operative Technic being more or less perfect as the knoivlcdge of the Surgical Anatomy and the conduction of the Surgical Manipulations are more or less perfect. Theoretically, it is proper to expect fourth-year Students to come into the Operating Room with their Anatomv in an available form for surgical work — practically, this is rarely found — and is often absent in seasoned Operators. In the arrangement of this work the subjects have been grouped under. The Operations of General Surgery (Part I), and, The Operations of Special Surgery (Part II) — as further detailed in the especially full Contents. In dealing with each group of tissues, or class of operations (in Part I), or with each organ (in Part II), the following divisions of the subjects are taken up, in order: — (i) Surgical Anatomy (of the region or organ); (2) Surface Form and Landmarks; (3) General Surgical Considerations (in operating upon that region or organ) ; (4) Instruments (used in such operations) — all being introductory to the specific operations, — after which each operation is taken up in turn, under the following headings: — (i) Title of Operation; (2) De- scription of Operation (including its general indications); (3) Preparation of Patient; (4) Position of Patient, Surgeon, and Assistant; (5) Landmarks of Operation; (6) Incision for Operation; (7) Steps of Operation; (8) Com- ments. In the description of the technic of the operations the "Incision" is given a heading to itself — to emphasize the importance of this step of the operation — recognizing that the Operator who starts out aright is a long way ahead of the man who takes his initial step erroneously. Under "Operation" the various steps are given in numbered paragraphs — the different paragraphs usually indicating, in a general way, some change in the technic or in the stage of the operation. The Principles of Operative Surgery, and Anesthesia, as well as the Operations of Plastic Surgery, many of the operations more properly classed as the operations of Special Branches of Surgery, and some of the many variations of the operations of General Surgery, have been omitted. In the [)reparation of these pages, obligations are hereby gratefully and fully acknowledged to the writings of many well-known Surgeons in the standard works of the day upon Operative Surgery, and in the current surgical literature, whose pages have been freely consulted — and to the work of many Surgeons, here and abroad, whose operative technic it has been the privilege of the author to witness — and to writings upon Anatomy. The name of the cfeviser of an operation is given, in brackets, after the title of the operation, wherever known to the author. Where slight de- partures from the manner of doing the operation as performed by its originator occur, such omission is accidental — or, where the original description is ambiguQus, the operation is given as it seems to be interpreted by the majority of Surgeons. Appreciation of encouragement shown during the preparation of the manuscript is gratefully acknowledged to Professors Bull, Dennis, Hal- sted. Hartley, Matas, Richardson, Senn, Weir, and Wyeth — and to my co-workers. Doctors Peck, Schmitt, and Taylor, in the Department of Op- erative Surgery at the College of Physicians and Surgeons — and to Doctor Gessner, my former co-worker in the Laboratory of Operative Surgery of Tulane University — and to Doctors Armstrong and LeBeuf — and to other friends whose kindly words have aided and lightened the work of preparation. The author feels deeply indebted to Miss Eleanora Fry, who has drawn, under his close directions, all the illustrations for the book, during many weeks of conscientious work and unflagging interest — the large majority of the five-hundred and fifty-nine illustrations being original, and the remainder so largeh' modified as to be, in many instances, ]jractically new pictures. I wish to thank the Publishers for the courteous consideration they have shown my every expression of wish throughout — for their interest in the manuscript — and for the quality of their finished work. I desire to e.xpress my high valuation of my Wife's ever-ready and untiring aid in all the proof-readings of the manuscript during the many months of its preparation. The imperfections of the present work are ver\' fulh' realized — and the author will be glad to receive all criticisms which may tend to the bettering of the te.xt and illustrations. WARREN STONE BICKHAM. 022 Madison Avenue, corner of 730 Street, New York City. CONTENTS. PART 1. THE OPERATIONS OF GENERAL SURGERY. CHAPTER I. OPERATIONS UPON ARTERIES. I. Ligation of arteries — General considerations, 17. II. Surgical Anatomy and Ligation of following Arteries of Head and Neck: — Innominate, by angular incision, Mott's operation, 26 — By oblique incision, 28 — By partial bony resection, 29 — By partial bony resection, Bardenheuer's operation, 30 — By splitting of manubrium sterni, 30 — Common carotid, above omohyoid. 33 — Below omo- hyoid, 34 — External carotid, below digastric, 35 — .^bove digastric, behind ramus of jaw, 36 — Superior thyroid, 37 — Lingual, near origin, 38 — Beneath hyoglossus, 38 — Facial, near origin, 40 — Over inferior ma.xilla, 40 — Occipital, near origin, 41 — Behind mastoid process, 41 — Posterior auricular, near origin, 42 — Behind ear, 42 — Temporal, just above zygoma, 43 — Internal maxillary (surgical anatomy), 44 — Trunk of middle meningeal, in cranium, through trephine-opening exposed by curved oblique incision, 47 — Anterior branch of middle meningeal, through trephine-opening exposed by horseshoe incision, 48 — Posterior branch of middle meningeal, through trephine-opening exposed by horse- shoe incision, 49 — Internal carotid, near origin, 50 — First part of right subclavian, by angular incision, 52 — First part of left subclavian, by angular incision, 53 — Second part of subclavian, 53 — Third part of subclavian, 54 — Vertebral, near origin, 56 — Inferior thyroid, 57 — Transversalis colli, at outer margin of sternomastoid, 58 — Suprascapular, at outer margin of sternomastoid, 59. III. Surgical Anatomy and Ligation of following Arteries of Upper Extremity and Thorax: — Internal mammary, in second intercostal space, 60 — First part of axillary, by curved transverse incision below clavicle, 62 — Third part of axillary, 63 — Subscapular along posterior axillary fold. 64 — Brachial, in mid-arm, 6q — .^t bend of elbow, 66 — Radial, in upper third, 69 — In middle third, 70 — In lower third, 70 — On back of hand, 71 — Deep palmar arch, 72 — Ulnar, in middle third, 74 — In lower third, 76 — Superficial palmar arch, 76 — Intercostal, by intercostal incision, 76 — Intercostal, by partial sub- periosteal excision of rib, by Hartley's method, 78. IV. Surgical .\natomy and Ligation of following Arteries of Trunk: — Abdominal aorta, by transperitoneal method, 80 — By retroperitoneal method, 81 — Common iliac, by retroperitoneal method, 82 — By transperitoneal method, 84 — Internal iliac, by retro- peritoneal method, 84 — Bv transperitoneal method. 84 — Obturator, at thvroid foramen, 85 — Sciatic, upon buttock, 86 — Internal pudic, upon buttock, 8S — In perineum, 88 — Gluteal, on buttock, 89 — External iliac, by retroperitoneal method, 00 — By transperi- toneal method, 92 — Deep epigastric, near origin, 93. V. Surgical Anatomy and Ligation of following .•\rteries of Lower Extremity: — Common femoral, at base of Scarpa's triangle, 95 — Profunda femoris, near origin, 97 — Superficial femoral, at apex of Scarpa's triangle, 97 — In Hunter's canal, 98 — Popliteal, in upper part of popliteal space, from behind, 100 — In upper part of popliteal space, from inner side of thigh, Jobert's operation, 100 — In lower part of popliteal space, loi — 3 4 CONTENTS. Anterior tibial, in upper third, 104 — In middle third, 105 — In lower third, 105 — Dorsalis pedis, just below ankle-joint, 107 — Posterior tibial, in upper third, above peroneal branch, log — In middle third, 109 — In lower third, no — Behind internal malleolus, in — Pero- neal, in middle of leg, 112 — External plantar, at origin, 114 — In sole of foot, 115 — Internal plantar, at origin, 115 — In sole of foot, 115. \T. Temporary ligation, 116 — Intermediate ligation, 117 — Arteriorrhaphy. 117 — Arterial forcipressure, 119 — Arteriostrepsis, 120 — Ligation for radical cure of aneurism, 120 — Operation for radical cure of aneurism based upon Arteriorrhaphy, Matas's method, 121 — Other operations for radical cure of aneurism, 124 — Wyeth's treatment of vascular angeiomata, 125. CHAPTER II. OPERATIONS UPON VEINS. Phlebotomy, 126 — Phleborrhaphy, 120 — Lateral ligation of veins, 127 — Transverse ligation of veins, 128 — Temporary ligation of veins, 128 — Venous ligation en masse, 129 — Venous forcipressure, 129 — Phlebostrepsis, 129 — Acupressure of veins, 129 — Phlebectomy, 129 — Intravenous infusion of normal salt solution, 130. CHAPTER III. OPERATIONS UPON LYMPHATIC GLANDS AND VESSELS. Surgical anatomy of thoracic duct, 132 — Suture of thoracic duct, 132 — Ligation of thoracic duct, 133 — Surgical anatomy of antero-lateral aspect of neck, 133 — Removal of lymphatic glands of neck, 135 — Surgical anatomv of axillary region, 138 — Removal of axillary lymphatic glands, 139 — Surgical anatomy of Scarpa's triangle, 139 — Removal of inguinal lymphatic glands, 140. CHAPTER IV. OPERATIONS UPON NERVES, PLEXUSES, AND GANGLIA. I. Neurotomy, 141 — Neurectomy, 142 — Neurectasy, 142 — Nerve-avulsion, 143 — Neurorrhaphy, 144 — Neuroplasty, 147 — Nerve-grafting, 149 — Operation for relief of nerve compressed by bony or fibrous cicatricial tissue, 151 — Intraneural infiltration for regional anesthesia, ic;i — Para-neural infiltration for regional anesthesia. 153. II. Surgical Anatomv and Exposure of following Nerves and Ganglia of Head and Neck: — Gasserian ganglion and three divisions of fifth, by intracranial exposure, Hartley- Krause method, 155 — Same, by extracranial exposure, Rose's method, 158 — Supraorbital, at supraorbital foramen, 160 — Meckel's ganglion and superior maxillary, by antral route. Carnochan's operation, 161 — Same, by orbital route, 162 — Same, by pterygo-maxillary route, Braun-Loessen operation, 162 — Infraorbital, at infraorbital foramen, 163 — Infe- rior maxillary nerve and otic and submaxillary ganglia (surgical anatomy), 164 — Inferior maxillary, at foramen ovale, 164; or superior ma.xillary, at foramen rotundum, Mixter's operation. 164 — Inferior dental, in mouth, Paravicini's intrabuccal method. 166 — Through ascending ramus of inferior maxilla, 167 — M mental foramen, from within mouth, 168 — Lingual (gustatory! of inferior ma.\illary, in mouth. 168 — Facial, in front of mastoid process, Baum's operation, 169 — Spinal accessory, at anterior border of sternomastoid, 170 — Occipitalis major, beneath complexus, 171 — Posterior divisions of first, second, and third cervical nerves. Keen's operation, 171 — Brachial plexus, in neck, 172. III. Surgical Anatomy and Exposure of following Nerves of Upper Extremity and Thorax: — Circumflex, on back of arm, 173 — Musculocutaneous, in upper part of arm, i73^Median, in middle of arm, 174 — M bend of elbow. 174 — Ulnar, above middle of arm, 175 — Just above internal condyle of humerus, 175 — Musculospiral, below middle of arm, 176 — Radial, at origin, 177 — Posterior interosseous, at origin, 177 — Intercostal between angle and middle of rib, 178. IV. Surgical .Anatomy and Exposure of following Nerves of Lower Extremity: — Anterior crural, below Poupart's ligament, 178 — Obturator, at thyroid foramen, 179 — Superior gluteal, upon buttock, 179 — Pudic, upon buttock, 170 — Great sciatic, at lower border of gluteus maximus, 179 — Internal Popliteal, at lower part of popliteal space, 180 — Posterior tibial, between origin and ankle, 180 — Behind internal malleolus, 181 — CONTENTS. 5 External popliteal (peroneal), behind tendon of biceps, i8i — Anterior tibial, near origin, 182. V. Surgical Anatomy of Cervical Sympathetic Ganglia and Cord, 182 — Total ex- cision of cervical sympathetic ganglia and cord, Jonnesco's operation, 183. CHAPTER V. OPERATIONS UPON BONES. Osteotomy in general, 184 — Linear osteotomy, by subcutaneous method, i8s — Linear osteotomy, by open method, 187 — Cuneiform osteotomy. 187 — Operations for recent or ununited fractures, in general, 188 — Operations for recent or ununited fractures, by resection of ends of bones, with retention of coaptated ends by immobilizing splints, i8q — Same, by wiring of ends of bones, with or without resection, iqi — Same, by suturing, with or without resection, ig? — .Same, by nailing, pegging, or screwing ends of bones, with or without resection, iq^ — Same, by Parkhill's clamp, 194 — Other operations for recent or ununited fractures, 195 — Operation for recent or ununited fracture of patella, by Stimson's method of mediate suture, 197 — Same, by wiring or suturing, 198 — Opera- tion for recent or ununited fracture of olecranon, by wiring or suturing, 200 — Seques- trotomy, 201 — Osteoplasty 202 — Excision, 203. CHAPTER VI OPERATIONS UPON JOINTS. Arthrotomy. 204 — Puncture of joints, 204 — Erasion, or arthrectomy, 204 — Excision 206 CHAPTER Vn. OPERATIONS UPON MUSCLES. Myotomy 207 — Myorrhaphy, 207 — Muscle-lengthening, 208. CHAPTER \TII OPERATIONS UPON TENDONS AND TENDON-SHEATHS. Tenotomy, 211 — Tenorrhaphy, 213 — Tendon-lengthening, 216 — Tendon-shortening, 220 — Tendon-grafting, 221 — Repair of ruptured or divided tendon-sheaths, 223 — Exci- sion of tendon-sheaths, 224 CHAPTER L\. OPERATIONS UPON LIGAMENTS. Svndesmotomy, 226 — Suturing of ligaments. 22fi — Lengthening of ligaments, 226 — Shortening of ligaments, 226. CHAPTER X. OPERATIONS UPON FASQ^. Fasciotomy, 227. CHAPTER XI OPERATIONS UPON BURS^. Puncture of bursse, 228 — Incision of bursae, 228 — Excision of bursae. 228. CHAPTER XII AMPUTATIONS AND DISARTICULATIONS. I. General considerations. 220 — The general technic in amputating, 232 — Loca- tion of line of bone-section, or disarticulation. 232 — Location of limits of skin incisions. 233 — Incision of skin and fascia, 234 — Freeing of skin and fascia. 237 — Retraction of skin and fascia, 238 — Division of muscles in circular methods of amputation 239 — Divi- 6 CONTENTS. sion of muscles in flap methods of amputation, 242 — Freeing and retracting of muscles, 246 — Making musculo-periosteal, or periosteo-capsular, covering for end of bone, 247 — Retraction of soft parts preparatory to sawing bone, 250 — Sawing bone or bones, 251 — Removing splintered bone, 252 — Ligating arteries and veins, 253 — Treatment of nerves, tendons, and tags of muscle, fascia, and skin, 255 — Trimming of flaps, 255 — Re-ampu- tation for improperly made flaps, 255 — Adjustment and suturing of musculo-periosteal, or periosteo-capsular, covering, 255 — Quilting of muscles, 256 — Drainage, 258 — Suturing of stump, 258 — Dressing of wound, 259 — Removal of dressings, 259. II. The methods of amputation, 259 — The evolution of amputation methods, 259 — Summary of amputation methods, 261 — Circular methods of amputation, 261 — Ordinary circular amputation (.imputation circulaire infundibuliforme), 261 — Cuff method of circular amputation (Circular amputation a la manchette), 263 — Modified circular ampu- tation (Mixed method), 264 — Oval method, 265 — Racket method, 266 — Flap methods of amputation, 267 — .Amputating by single flap of skin and muscle, 267 — By single flap of skin, 269 — Bv equal flaps of skin and muscle, 269 — By equal flaps of skin, 270 — By unequal flaps of skin and muscle, 271 — By unequal flaps of skin, 272 — By unequal rec- tangular flaps of skin and muscle (Teale's method), 272 — EUiptical method, 273 — Irregular methods of amputation, 275 — Selection of amputation method, 275. III. The amputation stump, 276 — Qualities of a good stump, 276 — Characteristics of a bad stump, 277 — Conditions influencing vitality of stump, 277 — Contractility of tissues of stump, 277 — Position of stump cicatrices, 278 — Function of amputation-stumps, 278. IV. Surgical .Anatomy, Surface Form and Landmarks, General Surgical Consid- erations and Methods in .Amputations and Disarticulations about the Fingers: — .Ampu- tation through last phalanx, by palmar flap, 283 — .At second phalangeal joint, by palmar flap, 284 — Same, by short dorsal and long palmar flaps, 284 — Through second phalanx, bv palmar flap, 285 — Same, by short dorsal and long palmar flaps, 285 — .At first phalangeal joint, bv palmar flap, 286 — Same, by short dorsal and long palmar flaps, 286 — Through first phalanx, by palmar flap. 286 — Same, by short dorsal and long palmar flaps, 287 — .At metacarpo-phalangeal joints of fingers in general, by oval method, 287 — Same of thumb, by oval method, 289 — Same of thumb, by oblique palmar flap (Farabeuf), 290 — Same of index, by externo-palmar flap (Farabeuf), 2qo — Same of little finger, by interno- palmar flap (Farabeuf), 291. V. Same, in .Amputations and Disarticulations about the Hand: — .Amputation of finger, in general, with part of its metacarpals, by racket method, 295 — Of thumb with part of its metacarpal, by racket, 296 — Of little finger with part of its metacarpal, by racket, 296 — Of two contiguous inside fingers, with part of their metacarpals, by racket, 296 — Of three innermost fingers, with parts of their metacarpals, by racket, 296 — Same, by equal dorsal and palmar flaps, 207 — Of all fingers (except thumb) with parts of their metacarpals, by anterior ellipse, 207 — Of an inner finger, with its metacarpal, by racket, 297 — Of index, with its metacarpal, by racket, 298 — Of little finger, with its metacarpal, by racket, 298 — Of thumb, with its metacarpal, by racket, 298 — Of two contiguous inside fingers, with their metacarpals, by racket, 299 — Of three inside fingers, with their meta- carpals, by racket, 290 — Of three inner fingers, with their metacarpals, by equal dorsal and palmar flaps, 300 — Of all fingers (except thumb) with their metacarpals, by anterior ellipse, 301 — Of fingers and thumb, at carpo-metacarpal articulation, by palmar flap, 302. VI. Same, in Disarticulations about the Wrist-joint: — Disarticulation at wrist-joint bv anterior ellipse 304 — By palmar flap, 305 — By external lateral, or radial, flap (Du- brueil's method), 306. VII. Same, in Amputations about the Forearm; — Through lower third, by modified circular, 309 — By circular (cuff variety), 310 — Through upper two-thirds, by equal ante- rior and posterior flaps, 311. VIII. Same, in Disarticulations about Elbow-joint: — Disarticulation of elbow-joint, by anterior ellipse (Farabeuf), 314 — By posterior ellipse, 315 — By long antero-intcrnal and short postero-external flaps, 316. IX. Same, in .Amputations about the .Arm: — .Amputation through lower third, by modified circular, 320 — Through upper two-thirds, by long anterior and short posterior flaps, 321 — Through surgical neck, by single external flap, 322. X. Same, in Disarticulations about the Shoulder-joint: — Disarticulation at CONTENTS. 7 shoulder-joint by anterior racket (Spence's operation), 327 — By external racket (Larrey's operation), 329 — By external or deltoid flap, 330. XI. .imputation of Upper Limb, together with Scapula and part of Clavicle, by antero-inferior (or pectoro-axillarv') and postero-superior (or cervico-scapular) flaps (Berger's operation), 331. XII. Surgical .Anatomy, Surface Form and Landmarks, General Surgical Consid- erations, and Methods in .\mputations and Disarticulations about the Toes: — .imputa- tion through last phalanx, by plantar flap, 336 — .•\t second phalangeal joint, by plantar flap, 337 — Through second phalanx, by plantar flap, 338 — .A.t first phalangeal joint, by oval, 338 — Through first phalanx, by oval, ^;}q — .Same, by circular, 340 — .\t metatarso- phalangeal joints of toes in general, by oval method, 340 — .At same of great toe, by interno- plantar flap (Farabeuf), 341 — .At same of Uttle toe, by externo-dorsal flap (Farabeuf), 341 — Disarticulation of two adjoining toes at metatarso-phalangeal joints, by oval method, 342 — Of toes en masse, at metatarso-phalangeal joint, by equal short dorsal and plantar flaps, 342. XIII. Same, in Amputations and Disarticulations about Foot: — .Amputation of all toes through the metatarsus, by short dorsal and long plantar flaps (Metatarsal amputa- tion), 348 — Disarticulation of toe, with its entire metatarsal, by racket method, 350 — Of great toe and its metatarsal, by racket, 350 — Of little toe and its metatarsal, by racket, 352 — Of two or three contiguous toes with their entire metatarsals, by oval or racket, 353 — Of all toes, at tarso-metatarsal joints, by short dorsal and long plantar flaps (Lisfranc's operation), 353 — Of all toes, at tarso-metatarsal joints, with sawing off of end of internal cuneiform, by short dorsal and long plantar flaps (Hey's operation), 354 — Of anterior part of foot at medio-tarsal joint, by short dorsal and long plantar flaps (Chopart's opera- tion), 355 — Of foot at astragalo-scaphoid and astragalo-calcaneal joints, subastragaloid disarticulation, by large interno-plantar flap (Farabeufl, 356 — Of foot at astragalo- scaphoid and astragalo-calcaneal joints, subastragaloid disarticulation, by heel-fiap, 35S. XIV. Same, in Disarticulations about .Ankle-joint: — Disarticulation of foot at ankle-joint, with removal of malleoli and articular surface of tibia, by heel-flap (Syme's operation), 360 — Disarticulation of foot at ankle-joint, with removal of malleoli, articular surface of tibia, and anterior part of os calcis, by heel-flap (Pirogoflf's osteoplastic ampu- tation), 361. XV. Same, in .Amputation about the Leg: — Through supramalleolar region, by oblique elliptical incision (Guyon's supramalleolar operation), 365 — Through lower third, by large posterior and small anterior flaps (Farabeuf), 365 — Through middle third, by long posterior and short anterior flaps (Hey's operation'), 367 — Through upper third, by large external flap (Farabeufl, 368 — Same, by bilateral hooded flaps (Stephen Smith's method), 370. XVI. .Same, in Disarticulations about the Knee-joint: — Disarticulation at knee- joint by bilateral hooded flaps (Stephen Smith), 374. XVII. Same, in .Amputations about the Thigh: — Through condyles of femur, transcondyloid amputation, by shorter anterior and longer posterior flaps (Lister's modi- fication of Garden's transcondyloid operation), 37Q — Just above condyles of femur, with splitting of patella (supracondyloid osteoplastic amputation of Gritti-Stokes) by longer anterior and shorter posterior flaps, 380 — Through lower third of thigh, by oblique cir- cular method, 382 — Through thigh in general, by long anterior and short posterior flaps, 382 — Same, by equal anterior and posterior flaps, 3.S4 — Through thigh just below tro- chanters, by external oval method, 386. X\TII. Same, in Excisions about the Hip-joint: — Disarticulation at hip-joint by W\eth's method, 390 — By external racket, 392 — By anterior racket, y);;i XIX. Osteoplastic Amputations, 394. CH.APTER XIII. EXaSIONS. I. General Considerations. 307 — Excision by subperiosteal method, 30S — Exci- sion by open method, 401. II. Surgical .Anatomy, Surface Form and Landmarks. General Surgical Considera- 8 CONTENTS. tions, and Methods in Excisions about the Fingers: — Excision of terminal phalanges, by U-shaped incision, 403 — Of second phalangeal joints, by two lateral incisions, 405 — Of second phalangeal joint of index, by dorso-external incision, 404 — Of second phalangeal joint of little finger, by dorso-internal incision, 405 — Of second phalanges of fingers in general, bv dorso-lateral incision, 405 — Of second phalanx, by dorso-external incision, for index-finger, 405 — Of second phalanx of little finger, by dorso-internal incision, 406 — Of first phalangeal joints, by same methods as for second phalangeal joints, 406 — Of first phalanges of fingers in general, 406. III. Same, in E.xcisions about Hand: — Excision of metacarpo-phalangeal joints of fingers, in general, by dorso-lateral incision, 406 — Of metacarpals, in general, by dorsal incision, 407 — Of metacarpal of thumb, by dorso-external incision, 408 — Of metacarpal of little finger, by dorso-internal incision, 408. IV. Same, in Excisions about Wrist-joint: — Excision of wrist by radial and ulnar dorsal incisions (Oilier), 40Q — Same, by single dorso-radial incision (Boeckel-Langen- beck), 410 V. Same, in Excisions about Bones of Forearm: — Total excision of ulna, by long posterior incision, 411 — Same, of radius, by long externo-dorsal incision. 412. VI. Same, in E.xcisions about Elbow-joint: — Excision of elbow-joint, by posterior median incision (Langenbeck), 413 — Same by posterior bayonet-shaped incision, with or without an additional short vertical ulnar incision (Oilier), 415 — Excision of superior radio-ulnar articulation, by posterior vertical incision, 416. VII. Same, in Excisions about Humerus: — Excision of humerus, by long external incision, 417. VIII. Same, in E.xcisions about Shoulder-joint and vicinity: Excision of shoulder- joint, by anterior oblique incision. 418 — Total e.xcision of clavicle, by long axial incision. 420 — Total e.xcision of scapula, by straight incisions along spine and vertebral border, forming superior and inferior flaps, 42 1 . IX. Same, in Excisions about the Toes: — E.xcision of terminal phalanges, 423— Of second phalangeal joints, 423 — Of second phalanges, 423 — Of first phalangeal joint. 423 — Of first phalanges, 424. X. Same, in Excisions about Foot: — Excision of metatarso-phalangeal joints, 424 — Of metatarsals, 424 — Of astragalus, by external curved incision, 424 — Same, by ex- ternal angular and internal curved incisions, 425 — Of os calcis, by horizontal curved and vertical incisions, 427. XI. Same, in Excisions about Ankle-joint; — Excision of ankle-joint, by trans- versely curved external incision (Lauenstein), 428^Same, by external curved and internal angular incisions, 42p. XII. Same, in Excisions about Bones of Leg: — Total e.xcision of tibia, by internal vertical incision, 430 — Total e-xcision of fibula, by posterior vertical incision, 431 — Total excision of patella, by vertical incision, 432. XIII. Same, in E.xcisions about the Knee-joint: — Excision of knee-joint, by curved transverse anterior incision, 433. XIV. Same, in E.xcisions about Femur; — Excision of parts of diaphysis, by external vertical incision, 435. XV. Same, in Excisions about Hip-joint: — Excision of hip-joint, by external straight incision (Langenbeck), 436 — Same, by anterior straight incision (Barker), 438 — Same, by posterior angular incision (Kocher), 43g. X\T. Same, in E.xcisions about Head; — Excision of superior maxilla, by median incision (Fergusson), 441 — Of temporomaxillary articulation, by angular incision, 444 — Of inferior maxilla, by single incision along inferior and posterior borders, 445. XVII. Same, in Excisions about Trunk; — Excision of entire rib and costal cartilage by parallel incision over center of rib, 447 — Of coccyx, by posterior median incision, 448. XVIII. Osteoplastic Resection of Bones and Joints: — Of anterior tarsus and tarso- metatarsus, bv internal and external dorso-lateral incisions, 44Q — Of mid-tarsus, by ex- ternal transverse curved incision, 450 — Of posterior tarsus, by external curved incision, 451 — Osteoplastic resection of foot, by transverse upper and lower, and oblique lateral incisions fWladimiroff-Mikulicz operation), 452 — Total excision of tarsus, or osteoplastic resection of foot, by externo-lateral cuned incision (modification of Wladimiroff-Mikulicz operation), 453 — Osteoplastic resection of superior maxilla, by contp;nts. 9 vertical and horizontal incisions, 454 — Chondro-plastic resection of nasal cartilages, to expose nose and anterior nasopharynx by nasal route, by transverse incision (Rouge), 455 — Osteoplastic resection of superior maxilla, to expose nasopharynx by palatine route, by transverse and median incisions (Annandale), 455 — Same, to expose nasopharynx by maxillary route, by two semilunar incisions (Langenbeck), 456 — Osteoplastic resection of inferior maxilla, to expose structures in front of fauces through divided symphysis, by median incision, 457. PART II. THE OPERATIONS OF SPECIAL SURGERY. CHAPTER I. OPERATIONS UPON THE HEAD. I. Cranio-cerebral Region; — Surgical anatomy of scalp, skull, and brain, 459 — Chief cranial landmarks, 463 — Cranio-cerebral topography, 464 — Localization of brain areas, 469 — Chipault's method of cranio-cerebral localization, 472 — Reid's method of same, 476 — Chiene's method of determining Rolandic fissure, 478 — General surgical considerations in cranio-cerebral operations, 478 — Instruments, 480 — Craniotomy, in general, 480 — Trephining, or circular craniotomy, 4S1 — Osteojjlastic resection of skull, 483 — Linear craniotomy, 4S7 — Partial craniectomy, 487 — Exploratory puncture of brain, 488 — Operation for intracranial hemorrhage, 489 — Ligation of middle meningeal artery and its anterior and posterior branches, 490 — Ligation of longitudinal or lateral sinuses, 490 — Operation for thrombosis of lateral sinus, 492 — Trephining for fracture of skull 492 — Operation for bullet-wound of brain, 493 — Operation for exposure of a motor center, 494 — Puncture and drainage of lateral ventricles, 495 — Incision of cerebellar subarachnoid space for drainage (Parkin), 496 — Operation for cerebral abscess, 496 — For cerebellar abscess, 497 — For cerebral tumor, 498 — For cerebellar tumor, 499 — Operations upon mastoid antrum and cells, 499 — Operations upon gasserian ganglion, 499. II. Bony ( Air1 Sinuses of Head and Face: — Operations upon mastoid antrum and cells, 500 — Surgical anatomy, 500 — Surface form and landmarks, 502 — General surgical considerations, 503 — Operation for exposure of mastoid antrum and cells (Antrum opera- tion of Schwartze), 504 — Operation for exposing mastoid antrum and cells, together with interior of tympanum and meatus, and the exenteration of middle-ear cavities (the tym- pano-mastoid exenteration, or radical operation, of Schwartze-Stacke, or Schwartze- Zaufal), 506 — Operations upon frontal sinuses, 508 — Surgical anatomy, surface form and landmarks, and general surgical considerations, 508, 509 — Instruments, 510 — Exposure and drainage of frontal sinuses, 510 — Operations upon maxillary sinuses, 511 — Surgical anatomy, surface form and landmarks, and general surgical considerations, 511, 512 — Instruments, 513 — Opening of maxillary sinus through its facial aspect, above alveolar margin, 513 — Opening through socket of second molar tooth, 514. III. Eyeball and Orbit: — Operations upon the eyeball, 514 — Surgical anatomy of orbit. 514 —Enucleation of eyeball, 515 — Evisceration of eyeball, 516. I\'. Ear and Eustachian Tube: — Surgical anatomy of membrana tympani, 516 — Introduction of ear speculum for examination of membrana tympani, 517 — Paracentesis tympani, 517 — Introduction of eustachian catheter, 517. V. Nose and Nasal Cavities, 518. VI. Tongue: — Surgical anatomy, 518 — General surgical considerations, 518 — Instruments, 319 — Excision of limited portions of tongue, 520 — Excision through mouth, without preliminarv ligation of lingual arteries (Whitehead), 520 — E.xcision through mnuth, after preliminary ligation of Unguals in neck, 522 — Excision of tongue, together lo CONTENTS. with cervical and submaxillary glands, by an incision in neck, after preliminary trache- otomy and ligation of lingual and facial arteries (Kocher), 522. CHAPTKR 11. OPERATIONS UPON THE SPINE AND SPINAL CORD. Surgical anatomy, ^26 — Surface form and landmarks, 527 — General surgical con- siderations, 52S — Instruments, 530 — Laminectomy, 530 — Osteoplastic resection of spine- 534 — Subarachnoid puncture for spinal anesthesia, 53S — Spinal puncture for drainage of subarachnoid space, 539 — Operation for removal of tumors of spinal cord, 539 — Intra- spinal partial neurectomy of posterior nerve-roots, 539. CHAPTER III. OPERATIONS UPON THE NEQC. I. Lan-nx: — Surgical anatomy of neck. 541 — Surgical anatom\ of larynx, 541 — Surface form and landmarks, 541— Instruments. 542— Laryngotomy. 543— Thyrotomy, 544 — Complete lar\'ngectomy, 545 — Partial laryngectomy, 546 — Intubation of laryrrx (O'Dwyer), 547 — Other operations, 548. II. Trachea; — Surgical anatomy, 548 — Surface form and landmarks, 549 — Gen- eral surgical considerations, 549 — Instruments, 550 — High tracheotomy, 550 — Low tracheotomy, 552 — Other operations, 552. III. 'Phan.-nx; — Surgical anatomy, 553 — Instruments, 553 — Median phan-ngotomy, by median vertical incision through mouth, 554 — Lateral pharyngotom\-, by curved lateral incision through neck (Kocher), 554 — Subhyoid pharyngotomy, by transverse curved incision through neck, 555 — e.xposure of retro-pharyngeal space, by lateral cer\-ical inci- sion along posterior border of sternomastoid (Chiene), 556. IV Esophagus: — Surgical anatomy, 557 — General surgical considerations, 558 — Instruments, 558 — Interna! cervical esophagotomy, 558 — Cervical esophagostomy, 560 — Partial cervical esophagectomy, 560 — Introduction of esophageal bougie, 561 — Other operations, 561. V. Tonsils: — Surgical anatomy, 563 — General surgical considerations, 563 — Instruments, 563 — Tonsillotomy, 563 — Partial tonsillectomy through mouth 564 — Com- plete tonsillectomv through mouth, ,64 — Complete tonsillectomy through nee k (Cheever), 565- VI. Parotid Gland and Stenson's Duct: — Surgical anatomy. 567 — Instruments. 568 — Excision, 568. VII. Submaxillary Gland and Wharton's Duct:— Surgical anatomy. 570 — Instru- ments, 570 — Excision, 571. Vlil. Sublingual Gland and Duct of Bartholin:— Surgical anatomy, 572— Instru- ments, 572 — E.xcision, through floor of mouth, 572. IX. Thyroid Gland:— Surgical anatomy, 573— Instruments, 573— Partial thy- roidectomy, by angular incision (Kocher), 573— Complete thyroidectomy, by transverse •curved incision (Kocher), 575. CHAPTER I\'. OPERATIONS UPON THE THORAX. I. Thoracic Wall and Contents: — Surgical anatomy, 576 — Surface form and landmarks, 578 — Instruments, 579. II. Female Mammary Gland:— Surgical anatomy, 579 — Surface form and land- marks, 580 — General surgical considerations, 580 — Incision of breast, 580 — Partial ex- cision of breast by elliptical incision, 581 — Radical excision, by Halsted's method, 582 — Radical excision, by Warren's method, 584 — Ordinar\' excision, by elliptical incision, 585 — Subcutaneous excision, by inferior cur\'ed incisicm, 586. III. Superior Mediastinum: — Surgical anatomy, 587 — Surface form and land- marks, 5S7 — General surgical considerations. 5S7. IV. .interior Mediastinum: — Surgical anatomy. 588 — .interior mediastinal thor- acotomv, bv long median incision (Milton's anterior mediastinotomy), 588 — .'Knterior CONTEXTS. 1 1 ■mediastinal thoracotomy, by osteoplastic resection of part of sternum corresponding with third, fourth, and fifth costal cartilages, 590 — Other operations, 592. V. Middle Mediastinum: — Surgical anatomy, 592 — Operations upon middle mediastinum, 592. VI. Posterior Mediastinum: — Surgical anatomy, 592 — Posterior mediastinal thoracotomy, by thoracoplastic flap (Bryant), 593- VII. Diaphragm: — Surgical anatomy 595 — Transthoracic e.Nposure of diaphragm, by partial excision of two or three ribs, 596. VIII. Pleuree: — Surgical anatomy, 509 — Surface form and landmarks, 600 — Para- centesis thoracis, 601 — Intercostal thoracotomy, 601 — Thoracotomy, by partial excision of one or more ribs, 602 — Thoracoplasty (Estlaender's operation), 604 — Thoracoplasty (Schede's operation), 607 — Other operations. 609. IX. Lungs: — Surgical anatomy, 609 — Pneumotomy, through a thoracoplastic flap, 611 — Partial pneumectomy, through an osteo-thoracoplastic flap, 612. X. Pericardium: — Surgical anatomy, 614 — Surface form and landmarks 615 — Paracentesis pericardii, 615 — Pericardiotomy, through intercostal incision, 616 — Expo- sure of pericardium and heart, by excision of left fifth costal cartilage, 617 — Exposure of pericardium and heart, by osteo-thoracoplastic resection of anterior chest-wall, 619 — Pericardiorrhaphy, 6ig. XI. Heart: — Surgical anatomy, 619 — Paracentesis of right auricle, 620 — Paracen- tesis of right ventricle, 621 — Cardiorrh^phy, 621. XII. Thoracic Trachea: — Surgical anatomy, A22 — Thoracic tracheotomy, 622. XIII. Bronchi: — Surgical anatomy, 622 — Bronchotomy, 623. XIV. Thoracic Esophagus, 623 — Surgical anatomy, 623 — Thoracic esophagotomy, by posterior mediastinal osteoplastic flap operation, 623. ch.\pti:k \". OPERATIONS UPON THE ABDOMINO-PELVIC REGION. I. .'\bdomino-pelvic Wall: — Surgical anatomy, 624 — Surface form and landmarks, 627 — General surgical considerations, 629 — Instruments. 631 — Median abdominal sec- tion, 631 — Anterolateral abdominal section, by McBurney's intramuscular "gridiron" incision, 637 — .Anterolateral abdominal section, by Weir's prolongation of the anterolateral intra-muscular incision through rectal sheath, with temporary displacement of rectus, 639 — .Anterior abdominal section through rectal sheath, with temjiorary displacement of rectus, by the Battle-Jalaguier-Kammerer method 641 — Median inferior abdominal section by Pfannenstiel's superficial transverse curved, and deep vertical incisions, 643 — Inferior anterolateral abdominal section, by Meyer's " hockey stick " incision, 6.-14 — Inferior anterolateral abdominal section, by Fowler's angular incision, 645 — Superior anterolateral abdominal section, by oblique subcostal incision, 646 — Lateral abdominal section by Vischer's lumbo-iliac incision, 646 II. Peritoneum: — Surgica lanatomy, 647 — General surgical considerations, 649 — Operations for separation, division, or ligation of peritoneal adhesions, 649 — Paracentesis abdominis, 651. III. Omentum: — Surgical anatomv, 6!;2 — General surgical considerations, 653 — Ligation of omentum, 653 — Omental grafting, 61^4. I\'. Mesentery: — Surgical anatomy, 654 — General surgical considerations, 655 — Partial e.xcision, 655 — Suturing. 655. V. Intestines: — Surgical anatomv of small intestines, 6^5 — .Surface form and land- marks of small intestines 658 — Surgical anatomy of large intestines, 658 — Surface form and landmarks of large intestines, 661 — General surgical considerations in operations upon the intestines 662 — Instruments, 662 — Enterotomy, 663 — Enterorrhaphy. in general, 663 — By Lembert's interrupted suture, 66^ — By Czcrny-Lembert interrupted suture, 666 — By Halsted's interrupted quilt or mattress suture, 667 — Bv Lembert's continuous suture, 668 — By Cushing's right-angled continuous suture, 668 — By combined overhand continuous suture of all coats, followed by interrupted Lembert suturing of outer coats, 6''o — Enterorrhaphy for wounds of intestine, 670 — Partial enterectomy, 672— Entero- enterostomy (intestinal anastomosis, approximation, and implantation) in general, 675 — {.\) Entero-enterostomy by methods of simple suturing, in general, 676 — By simple con- 12 CONTENTS. tinuous overhand suture of all coats, followed by interrupted or continuous Lembert sutures of outer coats, by author's method, 677 — By Czerny-Lembert interrupted suture, 685 — By Halsted's method of interrupted mattress or quilt sutures, 686 — By Maunsell's invagination method 688 — (B) Entero-enterostomy by means of absorbable mechanical devices left within the intestines in general, 6g6 — By means of absorbable bobbins, 6g7 — By absorbable buttons, 6q8 — By Ullmann's modification of Maunsell's method, 699 — By Coffey's method, 701 — (C) Entero-enterostomy by means of non-absorbable mechan- ical devices left within the intestinal canal, in general, 702 — By means of the Murphy button 703 — (D) Entero-enterostomy by mechanical means temporarily used for approxi- mating the intestinal edges during suturing, in general, 710 — By means of Halsted's in- flatable rubber cvHnder, 710 — By Lee's intestinal holder, 714 — By Laplace's intestinal anastomosis forceps, 718 — Excision of ilio-ca=cum, 720 — Appendicectomy, by McBurney's intramuscular operation, 722 — Appendicectomy, by the ordinary method, 727 — Entero--- tomy, in general, 727 — Right inguinal enterostomy (or ileostomy) for establishment h}-oid; origin sternothyroid (above three structures being at some distance); remains of thymus; fatty areolar tissue of superior mediastinum; left innominate vein. Posteriorly (from below upward) — trachea; esophagus; thoracic duct; recurrent laryngeal nerve. External (to left) — left pleura and lung (slightly overlapping); left |)neumo- gastric; left subcknian (both of latter being somewhat posterior). Internally (to right) — innominate artery; trachea; remains of thymus gland; left inferior thyroid vein, (b) Both Common Carotids in Neck : Anteriorly — skin; superficial fascia; platysma; deep fascia; sternomastoid; sternohyoid; sternothyroid; omohyoid; anterior jugular vein; thyroid body (often overlaps); middle thyroid vein; superior thyroid vein; lingual vein; facial vein; middle sternomastoid artery; descendens hypoglossi nerve (generally upon, some- times within, sheath); communicantes hypoglossi; lymphatic glands. Poste- riorly — pneumogastric nerve; sympathetic nerve; cervical cardiac branches of sympathetic and pneumogastric nerves; recurrent laryngeal nerve; inferior thyroid artery; longus colli; rectus capitis anticus major. Externally — internal jugular vein; pneumogastric nerve. (On right side a space is left at root of neck by divergence of vein, in which pneumogastric nerve and vertebral artery are found; on left side the internal jugular vein overlaps this space). Internally (from below upward) — trachea; esophagus; re- current laryngeal nerve; branches of inferior thyroid artery; lateral lobe of thyroid body; cricoid cartilage; thyroid cartilage; lower part of pharyn.x; carotid glands. Branches. — None, ordinarily. Line. — (With head turned moderately to opposite side and upward) — from sternoclavicular articulation to a point midway between angle of jaw and tip of mastoid process — that portion of this line between the sterno- clavicular articulation and the level of the upper border of the thyroid cartilage representing the common carotid. From the clavicle a little e.xternal to the sternoclavicular articulation would more accurately represent the line. The anterior margin of the sternomastoid muscle overlaps the carotid throughout. The omohyoid muscle crosses the carotid opposite and directly over Chas- saignac's "carotid tubercle" (costal process of si.xth cervical vertebra) — which is abiiut (1.7, cm. {2j inches) above the clavicle. Indications for Ligation. — \\ounds of itself and branches of e.xternal and internal carotid; distal and pro.ximal aneurism; distal angiomata; as a temporary ligature; to limit growth of inoperable tumors; hemorrhage from areas supplied by distal branches. Sites of Ligation. — .\bove the omohyoid muscle — place of election. Below the omohyoid — depth of artery and nature of relations make the operation more difficult and more fatal (Fig. 7, F and G). LIGATION OF COMMON CAROTID ARTERY. 33 Fig. 9.— Ligation of Right Common Carot nomastoid (retracted outward) ; C. Omohyoid (retn carotid (its sheath incised above omohyoid); F, H, Superior thyroid vein; I. Inferior thyroid veii external jujfular; IC. One of transversalis colli nerv communicans hypoglossi. ID ABovK Omohyoid:— A. A Platysma ; B. Ster- icted downward) ; D, Sternolhjroid ; E. Common Sternomastoid artery; G, Internal jugular vein; 1: J, Communicating vein between anterior and es ; L, Nerves from loop between descendens and LIGATION OF COMMON CAROTID ARTERY ABi:)\F. THE OMUHVOIU MUSCLE. Position. — Patient supine; shoulders elevated; neck prominent; chin upward and to opposite side. Surgeon on side of operation, or on the right for both sides. Landmarks. — I^ine of artery; anterior border of sternomastoid; cricoid cartilage. Incision. — .\bout 7.5 cm. (3 inches) in length, with center at level of cricoid cartilage — the incision lying in the line of the artery (Fig. 7, F). Operation. — Incise skin, superficial fascia, and platysma. Superficial veins connecting anterior and e.xternal jugulars, and sometimes intercom- municating veins between facial and anterior jugular, as well as cutaneous nerves, are encountered (Fig. 9). Divide the deep fascia along the anterior border of the sternomastoid and open up the cellular tissue. The upper border of the omohyoid is here exposed, either by direct incision or by follow- ing up the anterior border of the sternomastoid. Having identified the intersection of sternomastoid and omohyoid, the omohyoid is retracted downward (or may be divided if in the way) — and the sternomastoid outward. Fle.xing the chin aids during these manipulations, by rela.xing the parts. The common carotid is now located as it crosses the "carotid tubercle" (see Anatomy, "Line," page 32). Clear its sheath, avoiding or tying the sternomastoid artery and the superior and middle thyroid veins. Carefully incise the sheath, approaching from the inner side, to avoid the descendens 3 34 OPERATIONS UPON THE ARTERIES. hypoglossi nerve (generally on the antero-external side of the sheath) and the internal jugular vein, and see that artery is freed from its sheath in its entire circumference. Pass the needle from the internal jugular and pneu- mogastric nerve. Collateral Circulation. — Inferior thyroid, with superior thvroid. Deep cervical, with occii)ital. Transversalis colli, with occii)ital. Branches of two vertebrals, with branches of two external carotids. Circle of Willis. LIGATION OF COMMON CAROTID ARTERY BELOW THE OMOHYOID MUSCLE. Position — Landmarks. — As in the hgation above the omohyoid. Incision. — About 7.5 cm. (3 inches) in length, in line of arterv — from just below cricoid cartilage to just above sternoclavicular articulation (Fig. 7. 0)_. Operation. — Incise skin, superficial fascia, and platysma. Here are encountered the superficial veins between the facial, anterior and external jugular veins, and the cutaneous cervical nerves. Divide the deep fascia along the anterior border of the sternomastoid. Expose the inner border of this muscle, flexing the head to relax the parts. The sternohyoid is then exposed, and sometimes the underlving sternothvroid. The omohyoid is, ordinarily, not brought into the field of operation. These muscles, if en- countered, are retracted in their respective directions, or may be divided as far as necessary. Tie the inferior thyroid veins. The sheath is to be exposed as, and with the precautions, mentioned in the above operation. The recurrent laryngeal nerve and the inferior thyroid artery are to be espe- cially guarded in operating at this site. Comment. — The ligation of the common carotid is more difficult on ihe left side, owing to the nearness of the internal jugular vein (see .\natomy, "Relations," page 32), and the operation is less frequently done than on the right side. SURGICAL ANATOMY OF EXTERNAL CAROTID ARTERY. Description. — The smaller of the two divisions of the common carotid. About 6.3 cm. (2J inches) in length. Begins opposite upjjer border of thyroid cartilage; passes upward, forward, and then backward, under the stylohyoid and posterior belly of the digastric, to the interval between neck of condyle of inferior maxilla and the external auditory meatus, where it divides, in the substance of the parotid gland, into the internal maxillary and temporal arteries. Relations. — Anteriorly: skin; superficial fascia; platysma; deep fascia; anterior border of sternomastoid; hypoglossal nerve; lingual vein, facial vein; posterior belly of digastric; stylohyoid; temporomaxillary vein; superior cervical lymphatic glands; branches of facial nerve; parotid gland. Poste- riorly: internal carotid artery; styloglossus; stylopharyngeus; glossopharyn- geal nerve; pharyngeal branch of pneumogastric; stylohyoid ligament; parotid gland; superior laryngeal nerve. Externally: internal carotid artery. In- ternally: hvoid bone; pharynx; ramus of inferior maxilla; stylomaxillary ligament; submaxillary gland; parotid gland. Branches (from below). — .Ascending pharyngeal; superior thyroid; lingual; facial; occijiital; posterior auricular; temporal; internal maxillary. LIGATION OF EXTERNAL CAROTID ARTERY. 35 Line. — Upper part of line of common carotid artery (page 32). Indications for Ligation. — Wounds and aneurism of trunk and branches; hemorrhage from areas of branches; palliative in malignant growths; pre- liminary to ojierations; aneurism by anastomosis in the regions of the trunks. Sites of Ligation. — Below the digastric (between the superior thvroid and lingual branches) — place of election — the operation is easier and more branches are thus controlled. Above the digastric — the operation is more difficult and more apt to involve branches of the facial nerve. Note: — The digastric muscle crosses the artery about 3.2 cm. (ij inches) above its origin, opposite the upper border of the thyroid cartilage. The lingual arises oppo- site the great cornu of the hyoid bone (Fig. 7, H and I). Comment. — (i) The external carotid may be distinguished from the in- ternal carotid by the presence of its branches and by being to the inner side- of the e.xternal carotid. (2) The ligation of the external carotid is now generally done where formerly the common carotid was ligated for conditions of the former vessel and its branches — the practicability and desirability of the operation having been demonstrated by the work of Wyeth. LIGATION OF EXTERNAL CAROTID ARTERY BKLOW THE DIGASTRIC MUSCI.K. Position. — As for the common carotid (page t,^). Landmarks. — Sternomastoid; thyroid cartilage; angle of jaw. Incision. — .\bout 7.5 cm. (3 inches) — along the anterior border of the sternomastoid, or slightly in front of border — from level of middle of thyroid cartilage, to near angle of jaw (Fig. 7, H). Operation. — Incise skin, superficial fascia, and platysma (Fig. 10). Tie any veins which may lie in the line of incision. Divide the deep fascia and expose the anterior border of the sternomastoid and draw it outward. Find the posterior belly of the digastric at the upper angle of the wound. Ne.xt, locate the hypoglossal nerve crossing the external carotid below the origin of the occipital artery. Locate the tip of the great cornu of the hyoid bone, opposite which the lingual artery arises. Having fi.xed the location of these three structures, and avoiding the superior thyroid, facial, and lingual veins; expose the artery opposite the tip of the great cornu of the hyoid. Clear the sheath and pass the ligature between the superior thyroid and lingual branches — guanling the descendens hypoglossi nerve in front, and the supe- rior laryngeal nerve passing behind the artery — directing the needle from the internal carotid. Comment. — (i) The operation is not an easy one, and it is often difficult to recognize the branches. (2) Jacobson advises simultaneous ligation of the superior thyroid, the lingual, and, if possible, the ascending pharvngeal branches — on account of secondary hemorrhage. (3) Through this same incision the superior thyroid, lingual, facial, occipital, and ascending pharvn- geal may be ligated. Collateral Circulation. — Same as for the ligation of the common carotid above the omohyoid (page 34). 36 OPERATIONS UPON THE ARTERIES. Fig. 10.— Ligation of Right External Carotid below Digastric ; a.md also of Internal Carotid, Superior Thyroid, Lingl'al, Facial and Occipital, near Origin: — A, Superficial fascia; B. B, Platysma ; C, Cervical tascia ; D, Slernomastoid (retracted outward); E. Posterior belly of digastric; F, Hyoglossus. with lingual artery disappearing beneath it; G, Thyrohyoid M. ; H, Middle constrictor M. ; I, Inferior constrictor M. ; J. Tip of great coniu of hyoid bone ; K, External carotid A.; L, Internal carotid; M.Superior thyroid; N, Facial; O. Occipital; P. Internal jugular V. ; Q, Lingual and facial veins emptying into internal jugular ; R. Superior thvroid \'. ; S, Hypo- glossal N. ; T, Descendens noni N. LIGATION OF EXTERNAL CAROTID ARTERY ABO\T-; DIG.-VSTRIC .MUSCLE .A\D BEHIND R.^Ml'S OF JAW. Position. — As for the common carotid. Landmarks. — Line of artery; ramus of inferior ma.xilla. Incision. — From tragus of ear, to below angle of inferior maxilla, and placed just behind the ramus of the jaw. in the line of the artery (Fig. 7, I). Operation. — Incise skin and superficial fascia. Avoid, or doubly ligate and incise, the tributaries of the external jugular and facial veins. Divide the deep fascia. Expose the anterior border of the sternomastoid and retract outward. Expose the posterior belly of the digastric and stylohyoid and draw downward — partially or entirely dividing them if necessary. Avoid the branches of the facial nerve. E.xpose the parotid gland and draw upward and forward — thus exposing the vessel. Clear the artery and open its sheath — and pass the ligature around the artery prior to its entrance into the sub- stance of the parotid gland. Repair, by suturing, whatever muscles may have been incised. SURGICAL ANATOMV OF LINGUAL ARTERY. 37 SURGICAL ANATOMY OF SUPERIOR THYROID BRANCH OF EXTERNAL CAROTID. Description. — The second in order and an anterior branch of the ex- ternal carotid. Runs forward and a little upward beneath the great cornu of the hvoid bone, lying in the superior carotid triangle and covered by the skin, fascia, and platysma — then runs inward and downward, passing under the omohyoid, sternohyoid, and sternothyroid to the upper part of the thyroid gland. The superior thyroid vein runs beneath the artery on its way to the internal jugular vein. The superior laryngeal nerve is in close relation posteriorly. LIGATION OF SUPERIOR THYROID BRANCH OF EXTERNAL CAROTID. Position — Landmarks. — .\s for ligation of external carotid below the digastric (page ;, 5). Incision. — .\bout 5 cm. (2 inches) in length — along the line of the external carotid artery, with its center on a level with the upper border of the thyroid cartilage (Fig. 7, J)- Operation. — Practically the same as for the ligation of the external carotid l)elow the digastric, the main trunk being first exposed, and the superior thyroid branch being then located. Guard the superior laryngeal nerve. Place the ligature between the external carotid and the h3-oid branch, or beyond the sternomastoid branch. SURGICAL ANATOMY OF LINGUAL BRANCH OF EXTERNAL CAROTID. Description. — The third in order, and an anterior branch of the external carotid, .\rises opposite, or a little below, the great cornu of the hyoid bone, about 2 cm. (| inch) above the bifurcation of the common carotid, (a) First or Oblique Portion: — lies in superior carotid triangle, extending obliquelv upward to the external border of the hyoglossus, — being covered by skin, superficial fascia, platysma, deep fascia, and hypoglossal nerve, — and resting on the middle constrictor and laryngeal nerve, (b) Second or Horizontal Portion: — lies in the digastric triangle, running horizontally beneath the hyo- glossus muscle, along the superior border of the hyoid bone, — being covered by the hyoglossus muscle (which separates the artery from the hypoglossal nerve, posterior belly of the digastric, stylohyoid muscle, and lingual vein), — and resting upon the middle constrictor of the pharynx and geniohyo- glossus. (c) Third or .\scending Portion: — ascends between the hyoglossus and geniohyoglossus to the inferior surface of the tongue, (d) Fourth or Terminal Portion: — runs forward to tip of tongue, lying between the lingualis and geniohyoglossus, and covered only by mucous membrane. Two vense comites accompany the lingual artery beneath the hyoglossus. The ranine vein runs on the superficial surface of the hyoglossus. below the hypoglossal nerve. Several veins follow the dorsalis lingua^ artery. Sites of Ligature. — Its first or second portions are the parts usually tied — and of these, the second is preferable (Fig. 7, K and L). 38 OPERATIONS UPON THE ARTERIES. LIGATION OF LINGUAL BRANCH OF EXTERNAL CAROTID NKAK ITS OKIGIX. Position — Landmarks. — As for ligation of external carotid below the digastric (page 35). Incision. — In line of external carotid, with its center opposite the body of the hyoid bone (Fig. 7, K) Operation. — Same, practically, as for ligation of external carotid below the digastric, the main vessel being first exposed and the origin of the lingual then located. Comment. — The first part of the lingual may also be tied, though less readily, by a transverse incision extending from the level of the body of the hyoid bone to the anterior border of the sternomastoid, the artery being exposed and tied just before passing under the hyoglossus muscle. LIGATION OF LINGUAL BRANCH OF EXTERNAL CAROTID BENE.ATH THE HYOGLOSSUS. Position. — Patient supine; shoulders raised; neck prominent; head to opposite side and chin upward. Surgeon on side of operation, cutting from before backward on the right, and vice versa. Fig. II.— Ligation of Right Lingi-al Arterv beneath Hyoglossus:— A, A, Platysma : B, Transverse cervical fascia over submaxillarv Rlaiid ; C, Deep transverse cervical fascia under sub- maxillary gland; D. Submaxillary gland; E. Hyuid bone; P (at bottom of illustration). Anterior bellv of digastric; G, Posterior belly of digastric; H, Stylohyoid; 1, Mylohyoid; ]. Hyoglossus; K, bniohvoid; L, Thyrohyoid; M. Lingual artery seen through incision in hyoglossus: N. Sub- mental A.'; O, Tributarv of temporomaxillary V.; P (at right margin of illustration). Tributary of anterior jugular V. ; Q, Hypoglossal N. (above) and ranine V. I below ); R, Transverse cervical nerve ; S. Superior laryngeal nerve and \-essels. Landmarks. — Lower border of inferior maxilla; facial artery crossing inferior maxilla; hyoid bone. SURGICAL ANATOMY OK FACIAL ARTERY. 39 Incision. — Curved incision — beginning just below and external to sym- physis menti — and ending just below and internal to crossing of facial artery over inferior maxilla — its center being just above the greater cornu of the hyoid bone (Fig. 7, L). Operation. — Incise skin, superficial fascia, platysma, and deep fascia. Avoid or ligate tributaries of facial, anterior jugular, or temporomaxillary veins. Incise the transverse cervical fascia over the submaxillary gland — exposing the gland and retracting it upward, out of its bed, over the margin of the lower jaw (Fig. 11). Incise transversely the deep cervical fascia exposed by lifting out the submaxillary gland — and identify the mylohyoid muscle in the anterior aspect of the wound. Expose the two bellies of the digastric and firmly retract them downward at their point of attachment to the hvoid bone — which steadies the parts and renders the hyoglo.ssus more prominent. Clear the surface of the hyoglossus and identify the hypoglossal nerve crossing its anterior aspect. The ranine vein crosses the same surface just below and parallel with the nerve and at about the same level as the artery lies on the opposite side of the muscle. Retract both hypoglossal nerve and ranine vein upward. Divide the hyoglossus transversely for about 1.3 cm. (i inch) just above and parallel with the hyoid bone. This incision falls just over the artery, which generally bulges into the opening as .soon as it is made, or through which it is easily reached. Having isolated the artery, trace it backward until the dorsalis linguse branch is reached, so that the ligature may be placed upon its proximal side. Having passed the ligature, replace the submaxillary gland and close the wound. Comment. — The fascia of the submaxillary gland may be sutured over it, and the incision in the hyoglossus may be repaired by suturing, if either be considered indicated. SURGICAL ANATOMY OF FACIAL BRANCH OF EXTERNAL CAROTID. Description. — The fourth in order, and an anterior branch of the ex- ternal carotid. The Cervical Portion passes upward and forward in the posterior part of submaxillary triangle, under the digastric, stylohyoid, submaxillary gland, and horizontal ramus of inferior maxilla. The Facial Portion curves over lower border of inferior maxilla at the anterior border of masseter muscle — and, running forward and upward, crosses the cheek to the angle of mouth — thence upward along side of nose to end at internal canthus of eye. Relations. — Cervical portion rests on (from below upward) stylo- glossus; mylohyoid; submaxillary gland (in or under it); — and is covered ty (from below upward) posterior belly of digastric; stylohyoid; hypoglossal nerve (generally) ; submaxillary gland (beneath or in its suljstance) ; inferior maxilla; lymphatic glands; fascia; platysma; skin. Facial portion rests on (from below upward) inferior maxilla; buccinator; levator anguli oris; levator labii superioris (sometimes); infraorbital branches of fifth nerve; — and is covered by (from below upward) . risorius; zygomatici major and minor; supramaxillary and buccal branches of facial nerve; levator labii superioris; levator labii superioris aljeque nasi; infraorbital branches of facial. The cervical portion of the facial vein is more direct than the artery, and separated from it by submaxillary gland, posterior belly of digastric, stylohyoid muscle, and hyjjoglossal nerve. The facial portion of the facial vein is also more 40 OPERATIONS UPON THE ARTERIES. direct tlian the facial portion of the facial artery, and is separated from its artery liy the zygomatic! major and minor. Sites of Ligation. — Near origin (less frequently), — over lower jaw (the usual selection) (Fig. 7, M ). LIGATION OF FACIAL BRANCH OF EXTERNAL CAROTID N'E.\R llKIc'.IX. Position — Landmarks — Incision — Operation. — Practically the same as for ligation of the external carotid below the digastric. LIGATION OF FACIAL BRANCH OF EXTERNAL CAROTID o\'i;r infkkior m.wii.i.a. Position. — Patient supine; shoulders raised; head thrown back and to opposite side. Surgeon on side of operation, or on right for both sides. Landmarks. — Anterior margin of masseter muscle; horizontal portion of inferior maxilla. Fig. 12. — Ligation of Rich fascia ; B, IMalysma ; C, Deep ce Inferior maxilla ; G, Masseter M. lal A. ; Supraniaxillary N. r Facial over Border of Infer lo vical fascia ; D, Submaxillary gland ; H, Depressor anguli oris; I, Facial A. R Maxilla:— A, Cerv E, Mylohyoid muscle ; J, Facial V.; K, Subn Incision. — About 2.5 cm. (i inch) in length — placed along and under cover of lower border of lower jaw, with its center over the course of the artery (at the anterior margin of the masseter muscle) (Fig. 7, M). Operation. — Incise skin, superficial fascia, platysma, and deep fascia, when the artery should come into view — with the facial vein just posterior to it. Avoid branches of the facial nerve (Fig. 12). LIGATION OF OCCIPITAL I'.RANCH OF EXTERNAL CAROTID. SURGICAL ANATOMY OF OCCIPITAL BRANCH OF EXTERNAL CAROTID. Description. — The fifth in order, and a posterior branch of the external carotid — passing upward and backward to the interval between mastoid process of temporal and transverse process of atlas — thence horizontally backward in the occipital groove — thence upward onto the scalp. Relations. — First Part (internal to sternomastoid) — covered by skin, fascia, posterior belly of digastric; parotid gland; temporomaxillarv vein; hypoglossal nerve; — and rests on internal carotid artery; hypoglossal nerve; pneumogastric nerve; internal jugular vein, and spinal accessorv nerve. Second Part (beneath sternomastoid) — covered by sternomastoid; splenius capitis; trachelomastoid; origin of digastric; — and rests on capitis lateralis, in occipital groove of mastoid process of temporal, and on the insertion of" superior oblique muscle. Third Part (external to sternomastoid) — covered by skin, aponeurosis uniting occipital attachments of sternomastoid and trapezius— and resting upon the complexus. It perforates this aponeurosis just mentioned, or the posterior belly itself of the occipitofrontalis, together with the great occipital nerve — and follows, roughly, the line of the lambdoid suture, between the integument and the cranial aponeurosis. Two venae comites accompanv the occipital arterv. Sites of Ligation. — Near its origin — and behind the mastoid process of the temporal — according to site of lesion rec[uiring ligature (Fig. 7, X). LIGATION OF OCCIPITAL BRANCH OF EXTERNAL CAROTID XH.AR ORK.IN. Position— Landmarks — Incision — Operation. — .As for Ugation of the external carotid below the digastric (page 35). LIGATION OF OCCIPITAL BRANCH OF EXTERNAL CAROTID BEHIND MASTOID PROCESS. Position. — Patient supine; shoulders and head elevated; head turned well to opposite side (or patient resting slightly to one side). Surgeon stands behind, on side of operation. Landmarks. — ^lastoid process; external occipital protuberance. Incision. — About 5 cm. (2 inches) in length — beginning from tip of mastoid process and extending toward the external occipital protuberance (Fig. 7, X). Operation. — Having incised skin and fascia, divide the posterior half of the sternomastoid and its strong aponeurosis — then the splenius capitis — then as many fibers of the trachelomastoid as are in the way (Fig. 13). Relax and retract the muscles by turning .the head to the side of the operation. Expose the artery deep down between the mastoid process of the temporal and the transverse process of the atlas, resting upon the superior oblique and complexus muscles. Having separated from it the accompanying veins, and having guarded the veins from the mastoid foramen, the ligature i: passed. The lesser occipital nerve runs on the posterior surface of the sterno- OrERATIONS UPON THE ARTERIES. H : D A [ L ^ G B Fig- 13- — Ligation of Right Occipital Artery behind Mastoid Process;— A, Posterior cervical fascia ; B. Trapezius muscle; C. Stenioniastoid ; D, Splenius capitis; E, Trachelomastoid ; F. Occipital artery and vena comites, lying upon complexus muscle; G, Great occipital nerve; H, Lesser occipital nerie ; I, Posterior external jugular vein. mastoid, near its posterior border, and the great occipital nerve pierces the trapezius muscle near its outer border. SURGICAL ANATOMY OF POSTERIOR AURICULAR BRANCH OF EX- TERNAL CAROTID. Description. — The si.xth in order, and a posterior branch of the external carotid — arising generally just above posterior belly of digastric (sometimes under digastric), about on a level with tip of styloid process. Runs upward and backward in parotid gland to notch between cartilage of ear and mastoid process, and there divides into branches — crossing, in its course, the spinal accessorv nerve — and being crossed bv the facial nerve. LIGATION OF POSTERIOR AURICULAR BRANCH OF EXTERNAL CAROTID Xi;.\K OKICIX. Position — Landmarks — Incision — Operation. — As for ligation of ex- ternal carotid above the digastric (page 36). LIGATION OF POSTERIOR AURICULAR BRANCH OF EXTERNAL CAROTID PKHIXn FAR, Position. — Patient supine; shoulders elevated; head turned to opposite side. Surgeon behind, on side of operation. Landmarks. — Pinna of ear; mastoid process. LIGATION OF TEMPORAL BRANCH OF EXTERNAL CAROTID. 43 Incision. — About 3.8 cm. (i^ inches) in length, between posterior aspect of pinna of ear and anterior border of base of mastoid process. Operation. — Having incised skin and fascia and avoided facial and posterior auricular nerves, the artery is found, with accompanying vein, in the groove between the cartilage of the ear and the base of the mastoid process (Fig, 14). Fig. 14. — Ligation of Right Posterior Auricular behind Ear: — A, Sternomastoid ; B, Retraheiis aurem ; C, Poslerior auricular artery and vein : D, Same, beneath retrahens aurem ; E, Branch of occipitalis minor nerve; F. Auricularis magnus ner\-e ; G, Poslerior auricular branch of facial; H, Parotid gland. SURGICAL ANATOMY OF TEMPORAL BRANCH OF EXTERNAL CAROTID. Description. — The seventh in order and the smaller but more direct of the two terminal branches of the external carotid. .Arises in substance of parotid gland, opposite neck of inferior ma.xilla — and runs upward, beneath parotid gland, between condyle and external auditory meatus — thence upward, crossing the posterior root of the zygoma — and continuing upward under the attrahens aurem muscle and temporal aponeurosis for 3.8 cm. to 5 cm. (li to 2 inches), where it divides into anterior and posterior branches. A plexus of sympathetic nerves surrounds the vessel — it is crossed by the temporofacial division of the facial nerve — and is accompanied by the auriculotemporal nerve. Sites of Ligation. — Just above root of zygoma. The anterior and posterior branches may be ligated at their bifurcation, about 3.8 to 5 cm. (li to 2 inches) above the zygoma. LIGATION OF TEMPORAL BRANCH OF EXTERNAL CAROTID JfST ABOVE ZYGOMA. Position. — Patient supine; shoulders raised; head to opposite side. Surgeon on side of operation, cutting from above downward on right, and vice versa (or on right for both operations, cutting from above downward). Landmarks. — Tragus of ear; condyle of jaw; zygoma. 44 OPERATIONS UPON THE ARTERIES. Incision. — \"ertical, about 2.5 to 3.8 cm. (i to li inches) in length, over line of arterv, with center over zygoma, and extending downward in the interval between the tragus of the ear and the condvle of the lower jaw (Fig. 7- O). Operation. — Incise skin and dense subcutaneous tissue and parotid fascia — when the artery will be e.xposed lying quite superficial as it crosses the zygoma. Avoid the accompanying vein posteriorly — also avoid the branches of the temporofacial division of the facial nerve and the auriculo- temporal nerve (Fig. 15). Fig. 15.— Ligation of Right Temporal Ji-st above Zygoma: — A. Temporal artery, with i anterior and posterior bifurcations, and its transverse facial, middle temporal, and anleiiui- auricul; branches: B. Temporal vein, with branches corresponding to those of arter\ ; C. Temporal branch of auriculotemporal nerve ; D, Branch of temporofacial division of facial nerve ; E, Temporal fasci* SURGICAL ANATOMY OF INTERNAL MAXILLARY BRANCH OF EX- TERNAL CAROTID. Description. — The eighth in order and the larger of the two terminal branches of the external carotid, arising opposite neck of jaw, in substance of parotid gland. Course and Relations. — First or maxillary portion: — passes inward and forward between neck of inferior maxilla and internal lateral ligament, surrounded by deep part of parotid gland. Runs parallel with and just below auriculotemporal nerve and external pterygoid muscle, crossing the in- ferior dental nerve. Second or pterygoid portion : — takes one of two courses: (a) "Either runs between the two pterygoid muscles and ramus of jaw, and then turns up over outer surface of external pterygoid beneath the temporal muscle to gain the two heads of the external pterygoid, between which it sinks into the sphenomaxillary fossa — or (b) it passes behind and internal to the external pterygoid, and is covered by that muscle till it reaches the interval between its two heads, where it then often forms a projecting loop as it turns into the sphenomaxillary fossa" (Morris). Third or sphenomaxillary portion: — enters sphenomaxillary fossa, between two heads of external ptery- goid, and is placed beneath the superior maxillary division of the fifth nerve and in relationship with Meckel's ganglion — and here it divides into its terminal branches. Sites of Ligation. — When the ligation of the internal maxillary is indi- cated, the external carotid is tied, as being more easilv and safelv reached. SURGICAL ANATOMY OF MIDDLE MENINGEAL ARTERY. 45 The middle meningeal branch is tied within the cranium for intracranial hemorrhage. SURGICAL ANATOMY OF MIDDLE MENINGEAL BRANCH OF INTERNAL MAXILLARY BRANCH OF EXTERNAL CAROTID. Description. — The largest branch of the first or Maxillary Portion of the internal maxillary. Arises between internal lateral ligament and neck of inferior maxilla — and, under cover of external pterygoid, passes upward between the two roots of the auriculotemporal nerve to the foramen spinosum, being crossed by the chorda tympani nerve. It enters the skull through this foramen and ascends in the groove on the great wing of the sphenoid, where it divides into anterior and posterior branches which ramify between the bone and the dura. The point of bifurcation is generally given by anato- mists as corresponding, on the exterior of the skull, with a point 3.8 cm. (ij inches) behind the external angular process of the frontal bone, and 3.8 to 4.5 cm. (li to if inches) above the zygoma. The -Anterior Branch runs in a groove on the great ala of the sphenoid and the anterior inferior angle of the parietal. The Posterior Branch crosses the squamous portion of the temporal and then enters the groove on the posterior inferior angle of the parietal bone. In the voung these measurements are less. Indications for Ligation. — Intracranial hemorrhage. Sites of Ligation. — The common trunk, or the antericr or posterior branch, as indicated (Fig. 7, P. Q, R). Note. — liecause of the practical surgical bearing of the middle meningeal artery and its branches, and because of the wide variations from each other in the descriptions of the intracranial portion of the middle meningeal artery and its branches in various anatomies, and because of the equally wide variations of the artery and its branches, as actually found in the skull, from the text-book descriptions, — the following summary is given of the out- come of special research upon the subject made upon fifty dried skulls and thirty cadavera (representing 160, upon the two sides) by S. C. Plummer. In the following data it is to be remembered that, owing to beveling, the lower part of the coronal suture is 5 mm. to i cm. (y\- to | inch) more pos- terior on the inner than outer side of skull, and that the squamoparietal suture is from i to 1.5 cm. (f to | inch) lower on the inner than the outer side. Covering of Artery. — Instead of lying between dura and bone (as generally understood) the artery is really covered by a thin process of dura on its outer surface; hence its adherence to the dura in separation of the latter from the bone. Trunk of Middle Meningeal Artery. — (i) Present in 95 per cent. In 50 per cent., anterior and posterior branches entered separately, or the trunk divided at the foramen spinosum. (2) Point of Division into .Anterior and Posterior Branches: — 2 mm. to 5.5 cm. (little more than ^V to ^k inches) from foramen spinosum in a direct line — (less than i cm. or -^ inch) in 16 cases — between i and 3 cm. (-^^ and ly^^ inches) in 60 cases — over 3 cm. (ly^ inches) in 19 cases. Bifurcation was 58 times upon squamous part of temporal — 21 upon sphenoid — 15 upon squamosphenoidal suture — once on sphenoparietal suture. (Steiner, another investigator, found a common trunk present in only 43 per cent. — and found that bifurcation occurred in 57 per cent, at the foramen spinosum.) (3) Length: — corresponds with point of bifurcation, 46 orERATIUXS UPON THE ARTERIES. when point of bifurcation is not more than 2 cm. (J inch) above the foramen spinosum, — and from i mm. to 1.2 cm. (-jV to i inch) greater when the point of bifurcation is more than 2 cm. (f inch) above the foramen spinosum (due to curve in artery). (In Steiner's cases the length was from i to 3.5 cm., or f to I J inches, in 43 cases — and from 3.5 to 5 cm., or i| to 2 inches, in 8 cases.) (4) Direction: — almost invariably outward — and more frequently outward and forward than outward and backward. Generally runs outward for 2 mm. to 1.7 cm. (little more than ^^ to k inch) and thence outward and forward — - running in a gentle curve. (5) Location: — almost always runs from foramen spinosum onto the temporal (sometimes first runs onto the sphenoid, or squamosphenoidal suture) — generally running from 5 mm. to i cm. (y\ to | inch) ]::osterior to the squamosphenoidal suture; thence a long trunk generally runs onto the squamosphenoidal suture — and then onto the great vving of the sphenoid. Anterior Branch of Middle Meningeal Artery.— (i) Relative Size: — Generally the main branch and larger than the posterior. (2) Direction and Location: — Beginning at point at which lowest bifurcation occurs (v. s.), the anterior branch, after bifurcating on the squamous, squamosphenoidal suture, sphenoid, or on the sphenoparietal suture, as the case may be, passes forward and upward across the anterior and lower part of the squamous; — thence almost invariably crosses the upper part of the great wing of the sphenoid; — thence passes backward across the sphenoparietal suture onto the parietal — and runs thence generally upward and backward about parallel with the coronal suture, and generally within 2 mm. to 3 cm. (little more than ^ to iy\ inches) of it. Practically, the most constant position of the anterior branch is where it crosses the sphenoparietal suture — the cross- ing may be at any part of its 1.5 cm. (nearly f inch) length, but is usually on its anterior half. (3) As to Branches of Anterior Branch: — The anterior branch did not divide in 44 per cent. In the 56 per cent, in which it did divide, it divided 25 times on the right and 31 on the left. There were 2 branches in 49 cases — 3 branches in 5 cases — 4 branches in 2 cases; — and these divisions occurred 51 times on the parietal, 3 times on the sphenoparietal suture, and 2 times on the sphenoid. Kroenlein considers that the anterior branch, in the average case, divides into two branches, one of which runs up in front and one behind the rolandic fissure. Where the anterior branch divides into branches, one branch generally runs parallel with and within 2 cm. (J inch) of the coronal suture. (4) Bony Canal: — In from 38 per cent. (Steiner) to 60 per cent. (Plummer), the anterior branch was found to run through a bony canal upon the anterior inferior angle of the parietal bone — the canal sometimes beginning upon the sphenoid — being from 3 mm. to 2.8 cm. (i to I J inches) long. Posterior Branch of Middle Meningeal Artery. — (i) Much less con- stant in size and position than anterior branch. Generally smaller — often appearing as, and mistaken for, a branch of the anterior branch. Some- times appears to be a continuation of the trunk and larger than the anterior — and sometimes is larger without appearing to be main trunk. (2) Direction : — At first outward and backward, or upward and backward — rarely directly backward. Subsequently, in majority of cases, it passes horizontally backward — exceptionally, downward and backward. (3) Location: — (a) In Majority of Cases: — it runs appro.ximalely parallel with squamoparietal suture, gener- ally within I cm. (f inch), never more than 2 cm. (J inch) from it— gradually approaching it — crossing it (unless its terminal branches are given off on the temporal bone) generally within 2 cm. (f inch) of its posterior end, passing LIGATION OF TRUNK OF MIDDLE MENINGEAL ARTERV. 47 thence onto the parietal bone — its small branches running onto the occipital. (It may at first run parallel with the squamosphenoidal suture. It may cross the squamoparietal suture onto the parietal bone at any point.) (b) In Other Cases: — sometimes it runs outward and backward over the squamo- petrosal suture, or upon the squamous parallel with and generally within I cm. of the squamopetrosal suture — passing back over the base of the petrous bone, crossing the squamoparietal suture near its posterior end — thence back onto the parietal bone, superiorly to and parallel with the mastoparietal suture. (4) Branches of Posterior Branch: — In majority of cases the posterior branch divides into two branches — on the temporal bone, most frequently — on the parietal bone, next most frequently — and on the squamoparietal suture, least frequently. Summary. — (i) That no parts of the middle meningeal artery or its anterior or posterior branches have fi.xed relations, e.xcept the main trunk at its exit from the foramen spinosum, and the anterior branch where it crosses the sphenoparietal suture to reach anterior inferior angle of parietal. (2) That the common trunk is generally present. (3) That the anterior branch may be given otT from the orbital branch of the lachrvmal branch of the ophthalmic. (4) That a tendency to symmetry exists upon the two sides of the skull, but is not constant. (5) That the anterior branch runs through a bony canal in the anterior inferior angle of the parietal bone in the majority of cases. LIGATION OF TRUNK OF MIDDLE MENINGEAL ARTERY IN THE CRANIUM THKOl'CH TREI'HINE.OI'KN'IN'G E.XPOSED BY CURVED OBLIQUE IN'CISIOX. Position. — Patient supine; head supported, shaved and turned to oppo- site side; surgeon on side of operation. Landmarks. — A jioint is selected as the center of the trephine-opening which will fall over the trunk of the artery proximal to its bifurcation, — and which is taken to be about 3.8 cm. (li inches) behind the external angular process of the frontal bone and 2.5 cm. (i inch) above the zygoma. Incision. — Begins at external angular process of frontal bone — passes obliquely downward and backward to the posterior end of the zygoma — and from this point upward and backward above the auricle (Fig. 7, P). Operation. — (i) Having incised skin and temporal fascia, ligate the superficial temporal artery and vein, guarding the auriculotemporal nerve and branches of the facial (Fig. 16). Then carry the incision along the posterior border of the temporal muscle through the periosteum to the bone. Detach the temporal muscle forward subperiosteally. baring parts of the squamous, parietal, and sphenoid bones — guarding the deep temporal arteries. Firmly retract the soft parts thus freed upward and forward. (2) Using a trephine about 3.8 cm. (i^ inches) in diameter, place its center over a [)oint about 3.8 cm. (i^ inches) behind the external angular process and 2.5 cm. (i inch) above the zygoma. Having removed the disc of bone (which is here thin), expose the artery — and pass the needle carefully, to avoid wounding the brain. (3) In completing the operation, the disc of bone may be replaced, or not, according to the individual ideas of the surgeon. Allow the periosteum and soft parts to re-occupy their normal positions. Suture the margins of severed periosteum with buried catgut. Repair by gut-suturing any muscle tissue which may ha\e been cut and close the skin incision. Comment. — (i) This incision of Kocher, together with the subsequent 48 OPERATIONS UPON THE ARTERIES. retraction of the soft parts, involves less injury to the parts than the turning downward or upward of a semilunar or horseshoe flap, which is the method of approach most frequently adopted. (2) According to the researches of Plummer (v. s.), the osteoplastic flap operation of Hartley-Krause furnishes Fig. 16.— Ligation ok TpivK- of Right Mks-ingeal through Trf.phine-opeiN'Ing i.n Te.m- PORAL Fossa by Cur\i m ' 'i i '," i In-ision; — A. Temporal muscle (its aiuerior border retracted upward and backward), I; /'.; hmiIi^ iich.and temporal fossa just above; C, Main trunk and an- terior and posterior bran(.h,- "i mi, Ml, meningeal, exposed through trephine-opening (which is here shown somewhat too higti); n, Deep temporal artery; E, Superficial temporal artery and \ein ; F, Auriculotemporal nerve (retracted backward); G, Branches of facial nerve (retracted downwaid and backward). the best method of e.xposing the main trunk of the middle meningeal artery and its branches. (3) If the abo\e trephine-opening e.xpose the artery inconveniently near its circumference, the opening may be enlarged in the direction of the artery with rongeur forceps. LIGATION OF ANTERIOR BRANCH OF MIDDLE MENINGEAL ARTERY IN THE CRANIUM THROrCH TREPHINF.-OPENI.XG EXPOSED BV A HORSESHOE IMCISION. Position. — .\s for ligation of main trunk. Landmarks. — A point is selected as the center of the trephine-opening which will fall over the anterior branch just beyond its bifurcation — -and is taken to be about 3.8 cm. (lA inches) behind the external angular process of the frontal bone, and from 3.8 to 4.5 cm. (i^ to if inches) above the zygoma. Incision. — .\ horseshoe incision with its center over the above point and its convexity upward is outlined — its anterior limb being just behind the external angular process, and the posterior limb corresponding with a line extending vertically upward from the auditory meatus (Fig. 7, Q). Operation. — The incision is carried, throughout, through skin, temporal fa.scia, temporal muscle, and periosteum to bone. These soft parts are LIGATION 0¥ POSTERIOR BRANCH OF MIDDLE MENINGEAL ARTERY. 49 raised subperiosteally and turned downward. A trephine of about 3.8 cm. (i^ inches) diameter is applied with its center over the above point. The steps of the operation are, henceforth, the same, practically, as those for the main trunk (page 47). Comment. — (•) See the surgical anatomy of the middle meningeal artery and its branches for variations in the course of the anterior branch. (2) .\ccording to Chipault's method of cranio-cerebral localization (page 472), the anterior branch of the middle meningeal crosses the second tenths of the three primary lines. In following which method, therefore, the trephine should have its center placed over a line which will cross these tenths at about their middle. (3) According to the researches of Plummer (page 45), who recommends Kroenlein's method of locating the anterior branch as the best of several, the following points are of practical value: — (A) That site should be chosen — (1;) Which is high enough to avoid missing the anterior branch in case it originates from the orbital branch; — (h) which is high enough' to be above the orbital branch when that branch is only a communicating branch; — (< ) which is least ai)t to fall over the bony canal in the anterior inferior angle of the parietal, and over the bony ridge along the lower portion of the coronal suture: — (B) That a 2.5 cm. (i inch) trephine-opening placed just behind any portion of the coronal suture will almost certainly strike the ante- rior branch, or a branch of the anterior branch. (4) According to Kroenlein's method, Reid'sbase line (page 476) is first drawn — then a higher line is drawn parallel with it and on a level with the supraorbital border. On the latter line a point is taken 3 or 4 cm. (ry\ to ij\ inches) behind the external angular process. The center of the trephine will rest on the sphenoid in the majority of cases. (This corresponds, practically, with the data often given, of fixing upon a point from 3.2 to 3.8 cm. (i| to i^- inches), according to the size of the head, behind the external angular process — and from 3.8 to 4.5 cm. (ij to if inches) above the zygoma. LIGATION OF POSTERIOR BRANCH OF MIDDLE MENINGEAL ARTERY IN THE CRANIUM THROf(;H TREPHINE-OPEXIXG EXPOSED BV A HORSESHOE INCISION. Position. — As in ligating the main trunk. Landmarks. — A point is selected as the center of the trephine-opening which will fall o\er the posterior branch in the groove of the parietal bone — and is taken to be at the intersection of a line drawn horizonlallv backward on a level with the roof of the orbit, and one drawn vertically upward from directly Ijehind the mastoid f)rocess — which point of intersection lies just below the parietal eminence (Jacobson). Incision. — A horseshoe incision with its center over the above point, its convexity upward, and its limbs being from 5 to 5.7 cm. (2 to 2^ inches) apart (Fig. 7, R). Operation. — Performed in the same general manner as for ligation of the anterior branch. Comment. — (i) According to the researches of Plummer (page 41:), who recommends Steiner's method as the best of several for locating the posterior branch, the following points are of practical value : — (A) The posterior branch is incapable of being located with as much certainty as the anterior branch: — (B) The lateral sinus is to be guarded in exposing the po.sterior branch. (2) According to Steiner's method, Reid's base-line is first drawn — 4 50 OPERATIONS UPON THE ARTERIES. then a seconil higher line is drawn parallel with it and on a level with the supraorbital border. A third line is drawn vertically upward along the anterior border of the mastoid (drawing the ear forward). The intersection of the third with the second line marks a convenient site for reaching the posterior branch. The trephine-pin rests on the squamoparietal suture. When the posterior branch itself is not encountered, its two branches usu- allv are. SURGICAL ANATOMY OF INTERNAL CAROTID ARTERY. Description. — The larger of the two branches of the common carotid. Arises op]K)site u]jper border of thyroid cartilage (on level with fourth cervical vertebra) — at first comparatively superficial, and lies slightly e.xternal to external carotid, then sinks more deeply in neck and passes posteriorly to that vessel — ascending neck in front of transverse processes of upper cervical vertebrae to enter the carotid canal. The relations of its different portions are as follows: Relations. — (i) First or Cervical Portion :— Anteriorly (from below upward) — skin; superficial fascia; platx'sma; dee]) fascia; sternomastoid; posterior belly of digastric; stylohyoid; hypoglossal; occipital artery; posterior auricular artery; external carotid; styloglossus; stylopharyngeus; glosso- pharyngeal nerve; pharyngeal branch of pneumogastric; stylohyoid ligament. Posteriorly — rectus capitis anticus major; transverse processes of three upi)er cervical vertebra-; superior cervical ganglion; pneumogastric nerve; hypoglossal nerve; glossopharyngeal nerve; spinal accessory nerve; internal jugular vein. Externally — internal jugular vein; pneumogastric nerve. Internally — phar\nx; superior constrictor; tonsil; ascending pharyngeal artery; ascending palatine artery; eustachian tube; levator palati. (2) Second or Petrous Portion: — Within carotid canal in petrous portion of temporal bone. (3) Third or Cavernous Portion : — Between layers of dura mater, forming cavernous sinus. (4) Fourth or Cerebral Portion: — Enters inner extremit}' of fissure of Svlvius and gives oft' its branches. Branches. — From cervical portion — none. From petrous portion — tympanic; vidian. From cavernous portion — arteria receptaculi; pituitary; ga.sserian; anterior meningeal; ophthalmic. From cerebral portion — anterior cerebral; middle cerebral; posterior communicating; anterior choroid. Line. — Same, [)ractically, as for the external carotid, — or possibly a little to the outer side of that line at its lower part. Indications for Ligation. — Wounds; aneurism. Sites of Ligation. — Near origin (Fig. 7, S). LIGATION OF INTERNAL CAROTID ARTERY M:AK ORIGIN', Position — Landmarks. — .\s for ligation of external carotid below the digastric (page 35). Incision. — Slightly posterior to the incision for the external carotid artery — that is, along the anterior border of the sternomastoid, instead of just in front of it — with the center of the incision about 1.3 cm. (^ inch) above the up|)er border of the thyroid cartilage (Fig. 7, S). Operation. — The steps are, at first, the same as those for exyiosing the external carotid below the digastric. This artery (external carotid) is first SURGICAL AXATOMV OF SUBCLAVIAN ARTERY. $1 sought (all the structures mentioned in that operation being encountered) and traced to its bifurcation, and thus the internal carotid is exposed — the external carotid being drawn inward and the digastric upward. In opening the sheath special care must be taken to guard the internal jugular vein, pneumogastric nerve, cervical sympathetic, ascending pharyngeal artery — the needle being passed from the vagus and internal jugular vein. Collateral Circulation. — Circle of Willis. SURGICAL ANATOMY OF SUBCLAVIAN ARTERY. Description. — Subclavian artery on right side, about 7.5 cm. (3 inches) in length, arises from the innominate; and, on the left, about 10 cm. (4 inches) in length, arises from arch of aorta — arching, in both cases, across the root of neck, over the dome of the lung and pleura, to the lower border of the first rib, where it becomes the axillary artery. That portion of the subclavian internal to inner border of scalenus anticus being the first part — that portion behind this muscle being the second part — and that portion external to the outer border of scalenus anticus being the third part. The subclavian vein lies below and anterior to artery, the scalenus anticus intervening. The posterior IVorder of the sternomastoid corresponds with the external border of the scalenus anticus. _- Relations. — (a) First Portion of Right Subclavian: — About 1.7 cm. (ij inches) in length — arises from bifurcation of innominate, behind upper border of right sternoclavicular articulation — curves upward and outward (with convexity upward) at a variable distance above clavicle, over apex of right lung and pleura, to inner border of right scalenus anticus, having following relations: — Anteriorly — skin; superficial fascia; platysma; anterior layer of deep fascia; clavicular origin of sternomastoid; sternohyoid; sterno- thyroid; sternohyoid; deep cervical fascia; right innominate vein; internal jugular vein; vertebral vein; pneumogastric nerve; phrenic nerve; superior cardiac branches of sympathetic nerve: — Posteriorly — areolar tissue; longus colli; transverse process of seventh cervical and first dorsal vertebra; sym- pathetic nerve; inferior cardiac nerves; recurrent laryngeal nerve; apex of right lung and pleura; neck of first rib: — Inferiorly — pleura and lung; recurrent lar\-ngeal nerve; subclavian vein, (b) First Portion of Left Subclavian : — }iIuch longer than that of right — arises from distal end of transverse part of arch of aorta, opposite fourth dorsal vertebra, to left and slightly posterior to left common carotid — ascending, at first, almost vertically — then arching further upward and outward over apex of left lung and pleura to inner border of left scalenus anticus — having following relations: — Ante- riorly — left pleura and lung; sternothyroid; sternohyoid; sternomastoid; left innominate vein; internal jugular vein; vertebral vein; subclavian vein; phrenic nerve; pneumogastric nerve; left cervical cardiac nerves of sympathetic; left common carotid; thoracic duct: — Posteriorly — esophagus; thoracic duct; inferior cervical sympathetic ganglion; longus colli; vertebral column; left pleura and lung: — Externally — left pleura and lung: — Internally — trachea; recurrent laryngeal nerve; esophagus; thoracic duct, (c) Second Portions of Both Subclavian Arteries : — Highest part of the vessel — about 2 cm. (J inch) in length — lies behind scalenus anticus. which separates the artery from the subclavian vein — and has following relations: — Anteriorly — skin; superficial fascia; platysma; anterior layer of deep fascia; clavicular origin of sternomastoid; deep layer of deep fascia; phrenic nerve; subclavian vein; 52 OPERATIONS UPON THE ARTERIES. scalenus anticus: — Posteriorly — apex of lung and pleura; scalenus medius: — Superiorly— brachial [jlexus: — Inferiorly — lung and pleura, (d) Third Portions of Both Subclavians : — Lie in subclavian triangle (of sternomasloid, omohyoid, and clavicle). Extend from outer border of scalenus anticus downward and outward to lower border of first rib. and have following rela- tions: — Anteriorly — skin; superficial fascia; platysma; clavicular branches of descending portion of cervical plexus; anterior layer of deep fascia (from omohyoid to clavicle) ; posterior layer of deep fascia (from omohyoid to first rib); fatty areolar tissue between layers of deep cervical fascia; suprascapular artery; external jugular vein; suprascapular vein; transversalis colli vein; other tributary veins to external jugular; nerve to subclavius muscle; sterno- mastoid (sometimes); clavicle; subclavius muscle: — Posteriorly — scalenus medius; cord of brachial plexus formed bv eighth cervical and first dorsal: — Superiorly — brachial plexus; posterior belly of omohyoid: — Inferiorly — first rib. Branches. — From First Portion: — vertebral, thvroid axis (inferior thvroid, transversalis colli, suprascapular), internal mammarv. From Second Portion: — superior intercostal. From Third Portion: — No branches, ordinarily. Line. — A curve, with convexity upward, at base of posterior triangle — beginning at sternoclavicular articulation and ending at center of inferior border of clavicle — its mid-point being about 1.3 cm. (^ inch) above the superior border of clavicle. Indications for Ligation. — Wounds; aneurism; preliminary to extensive operations aliout the shoulder and upper extremity. Sites of Ligation. — Only three successful cases are recorded, as far as known by the writer, of ligature of the first portion of the right subclavian, and but one of the left — the ligation being particularly hazardous, especially upon the latter side. Nor is ligature of the second portion to be recom- mended, owing to the depth and relations of the artery. The third portion is the part of the artery usually selected for ligation (Fig. 7, T). LIGATION OF FIRST PORTION OF RIGHT SUBCLAVIAN BV ANGULAR IXCISIOX. Position— Landmarks — Incision. — As for ligation of innominate by angular incision (page 26). Operation. — Having incised skin and superficial fascia, this triangular flap is dissected up, as in ligation of the innominate. The anterior jugular vein is doubly ligated and divided, and the external jugular similarly treated, if in the way. Divide the deep fascia. Expose and sever the sternal and clavicular heads of the sternomastoid. Divide the sternohyoid and sterno- thyroid either in whole or in part. Expose the common carotid, carefully retracting the internal jugular vein and pneumogastric nerve outward and displacing or doubly ligating any overlying veins. Identify the subclavian vein by following down the common carotid on its postero-external aspect to the bifurcation. Clear the subclavian artery, carefully guarding the recurrent larvngeal and phrenic nerves and vertebral artery. Displace the pleura downward and outward with tip of finger, and pass the needle from below (from the pleura). The vertebral should also be secured at the same time and through the same incision — to accomplish which, the internal jugular and pneumogastric nerve are now retracted inward and the vertebral exposed by a few strokes of the knife as it lies between the longus colli and LIGATION" OF SECOM) PORTION OF SLBCI.AVIAX ARTERV. 53 scalenus, guarding the phrenic and recurrent laryngeal nerves and the inferior thyroid artery. Comment. — Excision of the right sternoclavicular articulation may be done when necessary, as in the ligation of the innominate by partial bony resection. Collateral Circulation. — Superior thyroid, with inferior thyroid; one vertebral, with opposite vertebral. Internal mammary, with deep epigastric and aortic intercostals. Superior intercostal, with aortic intercostals. Pro- funda cervicis, with princeps cervicis. Scapular branches of thyroid axis, with branches of axillary. Thoracic branches of axillary, with aortic inter- costals. LIGATION OF FIRST PORTION OF LEFT SUBCLAVIAN BY ,\NT,rL.\R INCISION. Position — Landmarks — Incision. — .\s for ligation of innominate by angular incision, except that the operation is placed upon the left side. Operation. — The steps of the operation are similar to those for ligation of the first portion of the right subclavian — up to the exposure of the common carotid and internal jugular. Here the common carotid and pneum.ogastric are retracted inward, the internal jugular is drawn outward and downward, and, with it, the left innominate vein. .\t this stage the head is bent forward to relax the parts. Special care is here given to identifying the thoracic duct before proceeding — the duct arching from the seventh cervical vertebra forward and downward over the subclavian artery in front of the scalenus anticus, and emptying into the left subclavian vein at the junction with it of the left internal jugular, being embedded in the loose areolar tissue of the part, making it often difficult to find, and sometimes dividing into several branches. Having safeguarded the important neighboring structures, follow down the common carotid with the finger until the subclavian is identified, on a plane posterior and external to that of the former vessel. The artery is then to be freed, carefully guarding the pleura; the sheath is opened and the needle passed from the pleura. Comment. — If more room be required than gi\en by the above incision, or if it be required to ligate the vessel nearer the arch, an excision of the sternoclavicular articulation can be done. Xo successful case of ligation of the first part of the left subclavian is known to the writer. Collateral Circulation. — See Ligation of First Part of Right Subclavian. LIGATION OF SECOND PORTION OF SUBCLAVIAN ARTERY. Position — Landmarks — Incision. — .\s for ligation of third portion of subclavian. Operation. — The steps of this operation, up to the division of the deep cervical fascia and the recognition of the outer border of the scalenus anticus (which lies directly under the outer border of the sternomastoid), are identical with those for the exposure of the third part of the subclavian. The further steps consist in the inward retraction of the scalenus anticus (and overlying sternomastoid), with the division of as many of their fibers as necessary, when the artery will be exposed and may be ligated. Especial care is taken to guard the phrenic nerve, which crosses obliquely the lower anterior surface of the scalenus anticus, — as well as the transversalis colli and suprascapular 54 OPERATIONS UPON THE ARTERIES. arteries, which cross the scalenus anticus transversely, — and the external jugular \ein, running parallel with the anterior scalene muscle. Comment. — This operation is often merely a pro.ximal continuation of the operation for the exposure of the third part of the suiiclavian. when the appKcation of a ligature to the third part is impracticable. LIGATION OF THIRD PORTION OF THE SUBCLAVIAN. Position. — Patient supine; shoulders raised; head thrown back and to opposite side; shoulder depressed by arm drawn downward and placed under the back (to open out the posterior cervical triangle). .Surgeon in front of shoulder. t K G N I- i 1 1 " C A 1 I f x^nSiS^^ ^K g^r^iij^ ^^ -^"^^^^^ 1 . j ■ 1 ^ ^^ E ^ 1 L J N r C Fig, 17.— Ligation of Third Part of Right Subclavian :— .A, Platysma ; B. Trapezius; C. Steniomasloid (posterior border incised): D, Scalenus anticus; E, Posterior belly of omohyoid (re- tracted upward); F, Clavicle ; G, Third part of subclavian : H, Transversalis colli A.; I, Suprascapu- lar A.; J, Subclavian \ciii, K, t'l'iui end of external jugular \'. (divided and retracted), with transversalis colli V, and r..niniMiii, .ilnii; branch to anterior jugular ; L, Lower end of external jugu- lar (di\ided and retractcil 1 \\ ali ^iii-Ki^capular branch ; M, Brachial plexus; N, N, N, Supraclavicu- lar nerves ; O, Deepcervi.,.1 las. 1.. Landmarks. — Posterior border of sternomastoid (which corresponds with the outer border of the scalenus anticus); anterior border of tra[)ezius; middle of clavicle. Incision. — With the skin of the ])osterior cer\ical triangle drawn down over the clavicle by the left hand, an incision about 7.5 cm, (,s inches) is made transversely over the clavicle down to the bone, from the posterior border of the sternomastoid to the anterior border of the trapezius, and with its center about 2.5 cm. (i inch) internal to the center of the superior border of ihe clavicle (Fig. 7. T), Operation. — (i) This incision will di\iiie the skin, fascia, ])latysma, some supraclavicular nerves, and nia\be a connecting \ein lietween the cephalic and internal jugular — but will a\oid the external jugular, which SURGICAL AXATOMV OF VERTEBRAL ARTERY. 55 passes through" the deep fascia above the clavicle. The incision will lie about 2.5 cm. (J inch) above the clavicle when the tension upon the skin is rela.xed (Fig. 17). (2) The margins of the sternomastoid and trapezius will be exposed, and, if more room be needed, may be divided along the clavicle as far as necessary. (3) The deep cervical fascia is next incised, the external jugular vein being carefully exposed and retracted, or divided between double ligatures. Tributary veins of the external jugular are to be similarly treated, especially the transversalis colli and suprascapular. (4) Generally the trans- versalis colli artery lies transversely above the incision, and the suprascap- ular transversely below it, under the clavicle and out of the way; but one or both mav present in the field, and are to be carefully preserved for collateral circulation. Retract the posterior belly of the omohyoid upward if in the way. Identify the outer margin of the scalenus (just under the outer margin of the sternomastoid) as a guide to the artery, and follow its outer border downward until the finger reaches the tubercle on the upper border of the" first rib, which lies between the subclavian vein in front, and the subclavian arterv behind — when the artery will be recognized and may be traced upward. (5) Expose the lowest cord of the brachial plexus — for the purpose of hence- forth avoiding it (as it has been mistaken and ligated for the artery). The subclavian vein will lie anteriorly and inferiorly to the artery. (6) Open the sheath — clear the artery — and pass the needle from the brachial plexus, guarding the subclavian vein and the pleura. Collateral Circulation. — (When the second or third part is tied) : — Supra- scapular and posterior scapular above, with acromiothoracic, infrascapular, subscapular, and dorsalis scapuke below; internal mammary, superior inter- costals, aortic intercostals above, with long thoracic and scapular arteries below; plexiform vessels from branches of subclavian above, with branches of axillary below. SURGICAL ANATOMY OF VERTEBRAL ARTERY. Description. — Largest and generally first branch of subclavian. Arises from upper and posterior portion of first part of subclavian, near inner border of scalenus anticus — ascends upward, backward, and outward, in interval between scalenus anticus and longus colli, to foramen in transverse process of sixth cervical vertebra — jMsses through foramina in all vertebra? above this — emerging from foramen in transverse process of atlas, it runs in groove on posterior arch of atlas, lying in the suboccipital triangle, and pierces the occipito-atloid ligament and dura mater — and passes into cranium through foramen magnum — upward u])osterior thoracic nerve. Externally — brachial plexus. Internally — axillary vein; anterior internal thoracic ner\e. (b) Second Part: — about ,5 cm. (i^ inches) in length — lying behind pectoralis minor muscle, and having following relations: Ante- riorly — integuments; superficial fascia; pectoralis major; pectoralis minor. Posteriorly — posterior cord of brachial plexus; areolar tissue and fat; sub- scapularis. Externally — external cord of brachial plexus; coracoid process (somewhat removed). Internally — internal cord of brachial plexus; axillary vein, (c) Third Part: — about 7.5 cm. (3 inches) in length — extending from lower border of jiectoralis minor to lower border of tendon of teres major (the upper half being in axilla, the lower half on arm), and having following relations: Anteriorly — integument; superficial fascia; pectoralis major; deep fascia of arm; internal root of median nerve; external brachial vena comes. Posteriorly — musculospiral nerve; circumflex ner\e; fatty areolar tissue; 62 OPERATIONS UPON THE ARTERIES. subscapularis; latissimus dorsi; teres major. Externally — external root of median nerve; musculocutaneous nerve; coracobrachialis. Internally — in- ternal root of median nerve; ulnar nerve; internal cutaneous nerve; lesser internal cutaneous nerve; a.xillarv vein. Branches. — From first part — superior thoracic, acromial thoracic. From second part — long thoracic, alar thoracic. From third part — sub- scapular, anterior circumtle.x, posterior circumfle.x. Line of Artery. — (With arm at right angle to trunk and hand supine) — from middle of clavicle to junction of anterior and middle thirds of the outer axillarv wall, between the anterior and posterior folds of the axilla. Sites of Ligation. — Third part, by preference; — first part, if third part not availal)le. Ligation of third portion of subclavian is usually considered preferable to that of first part of axillary (Figg. 19, C, and 7, W). Comment. — (1) When the arm is at a right angle to the body, the axillary vein is drawn across the first part of the artery. (2) The upper and lower borders of the pectoralis minor correspond, respectivelv, with lines drawn from the junction of the third rib and its cartilage to the coracoid process; and from the junction of the fifth rib and its cartilage to the coracoid process. (3) Two brachial ven;E comites are generally found at the lower part of the artery — and also the basilic vein, unless it have already joined the internal vena comes. LIGATION OF FIRST PART OF AXILLARY ARTERY BY Cl'RVKD TRANSVERSE INXISIO.X BELOW CLAN'ICLE. Position. — Patient on back, at edge of table; upper thorax raised ; shoulder backward. Surgeon near thorax on left, for left operation; near head on right, for right operation — (or between abducted limb and body on each side). Landmarks. — Clavicle; sternoclavicular articulation; coracoid process. Incision. — Curved incision in infraclavicular fossa — beginning just ex- ternal to the sternoclavicular joint — dipping, at lowest point, about 1.3 cm. (J inch) below clavicle — and ending at the coracoid process (Fig. 7, W). Operation. — Incise skin, platysma, supraclavicular nerves, and fascia. Carefully guard the cephalic vein and branches of acromial thoracic artery at outer part of wound, on account of collateral circulation. Divide the clavicular origin of the pectoralis major throughout the wound. Clear the areolar tissue beneath the pectoralis major. E.xpose the upper border of the pectoralis minor and draw it downward. Divide vertically, near the coracoid process, the costocoracoid membrane — through which pass the cephalic vein, branches of the acromiothoracic artery, and the anterior thoracic nerves — and displace it upward and outward. The cephalic vein, indicating the position of the axillary vein, is generally closely adherent to the costo- coracoid membrane. Expose the sheath and clear the artery — which lies between the axillary vein on the inner side and the brachial plexus on the outer, aided in the e.xposure by bringing the arm nearer the body, when the axillary vein will be carried from over the artery to its inner side. The ligature is placed above the acromiothoracic I>ranch. The incised pectoralis majiir muscle is repaired bv gut suturing. Comment. — This is the easiest and most frequent ligation of the first part, in the rare cases in which a ligation at this site is done — a ligation of the third portion of the subclavian being considered preferable. The first LIGATION OF THIRD PART OF AXILLARY ARTERY. 63 part may be exposed by an oblique incision between pectoralis major and deltoid. Collateral Circulation. — When ligated between the superior thoracic and acromial thoracic: — Suprascapular and posterior scapular; with acromial thoracic and subscapular. Internal mammary, aortic intercostals, superior intercostal; with long thoracic and subscapular. Plexiform vessels from subclavian; with plexiform vessels from axillary. Kig. 20.— Ll<;AriuN of Thiku 1'art of Right A.xillakv :— A, Coracobrachialis (retracted out- ward) ; li, Pectoralis major ; C. Teres major; D, Triceps; E. Axillary artery ; F. Basilic vein, becom- ing axillary vein after receiving two brachial vense comites ; G, Right brachial vena comes; H, Mus- culocutaneous nerve ; I, Median N. ; J, Internal cutaneous N. ; K, k, Ulnar N. LIGATION OF THIRD PART OF AXILLARY ARTERY. Position. — Patient supine at edge of table; shoulders raised; arm at right angle to body, and slightly rotated outward. Surgeon between arm and chest, on either side. Axilla to be shaved. Landmarks. — Junction of anterior and middle thirds of external axillary wall; cciracobrachialis. Incision. — About 7.5 cm. (3 inches) in length — beginning at the middle of the outlet of the axilla, at the junction of the anterior and middle thirds of its outer wall, and passing downward along the inner border of the coraco- brachialis (Fig. 19, C). 64 OPERATIONS UPON THE ARTERIES. Operation. — Having incised integument and fascia, expose the inner border (.A the coracobrachiahs (Fig. 20). Draw this muscle and the musculo- cutaneous nerve outward. The median nerve is exposed and also drawn outward. The internal cutaneous and ulnar nerves are drawn inward. Vena; comites are generally present at the lower part of the axilla and sometimes the basilic vein, which have to be guarded. Again, the axillary vein alone may be present to the inner side of the artery. Pass the needle from the vein, ligating the artery as far from a large branch as possible. Collateral Circulation. — (a) If tied lielow the circumflex arteries: — the posterior circumflex above, with the superior profunda below, (b) If tied between subscapular above and two circumflex branches below: — the supra- scapular and acromial thoracic above, with posterior circumflex below. SURGICAL ANATOMY OF SUBSCAPULAR BRANCH OF AXILLARY ARTERY. Description. — Arises from third part of axillarv arterv, opposite lower border of subscapularis; — passes downward and inward along the anterior margin of the lower border of that muscle, under cover of the latissimus dorsi to the angle of the scapula, accompanied by the long subscapular nerve and two venae comites. The dorsalis scapula branch is given otT about 2.5 cm. (i inch) from the origin of the main vessel. LIGATION OF SUBSCAPULAR BRANCH OF AXILLARY ARTERY Aioxi; rosri-.KioK ,\.\ili.ar\ fold. Position. — Patient supine; limb fully abducted. Surgeon between chest and arm. Landmarks. — Posterior axillary fold. Incision. — Begins at the arm and passes along the anterior surface of the posterior axillary fold. Operation. — Incise skin and superficial fascia. The intercostohumeral nerve may be encountered here. Divide the deep fascia. The artery lies at the upper edge of the insertions of the latissimus dorsi and teres major, which form the jjosterior axillary wall. Separate the artery from its vena" comites and long subscapular nerve and pass the needle. Comment. — Through this incision the dorsalis scapula; artery is also exposed, and at the upper part of this incision the circumflex nerve is seen. SURGICAL ANATOMY OF BRACHIAL ARTERY. Description. — Continuation of axillary artery. Extends down inner and anterior aspect of arm, from lower fjorder of tendon of teres major to about 1.3 cm. (^ inch) below center of crease at bend of elbow, and divides, opposite junction of head with neck of radius, into radial and ulnar arteries. The artery lies in the depression at the inner borders of the coracobrachiahs and biceps, and then in the groove between the supinator longus and pronator radii teres, passing under the bicipital fascia below. It lies to the inner side of humerus above, and in front of it below. LIGATION OF BRACHIAL ARTERY. 6S Relations. — Axiteriorly : integument; superficial and deep fascia; median nerve (in middle); median basilic vein and bicipital fascia (at elbow). Posteriorly : lies, in order, upon — long head of triceps (musculospiral nerve and superior profunda artery intervening); inner head of triceps; insertion of coracobrachialis; brachialis anticus. Externally: in order — coraco- brachialis; belly of biceps (both slightly overlap])ing the artery); tendon of biceps; median nerve, above (crossing artery at middle); e.xternal vena comes. Internally: internal cutaneous and ulnar nerves (above); median nerve (below); internal vena comes ; basilic vein. Branches. — Superior profunda; inferior profunda; anastomotica magna; nutrient; muscular. Line of Artery. — (.\rm extended and abducted, hand supine.) From junction of anterior and middle thirds of outer wall of a.xilla to center of bend of elbow (Fig. 19, \ and B). Sites of Ligation. — Middle of arm (preferably); bend of elbow. Fig. 21. — Ligation of Right Brachial at Middle of Arm: — A, Biceps; B, Coracobrachi- alis (retracted outward) ; C. Triceps; D, Brachial artery and branches; E, Bracliial \'enae comites and connnunicating branches ; F. Basilic vein ; G. Branch from basilic to cephalic vein ; H, Median nerve ; I. L'hiar N. ; J, hitcrnal cutaneous N. LIGATION OF BRACHIAL ARTERY IX .MIDDLE OF ARM Position. — Limb e.xtended, abducted, and hand supine. Surgeon to outer side of limb, cutting from above downward on right, and from below upward on left. 5 66 OPERATIONS UPON THE ARTERIES. Landmarks. — Inner border of coracobrachialis and biceps; line of artery. Incision. — About 5 to 7.5 cm. (2 to 3 inches) in length, extending along inner border of biceps, in line of artery, opposite middle of arm (Fig. ig, D). Operation. — The skin and fascia having been divided, the inner border of the biceps must be clearly recognized and retracted outward — when the artery is generally found under its inner margin — the median ner\e usuallv crossing the front of the artery at its middle — the internal cutaneous nerve lying to the inner side (Fig. 21). The vena; comites and basilic vein are to be separated from the artery. The needle is passed from the nerve. Comment. — (i) The artery is not as easily found in this situation as the superficial position would suggest. Its exposure is made easier by an assistant's holding the limb by the wrist, so that it cannot rest on the table, where the triceps is apt to be pushed upward and mav protrude the inferior profunda artery and ulnar nerve, instead of the brachial artery and median nerve (Heath). (2) In ligating higher than the middle third, the artery lies to the inner side of the coracobrachiahs, the median nerve to the outer side, and the ulnar nerve to the inner. Fig. 22. — Ligation of Right Brachial at Bend of Elbow : — A. Median basilic vein Median cephalic; C. Internal culaneous nen-e and branches; D, Biceps; E, E, Bicipital fascia Brachial artery ; G, Brachial venK coiniles and communicating branches; H, Median nerve - Brachialis amicus muscle. LIGATION OF BRACHIAL ARTERY AT BKND OK ELBOW. Position. — Limb extended (not overextended) and abducted. Surgeon to outer side of limb, cutting from above on right, and from below on left. Landmarks. — Inner border of biceps tendon. SURGICAL ANATOMY OF RADIAL ARTERY. 67 Incision. — About 5 cm. (2 inches) in length — in the internal bicipital fossa, along the inner border of the biceps tendon — its center corresponding to the "fold of the elbow." This incision will be oblique and its upper end will commence opposite the tip of the internal condyle of the humerus. It is well to compress the veins above, to get an idea of their position at the elbow, and thus avoid them, if possible. Ordinarily the incision will lie above and to the outer side of the median basilic (Fig. 19, E). Operation. — Having incised skin and superficial fascia, isolate the median basilic vein and accompanying internal cutaneous nerve and retract them inward (Fig. 22). Incise, in the direction of the original wound, the deep fascia and the bicipital fascia — the latter (passing inward and down- ward) is to be incised to as limited an extent as possible. Beneath the bicipital fascia lies the arterv, with its venae comites — the median nerve generally lying out of the way and to the inner side, nearer the ujjper than the lower part of the wound. Pass the needle from the side of the ulnar nerve. Resuture the bicipital fascia with gut. SURGICAL ANATOMY OF RADIAL ARTERY. Description. — Smaller but more direct of two divisions of brachial. Begins at bifurcation of brachial, about 1.3 cm. (^ inch) below bend of elbow —runs outward and downward along radial side of forearm to styloid process of radius — thence passes around outer side of carpus over e.xternal lateral ligament and beneath e.xtensor tendons of thumb, to back of wrist — and enters palm between first and second metacarpal bones, passing between the two heads of first dorsal interosseous muscle — thence crosses metacarpal bones and interossei muscles, anastomosing at ulnar side of hand with deep branch of ulnar, to form deep palmar arch. The artery is accompanied by two vena? comites. Relations. — (a) In Forearm : — The artery runs in outermost intermuscu- lar s]iace, Iving between supinator longus and pronator radii teres above, and between supinator longus and tendon of flexor carpi radialis below. Ante- riorly — skin; fascia; supinator longus (above). Skin; fascia; cutaneous vessels and nerves (below). Posteriorly — (from above downward) tendon of biceps; supinator brevis; insertion of pronator radii teres; radial origin of fle.xor sublimis digitorum; flexor longus pollicis; pronator quadratus; anterior surface of lower end of radius. Externally — supinator longus (guide to arterv) and external vena comes (throughout); radial nerve (middle third). Internally — pronator radii teres (upper third); tendon flexor carpi radialis (lower third) ; internal vena comes (throughout), (b) At Wrist : — The artery winds over outer side of carpus, from a point just below and internal to styloid process of radius, to base of first interosseous space, entering the palm between the two heads of the first dorsal interosseous muscle (ab- ductor indicis) to form the deep palmar arch. It is covered, successively, by extensor ossis metacarpi pollicis; extensor brevis pollicis; branches of radial nerve; superficial radial veins; extensor longus pollicis; — and rests, in order, upon external lateral ligament; scaphoid; tra])ezium; base of first metacarpal; dorsal carpal ligaments. It is accompanied by two venae comites and branches of musculocutaneous nerve, (c) In the Palm : — Enters palm in upper part of interval between first and second metacarpals, passing between two heads of first dorsal interosseous muscle (abductor indicis) — runs inward between adductor obliquus pollicis and adductor transversus 68 OPERATIONS UPOX THE ARTERIES. poUicis — crossing the palm transversely, with slight downward curve, to base of metacarpal of little finger, and there anastomoses with deep branch of ulnar, forming the deep palmar arch. The deep palmar arch, therefore, extends from base of first interosseous space to base of metacarjial of little finger, and is about 2 cm. (| inch) nearer the wrist than is the superficial palmar arch. It is covered by the superficial and deep fle.xor tendons; ad- * — L Fig- 23.— Incisions fok Ligating Right Radial and Ulnar Arteries, and Superficial AND Dekp Palmar Arches : — A, Ligation of radial in upper third of forearm ; B, of radial in middle third ; C, of radial in lower third ; D. of deep palmar arch ; E. Ligation of ulnar in middle third of forearm; F, of ulnar in lower third; G, of superficial palmar arch; H. Center of bend of elbow ; I. Antero-internal aspect of styloid process of radius ; J. Radial sideof pisiform bone ; K. Anterior aspect of inner condyle of humerus; L, Point on inner aspect of forearm at junction of upper and middle thirds. LIGATION OF RADIAL ARTERY. 69 durtor obliquus pollicis; part of flexor brevis minimi digiti; part of opponens minimi digiti; lumbricales. It rests upon adductor transversus pollicis; carpal extremities of metacarpal bones; interossei muscles. It is accom- panied by two ven;B comites and the deep branch of the ulnar nerve (running in opposite direction). Branches. — (a) In Forearm — radial recurrent; muscular; anterior radial carpal; superficialis vote, (b) At Wrist — posterior radial carpal; metacarpal (first dorsal interosseous); dorsalis pollicis; dorsalis indicis. (c) In Palm — princeps pollicis; radialis indicis; palmar interosseous; recurrent; per- forating. Line of Artery. — (a) In Forearm (with hand supine) — from center of bend of elbow, to inner side of forepart of styloid process of radius (Fig. 23, H and I), (b) .\t Wrist — from inner side of forepart of styloid process to base of first interosseous space, (r) In Palm — runs about 2 cm. (f inch) nearer wrist than does superficial palmar arch (which corresponds with a line continued across on level with lower border of outstretched thumb). Sites for Ligature. — Upper forearm (rarely); middle forearm; lower forearm (preferably); back of hand (rarely). In palm — the arch may be tied in case of wounds, under which circumstances it may be ligated at any site (Fig. 23, D). Anatomy of the "Tabatifere," or "Snuff-box." — The triangular space on back of hand — bounded, on radial side, by extensor ossis metacarpi pollicis, and extensor brevis pollicis; — on ulnar side, by extensor longus polli- cis; — above, by lower edge of posterior annular ligament. Its floor is formed by trapezium, part of scaphoid, base of first metacarpal. It con- tains radial artery, cejjhalic vein of thumb, branch of internal division of radial nerve, branch of musculocutaneous nerve. LIGATION OF RADIAL ARTERY IN" UPPER THIRD OF FORF..\RM. Position. — Hand supine; wrist extended. Surgeon stands outside of limb, cutting downward on right and upward on left. .Assistant holds fingers with one hand and grasps forearm with other. Landmarks. — Line of artery; inner border of supinator longus. Incision. — From 5 to 7.5 cm. (2 to 3 inches), in line of artery — with center o\er the point to be tied (Fig. 23, A). Operation. — Having incised skin and superficial fascia, the radial or median vein may be met. Divide the deep fascia and open up the space between the supinator longus (fibers running directly downward) and the pronator radii teres (fibers running downward and outward) (Fig. 24). The artery lies under the edge of the supinator longus and upon the inser- tion of the pronator radii teres. The radial nerve lies well to the outer side. Comment. — Unless one recognize the inner margin of the supinator longus, there is possibility of hitting otT the wrong intermuscular septum and getting too near the middle of the forearm. The supinator longus (and not its inner border) appears at first, in operating upon the muscular — and this must be well retracted outward. 7° OPERATIONS UPON THE ARTERIES. l-ig. 24.— Ligation OF Upper Third of Right Radial:— A, Anterior branch ulnmsculocutaneous nerve; B, Branch of radial vein ; C, C, Supinator longus muscle, retracted outward ; D, D. Pronator radii teres; E, Flexor carpi radialis ; F, Radial artery ; G, G, Radial venae comiles ; H, Radial nerve. LIGATION OF RADIAL ARTERY IN MIDDLE THIRD OF FOREARM. Position. — As for upper third. Landmarks. — Line of artery (especially as inner border of supinator lonpus is not always evident). Incision. — From 5 to 6 cm. (2 to 2^ inches) — in line of artery, with its center opposite center of forearm, so as to fall between supinator longus and fle-xor carpi radialis (Fig. 23, B). Operation. — Having incised skin and superficial fascia, branches of the radial and median veins and anterior branch of the musculocutaneous nerve are generally encountered. Incise the deep fascia and recognize the inner margin of the supinator longus (its fibers running directly downward) and retract outward while elbow is slightly flexed. The artery is found upon the fle.xor sublimisdigitorum and fle.xor longus pollicis — or. if higher up, upon the insertion of the pronator radii teres, with its venoe comites. Clear the artery and pass the needle from the nearer vein. The radial nerve lies to the radial side of the arterv, but mav not come into the field. LIGATION OF RADIAL ARTERY l\ I OWER THIRD OF FOREARM. Position. — .As for upper third. Landmarks. — Tendons of supinator longus and flexor carpi radialis. LIGATION OF RADIAL ARTERY. 71 Incision. — From 2.5 to 5 cm. (i to 2 inches), vertically, in center of interval between tendons of supinator longus and flexor carpi radialis (Fig. 23, C). Operation. — Having incised skin and superficial fascia, the radial vein, or a large branch, and often the superficialis vola; artery, are met and are Fig. 25.— Ligation of Lower Third of Right Radial (Jl'ST above Wristj : — A. Radial vein ; B, Anterior branch of musculoculaiieous ner\ e ; C, Supinator longus tendon ; D. Flexor carpi radialis tendon ; E. Pronator quadratus ; F. Radial arterj- ; G, Superficialis volae artery; H. H, Radial venae comites. displaced to one side (Fig. 25). The deep fascia is divided, and the interval between the tendon of the supinator longus, externally, and the tendon of the fiexor carpi radialis, internally, is opened up and the artery and its venae comites are found between them, accompanied by the anterior branch of the musculocutaneous nerve. LIGATION OF RADIAL ARTERY ' IX BACK OF H.Wn. Position. — Limb rests on ulnar margin. Assistant holds thumb e.xtended and abducted, and fingers straight, and so manipulates them as to bring out the boundaries of the snuff-box. Landmarks. — Tendons of extensor ossis metacarpi pollicis and extensor brevis pollicis, on radial side — and that of extensor longus polhcis, on ulnar side. Incision. — From 2.5 to 4 cm. (i to i^ inches), midway between the two ridges made by the above tendons — beginning on a level with the tip of the styloid process, and extending downward, but stopping short of the lower end of the vessel. Operation. — Having incised skin and superficial fascia, separate the divided fascia carefully, .\void the cephalic vein of the thumb and branches of the radial and musculocutaneous nerves. Demonstrate the tendons forming the boundaries of the snuff-box. The artery is found deeply placed and closely surrounded by venee comites, which may be included in the ligature if necessary. Comment. — Guard against opening the synovial sheaths of the tendons. 72 OPERATIONS UPON THE ARTERIES. Fig- 26.— Ligation of Lkft Superficial and De ment ; B. Flexor brevis pollicis {pari of its origin from a flexor subliniis digitorum and outer lumbrical (drawn ini Adductor transversus pollicis; F. F. Branches of median i Deep palmar arch and its venie comites ; 1,1. Superficial \' Palmar Arches: — A, Annula ilar ligament incised) ; C, Tent dl : D. Adductor obliquus pollii ve; H, H, Superficial palmar ar LIGATION OF DEEP PALMAR ARCH OF RADIAL ARTERY. Position. — Limb supine; hand extended. Assistant steadying fingers and wrist. Surgeon cuts from above downward on both sides. Landmarks. — ObHque crease running downward and outward from junctiim of thenar and hypothenar eminences and partially circumscribing the thenar eminence. Incision. — From junction of the thenar and hypothenar eminences — and running along the thenar crease toward the metacarpo-phalangeal joint of the inde.x-finger — with the center of the incision opposite the center of the ball of the thumb (Fig. 23, D). SURGICAL ANATOMY OF ULXAK ARTERY. 73 Operation. — Having incised skin and superficial fascia, expose and ligate the superficial palmar arch (crossing the palm on a level with the lower border of the outstretched thumb) (Fig. 26). The muscles of the thenar eminence are now exposed, and these, with the annular ligament, are incised at the upper part of the wound to as limited an extent as possible. The interval between the flexor tendon of the index-finger and its accompanying lumbrical muscle, on the one hand, and the muscles of the thumb, on the other, is made out and opened up by deep retraction, guarding the branches of the median nerve. In the interval thus exposed by retraction is seen the adductor obliquus pollicis, which is to be divided vertically, when the arch will be found under it, running transversely from between the adductor obliquus pollicis and adductor transversus pollicis onto the deep fascia covering the interossei, and about 2 cm. (J inch) nearer the wrist than does the super- ficial arch. The needle is to be carefully passed in the deep wound, to avoid the nerves and veins. Comment. — The position for ligating can be located by feeling for the apex of the first interosseous space on the back of the hand. SURGICAL ANATOMY OF ULNAR ARTERY. Description. — Larger of two divisions of brachial artery. Begins at bifurcation of brachial, about 1.3 cm. (J inch) below bend of elbow, and in middle of forearm — runs through upper half of forearm, with slight curve (convexity to ulnar side), to ulnar aspect of limb, passing beneath the pronator radii teres and superficial flexors — thence vertically down the lower half of the forearm, along its ulnar border to the wrist, being slightly overlapped by the flexor carpi ulnaris. It crosses the annular ligament immediately to the radial side of the pisiform bone, and, entering the palm, divides into superficial and deep palmar branches, to help form superficial and deep palmar arches. It is accompanied by two venae comites. The ulnar nerve comes into contact with the artery at the junction of its upper and middle thirds, and remains in relation with it to the palm, being upon its ulnar side. Relations. — (A) In Forearm: — Anteriorly — (a) .\bove — skin; fascia; superficial flexors (pronator radii teres, fle.xor carpi radialis, palmaris longus, flexor sublimis digitorum) ; median nerve (separated from artery by deep head of pronator radii teres), (b) L'pper part of lower half — skin; fascia; and overlapped by tendon of flexor carpi ulnaris. (c) Lower part of lower half — skin; sujierficial fascia; deep fascia; palmar cutaneous branch of ulnar nerve. Posteriorly — brachialis anticus; flexor profundus digitorum. Ex- ternally—flexor sublimis digitorum (in lower two-thirds of artery's course). Internally — flexor carpi ulnaris (in lower two-thirds) ; ulnar nerve (in lower two thirds). (B) At Wrist : — This part of the artery extends from the upper to the lower part of the annular ligament, running in a channel formed by the pisiform and unciform process of unciform bone and by expansion of flexor carpi ulnaris extending from pisiform to unciform process. Ante- riorly — skin; fascia; expansion of flexor carpi ulnaris from pisiform to unci- form process of unciform. Posteriorly — anterior annular ligament. Ex- ternally — unciform process of unciform bone. Internally — pisiform bone; ulnar nerve. (C) In Palm: — On entering the palm, the ulnar divides into superficial branch and deep branch: — (i) Superficial branch of ulnar — direct continuation of ulnar artery — descends short distance toward gap 74 OPERATIONS UPON THE ARTERIES. between fourth and fifth fingers, thence curves outward (with convexity toward fingers) and anastomoses opposite gap between index and middle finger, and at junction of upper and middle thirds of hand, with superficialis vola' of radial (sometimes with branch from radialis indicis of radial) to form superficial palmar arch — having following relations: Anteriorly — skin; fascia; and, from ulnar to radial side, by palmaris brevis, palmar branch of ulnar nerve, palmar fascia, palmar branch of median nerve. Posteriorly — in order, from ulnar to radial side — annular ligament; short muscles of little finger; digital branches of ulnar nerve; superficial flexor tendons; digital branches of median nerve. (2) Deep (communicating) branch of ulnar artery — runs deeply inward, between abductor minimi digiti and flexor brevis minimi digiti — anastomosing with termination of radial to form deep palmar arch. Branches. — (a) In Forearm — anterior ulnar recurrent; posterior ulnar recurrent; common interosseous (anterior and posterior interosseous); mus- cular, (b) At Wrist — anterior ulnar carpal; posterior ulnar car])al. (c) In Palm — superficial palmar arch; deep (communicating) palmar. Line of Artery. — Upper third of artery corresponds with line from a point about 1.3 cm. (^ inch) below center of bend of elbow, passing to inner side with gentle curve (convexitv to ulnar side), to a point at junction of upper and middle thirds of following line. Lower two-thirds corresponds with line from anterior surface of internal condyle of humerus to radial side of pisiform bone (Fig. 23, H, L, and K, J). Sites for Ligation. — Upper third of forearm (rarely) ; middle third; lower third (commonly) ; superficial palmar arch (for wounds at that site) (Fig. 23). LIGATION OF ULNAR ARTERY l\ MIUDLK THIRD OF FOKE.VRM. Position. — .\s for the radial artery. Landmarks. — Line of artery. The muscular landmarks at the middle of the forearm are generally difficult to recognize. Incision. — .\bout 7.5 cm. (3 inches), in line of artery, with its center corresponding with the center of the forearm (E, Fig. 23). Operation. — Incise skin and superficial fascia. The anterior ulnar vein and anterior branch of internal cutaneous nerve are likely to be en- countered (Fig. 27). Divide the deep fascia somewhat to the outer side of the skin incision, as the flexor subhmis digitorum is generally slightly over- lapped by the flexor carpi ulnaris. In this deep fascia the intermuscular plane between the flexor carpi ulnaris and flexor sublimis digitorum is sought by exposure and by the sense of touch. A muscular branch will often lead to it. These muscles are retracted well apart, when the ulnar nerve is first encountered between them — and, following inward on the same plane, the artery will be found upon the flexor profundus, surrounded by the venae comites, and with the ulnar ner\e to the ulnar side. Comment. — It is sometimes exceedingly difficult to hit off the inter- muscular space and to find the artery when once in it. Remember that the anterior margin of the flexor cari)i ulnaris slightly overlaps the flexor sublimis digitorum at this level. Also remember, when once in the intermuscular space, not to pass below the ulnar nerve, and thus go too deeply on the ulnar side of the forearm, but rather work inward from the level of the nerve. LIGATION OF ULNAR ARTERY. 75 Fig. 27.— LiciAMoN OF Right LIln vein ; B, Anterior branch of internal cu digitorum ; E. Flexor profutidus digitoi (drawn to ulnar side I. Upper Part of Middle Third:— A, Anterior ulnar 've ; C. Flexor carpi ulnaris; D, Flexor sublitnis F, Ulnar nerve; G, Ulnar artery and its vena: comites Fig. 2S.— Ligation oi. Lowkk Third of Ri<;ht Ulnar (Jlst abovf; fhe Wrisvi ;— A, An- terior ulnar vein ; B, Anterior branch of internal cutaneous nerve ; C. Tendon of tlexor carpi ulnaris ; D. Tendon of flexor subliniis digitorum ; E, Ulnar artery ; F, Communicating branch of ulnar ; G, ■Ulnar veniE comites : H, Ulnar nerve. 76 OPERATIONS UPON THE ARTERIES. LIGATION OF ULNAR ARTERY IN LOWER THIRD OF FOREARM. Position. — As for radial. Landmarks. — Outer border of fle.xor carpi ulnaris. Incision. — .\bout 5 cm. (2 inches) in length — ending about 2.5 cm. (i inch) above the pisiform bone — and placed between the tendon of the fiexor carpi ulnaris and the innermost tendon of the fle.xor sublimis digitorum. (As the innermost tendon of the ile.xor sublimis digitorum is not ahvavs recognizable, the incision is generally placed to the outer side of the tendon of the flexor carpi ulnaris.) (Fig. 23, F.) Operation. — Having incised skin and superficial fascia, avoid the anterior ulnar vein or its branches (Fig. 28). Divide the deep fascia. Partly fie.x the wrist to relax the structures, and retract the flexor carpi ulnaris outward. The artery will be found upon the flexor profundus digitorum, with the venae comites closely surrounding it, and the ulnar nerve lying closely to the ulnar side. LIGATION OF SUPERFICIAL PALMAR ARCH OF ULNAR ARTERY. Position. — .\s for the deep palmar arch. Landmarks. — Junction of thenar and hypothenar eminences. Incision. — \'ertical — extending from junction of thenar and hypothenar eminences toward base of ring-finger, with center opposite a line crossing the palm transversely, on a level with the lower border of the outstretched thumb. The arterv lies at the intersection of these two lines (Fig. 23, ^')- . ' Operation. — Divide the skin, superficial fascia, and palmar fascia, when the arch will be found in the underlying fat, lying upon the digital branches of the median and ulnar nerves (Fig. 26, H, H). Comment. — If the arch cannot be found, ligate the artery at the pisiform bone. SURGICAL ANATOMY OF INTERCOSTAL BRANCHES OF THORACIC AORTA. Description. — The ten aortic intercostals generally supply from the third to eleventh intercostal spaces inclusive — the first space being supplied by superior intercostal alone — and the second space also by superior inter- costal alone, or conjointly by it and the first aortic intercostal. The tenth aortic intercostal runs below the twelfth rib (subcostal artery), (a) The \'er- tebral Portions of the Intercostal .Arteries, arising in pairs from the posterior part of the thoracic aorta, pass around the vertebrw — the right being covered by thoracic duct, vena azygos major, pleura, lung, esophagus —the left, by vena azygos minor, left superior intercostal vein, third vena azygos pleura, lung. The arteries here divide into posterior or dorsal, and anterior or intercostal branches, (b) The Intercostal Portions run forward and obliquely upward in the intercostal space to the lower border of the superior rib, and divide near the angle of the rib into upper (larger) and lower (smaller) branches — the former, to run in the groove along the lower border of the upper rib and anastomose with the superior intercostal branch of the internal mammary in the upper spaces, and of the musculophrenic in the lower — the LIGATION OF AX INTERCOSTAL ARTERY. 77 latter, to run along the upper border of the lower rib and anastomose with the inferior branch of the internal mammary in the upper spaces, and of the musculophrenic in the lower. At first these arteries lie between pleura.', lungs, endothoracic fascia, and infracostals internally— and e.xternal inter- costal muscles externally —then (from the angles of the ribs) between the external and internal intercostal muscles. The sympathetic nerve crosses them opposite the head of the ribs. The intercostal vein lies above and the intercostal nerve below the intercostal arteries — except in the upper spaces. The arteries of the tenth and eleventh spaces run outward between the abdominal muscles. LIGATION OF AN INTERCOSTAL ARTERY B\ .\\ INTERCOST.AL I\CISK.)X. Position. — Patient supine, and so turned as to render site of operation prominent, and chest supported below, so as to increase width of intercostal spaces. Surgeon stands on side of operation. Assistant opposite. Landmarks. — Lower border of rib in the groove of which the special artery runs; or the upper border, in case it be the lower branch of the inter- costal artery. Incision. — About 5 cm. (2 inches), parallel with and just below the lower border of the indicated rib; or just above the upper border, as the case ma}' be. Operation. — Incise skin and superficial fascia. As to what muscle, and as to what amount of muscle tissue, as well as fascia, will have to be further incised in the line of the original incision, before the intercostal muscles are reached, will depend upon the site at which the artery is to be exposed. Having passed through the overlying muscle-covering of the thoracic w-all, the inter- costal fascia is met and incised, then the external intercostal muscle (if operat- ing anywhere between the tubercles of the ribs behind, and the costal car- tilages in front). The two cut margins of the external intercostals are then drawn upward and downward and the artery sought as it lies partially or entirely concealed in the inferior intercostal groove, with intercostal nerve below and vein above. The artery may be drawn out of its groove and down into view by the curved tip of the aneurism-needle. The vessel should be doubly ligated (its supply coming from both directions). The incised inter- costal muscle and fascia may be sutured with gut in closing the wound. Comment. — (i) If difficulty in exposing the artery be experienced, the rib may be ex])osed subpericsteally, as in the following operation. (2) It is to be remembered, in operating posterior to the angle of the rib, that the intercostal artery has not yet reached the inferior groove of the upper rib, but lies between the two ribs, and has not divided into its upper and lower branches. (3) If it be desired to ligate the upper and lower branches of the intercostal (anywhere between the angle and costal cartilages), the incision is made midway between the ribs, and, after retracting the cut external intercostal muscle, the upper branch is sought as above, and the lower branch is found along the upper border of the lower rib. Both are doubly ligated. 78 OPERATIONS UPON THE ARTERIES. FiR. 2q.— Ligation of Left Intercostal Artery, in Lower Anterior Thoracic Region, BY Partial Excision of a Rib:— A. Tlioracic muscles; B. External iiilercoslal muscle; C, Rib, with half-button of bone bitten out with rongeur forceps; D, Periosteum, incised OYer center of rib ; E, Lower half of anterior layer of periosteum retracted downward ; F, F. Posterior layer of peri- osteum incised and retracted upward and downward, showing intercostal Yessels beneath ; G, Inter- costal artery ; H, Intercostal Yein : I, Intercostal ner\-e. (Hartley's method.) LIGATION OF AN INTERCOSTAL ARTERY BV r.\RTI.\I., SrKPEKIOSTEAL EXCISIDN OK RIB (HARTLEVS METHOD.) Position — Landmarks. — As in the preceding operation. Incision. — .About 6 cm. (2^ inches), parallel with and directly over center of rib. Operation. — The above incision passes through skin, superficial fascia, any overlying thoracic muscles (according to site of operation), deep fascia and periosteum (Fig. 2g). \\'ith periosteal elevator, free the lower half of the anterior surface, the inferior groove, and the lower half of the posterior sur- face of the rib, all subperiosteally. Then, with rongeur bone-forceps, bite out a "half-button" of bone from the bared lower half of the rib, being careful to insert the lower blade of the rongeur between the detached peri- osteum and the rib. After the half-button of bone is removed, the position of the artery is plainly evident — and the vessel is e.xposed by incising through the periosteal membrane, directly over it. Comment. — The artery may also be e.xposed by the f)rdinary method of subperiosteal excision of about 4 cm. (i^ inches) of rib throughout its entire thickness. SURGICAL ANATOMY OF ABDOMINAL AORTA. Description. — Continuation of thoracic aorta. Commences at aortic opening of diaphragm, opposite lower border of twelfth dorsal vertebra — and passes down between pillars of diaphragm, in front of lumbar vertebra;, at first in median line, but deviating to left as it descends, until it lies a little to left of spine at its point of bifurcation, opposite lower border of fourth lumbar vertebra, where it divides into right and left common iliac arteries Its point of bifurcation is represented externally, roughly, by a point about 1.3 cm. (J inch) below and a little to left of umbilicus — and, more accurately, SURGICAL ANATOMY OF ABDOMINAL AORTA. 79 by a line crossing the abdomen on a level with the highest points of the iliac crests. The accompanying vena cava is separated from the aorta above by the right crus of the diaphragm, and is on a plane anterior to it. Below, the vein lies in contact with the artery, and on a somewhat posterior plane. The artery is covered only by peritoneum at the site indicated for ligation, but between the serous covering and the artery lie important sympathetic nerve-cords from the aortic plexus (lying along the aorta between the superior and inferior mesenteric arteries) to the hypogastric ple.xus (lying between the common iliacs). Relations. — Anteriorly (from above downward, in order) : right lobe ■<«Xx.I*^' Fig. 30.— Incisions FOR Ligations in the .-Vbdomi-N'o-pelvic Region:— A, Exposure of abdoinitial aorta by transperitoneal route, through median incision over umbilicus; B, Exposure of internal iliac, common iliac, and abdominal aorta In- retroperitoneal route, through oblique incision parallel with Poupart's ligament ; C, Exposure of external, internal, and common iliacs by transperi- toneal route, through median incision below umbilicus ; D, of external and deep epigastric, retro- peritoneally, through oblique incision parallel with Poupart's ligament ; E, of common, internal, and external iliacs, transperitoneally, through \'ertical incision in linea semilunaris: F. of external iliac, transperitoneally, through intramuscular incision ; G, G, Anterior superior iliac spines ; H.S>mphysis pubis. of liver; solar plexus; lesser omentum; termination of esophagus in stomach; ascending layer of transverse mesocolon; splenic vein (or beginning of vena porta?); pancreas; left renal vein; third part of duodenum; mesentery; aortic plexus of sympathetic; spermatic (or ovarian) arteries; inferior mesenteric artery; median lumbar Ivmphatic glands and vessels; small intestines. Pos- teriorly : bodies of lumbar vertebra'; intervening intervertebral cartilages; anterior common ligament; left crus of diaphragm; left lumbar veins. To right: right crus of diaphragm; great splanchnic nerve; spigelian lobe of liver; receptaculum chyli (on a posterior plane); thoracic duct (on a posterior plane); right semilunar ganglion; inferior vena cava; vena azygos major. 8o OPERATIONS UPON THE ARTERIES. To left: left crus of diaphragm; left splanchnic nerve; left semilunar gan- glion; tail of pancreas; small intestines. Branches. — (From above downward.) Phrenic, coeliac a.xis (gastric, hepatic, splenic); suprarenals; first lumbars, superior mesenteric; renals; spermatics (ovarians); second lumbars; inferior mesenteric; third lumbars; fourth lumbars; common iliacs; middle sacral. Line of Artery. — From a i)oint in the anterior median line, on a level with the lower border of twelfth dorsal vertebra, to a point a little to left of umbilicus, on a level with the highest points of the iliac crests. Indications for Ligation. — Iliac and inguinal aneurisms and primary and secondarv Iiemorrhage — in cases where no other means are possible. More than a dozen cases have been reported — one case living ten days. Sites for Ligation. — Between the origin of the inferior mesenteric (be- tween 2.5 and 5 cm., or i and 2 inches, abo\e the bifurcation) and the bifurca- tion (Fig. 30). LIGATION OF ABDOMINAL AORTA BY TRANSPERITONE.AL METHOD. Description. — The abdomen is opened in the median line, the intestines displaced, and the posterior parietal peritoneum opened over the artery. Position. — Patient supine; shoulders raised; knees slightly flexed. Surgeon on right, .\ssistant opposite. Landmarks. — Median, vertical abdominal line; transverse line on level with highest points of iliac crests. Incision. — About 10 cm. (4 inches) in length, in linea alba, with its center corresponding with the umbilicus — the incision passing slightly to left of the navel, to avoid the round ligament of the hver and the urachus (Fig. 30. A). Operation. — The peritoneal cavity having been opened in the usual manner, the small intestines and mesentery are well retracted upward and to the sides. Guided to the artery by its known position and by its pulsation, the peritoneum covering the vessel is carefully divided between the inferior mesenteric and its bifurcation in the iliacs. The clearing of the artery should be done with especial care, as inclusion of the sympathetic nerve-fibers (see Surgical Anatomy) is otherwise apt to take place — and is supposed to have been done in one case, which quickly ended fatally. A flat ligature should be used (kangaroo tendon, chromicized gut and silk, flat and round, have been used). The needle should he of special make and shape, and should be passed from the inferior vena cava. Comment. — This is the more desirable form of operation, though the case which survived longest was done through a posterior retroperitoneal incision. Collateral Circulation. — Internal mammary, above; with deep epi- gastric, below. Inferior mesenteric, above; with internal pudic, below. Possibly by lumbar arteries, above; with branches of internal iliac, below. And, if above the inferior mesenteric, by superior mesenteric, above; with inferior mesenteric, below. SURGICAL ANATOMY OF COMMON ILIAC ARTERIES. LIGATION OF ABDOMINAL AORTA BV RFTROPEKITONEAL OPERATION. Description. — The artery is here approached from the anterolateral abdominal region, the peritoneum being pushed back from the iliac vessels until the aorta is reached and exposed. Position — Landmarks — Incision — Operation. — The operation is prac- tically similar to that for the exposure and ligation of the common iliac extra- peritoneally, the site being reached by an extension of those steps (Fig. 30, B). The jiatient is tilted so as to lie upon the sound side, the surgeon standing behind the patient, upon the side of the operation (the left). An extension of the incision employed for the common iliac is carried further upward to give the necessary room; and, if still required, additional room may be gotten by a second incision running parallel with the ribs, at a right angle to the main incision. The separation of the parts and exposure of the common iliac are, otherwise, the same as for the ligation of that vessel. The incision is made upon the left side — its general direction being from just within the anterior superior iliac spine toward the tip of the tenth rib — and the aorta is reached by following up the common iliac in the peeling back of the peri- toneum from the iliac fascia. The vessel is thus less satisfactorily e.xposed than by the intra-abdominal operation, and there is greater difficulty in avoiding the sympathetic nerve-cords that surround the vessel. The ligature is placed upon the same site as in the intra-abdominal operation, and the inferior vena cava is guarded in passing the needle. SURGICAL ANATOMY OF COMMON ILIAC ARTERIES. Description. — .^rise from bifurcation of the abdominal aorta, opposite lower border of left side of body of fourth lumbar vertebra (corresponding, approximately, to a point about 1.3 cm. [k inch] below and a httle to left of umbilicus — or, more accurately, on a level with a line passing transversely through the highest points of the iliac crests) — and pass thence downward and outward over the body of the fifth lumbar vertebra to margin of pelvis, bifurcating opposite upper border of sacro-iliac synchondrosis, into e-xternal and internal iliac arteries. The relations of right and left common iliacs differ slightly. Relations of Right Common Iliac Artery. — Anteriorly: peritcneum; right ureter (a little above its Ijifurcation) ; ovaries (in female); termination of ileum; terminal branches of superior mesenteric; branches of sympathetic to hypogastric plexus. Posteriorly: right common iliac vein; end of left common iliac vein; beginning of inferior vena cava; and, in less immediate relationship, the following — psoas magnus; sym[:)athetic nerve; lumbosacral cord; obturator nerve; iliolumbar artery. Externally: beginning of inferior vena cava; end of right common iliac vein; psoas magnus. Internally: right common iliac vein; end of left common iliac vein; hypogastric plexus. Relations of Left Common Iliac Artery. — Anteriorly: peritoneum; small intestines; ureter; ovarian artery (in female); branches of sympathetic to hypogastric plexus; termination of inferior mesenteric artery; sigmoid flexure; sigmoid mesocolon; superior hemorrhoidal artery. Posteriorly: lower part of body of fourth lumbar vertebra; fifth lumbar vertebra; inter- vertebral discs; left common iliac vein; and, in less immediate relationship. 82 OPERATIONS UPON THE ARTERIES. the following — psoas muscle; obturator nerve; lumbosacral cord; iliolumbar artery. Externally: psoas muscle. Internally: left common iliac vein; hypogastric plexus; middle sacral artery. Branches. — Peritoneal; subperitoneal; ureteric; internal iliac; external iliac. Line of Artery. — Draw a line transversely across the abdomen, on level with highest points of iliac crests, which will cross the abdominal aorta at its bifurcations-draw a second line transversely across the abdomen on a level with the anterior superior iliac spines, which will cross the common iliacs at their bifurcation — draw a third line from a point on the first line about 1.3 cm. (i inch) to the left of its center (which is the linea alba), to a point midway between the anterior superior iliac spine and svmphvsis pubis. That portion of the third hne between the two zones represents the common iliac— and that portion below the lower zone, the external iliac. The right common iliac is about 5 cm. (2 inches) in length; and the left, about 4.5 cm. (if inches). Site for Ligation. — As nearly midway of its length as possible (Fig. 30). LIGATION OF COMMON ILIAC ARTERY BY RETROPERITONE.AL OPERATION. Position. — Patient supine, or slightly turned to one side. The intes- tines are more easily displaced from the field of operation if the patient be in the Trendelenburg position. Surgeon stands upon side of operation. •Assistant opposite. Landmarks. — Line of external iliac (v. s.); Poupart's ligament; anterior superior spine of ilium; eleventh rib. Incision. — Begun as for exposure of external iliac (page 90) and con- tinued in the cleavage line of the external oblique as far upw-ard toward the eleventh rib as necessary to furnish sufficient room (Fig. 30, B). Operation. — The steps of the operation are identical with those for e.xposure of the external iliac (page go), with an extension upward, in the present operation, of the separation of the fibers of the external oblique and a division of the fibers of the internal oblique and transversalis as far up toward the eleventh rib as necessar\ — the incision of the two latter muscles corresponding in direction with the separation of the fibers of the external oblique (Fig. 31). In this higher part of the wound the last dorsal and other dorsal nerves are apt to be encountered between the internal oblique and transversaHs, and are to be carefully preserved. The deep circumflex iliac artery and the lumbar arteries are apt to be met here above the crest of the ilium. Having divided the transversalis fascia and separated the peritoneum from the iliac fascia (which overlies the iliacus muscle), detaching it downward and backward to the psoas muscle and then upward to the sacral promontory, the structures in the floor of the iliac fossa are exposed. The e.xternal iliac artery is first found, and this is followed up to the common iliac, guarding the deep epigastric. The genitocrural, external cutaneous, and anterior crural nerves, branch of the iliolumbar, and the spermatic arteries cross this area. The ureter crosses either the common iliac, or the external iliac, obliquely, opposite the first piece of the sacrum, having the ileum in front of it on the right, and the sigmoid flexure of the colon in front of it on the left; but in the peeling back of the peritoneum the ureter usually adheres to the peritoneum, and is thus removed from the area of operation LIGATION OF COMMON II.IAC ARTEKY. 83 withe lut trouble. The artery having been reached and bared of peritoneum, the needle is passed from the iliac vein. Comment. — The line of incision may begin further to the outer side of the e.xternal iliac than for the typical operation upon that artery, though that vessel is then a little less easily encountered. As to a choice between the e.xtraperitoneal and intraperitoneal operations, the former is to be pre- ferred wherever the relations of the parts are not too much disturbed by disease or injury. Fig. 31. — Ligation of Right Commo.n and Internal Iliacs. Retroperitoneallv :— A. A. External oblique muscle and aponeurosis; B. Internal oblique; C. Transversalis ; D, Conjoint ten- don ; E, E, Peritoneum retracted ; F, l^reter, retracted ; G. Common iliac artery (sheath incised) ; H, Ititernal iliac artery (sheath incised) ; I, External iliac artery; J, External and internal iliac veins; K. K, Deep epigastric artery ; L. Deep circumflex iliac artery; M, Lumbar artery ; N. Iliolumbar artery: O, Spermatic artery; P. .interior crural nerve; Q, llio-inguinal nerve; R. Geriitocrural nerve; S, External cutaneous nerve; T, Iliac fascia; M. Lumbar artery and iliohypogastric lor dorsal) nerve. Collateral Circulation. — Internal mammary and lower intercostals above, with deep epigastric below. Lumbar above, with deep circumfle.x iliac and iliolumbar below. Superior hemorrhoidal above, with middle and inferior hemorrhoidal below. ^liddle sacral above, with lateral sacral below. Pudic, epigastric, obturator and epigastric branches of one side, with corre- sponding arteries of other side. g^ OPERATIONS UPON THE ARTERIES. LIGATION OF COMMON ILIAC ARTERY BY TRANSPERITONEAL OPERATION. Position-Landmarks-Incision-Operation.-The steps are prac- tically the ^ame as for the transperitoneal ligation of the abdominal aorta, though somewhat less extensive, and with the slight modihcations necessitated bv the anatomy of the parts (Fig. 30, C). Especial care is taken to recognize the position of the ureter before incising the peritoneum. SURGICAL ANATOMY OF INTERNAL ILIAC ARTERY. Description.-.Vbout 4 cm. (i* inches) in length-arising from bifurca- tion of common ihac, opposite upper border of sacroiliac synchondrosis Descends in peMs to upper margin of great sacrosciatic foramen, where it divides into anterior and posterior branches. _ Relations.-Anteriorly : peritoneum; ureter. Posteriorly: termina- tion of external iliac vein; internal iliac vein; inner border of P^o^s, bmbo- sacral cord; obturator nerve; sacrum. Externally: psoas. Internally. internal iUac vein; peritoneum. . Branches.-From .\nterior Trunk:-Hypogastnc; superior, middle, and inferior vesical; middle hemorrhoidal: obturator; sciatic; internal pudic; uterine; vaginal. From Posterior Trunk — Iliolumbar; lateral sacral; glu- teal. Line of Artery.— See under Line of Common Ihac. Indications for Ligation.-Oluteal and sciatic aneurism; hemorrhage; to cause atroiihv of prostate gland. _ _ , ■ , -r Sites for Ligation.— Midway between its ongm and its bifurcation. LIGATION OF INTERNAL ILIAC ARTERY BV RETROPERITONICAL OPERATION. Position-Landmarks-Incision-Operation.-Same as for the retro- peritoneal ligation of the external iliac-which. havmg been exposed, is followed up to the bifurcation of the common iliac (Iig. 3°. »)■ Collateral Circulation.-Sciatic above, with superior branch of profunda below Inferior mesenteric above, with hemorrhoidal arteries below. Pubic branch of obturator of one side, with same of opposite. Branches of pudic of one side, with same of opposite. Circumflex and perforating of profvinda above, with sciatic and gluteal below. Middle sacral abo^■e, with la eral sacral below. Circumflex ihac above, with iliolumbar and gluteal below. LIGATION OF INTERNAL ILIAC ARTERY BV TRANSPERITONEAL OPERATION. Position-Landmarks-Incision-Operation.-Same as for the trans- peritoneal ligation of the abdominal aorta, with the modihcations necessi a ed bv the anatomy of the parts (Fig. 30, C). Recognize the position of the ureter before incising the peritoneum. SURGICAL ANATOMY OF SCIATIC ARTERY. 85 SURGICAL ANATOMY OF OBTURATOR BRANCH OF ANTERIOR DIVI- SION OF INTERNAL ILIAC. Description and Relations. — Generally arises from anterior trunk, but often from ])osterior trunk (and sometimes from the deep epigastric). Runs forward and downward, below brim of pelvis to upper part of obturator foramen, with obturator nerve above, and obturator vein below, lying between peritoneum and pelvic fascia — piercing the pelvic fascia to enter the canal in the upper and outer part of the obturator membrane — being crossed in its course by the vas deferens — and dividing, on its e.xit from the canal, into external and internal branches, which skirt the external and internal margins of the thyroid foramen. Sites for Ligation. --.\t exit from thyroid foramen. Comment. — When the obturator arises from the deep epigastric, it may pass down in contact with the external iliac vein, on the outer side of the femoral ring — or it may pass along the free margin of Gimbernat's liga- ment, almost encircling the neck of a hernial sac, and thus be in danger in the usual operation. LIGATION OF OBTURATOR ARTERY .AT THYROID FOK.VMEN'. Position. — Patient supine; limb slightly abducted and rotated ou'ward. Surgeon stands to right side, facing patient, on left — and between the limbs, on the right (or leans over from the left). Landmarks. — Middle of Poupart's ligament. Incision. — \'ertical, made downward from a point about 2 cm. f J inch) internal to the center of Poupart's ligament. Operation. — Divide skin, superficial fascia, and fascia lata. Draw in- ternal saphenous vein outward. Incise fascia over pectineus just internal to femoral vein. Expose the outer border of the pectineus muscle and draw the muscle inward, separating it from the os pubis and fascia of the obturator externus — and divide the fascia over the obturator externus, exposing the muscle. Follow the upper border of the muscle to the inferior margin of the obturator foramen, to the grooxe for the obturator vessels and nerve — where the artery will be found emerging between the nerve above and vein below. SURGICAL ANATOMY OF SCIATIC BRANCH OF ANTERIOR DIVISION OF INTERNAL ILIAC. Description and Relations. — Larger of two terminal branches of anterior trunk. De.scends over sacral plexus and pyriformis muscle to lower part of great sacrosciatic foramen, whence it passes out of pelvis between pyriformis and coccygeus muscles, with pudic artery anterior and internal to it. Emerging through great sciatic foramen upon buttock, beneath the gluteus maximus, it descends the thigh midway between trochanter major and tuberosity of ischium, resting upon gemellus superior, obturator internus, gemellus inferior, quadratus femoris and adductor magnus — being to inner side of great sciatic nerve and accompanied by small sciatic nerve. 86 OPERATIOXS UPON THE ARTERIES. Line of Artery. — Having rotated the thigh inward and sHghtly flexed it, draw a line from the posterior superior iHac spine to the outer border of the tuberosity of the ischium. A point on this line, at the junction of its middle and lower thirds, will represent the site at which the sciatic and pudic arteries emerge from the lower part of the sciatic foramen upon the gluteal region (Fig. 32, A, C, E). Kig. 32. — Incisions for Ligations aboi't the Buttock : — A, Posterior superior ili.ic spine ; U. Great trochanter; C, Tuberosity of ischium ; D. Incision for exposure of gluteal branch of internal iliac at its emergence from upper part of great sacrosciatic notch ; E, For exposure of sciatic and internal pudic branches of internal iliac at their emergence from lower part of great sacrosciatic notch. Indications for Ligation, — Wounds. Site for Ligation. — At its emergence onto the gluteal region, just below the pyriformis muscle (Fig. ^2). LIGATION OF SCIATIC BRANCH OF INTERNAL ILIAC rPON THE Bl'TTOCK Position, — Patient upon uninvolved side, rolled nearly onto chest, with knee flexed and thigh rotated in. Surgeon on side of operation; assistant opposite. Landmarks. — Posterior superior iliac spine; tuberosity of ischium. Incision. — Having drawn the line given under Anatomy, make an in- cision about 10 cm. (4 inches) in length, obliquely across this line, in the direction of the fibers of the gluteus maximus (which run from above and behind, downward and forward) — with its center corresponding to the junc- tion of its middle and lower thirds (Fig. 32, E). Operation. — Having incised skin and thick fatty areolar tissue, divide SURGICAL ANATOMY OF IXTP:RNAL PL'DIC ARTERY. 87 the fibers of the gluteus maximus in their cleavage line (Fig. 33, F). Retract the separated margins of this muscle upward and downward, respectively. E.xpose the lower margin of the pyriformis muscle. Follow the lesser sacro- sciatic ligament to the spine of the ischium — when the sciatic artery will be Fig- 33 — l-iOATioN OF Right Intern.al Pvdic ..^nd Sciatic .\rteries upon the Bvttock, be- low THE Pyriformis: — A, A, Gluteus maximus (incised and retracted); B, Pyriformis (lower border retracted upward): C. Obturator internus, with gemellus superior and inferior, above and below ; D, Pudic artery and venfe comites ; E. Internal pudic ner\-e ; F. Sciatic artery and venae com- ites ; G, Small sciatic ner\-e; H. Great sciatic nerve. found emerging from beneath the pyriformis muscle — passing out of the pelvis above the spine of the ischium, and the lesser sacrosciatic ligament attached to it — and lying posterior and external to the pudic artery. SURGICAL ANATOMY OF INTERNAL PUDIC BRANCH OF ANTERIOR DIVISION OF INTERNAL ILIAC. Description. — Smaller of two terminal branches of anterior trunk of internal iliac. Descends over pyriformis and sacral plexus to lower border of great sacrosciatic foramen, lying in front and to inner side of sciatic artery — passes thence out of pelvis between pyriformis and coccygeus — crosses over outer surface of spine of ischium, under gluteus ma.ximus, and re-enters pelvis through lesser sciatic notch — passing, thence, forward over obturator internus muscle, along outer wall of ischiorectal fossa, about 4 cm. (ik inches) above the lower margin of the tuberosity of ischium, and contained in a canal of the obturator fascia. Graduallv approaching the border of the ischial ramus, it runs forward and upward — pierces posterior layer of deep perineal fascia, runs forward along inner margin of ramus of pubis, giving off artery of crus penis and artery of bulb between layers of triangular ligament — piercing anterior layer of deep perineal fascia as the dorsal artery of penis. Relations. — (a) Within Pelvis —descends over pyriformis muscle and sacral ])lexus to lower border of great sacrosciatic notch, whence it emerges between pyriformis and coccygeus muscles, together with sciatic artery, pudic nerve, greater and lesser sciatic nerves, and nerve to obturator internus 88 OPERATIONS UPON THE ARTERIES. muscle, (b) Crossing Spine of Ischium: — is covered by gluteus ma.ximus and edge of great sacrosciatic ligament. A vena comes is on either side, and the nerve to the obturator internus to the outer side and the pudic nerve to the inner side, (c) On Obturator Internus Muscle: — bound to muscle by sheath of obturator layer of pelvic fascia (Alcock's canal), with dorsal nerve of penis above and superficial perineal nerve below, (d) Between Two Layers of Triangular Ligament: — runs near to ramus of pubis, in substance of com- pressor urethra? muscle. Line of Artery. — See Surgical Anatomy of Sciatic Artery. Indications for Ligation. — Wounds. Sites for Ligation. — Over the spine of the ischium, or in the perineum (Fig. 32). Comment. — The main trunk of the arterv is the same in both sexes. LIGATION OF INTERNAL PUDIC BRANCH OF INTERNAL ILIAC I'PO.N" THE BfTTOCK:, Position — Landmarks — Incision — Operation. — Same as for Ligation of Sciatic Branch of Internal Iliac upon the Buttock — the arteries lying side by side at their e.xit from the pelvis, below the lower border of the pyriformis (Fig. 32, E, and Fig. ^^, D). LIGATION OF INTERNAL PUDIC BRANCH OF INTERNAL ILIAC IN THE PERlN'EfM. Position. — Patient in lithotomy position. Surgeon sits facing buttock. Landmarks. — Tuberosity and ascending ramus of ischium. Incision. — Begins about 7.5 cm. (3 inches) above inner border of tuber- ositv of ischium and passes downward along the margin of the ascending ramus of the ischium. Operation. — Divide skin and fascia, avoiding inferior pudendal nerve beneath the superficial fascia. The erector penis muscle is exposed (in the male). The transversus perinaei is either cut or drawn downward and in- ward. Divide the base of the triangular ligament and adjacent parietal pelvic fascia — when the artery will be found running forward above the pudic nerve, upon the inner surface of the obturator internus muscle, and above the attachment of the great sacrosciatic ligament. SURGICAL ANATOMY OF GLUTEAL BRANCH OF POSTERIOR DIVI- SION OF INTERNAL ILIAC. Description and Relations. — Largest branch of posterior division, of which it is the continuation. Passes backward and downward between first sacral nerve and lumbosacral cord — leaving pelvis through upper part of sacrosciatic notch, above pyriformis, in osseotendinous groove formed by margin of bone and pelvic fascia, accompanied by gluteal vein and superior gluteal nerve, — emerging from the pelvis under the gluteus maximus, where it divides into its branches just above the upper border of the pyriformis muscle. LIGATION OF GLUTEAL BRANCH OF INTERNAL ILIAC ARTERY. 89 Line of Artery. — Having rotated inward and slightly flexed the thigh, draw a line from the posterior superior iliac spine to the top of the great trochanter. A point on this line at the junction of the upper and middle thirds will correspond with the emergence of the gluteal artery from the sciatic notch (Fig. ,^2. A. B, D). Indications for Ligation. — Wounds; aneurism. Site for Ligation. — M emergence from sciatic notch, at upper border of pvriformis muscle (Fig. 32). LIGATION OF GLUTEAL BRANCH OF INTERNAL ILIAC ARTERY ON THE BITTOCK. Position. — Patient on involved side, rolled nearly onto chest; knee fle.xed; thigh rotated inward. Surgeon on side of operation. Landmarks. — Posterior superior iliac spine; top of great trochanter. Incision. — Having drawn the line given under Surgical Anatomy, an incision about 10 cm. (4 inches) in length is drawn along this line, with its center corresponding with the junction of its upper and middle thirds, which will be over the site at which the gluteal arterv leaves the sciatic notch (Fig. 32, D). Fig. 34.— Ligation of Right Glcte.al .\ktkkv i_ i-u.n Tut, Blttock. .\bove the Pvriformis: — A. Deep fascia over gluteus ma.\inius; B, B, Gluteus maximus, incised and retracted; C, Gluteus inedius (retracted upward); D. Pyriformis (retracted downward); E. Fascia between gluteus max- imus and gluteus medius and pvriformis; F, Gluteal arterv and venae comites ; G, Superior gluteal neiveand ijranches; H. Gluteus minimus. Operation. — .\fter dividing skin, superficial fascia, some superficial nerves, and the fascia of the gluteus ma.ximus, the muscle itself is met, its fibers running parallel with the skin incision (Fig. 34). Incise the muscle- fibers of the gluteus ma.ximus along their cleavage line. Having passed through the thickness of the gluteus maximus, a branch of the gluteal artery will generally lead to the interval between the gluteus medius and pyriformis (which otherwise is sought without this guide). Having divided the fascia over the lower border of the gluteus medius, separate these muscles by re- tractors and expose the upper margin of the sciatic notch by passing the 90 OPERATIONS UPON' THE ARTERIES. finger under the lower border of the gluteus medius — and through the upper portion of the sciatic notch, between the lower border of the gluteus medius and upper border of the pyriformis, emerge the gluteal artery, vein, and superior gluteal nerve. SURGICAL ANATOMY OF EXTERNAL ILIAC ARTERY. Description. — The larger (in the adult) branch of common iliac. About 9 to lo cm. (3J to 4 inches) in length. Arises at bifurcation of common iliac at sacro-iliac synchondrosis — running thence obliquely downward and outward along brim of pelvis, upon inner border of psoas muscle — passing under lower border of Poupart's ligament, midway between anterior superior iliac spine and symphysis pubis, to become femoral. The external iliac vein lies to inner side of artery below, and to inner and posterior aspect above. The deep epigastric artery arises about 6 mm. (^ inch) above Poupart's ligament, and runs between transversalis fascia and peritoneum toward the umbilicus. The deep circumfle.x iliac arises below the deep epigastric, and passes behind Poupart's ligament upon the iliacus muscle. The internal abdominal ring is situated about 1.3 cm. (^ inch) above Poupart's ligament, and midway between anterior superior iliac spine and spine of os pubis, and hence just external to course of arter\'. Relations. — Anteriorly: Parietal peritoneum; subperitoneal fascia; end of ileum, on right; sigmoid fle.xure of colon, on left; genital branch of genito- crural nerx'e (over its k)\ver third); circumflex iliac \ein; spermatic artery and vein; ovarian vessels (in female); \as deferens; ureter (sometimes); ex- ternal iliac lymphatic vessels and glands. Posteriorly: External iliac vein; inner border of psoas magnus and its tendon; iliac fascia. Internally: E.xternal iliac vein; peritoneum; vas deferens; ovarian vessels, in female. Externally : Psoas magnus; iliac fascia. Branches. — Deep epigastric; deep circumflex iliac; several branches to psoas magnus and Ivmphatic glands. Line of Artery. — See Surgical .Anatomy of Common Iliac. Indications for Ligation. — Wounds; secondary hemorrhage; femoral or iliofemoral aneurisms; to arrest malignant growths; in elephantiasis arabum; as a distal ligation in aneurism of common iliac. Sites of Ligation. — Proximal to deep epigastric and deep circumflex iliac branches (Fig. 30, D). LIGATION OF EXTERNAL ILIAC BY RETROPERITONEAL ROUTE. Position. — Patient supine, near edge of table. Surgeon on side of operation. Landmarks. — Poupart's ligament; anterior superior iliac spine; line of artery. Incision. — Begins over external iliac artery, about 1.3 cm. (^ inch) above Poupart's ligament, and passes upward and outward parallel with the ligament, to the anterior superior iliac spine — and is prolonged upward as far as necessary, in the cleavage line of the external oblique (Fig. 30, D). Operation. — (i) Having incised skin, superficial fascia — together with, possibly, the superficial ei)igastric, branches of superficial circumflex iliac, LIGATION OF EXTERNAL ILIAC. QI with their veins, Hgating where necessary, expose the aponeurosis of the external obHque (Fig. 35). (2) Divide this aponeurosis in its cleavage line, without cutting its fibers — and continue this division, or separation, in the cleavage line as far toward or beyond the anterior superior iliac spine as indicated to give free room for manipulation. (3) Having retracted the cut edges of the external oblique well apart, separate from the outer half of Poupart's ligament the attachment of the internal oblique. Carefully retract the cut edges of the internal oblique, being on the watch for branches of the iliohypogastric and ilio-inguinal nerves between the internal oblique and transversalis, and, if encountered, carefully displace them above or below, but avoid cutting them. If necessary to gain more room, the internal oblique is to be incised in the line of the separation of the external oblique as far as f'ig- 35.— Ligation of Right External Iliac, Retroperitoneally— through Obliql'e In- cision Parallel with Poupart's Ligament ;—.\. .\. Superficial epigastric artery; B, External oblique muscle; C. C. G, E.xtenial oblique aponeurosis ; D, Internal oblique; E, Ilio-inguinal nene ; F, Transversalis muscle; H, Deep circumflex iliac artery and accompanying vein; I, Deep epigas- tric arterv and venae comites ; J, Genitocrural nerve ; K. Peritoneum (peeled back and retracted up- ward I ; L, Iliac fascia ; M, External iliac artery (its sheath incised) ; N, E.xternal iliac vein ; O, An- terior crural nerve (seen through fascia) ; P, Poupart's ligament. the upper limit of the separation of the fibers of the latter muscle. (4) Having incised the internal oblique and protected the nerves encountered, detach the transversalis from the outer third of Poupart's ligament, and as far beyond as necessary, incising its fibers transversely to their direction, but in the direction of the division of the internal oblique. After dividing the trans- versalis, guard the deep circumflex iliac artery and vein and the genitocrural nerve, both lying between the transversalis fascia and peritoneum. (5) Having now separated the fibers of the aponeurosis of the external oblique, and divided the fibers of the internal oblique and transversalis in the same line as the separation of the external oblique aponeurosis, and having safe- guartled the important nerves encountered, the fascia transversalis is then exposed and is divided over the arten,' in a transverse direction, corresponding 92 OPERATIONS UPON THE ARTERIES. with the preceding separation and incision lines. The arten' is here clearly defined, and the deep epigastric, the main source of collateral circulation, is carefully guarded. (6) As soon as the artery is clearly located, the sub- peritoneal tissue about the vessel is carefully opened up and the arterv well exposed — as well as the deep epigastric, for the purpose of guarding it. The peritoneum is then pushed and rolled backward and upward from the vessel with the fingers and held out of the way by retractors. (7) When sufficiently exposed, the sheath of the artery is opened and the needle passed from the vein on its inner side guarding the anterior crural nerve on its outer side. The ligature should be about 3 cm. (ij inches) above Poupart's ligament. (8) In concluding the operation, the cut edges of the transversalis are united by buried catgut sutures to their line of severance from Poupart's ligament, and as far beyond as they may have been divided. The cut edges of the internal oblique are similarly sutured to their former attachment to Poupart's ligament, and to their opposite cut margin as far beyond as divided. And, finally, the separated margins of the external oblique are united by a buried gut suture. The skin wound is then closed. Comment. — The incision for exposure may, if thought necessary, begin about 3 cm. (i\ inches) to the outer side of the spine of the os pubis — being thus begun well to the inner side of the arterv, as in the modified Astlev Cooper operation. Collateral Circulation. — Internal mammary, lumbar, lower intercostals, above; with deep epigastric, below. Iliolumbar, lumbar, gluteal, above; with deep circumflex iliac, below. Obturator and sciatic, above; with internal circumflex below. Sciatic, above; with .superior perforating, below. Gluteal, above; with external and internal circumflex and first perforating, below. Internal pudic, above; with external pudic, below. LIGATION OF EXTERNAL ILIAC BV TK.\.NSPERlTONEAI. ROUTE. Position. — .•Vs in the extraperitoneal operation. Or in the Trendelen- burg jKisition. Landmarks. — .\s for the extraperitoneal exposure. Incision. — The incision may be in one of three sites: (a) As an intra- muscular incision, placed over the site of the artery to be tied (Fig, 30, F); (b) vertical, in the linea semilunaris (Fig. 30, E) ; or (c) vertical, in the linea alba (Fig. 30, C). Operation. — The steps of the operation and the mani]iulation to expose the site of ligation are, practically, similar to those in the transperitoneal exposure of the common iliac, or the internal ili.ic. SURGICAL ANATOMY OF DEEP EPIGASTRIC BRANCH OF EXTERNAL ILIAC ARTERY. Description and Relations. — The deep epigastric generally arises from inner side of external iliac, about 6 mm. (^ inch) above Poupart's Hgament. It descends from its origin to Poupart's ligament (thereby forming a loop over which the vas deferens in male, and round ligament in female, pass on their way to the internal ring) — thence ascends along inner border of internal abdominal ring, lying behind inguinal canal and slightly above and to outer SURGICAL AXATOMV OP' FEMORAL ARTERY. 93 side of femoral ring — thence it continues upward and inward toward the umbilicus, between fascia transversalis and peritoneum, passing above and to outer side of external abdominal ring to inferior border of posterior layer of rectal sheath (semilunar fold of Douglas). Having passed beneath the fold of Douglas, it runs upward between the rectus muscle and sheath, about midway between its e.xternal and internal borders, to enter the muscle and anastomose with the superior epigastric of the internal mammary. Two venae comites accompany the artery. Comment. — The position of the arter\- between the two abdominal rings, and to the upper and outer side of the femoral ring is important. Line of Artery. — From a point on Poupart's ligament midway between the anterior superior iliac spine and the symphysis pubis toward the um- bilicus — but after this line crosses the linea semilunaris it passes upward about midway between the external and internal borders of the rectus. Sites of Ligation. — Preferably, between 0.6 and 2.5 cm. (J and i inch) from origin. It may also be ligated in the lower abdominal wall. LIGATION OF DEEP EPIGASTRIC XI-.AR ORIGIN- Position. — .\s for ligation of external iliac retroperitoneally. Landmarks. — Poupart's ligament; position of external iliac artery. Incision — Operation. — .\s for ligation of external iliac retroperitoneally — that artery lieing first exposed — and the epigastric branch traced from it (Fig. 30, D and Fig. 35, I). SURGICAL ANATOMY OF FEMORAL ARTERY. Description. — Continuation of external iliac. Begins at lower border of Poupart's ligament, midway between anterior sujjerior iliac spine and symphysis pubis — passes down anterior and inner side of thigh to opening in adductor magnus, at junction of middle and lower thirds of thigh, through which it passes into popliteal space, becoming popliteal artery, .\bove, the artery lies near the antero-internal aspect of head of femur. Below, it is close to inner side of bone. Between, it is some distance from bone. In its upper third the arter}- passes from the center of base to apex of Scarpa's triangle. [Scarpa's triangle is bounded, externally, by sartorius; internally, by adductor longus; its base, above, being formed by Poupart's ligament; its apex, below, at junction of sartorius and adductor longus. Its floor (from without inward) is formed by iliacus, psoas, pectineus, small part of adductor brevis, and small part of adductor longus. It contains femoral artery (in its center), with its cutaneous and profunda branches; femoral vein (toward inner side), with deep femoral vein and internal saphenous branches passing from middle of base to apex; anterior crural nerve (to outer side); lymphatic glands.] In its lower third the arter\- passes through Hunter's canal. [Hunter's canal is an aponeurotic canal extending from apex of Scarpa's triangle to femoral opening in adductor magnus, and formed, ex- ternally, by vastus internus; postero-internailv, bv adductor longus and magnus; antero-internally, by aponeurosis stretching from vastus internus over femoral vessels to adductor longus and magnus, the sartorius passing over top of this aponeurosis. It contains femoral artery, femoral vein (each 94 OPERATIONS UPOX THE ARTERIES. in its own sheath, the vein being behind and external to artery), and long saphenous nerve (external to vessels).] Divisions of Artery. — Common Femoral — first 4 cm. {ih inches). Superficial Femoral — made up by remainder (about 9 cm. — 3 A inches). Deep Femoral — profunda femoris branch. Relations. — (a) Common Femoral :— Anteriorly — skin; superficial fascia; superficial inguinal glands; iliac portion (;f fascia lata; continuation of trans\ersalis fasci into femoral sheath; crural branch of genitocrural nerve; superficial circumflex i iac vein; superficial epigastric vein (sometimes). Posteriorly — continuation of iliac fascia into femoral sheath; pubic portii n of fascia lata; nerve to pectineus; psoas muscle; pectineus muscle; capsule of hip-joint. Externally — anterior crural nerves. Internally — femoral vein, (b) Superficial Femoral Artery in Scarpa's Triangle : — Anteriorly — skin; superficial fascia; crural branch of genitocrural nerve; deep fascia; Fig. 36. — Incisions for Ligation of Chikf Arteries of Thigh ;— A, Anterior superior iliac spine : B. Syinpliysis pubis : C, Adductor tubercle ; D. Mid-point between anterior superior iliac spine and symplnsis pubis ; E, Ligation of common femoral at base of Scarpa's triangle, by parallel incision over artery ; F. Same, by incision parallel with Poupart's ligament and just below; G, Of profunda femoris. near origin ; H, Of superficial femoral at apex of Scarpa's triangle ; I. Of superficial femoral in Hunter's canal ; J, Of popliteal in upper part of pojiliteal space, from iiuier side of thigh. internal cutaneous nerve. Posteriorly — femoral vein; profunda vein; pro- funda artery; pectineus muscle; adductor longus. Externally — long saphe- nous nerve; nerve to vastus internus. Internally — femoral vein (getting behind artery at apex of Scarpa's triangle), (c) Superficial Femoral Artery in Hunter's Canal: — Anteriorly — skin; superficial fascia; deep fascia; sartorius; aponeurotic roof of Hunter's canal; internal saphenous nerve. Posteriorly — angle of junction of vastus internus and adductors; femoral vein (lying, in middle of Hunter's canal, behind and becoming slightly external and closelv adherent to arterv). Externally — vastus internus, femoral vein (at lower part of Hunter's canal). Internally — adductrr longus (above); adductor magnus (below). Branches. — From Common Femoral — superficial epigastric, superficial circumflex iliac, superficial external pudic, deep external pudic, profunda. From Superficial Femoral in Scarpa's Triangle — muscular, saphenous. LIGATION OF COMMON FEMORAL. 95 From Superficial Femoral in Hunter's Canal — muscular, anastomotica magna. Line of Artery. — (With hip slightly flexed, thigh abducted and rotated outward.) From a point midway between anterior superior iliac spine and symphysis pubis, to adductor tubercle of internal femoral condvle (Fig. 36, D, C). (When thigh in normal position and parallel with its fellow — from midway between anterior superior iliac spine and symphysis pubis. t(i inner border of patella.) Sites for Ligation. — Common femoral at base of Scarpa's triangle — rare (on account of pro.ximity of large vessels). Superficial femoral at apex of Scarpa's triangle — operation of election. Superficial femoral in Hunter's canal — not common (Fig. 36). Comment. — (i) .\ short common femoral is more frequent than a long one. (2) .Apex of Scarpa's triangle is from 7.5 to 9 cm. (3 to 3^ inches) below Poupart's ligament. (3) Profunda femoris arises aJDOUt 4 cm. (i^ ■ inches) below Poupart's ligament. (4) At groin, femoral artery and vein are on same plane — at apex of Scarpa's triangle, vein is posterior — in middle of Hunter's canal, vein is posterior and slightly external — at lower part of Hunter's canal, vein is external. (5) Order of vessels at apex of Scarpa's triangle, from before backward, is femoral artery, femoral vein, profunda vein, profunda artery. (6) Line approximately representing course of long saphenous vein is one running from a point about 2 cm. (J inch) internal to mid-point between anterior superior iliac spine and symphysis pubis, to posterior border of sartorius muscle at femoral condyle. LIGATION OF COMMON FEMORAL Ar li.VSE OF SC.ARI'.X'S TRI.AXGLE. Position. — Patient supine; hip slightly fle.xed; thigh abducted and rotated outward ; knee bent and lying upon its outer aspect. Surgeon stands on side of operated limb, cutting from above downward on the right, and vice versa. Landmarks. — Line of artery. Incision. — .\bout 5 cm. (2 inches), beginning just a little abo\e Poupart's ligament and extending downward in line of artery (Fig. 36, E). Operation. — Incise skin and superficial fascia. .Avoid lymphatic glands — also the superficial circumflex iliac, superficial epigastric, and superficial external pudic arteries and veins. Divide the iliac portion of the fascia lata (f^'S- 37)- A\oid the crural branch of the genitocrural nerve on the femoral sheath, a little external to the artery. Expose and open the sheath, guarding the femoral vein, which lies immediately to the inner side of the artery and within the sheath — and the anterior crural nerve lying further to the outer side of the artery and outside of the sheath. Pass the needle from the \ein. Comment. — (i) Ligation at the base of Scarpa's triangle is rarely done, owing to the nearness and number of the branches — except in such cases as wounds, and to control hemorrhage at the hip-joint, or for temporary control in operating about the thigh. Where not otherwise indicated, ligation of the external iliac is the better operation. (2) The artery may also be exposed, at this site, by an incision parallel with and about 6 mm. (i inch) below the middle third of Poupart's ligament (Fig. 36, F). Collateral Circulation. — Internal pudic of internal iliac; with pudic q6 OPERATIONS UPON THE ARTERIES of femoral. Gluteal; with external and internal circumflex and superior perforating. Superficial circumflex iliac; with external circumflex. Ob- turator; with internal circumflex. Sciatic; with superior perforating and Fig- 37- — Ligation of Right Common Femoral at Base of Scarpa's Triangi.e ;— A, Super- ficial fascia; B, B. Fascia lata; D, Pectineus ; E, Psoas; F, Iliacus; G, Pouparfs ligament and ex- ternal oblique: H, Comnion femoral artery, with superficial epigastric, external pudic. and circum- flex iliac branches; 1. Femoral \ein ; J. Internal saphenous, with superficial epigastric, external pudic, aiul circumflex iliac veins; K. .Anterior crural nerve; L. Crural branch of i;eiiitucruial. internal circumflex. Comes nervi ischiadici; with all the perforating branches of profunda and articular of popliteal. SURGICAL ANATOMY OF PROFUNDA FEMORIS BRANCH OF COMMON FEMORAL ARTERY. Description, — Largest branch of femoral, nearly equaling main trunk. Arises from externo-posterior aspect of common femoral, about 4 cm. (i^ inches) below Poupart's ligament — passing down thigh, at first external to superficial femoral — thence posterior to femoral artery and vein to inner side of femur — thence leaves femur and runs beneath adductor longus and adductor magnus. Relations. — Anteriorly: (near origin) skin; superficial fascia; deep fascia; branches of anterior crural nerve; (lower down) femoral vein; pro- funda vein; (still lower) adductor longus. Posteriorly: (in order) iliacus; pectineus; adductor brevis; adductor magnus. Externally : vastus internus. LIGAIIOX OF SUPERFICIAL FEMORAL ARTERY. 97 Internally : jiectineus; angle of junction of adductor brevis and adductor m.ii^nus. Branches. — E.xternal circumflex; internal circumfle.x; three perforating. Site of Ligation. — At origin. LIGATION OF PROFOTJDA FEMORIS XEAR ORIGIN'. Position. — Patient supine; limb extended and parallel with fellow. Surgeon on outer side of operated limb, cutting from above downward on the right, and vice versa. Landmarks. — Line of artery fwith e.xtended limb — see page 95); Pou- part's ligament. Incision. — About 5 or 6 cm. (2 or 2^ inches) in length, in line of artery — calculating to fall over its outer border, with the center of incision over a point in the course of the arter\- about 4 cm. (i^ inches) below Poupart's ligament (Fig. 36, G). Operation. — Incise skin, superficial fascia, and fascia lata. Expose the inner edge of the sartorius and retract it outward. Beneath this muscle lies the rectus, with branches of the anterior crural nerve in close relation — these are to be drawn outward. The trunk of the common femoral will then be exposed, with the profunda coming off from its postero-external aspect, and running outward and downward, with the external circumflex arising from it and passing under the rectus. The artery is then freed and the ligature passed. LIGATION OF SUPERFICIAL FEMORAL .\T M'EX OF SCARPA'S TRIANGLE. Position. — Same as for ligation of common femoral at base of Scarpa's triangle. Landmarks. — Line of artery. Incision. -.About 7.; cm. (3 inches) in length, in hne of artery — with its center iner apex of Scarpa's triangle, that is, about 7.5 cm. (3 inches) below Poujjart's ligament (Fig. 36, H). Operation. — Incise skin and superficial fascia. Draw aside, or ligate, branches of internal saphenous vein (Fig. 38). Divide fascia lata. Identify inner margin of sartorius (fibers running downward and inward) and retract outward. Open up the groove between the sartorius and adductor longus (fibers of latter running directly downward, or downward and outward) and retract the adductor longus internally, if necessary. The internal cutaneous nerve and long saphenous nerve are encountered anterior to the arten.', and are to be displaced to one side. Clearly identify the femoral sheath and incise — guarding the femoral vein, which lies posteriorly and internally to the artery. Pass the needle from the vein. Collateral Circulation. — External circumflex; with lower muscular branches of femoral, anastomotica magna, superior articular of popliteal, and anterior tiijial recurrent. Perforating and terminating of profunda, with muscular branches of femoral and muscular and superior articular OPERATIONS UPON THE ARTERIES. F'g- 3S-~LiGATioN OF Right Femoral at Apex of Scarpa's Triangle :— A, Sartorius; B, Adduclor longus; C, Femoral artery and muscular branches, with its sheath incised and retracted; D. Femoral vein ; E, Branch of internal saphenous vein ; F, Long saphenous nerve ; G, Internal cuta- branches of popliteal. Comes nervi ischiadici; with perforating of profunda and art cular of popliteal. LIGATION OF SUPERFICIAL FEMORAL IX HrXTERS CAN.M. Position. — Same as for common femoral at base of triangle. Landmarks. — Line of artery. Incision. — From 7.5 to g cm. (3 to 3J inches), in line of artery — over middle third of thigh (Fig. 36, I). Operation. — Incise skin and superficial fascia. The anterior branch of the internal cutaneous nerve, to the outer side, and the long saphenous vein, to the inner side, are likelv to be encountered. Divide the fascia lata. Ex- pose the outer edge of the sartorius (its fibers running downward and inward) and retract inward from its position over the roof of Hunter's canal. Hunter's canal is thereby exposed in the interval between the vastus internus and the adductor magnus (the fibers of the latter running obliquelv downward and outward). The nerve to the vastus internus may be here expo.sed. Incise the roof of the canal, when the internal saphenous nerve is found between the aponeurotic roof and the sheath of the vessels, running from without inward. Open the sheath and pass the needle from the vein. SURGICAL AXATOMV OF PCIPLITEAL ARTERY. 99 Comment. — Guard against taking the vastus internus for the sartorius — the fibers of the former running down- ward and outward. Collateral Circulation. — Same as for the superfuial femoral at the apex of Scarpa's triangle. SURGICAL ANATOMY OF POPLITEAL ARTERY. Description. — Continuation of fem- oral. E.xtends from aponeurotic open- ing in adductor magnus, at junction of middle and lower thirds of thigh, down- ward and outward through the popliteal space to its center behind the knee-joint — thence vertically downward to the in- ferior border of tlie popliteus muscle, op- posite the lower border of the tubercle of the tibia, where it divides into anterior and posterior tibial arteries. Relations. — Anteriorly : (from above downward) popHteal surface of femur; posterior ligamenl of knee; posterior artitular surface of tibia; popliteus mus- cle. Posteriorly : (above) semimem- branosus; (center) skin, superficial fascia, deep fascia; (below) internal head of gas- trccnemius, aponeurotic arch of soleus. Po])liteal vein lies behind artery through- nut its course, crossing obliquely from outer to inner side, and may be double below. Internal pophteal nerve lies be- hind artery and vein (immediately pos- terior to latter), crossing the vessels ob- iicjuely at their center, from outer to inner side. Externally: (above) ex- ternal condyle, biceps, internal popliteal nerve; (below) outer head of gastroc- nemius, plantaris. Internally : (above) semimembranosus; (below) inner head of ga^lrocncmius, internal popliteal nerve. Branches. — Cutaneous; muscular (superior muscular, inferior muscular or sural); articular (superior external artic- ular, superior internal articular, inferior external articular, inferior internal artic- ular, azygos articular) ; terminal (poste- rior tibial, anterior tibial). upper part of popliteal space, it, Of posterior tibial in its upper tl)ird ; beliitid ; , Same, K. Same, heliind internal malleolus : L, Incision for peroneal in middle of leg. Fig. 39.— Ligation or Hopliikal, Posterior Tibial, and Pkroneal .Ar- teries: — A. Outer border of semimem- branosus (at junction of middle and lower thirds of thigh); B, Middle of popliteal space ; C, Center of posterior aspect of leg on level with tibial tubercle; D, Point midway between convexity of heel and lip of internal nialleolu?.; H, Mi.ipc.nn between outer border of U:u.\.. \> Inlli- and tip of e.xternal malleolus ; \' . hi. i-.i.'m p t popliteal K, Same, in lower p;ut oi pciplncal space; i middle third ; ]. Same, in its lower third ; lOO OPERATIOiXS UPON THE ARTERIES. Line of Artery. — From outer border of semimembranosus (at junction of middle and lower thirds of thigh) obliquely down to middle of popliteal space, directly posterior to the knee-joint (for upper part of artery) ; and from mid-point of popliteal space vertically down to level of lower border of tubercle of tibia (for lower part of artery). (Fig. 39, A, B, C.) Sites of Ligation. — May be ligated either in its upper part or lower part — the artery being tied with difficulty in its middle, owing to its depth and relations (Figs. 36 and 39). Indications for Ligation. — Rare, other than wounds and aneurism — the superficial femoral usually being ligated instead. LIGATION OF POPLITEAL ARTERY IN UPPER PART OF POPLITEAL SPACE FROM BEHIND. Position. — Patient as nearly prone as feasible, resting on side of shoulder and chest, with limb extended. Surgeon to outer side of left limb, cutting downward; and to outer side of right limb, cutting upward (or inside of right limb, cutting downward). Landmarks. — Line of artery and upper boundaries of popliteal space. Incision. — About 9 cm. (3 J inches) in length, in line of arterv, beginning at outer border of semimembranosus, at junction of middle and lower thirds of thigh, and passing obliquely downward to the middle of the popliteal space (Fig. 39, F). Operation. — Incise skin and superficial fascia. Avoid the small sciatic nerve. Open up the deep fascia. Retract the hamstring muscles to the outer and inner sides. The popliteal nerve is first encountered crossing from the outer to the inner side — the popliteal vein crossing similarly. Displace these structures laterally — when the artery is found, generally lying in fatty areolar tissue. Collateral Circulation. — Where the ligation is between the superior and inferior articular arteries; — anastomotica magna, superior e.xternal and internal articular, descending branch of external circumflex, above; with in- ferior e.xternal and internal articularand anterior tibial recurrent (also, possibly, posterior tibial recurrent and superior fibular of anterior recurrent), below. LIGATION OF POPLITEAL ARTERY IN UPPER PART OF POPLITEAL SPACE IKOM INNER SIDK OF TIIK.H— JOBF.RTS OPER.\TION. Position. — Patient supine; thigh slightly fle.xed; fully abducted and rotated outward; knee at a right angle and resting on external aspect. Surgeon on outside, cutting downward on right, upward on left (or may stand on inner side of right and cut downward). Landmarks. — Tendon of adductor magnus. Incision. — .-Xbout 7.5 cm. (3 inches) in length, beginning opposite the junction of mi(idle and lower thirds of thigh, and running parallel with and immediately posterior to the tendon of the adductor magnus (which is inserted into the adductor tubercle on the internal condyle of the femur). (Fig. 36, J.) Operation. — Incise skin and superficial fascia. Avoid anterior branch of internal cutaneous nerve (Fig. 40). Divide deep fascia. E.xpose the LIGATION- OF POPLITEAL ARTERY. loi anterior edge of the sartorius and retract it backward, together with the internal saphenous vein, if in view (the internal saphenous nerve being beneath the sartorius, out of view). Having thoroughly divided the deep fascia, the adductor magnus tendon is identified and drawn forward — then the semi- Fig. 40,— Ligation op Upper Part of Right Popliteal from Inner Side of Thigh : — A, .Anterior branch of iiUernal cutaneous ner\'e ; B, Internal saphenous vein ; C, Sartorius (its anterior border retracted posteriorly) ; D. Interna! saphenous ner\-e (mainly under sartorius. outol sight) ; E. .Adductor niaKUUs (drawn anteriorly); F, Semimembranosus (drawn posteriorly); G, Popliteal artery ; H. Popliteal vein (below and external to artery). membranosus is identified and drawn backward — and the arterv is then sought between these two structures, near the bone and in considerable fatty areolar tissue. Both popliteal vein and nerve lie on a plane posterior to the artery, and are generally not brought to view. LIGATION OF POPLITEAL ARTERY IN LOWER PART OF POPLITEAL SPACE P.V POSTERIOR MEDIAN INCISION. Position. — .\s for ligation in the upper part of the space. Landmarks. — Boundaries of the popliteal space (the biceps above, and the plantaris and outer head of gastrocnemius below, forming the outer boundary; — and the semimembranosus and semitendinosus above, and the inner head of the gastrocnemius below, forming the inner boundary). I02 OPERATIONS UPON THE ARTERIES. Incision. — About 9 cm. (3^ inches) in length, beginning at the middle of the jiopliteal space (on a level with the knee-joint) and passing downward between the two heads of the gastrocnemius (Fig. 39, G). Operation. — Incise skin and superficial fascia. Avoid the external saphenous vein and e.xternal saphenous nerve in the outer aspect of the wound, or the communicans poplitei nerve which helps form the external saphenous nerve (Fig. 41). Divide the deep fascia. E.xpose the inner and outer heads of the gastrocnemius, with the sural arteries going to them — and retract these and the plantaris muscle to their respective sides. Muscular branches of the internal popliteal nerve may be met with here, and maybe Fig. 4t.— Ligation of Right Popliteal at Lower Part of Popliteal Space :— A, Inner head of gastrocnemius (retracted inward); B, Outer head of gastrocnemius (drawn outward); C, Plantaris ; D. External saphenous vein ; E, Communicans poplitei nerve ; F. Internal popliteal nerve (drawn inward); G, Popliteal vein (drawn inward ) ; H. Popliteal artery and muscular branches ; 1, }*opliteus muscle. the posterior tibial nerve. The external saphenous vein is the guide to the popliteal vessels. The internal popliteal nerve is found most superficial of the three important structures — the popliteal vein next (both crossing to the inner side, toward which side they are further retracted) — and the artery deepest of all, near the bone and in much fatty areolar tissue. The needle is passed from the side of the vein, flexure of the knee aiding during this stage. Comment. — A continuation upward of the above incision would amount to ligation of the popliteal artery in the middle of the popliteal space. SURGICAL AXATUMV OF ANTERIOR TIBIAL ARTERV. 103 Collateral Circulation. — If the artery be ligated between the superior and inferior articular branches, the collateral anastomosis would be the same as after the above operation. SURGICAL ANATOMY OF ANTERIOR TIBIAL ARTERY. Description. — The smaller bifur- cation of popliteal arten.-, at lower border of popliteus muscle, passing thence forward between the two heads of tibialis posticus, through aperture in upper part of interosseous mem- brane, between tibia and fibula, to deep part of front of leg — descending, at first, on anterior surface of interos- seous membrane, then on th.e tibia, and finally onto front of ankle-joint, beneath anterior annular ligament, where it becomes dorsalis pedis. It is accompanied by two vena.' comites. The anterior tibial nerve accompanies its lower three-fourths, lying upon its fibular side, though partly overlapping it in middle of leg. Relations. — Anteriorly : skin, superficial fascia; deep fascia; anterior tibial nerve (at middle) ; tibialis an- ticus (above); extensor longus digi- torum (above) ; e.xtensor proprius pol- licis (below) ; anteror annular ligament (below). Posteriorly: interosseous membrane (upper two-thirds); tibia and ankle-joint (lower one-third). Ex- ternally : anterior tibial nerve (above and below); extensor longus digitorum (upper third); extensor projirius pol- licis (middle third). Internally : tibi- alis anticus (upper two-thirds); ex- tensor proprius poUicis (crosses lower part of artery). Branches. — Posterior tibial recur rent, superior fibular (sometimes), an- terior tibial recurrent, muscular, in- ternal malleolar, external malleolar. Line of Artery. — From inner side of head of fibula, to center of line be- tween the malleoli — (according to Kocher, from midway between ex- ternal surface of head of fibula and center of tubercle of tibia, to the same point below Kig. 42.— Incisions for Ligatio.s' of Anterior Tibial and Dorsalis Pedis Ar- teries : — \. Incision for upper Uiirdot anterior tibial; B, For middle third of anterior tibial; C. For lower third of anterior tibial ; D, For dorsalis pedis just below ankle-joint: E, For dorsalis pedis in first interosseous space ; F. Inner side of head of fibula; G, Mid-point be- tween two malleoli. The artery passes ro4 OPERATIONS UPON THE ARTERIES. through the interosseous membrane about 3 cm. (ij inches) below the level of the head of the fibula. Indications for Ligation. — Wounds (of anterior tibial or in foot); aneurism. Sites of Ligation. — Upper and middle thirds — rarely, except in wounds. Lower third — most frequent site (Fig. 42). LIGATION OF ANTERIOR TIBIAL I.\ ITS UPPER THIRD. Position. — Patient supine; leg extended and rotated inward. Surgeon on outer side (cutting from above downward, on the right — and vice versa). Landmarks. — Line of artery. Incision. — About 7.5 cm. (3 inches) in length, in line of artery — beginning about 2.5 cm. (i inch) below head of fibula (Fig. 42, A). CATION OF Upper Third of Right Anterior Tibial :— A, Tibialis amicus muscle ; imunis digitorum ; C, Anterior tibial artery and branches. D. D. Anterior tibial venie comiles ; H, Anterior tibial ner\e ; F, Branch of internal saphenous vein ; G, Interosseous membrane. Operation. — Incise skin, superficial fascia, and deep fascia. Define the gap between tibialis anticus, internally, and extensor longus digitorum, externally, and retract these structures to their respective sides (Fig. 43). Open up this interval — flexing the foot to relax the parts. Aim to reach the external aspect of the tibia, covered by the tibialis anticus, and, when reached. LIGATION OF ANTERIOR TIBIAL. 105 follow down to the interosseous membrane, upon which the artery will be found. Two vena comites lie in verv close contact, in front of and behind the artery. The anterior tibial nerve may not yet have reached the outer side of the arterv. If the vena' comites be not separable, include them in the lij;ature. Comment. — The interval between the tibialis anticus and extensor longus digitorum is the key to the situation, and is rather hard to find. The outer edge of the tibialis anticus often overlaps the e.xtensor longus digitorum. And also one may get into the septum between the extensor longus digitorum and [jeroneus longus and work down toward the fibula. Guides to the proper intermuscular gap, accessory to the sensation of touch, are the " while line" (sometimes visible) and a small artery leading to the anterior tibial. LIGATION OF ANTERIOR TIBIAL IN ITS MIDDLE THIRD. Position — Landmarks. — .\s for ligation of the upper third. Incision. — About 7.5 cm. (3 inches) in length, in line of artery, with its center over the center of the leg (Fig. 42, B). Operation. — Incise skin, su]jerficial and deep fascia. Recognize the interval between the tibialis anticus (its outer edge still muscular) internally — and the extensor longus digitorum (its inner edge tendinous) externally. A yellow fatty line may sometimes indicate the interval. Open up this interval. Hexing the foot. Retract these muscles to their own sides — and, deeper in the wound, a'so retract the extensor proprius pollicis to the outer side. Follow down the gap toward the tibia (and not the gap between the extensor longus digitorum and extensor proprius pollicis). The anterior tibial nerve will be found slightly overlapping the artery — draw it outward. The artery will be found on the interosseous membrane, under cover of the muscular fibers of the tibiaUs anticus, with the extensor proprius pollicis on its outer side. The ven;e comites are separated with difficulty, and, if so, may be included in the ligature. LIGATION OF ANTERIOR TIBIAL 1\ ITS LOWKR THlkli. Position. — As for ligation of the upper third — without the inward rota- tion of the foot. Landmarks. — Line of artery. Incision. — From 5 to 7.5 cm. (2 to 3 inches) in length, with center over center of lower third of leg (Fig. 42, C). Operation. — Incise skin and fascia. Clearly identify tendon of tibialis anticus. Divide the upper y^art of the superior band of the anterior annular ligament in the line of the wound (Fig. 44). Demonstrate the interval be- tween the tendon of the tibialis anticus and tendon of the extensor proprius pollicis — flexing the foot and retracting these tendons to their own sides. The anterior tibial artery will be found between them, lying upon the anterior aspect of the tibia and held down by fatty areolar tissue — accompanied by two vena? comites, and with the anterior tibial nerve on the outer side. Pass the needle from the nerve. In closing the wound, suture the anterior annular ligament. io6 OPERATIONS UPON THE ARTERIES. Comment. — If the artery were ligated after passing beneath the obhquely crossing extensor proprius polHcis, it would then have the tendon of the extensor proprius poUicis to its inner side and the innermost tendon of the extensor longus digitorum to its outer side. Collateral Circulation. — (When ligated below the malleolar branches.) External malleolar of anterior tibial, with anterior peroneal of peroneal and Fig. 44.— Ligation of Lower Third of Right Anterior Tibiai. :-.A, Tendon of tibialis anticus. retracted inward; B. Extensor proprius hallucis, retracted ontward ; C, Extensor longu; digitorum ; D, Ainudar ligatuent ; E, Anterior tibial artery and branches ; F. F, Anterior tibial vena comites : G. Anterior tibial nerve; H. Branch of musculocutaneous ner\'e (iinier branch); I Branch of internal saphenous vein. with calcaneal of posterior peroneal. Internal malleolar of anterior tibial, with internal malleolar of posterior tibial. Dorsalis pedis and branches, with internal plantar of posterior tibial, with external plantar of posterior tibial, with anterior peroneal of peroneal, and with calcaneal of posterior peroneal. Muscular branches of anterior tibial anastomosing through the interosseous membrane with muscular branches of posterior tibial. SURGICAL ANATOMY OF DORSALIS PEDIS (OF ANTERIOR TIBIALS. Description. — Continuation of anterior tibial — extending from bend of ankle along tiliial side of foot to apex of first intermetatarsal space — passing into sole (as communicating artery) between two heads of first dorsal inter- osseous. The anterior tibial nerve lies upon its outer side. The artery is accompanied by two vena? comites. Relations. — Anteriorly: Skin, superficial fascia; deep fascia; anterior LIGATION OF UORSALIS PEDIS. 107 annular ligament; extensor longus poUicis; innermost tendon of extensor brevis digitorum. Posteriorly: (from above downward) Astragalus; scaph- oid; internal cuneiform; ligament of first and second metacarpals. Ex- ternally : Innermost tendon of extensor longus digitorum (above) ; innermost tendon of extensor brevis digitorum (below) ; anterior tibial nerve. In- ternally : Extensor longus poUicis. Branches. — Tarsal; metatarsal; dorsalis hallucis; communicating (plantar digital). Line of Artery. — From center of line connecting two malleoli, to proximal end of fir>t metatarsal space. Indications for Ligation. — Rare — wounds, aneurism. Sites of Ligation. — .\t ankle-joint (involves cutting anterior annular ligament) ; below ankle-joint (general site) ; at first interosseous space (Fig. 42)." LIGATION OF DORSALIS PEDIS JUST r.KI.OW AXKLK.JOINT. Position. — Patient supine; foot resting on heel and extended. Surgeon below foot, on either side (or on outer side of both limbs, cutting downward on right, and upward on left). .Assistant steadies foot. Landmarks. — Line of arterv. F'g- 45— LiiiATioN OF Right Dorsalis Pedis Jl'st below Ankle-joint :— A, A. Branches of internal saphenous vein ; B. Internal branch of musculocutaneous nerve and its divisions ; C, Tendon of extensor proprius hallucis ; D. Inner tendon of Bexor longus'digitorum ; E. Inner tendon of exten- sor brevis digitorum ; F, Dorsalis pedis artery ; G, Vena; comites of dorsalis pedis artery ; H, .inte- rior tibial nerve; I, .Annular ligament. Incision. — From 2.5 to 5 cm. (i to 2 in.), in line of artery, passing from lower border of anterior annular ligament — between tendon of extensor poUicis and inner tendon of extensor longus digitorum (Fig. 42, D). loS OPERATIONS UPON THE ARTERIES. Operation. — Incise skin and superficial fascia. Tributaries of internal saphenous vein and the internal branch of the musculocutaneous nerve lie in the line of incision (Fig. 45). Open up the deep fascia between the tendon of the extensor proprius pollicis and innermost tendon of fle.xor longus digitorum — when the artery will be found upon the tarsal ligaments. The anterior tibial nerve lies upon its fibular side — two venie comites accompanving the artery. Avoid opening the tendon sheaths. Comment. — When the artery is tied at the base of the first interosseous space, an incision is made from the apex of the first interosseous space, passing down between the first and second metatarsals. The artery is found emerging from under the innermost tendon of the extensor brevis digitorum, which is retracted inward. SURGICAL ANATOMY OF POSTERIOR TIBIAL ARTERY. Description. — Larger and more direct di\ision of jiopliteal arterv — extending from lower border of po[)liteus muscle (on level with lower border of tubercle of tibia), down tibial side of back of leg, between superficial and deep muscles, to middle of fossa between tip of internal malleolus and os calcis — and dividing, under abductor hallucis, into internal and external plantar l^ranches. It arises midway between tibia and fibula, covered by the superficial muscles — lower down it lies behind the tibia — and at its low-er third it is covered by only skin and fascia, and then passes beneath the internal annular ligament. It is accompanied by two vena; comites. The posterior tibial nerve crosses the artery, from the inner to outer side, about 2.5 to 4 cm. (i to I J inches) below inferior border of popliteus, and runs thence along its fibular aspect. Relations. — Anteriorly: (From above downward) tibialis posticus; flexor longus digitorum; tibia; internal lateral ligament of ankle-joint. Pos- teriorly: Skin; superficial fascia; gastrocnemius; soleus; deep intermuscular (transverse) fascia binding artery to underlying muscles; posterior tibial ner\'e (crossing from inner to outer side above, and then running r.long fibular side). In lower third, covered onlv bv skin and fascia. Externally : Poste- rior tibial nerve (lower three-fourths) ; vena comes. Internally : Posterior tibial nerve (upper one-fourth) ; vena comes. At Ankle-joint : Posterior tibial artery lies under internal annular ligament and abductor hallucis — resting upon internal lateral ligament of ankle — having tibialis posticus and fle.xor longus digitorum in front — and posterior tibial nerve and flexor longus hallucis behind and externally. Branches. — Peroneal, muscular, medullary, cutaneous, communicating, internal malleolar, internal calcaneal, external plantar, internal plantar. Line of Artery. — Lower half — line from a yjoint 5 cm. (2 inches) below center of popliteal space, to midwav between tip of internal malleolus and center of convexitv of heel. Upper half — forms a slight curve inward from this line. Indications for Ligation. — Wounds; aneurisms. Sites of Ligation. — Upjier third — not infrequent — difficult because of depth. Middle third — same. Lower third — most usual site. Behind ankle — also common (Fig. 39, K). LIGATION OF POSTERIOR TIBIAL. 109 LIGATION OF POSTERIOR TIBIAL IN ITS UPPER THIRD— ABOVE ORIGIN OF PERONEAL BRANCH. Position. — As for ligation of lower part of popliteal artery (page loi). Landmarks. — Popliteal boundaries (page 101); head of fibula. Incision. — Begins in popliteal space, on level with head of fibula, and passes directly down the middle line for about 7.5 cm. (3 inches) (Fig. 39, H). Operation. — Incise skin, superficial fascia, avoiding external saphenous vein and nerve. Divide deep fascia, exposing two heads of gastrocnemius. Incise their connecting raphe freely and separate them fully, avoiding their nerves and vessels as much as possible. Expose the upper border of the soleus beneath the external head of the gastrocnemius. Retract the plantaris- (found between the outer head of the gastrocnemius and soleus). The lower border of the popliteus, opposite which the posterior tibial nerve begins, about corresponds with the upper border of the soleus — so that after re- tracting the internal popliteal nerve and vein to the inner side, draw the upper border of the soleus downward (or nick its upper border) and thus expose the Ijifurcation of the popliteal artery into anterior tibial (passing through the interosseous membrane) and posterior tibial (descending on the deep muscles). Pass the needle between the anterior tibial and peroneal branches. Collateral Circulation. — (When ligated between the bifurcation and origin of the peroneal.) Peroneal of posterior tibial, with communicating and muscular branches of the posterior tibial; external calcaneal of peroneal, with internal calcaneal of external plantar; external malleolar of anterior tibial, with external plantar; internal malleolar of anterior tibial, with internal malleolar of posterior tibial; dorsalis pedis and branches, with internal and external plantar. LIGATION OF POSTERIOR TIBIAL IN ITS MIDDLE THIRD Position. — Patient supine; knee flexed; leg on outer side. Surgeon to outer side, cutting downward on right, and upward on left. Landmarks. — Inner margin of tibia. Incision. — From 7.5 cm. to 10 cm. (3 to 4 inches) in length, placed parallel with and 2 cm. (f inch) behind the inner margin of the tibia, along its middle third (Fig. 39, I). Operation. — Incise skin and superficial fascia. Avoid internal saphenous vein and internal saphenous nerve (Fig. 46). Divide the deep fascia. The inner edge of the gastrocnemius should be identified here — and retracted outward. Having gone through the deep fascia, the soleus is exposed, and is to be divided along its attachment to the tibia, and its outer part retracted. The transverse intermuscular fascia (between superficial and deep muscles of back of leg) is now in view, and is incised in the axis of the limb, whereby the fle.xor longus digitorum is reached — and, by following along the surface of this muscle until nearly opposite the outer border of the tibia, the vena comes interna, posterior tibial artery, vena comes externa, and posterior tibial nerve are met in order, lying upon the tibialis posticus, or between it and the fiexor longus digitorum. Pass the needle from the nerve, including the vena; comites if unavoidable — flexing the knee and foot to relax the structures. no OPERATIONS UPON THE ARTERIES. Comment. — The knife should be held at a right angle to the surface of the muscle, in cutting through the soleus, pointing toward the tibia until the transverse fascia is reached — and thereby wandering too deeply, or in the wrong direction, is less likely. If one incise too near the tibia, the fle.\or Fig. 46.— LiGATio.N OF .Middle Third of Right Posterior Tibial:— A. Internal saphenous vein; B, Internal saphenous nerve; C. Soleus, incised vertically, and margins of incision well retracted ; D, Inner head of gastrocnemius strongly retracted outward ; E, Transverse intermuscu- lar fascia ; F, Flexor longus digitorum ; G, Tibialis posticus; H, Posterior tibial artery; I, I, Poste- rior tibial vense comites ; J, Posterior tibial nerve. longus digitorum may be divided and the interosseous membrane reached. While incising the soleus, do not mistake its central membranous tendon for the transverse intermuscular fascia. The artery lies about 3 cm. (i^ inches) e.xternal to the inner border of the tibia. LIGATION OF POSTERIOR TIBIAL IN ITS LOWF-R THIRD. Position. — .\s for the middle third. Landmarks. — Line of artery. Incision. — About 5 cm. (2 inches) in length, in line of artery, with its center over the lower third of the leg — which should fall midway between the inner border of the tendo Achillis and the inner border fif the tibia (Fig- ,^9. .!)• Operation. — Incise skin and superficial fascia. Divide the deep fascia binding down the flexor tendons — when the artery will be found lying be- tween the fle.xor longus digitorum and t'!e.\or longus poUicis — the posterior LIGATION OF POSTPIRIOR TIBIAL. Ill tibial nerve lying to its fibular side, with the venae comites surrounding the artery. Comment. — If the incision be at the upper part of the lower third of the artery, the vessel will be found upon the fle.xor longus digitorum. If the incision be at the lower part of the lower third, the upper part of the internal annular ligament must be cut. LIGATION OF POSTERIOR TIBIAL BEHIND INTEKN.AI. M.M.l.EOI.l'S. Position. — .^s for ligation of the lower third. Landmarks. — Internal malleolus. Incision. — .\bout 5 cm. (2 inches) in length, placed about 1.3 cm. (i inch) posterior to and parallel with the inner malleolus (Fig. 39, K). Operation. — Incise skin and superficial fascia — during which branches of the internal saphenous vein are encountered (Fig. 47). E.xpose the in- ternal annular ligament and divide it over the vessels — the artery being found Fig. 47. — Ligation of Right Postfrior Tibial behind Internal Mallfoi.us: — A, Branch of internal saphenous vein; B. Branch of internal saphenous nerve; C, Internal annular ligament (incised): D. Tendon of flexor longus hallucis; E, Tendon of flexor longus digitorum; F, Tendon of tibialis posticus ; G. Posterior tibial artery ; H, H, Posterior tibial venje comites ; I, Posterior tibial in the interval between the flexor longus digitorum and flexor longus hallucis, surrounded by its vena:' comites and with the nerve upon its fibular side. Comment. — Keep the knife pointed toward the tibia, in making the incision. .-Xvoid opening the sheaths of the tendons. Behind the internal malleolus and posterior surface of the tibia are four compartments, which, passing from tip of malleolus toward heel, are — first, a canal in the annular 112 OPERATIONS UPON THE ARTERIES. ligament for the posterior tibial muscle tendon — a second canal for the flexor longus digitorum tendon — a third space occupied by the posterior tibial artery, its vena; comites, and the posterior tibial nerve — and a fourth canal for the flexor longus hallucis. SURGICAL ANATOMY OF PERONEAL BRANCH OF POSTERIOR TIBIAL ARTERY. Description. — Arises from posterior tibial about 2.5 cm. (i inch) below inferior border of popliteus — and curves (with convexity outward and upward) obliquelv outward and downward to fibula — descending thence close to inner border of fibula, to lower third of leg, where the anterior peroneal is given ofT (which pierces the interosseous membrane to front of leg) — thence passes, as posterior peroneal, to inferior tibiofibular joint and external malleolus. It is accompanied by two venae comites. Relations. — (From origin to bifurcation.) Anteriorly : (from above downward) Tibialis posticus; fibrous bed between origins of tibialis posticus and flexor longus hallucis. Posteriorly: (from above downward) Soleus; flexor longus hallucis (completing fibrous canal of artery). Branches. — Muscular, nutrient, anterior peroneal, communicating, posterior peroneal, external calcanean. Line of Artery. — From middle of popliteal space, on level of lower border of tubercle of tibia, arching slightly outward and then downward along inner border of posterior surface of fibula. For purposes of ligation, the arterv is represented by a line from posterior border of head of fibula to point midway between external malleolus and outer margin of tendo Achillis. Indications for Ligation. — Rare — except for wounds, when the vessel is cut down upon at the point wounded. Sites of Ligation. — Upper part — rare, owing to depth. Middle — usual site (Fig. 39). LIGATION OF PERONEAL BRANCH OF POSTERIOR TIBIAL I.N .MIDUl.K OF LEG. Position. — Patient rests on shoulder and chest of opposite side; knee flexed; leg on antero-internal surface. Surgeon on outer side, cutting from below on right, and from above on left. Landmarks. — External border of fibula. Incision. — .\bout 7.5 cm. (3 inches) in length — parallel with and just behind external border of fibula, with its center over the middle of the leg — which falls behind the peronei muscles (Fig. 39, L). Operation. — Incise skin and superficial fascia. Branches of the external saphenous nerve and external saphenous vein are apt to be encountered here (Fig. 48). Expose the soleus (which, at this site, no Uinger arises from the fibula) and retract it upward and inward (incising its lower fibers if any be found attached to the fibula at this height). Divide the deep fascia behind the peronei. Expose the flexor longus hallucis and incise through its thick- ness, close to the fibula — until the fibrous canal of which it forms the roof SURGICAL ANATOMY OF THE EXTERNAL PLANTAR ARTERY. 1 13 Fig. 4,S.— Ligation of Right Peroneal in Middle of Leg ; — A, Branch of external saph- enous nerve; B, Branch of external saphenous vein; C, Gastrocnemius, retracted inward ; D, Soleus. retracted upward and inward : E. Peroneus longus ; F, Peroneus brevis ; G, Tibialis posticus ; H, Flexor longus hallucis. incised, showing roof of aponeurotic canal enclosing vessels ; I. Peroneal artery ; J, Peroneal vena: coniites. is reached. Divide the aponeurotic canal and expose the artery lying the fibula, with its venje comites SURGICAL ANATOMY OF EXTERNAL PLANTAR BRANCH OF POS- TERIOR TIBIAL. Description. — Larger of two terminal branches oi\-en off by posterior tibial at inner ankle. Passes from beneath internal annular ligament, obliquely forward and outward across sole of foot to base of fifth metatarsal — thence curves forward and inward to base of first interosseous space — where it anastomoses with communicating branch of dorsalis pedis, to form plantar arch. Two vense comites accompany the artery. Relations. — First part (from inner ankle-joint to base of fifth meta- tarsal): Rests on os calcis; fle.xor accessorius; fle.xor minimi digiti. Covered by — skin; superficial fascia; plantar fascia; abductor hallucis; flexor brevis digitorum and abductor minimi digiti. Lies between — flexor brevis digi- torum and abductor minimi digiti. Accompanied by — external plantar nerve and two vens comites. Second part: (Plantar arch; from base of fifth metatarsal to proximal end of first interosseous space.) Rests on — proximal ends, and corresponding interosseous muscles, of second, third, and fourth metatarsals. Covered by — skin; superficial fascia; plantar fascia; flexor brevis digitorum; tendon of flexor longus digitorum; lumbricales; branches of internal plantar nerve; adductor hallucis. 8 114 OPERATIONS UPON THE ARTERIES. Branches. — Muscular, calcaneal, cutaneous, anastomotic, articular, pos- terior perforating, digital. Line of Artery. — First Part: from point midway between tip of internal malleolus and great tubercle of os calcis, to base of fifth metatarsal. Second Part: — from base of fifth metatarsal, to posterior part of ball of great toe. Fig. 49. — Incisions for Ligation OF Plantar Arteries: — A. Incision for external plantar in sole of foot ; B, For internal plantar in sole of foot ; C. For external plantar arch at base of first in- terosseous space; D, Ball of heel; E, Base of fourth toe ; F, Base of first toe. Fig. 50. — Ligation of Right External Plantar IN Sole of Foot: — A, Superficial fascia ; B. Abductor minimi digiti ; C, Flexor brevis digitorum ; D. Deep plantar fascia ; E, External plantar artery ; F, F, Ex- ternal plantar venas comites ; (i. External plantar nerve. (The foot here rests upon the toes, the reverse of the position in Fig. 49. where it rests upon the heel.) Indications for Ligation. — \\'ounds and aneurisms. Sites of Ligation. — .\t crigin — more frequent site. In the sole. Plantar arch — rare. (I'ig. 49, -^, <- ■) LIGATION OF EXTERNAL PLANTAR .\T (ikir.ix Position. — .\s for the posterior tibial at the ankle. Landmarks. — Sustentaculum tali. Incision. — Begins 2 cm. (J inch) below and in front of sustentaculum tali and passes backward along inner border of foot, above the abductor hallucis prominence. Operation. — Incise skin, superficial fascia, exposing the abductor hallucis. Draw this muscle downward. Divide the deep fjscia lying beneath the abductor hallucis — and the bifurcation of the artery will be found just in front of a line let fall from the posterior margin of the internal malleolus — accompanied by veins and the posterior tibial nerve. LIGATION OF IXTERXAL PLANTAR. II5 LIGATION OF EXTERNAL PLANTAR IX SOLE OF FOOT. Position. — Patient supine; foot resting upon heel, steadied upon a sup- port. Suriieon at foot of table. Laxidmarks. — Ball of heel; fourth toe. Incision. — .\long arch of foot, in a line from ball of heel to fourth tie — atjout 6 cm. (2^ inches) in length (Fig. 49, A). Operation. — Divide skin, superficial fascia, fatty areolar tissue, and plantar fa.'-cia. E.xpose the gap between the flexor brevis digitorum and abductor minimi digiti — in which the artery is found, with accompanying nerve arid veins (Fig. 50!. SURGICAL ANATORIY OF INTERNAL PLANTAR BRANCH OF POSTE- RIOR TIBIAL. Description. — Smaller of two terminal branches given off by posterior tibial at inner ankle — passing forward along inner side of sole, generally to t'lrst interosseous space, to anastomose with fifth plantar digital of com- municating branch of dorsalis pedis. Relations. — First covered by abductor hallucis — then lies between abductor hallucis and fie.xor brevis digitorum — and, toward distal end, is covered by skin and fascia. Branches. — Muscular, cutaneous, articular, anastomotica, superficial digital. Sites of Ligation. — At origin — more frequent. In sole. (Fig. 49, B.) LIGATION OF INTERNAL PLANTAR AT (IKir.IX. Position — Landmarks — Incision — Operation. — .\s for ligation of e.x- ternal plantar at origin. LIGATION OF INTERNAL PLANTAR 1\ SOLE (IF FOC IT. Position. — .\s for external plantar. Landmarks. — Heel; great toe. Incision. — .\long arch of foot, in line from point of heel to great toe — about 6 cm. (2^ inches) in length (Fig. 49. B). Operation. — Divide skin, superficial fascia, and fatty areolar tissue. E.xpose the gap between the abductor hallucis and fle.xor brevis digitorum — in which interval the artery is found (Fig. 51). Il6 OPERATIONS UPON THE ARTERIES. Fig- 5].— Ligation of Right Internal Plantar Artery in Sole of Foot :— A. Superfi- cial fascia ; B. Abductor hallucJs ; C, Flexor brevis digitorum ; D, Internal plantar ail,er>' ; E, E, In- ternal plantar vena? comites ; F, Internal plantar nerve. (The foot here rests upon the toes, the reverse of the position in Fig. 49, where it rests upon the heel.) TEMPORARY LIGATION OF ARTERIES. Definition. — The temporary arrest of circulation in an artery by means of a lii^ature carried beneath the vessel — whereby the artery is drawn upon until the flow teases, but is not tied. Indications. — Where it is desired to control for a time the arterial circu- lation during the steps of an operation — or where a ligature is placed about an artery in advance of, or preparatory for, any emergency which may arise — (c g.. temporary ligature of common carotid in the removal of a tumor of the neck, or of the femoral in popliteal aneurism). Operation. — All the steps, up to the exposure of the sheath of the artery, are similar to those for an ordinary ligation. At this point, instead of opening the sheath, the sheath itself is isolated (unless a common sheath contain other important structures). A stout ligature (preferably broad) that will not cut is passed beneath the sheath. The two ends of the ligature are not tied upon the artery, but are simplv grasped by clamp-forceps in the hands of an assistant (or knotted into a loop). When it is desired to control all flow through the vessel, the assistant simply lifts the artery slightly from its position — the under wall of the artery is thereby pressed into contact with the upper wall by the loop of the ligature, over which the artery makes an angle, and the flow ceases. On relaxing tension, the artery falls back into its normal position and the flow continues. Where no further need exists for this control, one end of the loop is drawn upon and the ligature slips out from under the artery. Where the temporary is converted into a permanent ligature, the ligature is tightened in the ordinary manner — although, were this likelihood foreseen, it would be better to open the sheath of the ARTERIORRHAPHV. 117 artery at first and place the temporary ligature directly around the artery proper. Comment. — As this secondary operation is generally resorted to in the course, and in the site, of some more major and primary operation, the steps of the temporary ligature are modified by these of the main operation. INTERMEDIATE LIGATION, OR LIGATURE EN MASSE. Definition. — Ligature at masse for parenchymatous hemorrhage is a method of controlling hemorrhage which comes from no definite vessels, or from inaccessible sources, or as a capillary oozing. Description. — A fully curved needle, armed with catgut, is made to enter the tissue to one side of the site from which the flow comes — passes deeplv into the parts, and, in emerging, more or less completely surrounds the area of hemorrhage — which is controlled by the tightening of the ligature. Or, in hemorrhage from a larger area, a curved needle, held in a holder, mav be made to surround the area from which parenchymatous bleeding comes bv circumventing that area with a purse-string ligature introduced bv several consecutive insertions of the needle — at, for instance, four points (if a circle. The ends of beginning and ending of this catgut ligature are then drawn and knotted — only tightly enough to control hemorrhage, and nut tightly enough to strangulate the p)arts. ARTERIORRHAPHY. Definition. — Suture of an artery. Indications. — .\rteriorrhaphy may be required in longitudinal wounds of an arterv; in limited transverse wounds; in transverse wounds of more than half the circumference; and in complete division, or in division with partial resection (the resected portion not exceeding more than about 2 cm. — J inch). Operation. — (a) In wounds of artery: (i) With aseptic precautions, the sheath of th,e artery is exposed and ojiened with minimum injury to vessel and surroundings. If the circulation have not been controlled by a constrictor, or some form of pressure, the artery is clamped above and below the injury with special forceps (e.g., Billroth's, with broad blades protected by pieces of rubber drainage-tubes drawn over them; or by means of floss silk lightly tied, or looped). (2) Seize, in turn, the lips of the wounded artery with a pair of ocuhst's rat-tooth fixation-forceps. Using a fully curve] and round conjunctival needle (or straight floss-needle, or cambric needle) threaded with twisted silk of exact size as eye of needle (that hemorrhage may not occur through the needle-hole which the silk has not fully filled), penetrate the tunica adventitia and muscularis, down to (but not through) the intima. The lips of the wound are pierced immediately opposite each other. The knots are interrupted — are from i to 2 mm. (about -jV to -j-'^ inch) apart — enter artery about 1.5 mm. {^-f^ inch) from edge of wound — and are lightly tied with a reef-knot, avoiding inversion of the lips of the artery The sheath of the artery is separately sutured over the vessel, if possible. The skin wound is closed as usual. A wound in the long axis of the artery tends to gape least, and a transverse wound most. If the artery be divided through one-half of its circumference, it should be entirely divided ii8 OPERATIONS UPON THE ARTERIES. and re-united by some method of suture, preferably by invagination, (b) In complete division of artery : The artery should be united end-to-end Fig. 52. — Arteriorrhaphy in Complete Circular Divisio.n of an .-\rtery (Murphy's Method): — A, IiUussusceptum, with sutures passing through outer and middle coats; B, Ititus- suscipiens (split to aid iti\-aginatiot)) with sutures passing through all coats. Fig- 53- — C, Same, showing all sutures tied. by invagination. A piece of finely twisted silk is threaded upon two needles — one of which is passed through the outer and middle coats of the proximal Fig. 54.— Circular .Vrtkkiorkhaphv in Complei Salomoni and Tomaselli - interrupted sutures through al Fig. 55.— B. Same, method of Gluck— interrupted su inder of decalcified bone, ivory, or rubber. Division of an Artery :— A, Method of ires through outer coats, protected by cyl- end, in the long axis — then both needles, held side by side, are simultaneously ARTERIAL FORCIPRESSURE. 1 19 passed through all coats of the distal end (intussuscipiens) about 7 to 12 mm. (J to J inch) from its free end, passing from within outward. Two or three of these sutures are applied equidistantly. The distal end is then slit a short distance (the slit not extending as low as the sutures) to aid in invagi- nation — which is then accomplished by traction upon the sutures — which are, after invagination is complete, tied lightly with reef-knot. Reinforcing I-igs. 56-5S.— Cl N Artery : — The metliods of Bou^jle. sutures are placed at the line of junction, and uniting the lips of the slit — hut do not pass through the intima of the intussceptum. (See Figs. 52 and 53.) Comment. — Besides the method of Murph\-, al)ove described, end-to-end union may also be accomplished by suturing through all the coats, of both ends, as in Salomoni's and Tomaselli's method (Fig. 54). Or one of Bougie's methods may be used (Figs. 56, 57, and 58) — or Gliick's method (Fig. 55). ARTERIAL FORCIPRESSURE. Definition. — Pressure of artery by artery-clamp forceps. Description. — This is the ordinary method of controlling hemorrhage by seizing arteries in a wound, upon an amputation stump or in the course of any operation — by means of clamp, or hemostatic forceps. The forceps are allowed to remain in silii for a period of time after their application, but are not twisted upon their axis (as in the following operation). The hemostat should grasp the bleeding end of the artery, and as little else as possible. Where circumstances allow, the artery to be subjected to forcipressure should be cleared of surrounding connective tissue by a stroke or two of the knife, especially in the case of the larger vessels. In the case of the smaller arteries, the forceps may be removed and nothing further done, with fair certainty that no further bleeding will occur from the crushed vessels. In the case of the larger arteries, a catgut ligature should be applied over the point of the forceps, just prior to their removal. I20 OPERATIONS UPON THE ARTERIES. Comment. — In some (i))erations, as in vapiinal hvsterectomv bv the clamp method, the forceps are left in the wound for twenty-four or forty- eight hours. ARTERIOSTREPSIS. Definition. — Torsion of an artery by means of artery-clamp forceps. Description. — The operation consists in the seizing of the divided end of an artery with forceps and twisting it through two or three revolutions, in the direction of its long axis — causing a rupture and retraction of its inner and middle coats within the outer coat. A clot forms and organizes upon and in the roughened inner coats and is protected by the outer coat. The twisting should cease short of causing a complete severance of the end of the artery. This is the common method of arresting hemorrhage from the smaller vessels bleeding in a wound or upon the surface of an amputation stump, and its use should be confined to such vessels, although the femoral artery has been successfully controlled by torsion (occurring in accidents). The technic differs slightly in the application of arteriostrepsis to small and medium vessels: (a) Upon Smaller Arteries: — seize the e.xtremity of the bleed- ing vessel with catch-forceps, including as little tissue, other than the sheath of the artery, as possible — draw it out from its connections and twist it around two or three times and release the hold, (b) Upon Medium Arteries: — seize the extremity of the severed artery, in its long axis, with catch-forceps, and draw the vessel out of its sheath for about 1.3 to 2 cm. (^ to | inch). With a second pair of catch-forceps, grasp the bared artery about 1.3 cm. (i inch) from its extremity, at a right angle to its long axis, and hold steadily. Then rotate the vessel two or three times by means of the terminal forceps, and let go. Thus the proximal forceps prevent the artery from being twisted in its sheath, which w-ould sever its vasa vasorum in their passage from the sheath to the artery. Only that portion of the artery, therefore, between the clamps is twisted. LIGATION FOR RADICAL CURE OF ANEURISM. Description. — Several methods of a])plying ligatures for the radical cure of aneurism have been adopted — either as a means alone, or in conjunction with otlier steps. Methods. — (1) Antyllus's Method ("Old Method"): — The sac is incised — the clots are turned out — and the involved artery ligated above and below the sac. (2) .^nel's Method: — Ligature of the involved artery just above (proximal to) the sac. (3) Hunter's Method: — Ligature of the main vessel involved at some distance above (proximal to) the sac, so that one branch, at least, intervenes between sac and ligature, thereby only partly cutting off the circulation through the sac. (4) Brasdor's Method: — Ligature of the main artery involved beyond (distal to) the sac, entirely cutting off the cir- culation through the sac. (5) Wardrop's Method: — Ligature of one or more of the distal branches. (6) Extirpation: — Ligature of the main vessel (and collateral branches) above and below the sac, with extirpation of the aneurism — with or without opening the sac. OPERATION FOR RADICAL CURE OF ANEURISM. OPERATION FOR RADICAL CURE OF ANEURISM, BASED UPON ARTERIORRHAPHY. MATASS MK riKlIl. Description. — The aneurismal sac is laid open — tlie openings of the main and collateral vessels are closed by suture — and the cavity of the sac obliterated by suturing its walls, and overlying integumentary parts, to its floor. Four cases thus far operated in the above manner by the author of the method have been uncomplicated and have resulted in complete cure. Matas now further proposes to restore the circulation through the part, by forming a new blood-channel by suturing the lower part of the sac over a temporarily placed rubber tube — which is withdrawn just before the re- mainder of the sac is obliterated. Indications. — The method is applicable to all cases where (a) a distinct FOR Radical Cvre of Anei'KISM (Matas's Method) :— .A, First stage of :ism laid open, showing two ojjenings and intervening groove. (Modified Fig. 59.— Opera operation — fusiform from Matas.) Fig. 60. — B, Final stage — showing walls of aneurism-sac and integuments sutured to fli over gauze rollers. (Modifiedfrom Matas.) sac exists (whether fusiform or saccular), and (b) where the proximal circula- tion can be controlled. In the fusiform type of aneurism two openings of the main vessel exist, one at either end, generally with a groove connecting them. Here both openings are obliterated bv suture, as well as the floor of the aneurism. It is now proposed to restore the circulation through these two openings and groove in the manner above described. In the saccular type a single opening of the main vessel exists. Here the margin of the opening is obliterated by suture, leaving the artery intact and capable of carrying on circulation. Operation. — (1) Control of circulation through sac by digital or con- 122 OPERATIONS UPON THE ARTERIES. Stridor compression, traction-loop around vessel, or by special artery-clamps. (2) Free median incision of the overlying parts and of the aneurismal sac, from end to end. All clots are turned out. All laminated fibrin is rubbed Fig. 6i. — Operation for Radical Cure of Aneuri gether borders of openings in main and collateral arter: channel of main artery intact. (Modified from Matas.) I'^i.n- h2.— B. Same, showing openings completely closed. (Modified from Matas.) A, Suturing lo- eurism. leaving off with gauze mops from the walls of the sac. All openings into the sac are thus exposed (Fig. 59). (3) Obliteration of all vascular openings by inter- Fig. 63.— Operation for RAnicAi. CtRE of Aneurism (Matas's Method) :— A. A (two upper A'sl, First tier of sutures all placed and partly tied, in a fusiform aneurism ; A (lower A), Second tier partly placed. (Modified from Matas.) Fig. 64. — Same : — C. Second tier (here shown continuous), placed and tied, obliterating openings and groove ; D, D. Placing sutures witli cur^-ed needle, to approximate aneurism-wall to floor of aneurism ; E, E, Reverdin needle in act of drawing sutures through aneurism wall. (Final t\iiig of these four sutures is shown in Figs. 60 and 66.) (Modified from Matas.) OPERATION FOR RADICAL CURE OF ANEURISM. 123 rupted or continuous Lembert sutures of chromic gut introduced bv curved needle in holder, and taking firm and deep hold of the lips to be approximated (Figs. 61 and 62). (4) Reinforcement of first tier of sutures, especially in large aneurisms, by a second tier of Lemberts, preferably continuous. Object fig. 65.— Operation for Radical Cl're of Aneurism (Matas's Method) :— I. Diagram of cross-sect ioi) of parts in complete obliteration of sac and blood-channel; A. Integuments; B, Aneu- rismal sac ; C, Walls of blood-channel ; D. First tier of sutures, approximating borders of blood- channel ; E. Second tier of sutures, approximating floor of sac over first tier ; F. F. Sutures through walls and into floor of aneurism, approximating former to latter; G. Suture through margin of in- teguments and into floor of sac. over second tier. (Modified from Matas.) Fig. 66. — II, Diagram of cross-section of parts in complete obliteration of aneurism-sac, but with restoration of blood-channel ; parts are same as in above, except that D represents suture approxim- ating walls of sac over a temporary rubber tube ; H. Restored blotKl-channel. (Modified from Matas.) of second tier is to protect against leakage and for the purpose of reducing the size of the sac and building it up from the bottom toward the surface, in the middle line (Figs. 63 and 64). (5) In-folding of the walls of the aneu- Fig. 67.— Operation f*>r 1 ders of openings and connectin (Modified from Matas.) Fig. 68.— B, Same, withdraw Matas.) ; OF Anel'rism (Matas's Method) : — A. Suturing bor- r temporary rubber tube, in case of fusiform aneurism. ing tube through temporarily displaced sutures. (Modified fn rismal sac. together with the overlying integumentary tissues — and the oblitera- tion, thereby, of the sac by complete approximation of these tissues to the floor of the sac and to the central elevation formed bv the one or two tiers 124 OI'ERATIONS I'l'ON THE ARTERIES. of sutures just described. The two flaps thus in-turned consist of aneurismal wall and integumentary coverings. These rela.xed flaps are sutured to the bottom of the aneurism by interrupted sutures deeply placed (Fig. 64) — and, especially in large aneurisms, the appro.ximation is made more complete, and dead spaces between the wall of sac and integuments, on the one hand, and the floor of the sac, on the other, rendered less likely by the passage of deep chromic gut, or silkworm-gut, sutures — passing through all the walls of the sac and into the floor of the aneurism, and tied over rollers of gauze on the skin surface (Fig. 60). .\ hollow ovoid is thus left on the skin surface where formerly a convexity existed (Fig. 66). (6) Where a new blood-channel is to be formed, a rubber tube is carried through both openings and made to occupy the groove which usually exists between the two openings (Fig. 67). Over this tube the sac is sutured, as in Witzel's gastrostomy (page 769). All sutures are placed before any are tiefi. The end sutures are then tied over the tube — when the tube is withdrawn through the separated middle sutures, which are then tied (Figs. 68 and 65). The operation is then completed as in cases where the circulation is entirely obliterated. Comment. — (1) Union lakes place between the serous surfaces lining the sac (the arteries being mesoblastic). (2) The sutures take good and strong hold in the waUs of the sac. (3) .\dvantage of this method of operating are the following: simpler technic; less traumatism; elimination of any liga- turing; no disturbance of structures in vicinity of aneurismal sac; collateral circulation preserved; circulation of main artery preserved, in favorable cases; usually prompt healing by approximation of skin to floor of aneurismal sac. OTHER OPERATIONS FOR RADICAL CURE OF ANEURISM. Acupuncture. — A method of treating aneurisms by the introduction of long needles into their sacs. Several long, fine needles are simultaneously introduced, by the safest route, through overlying integuments, into and through the wall of the aneurism — and on beyond, until in contact with the opposite w-all. Here they are allowed to quietly rest for several hours, and are then withdrawn. Repetition of this process may be resorted to upon successive occasions. Coagulation is thus favored. Needling (Macewen's Operation). — The introduction of one or two long needles into the sac, with irritation of its wall. A long, fine needle is introduced, by the safest route, through skin and connective tissue, into and through the wall of the aneurism — and is pushed on until in contact with the inner surface of the opposite wall. The wall of the aneurism is then gently irritated by a process of scratching, by means of the point of the needle —which is then withdrawn. The interior of the sac should be evenly irritated throughout, or at different sites consecutively. This direct irritation of the wall should be only great enough to produce a reparative exudation together with a deposit of fibrin— and thus white thrombi are formed upon the surface of the sac. Two or more needles may be used simultaneously in a large sac, and several hours may be consumed in the process — and their use repeated upon successive occasions. Introduction of Wire. — .\ fine cannula is introduced, by the safest route, through skin, fascia, and wall of aneurism, into the cavity of the sac. Through this cannula several yards of fine wire (according to size of aneurism) are introduced and left, the cannula being withdrawn. Cure is efi'ected by the clotting of blood upon this wire meshwork. Catgut, silk, horsehair, and the TREATMENT OE VASCULAR NEOPLASMS. 125 like have been used — but silvered copper wire has proved the most satis- factorv. THE TREATMENT OF VASCULAR NEOPLASMS BY INJECTION OF WATER AT HIGH TEMPERATURE. WYKTH S UPERATIUN, Description. — This method of treatment consists in the injection into the substance of vascular neoplasms (angeiomata) of water at a temperature of from igo° to 212° F. and over — the object tjeing immediatelv to coagulate the blood and albuminoids of the tissues. The vascular tumors thus far treated by the author of the operation have been arterial angeiomata (cirsoid aneurisms), capillary angeiomata ("' mother's marks"), and venous angeiomata (cavernous na-vi). Instruments. — Syringe with metallic cylinder and an adjustable piston, and needles of various sizes. The water is usually gotten from some im- mediately adjacent vessel in which it has come to a boil, and under all aseptic precautions. In cirsoid aneurisms and in the larger cavernous na;vi, where the water should be kept at the boiling-point during the use of the needle and syringe, the author of the operation has devised a long metallic instru- ment under the cylinder of which a Bunsen burner is held during operation. Operation. — (1) The region of the injection is rendered aseptic in the usual manner. The operation is done under complete narcosis. The quan- tity and temperature of the water will vary according to the size and nature of the growth. (2) In arterial and venous angeiomata the needle is carried deejjly into the substance of the growth and from 30 to 60 minims of water are thrown out in one site — the needle is then withdrawn from 1.3 to 2.5 cm. (i to I inch) and about the same amount injected — and the same steps repeated in different sites until the whole tumor is solidified. While using water of a temperature sufficiently high to coagulate the blood and albu- minoids of the neighboring tissues, it should not be delivered into the part so exceedingly hot nor with such pressure as to cause subsecjuent sloughing of the overlying parts. Evidence of suflicient distention of the part to dis- continue the injection in that particular site is given by slight bleaching of the skin. (3) In capillary angeiomata, especially upon dehcate parts, water a little below boihng (about 190" F.) should be used — and only about two to si.\ minims thrown in at a single puncture — beginning at the periphery of the growth. Sloughing is more apt to occur in the capillary angeiomata. The injection may be repeated in from seven to ten days, if necessary. (4) A surgical dressing is then applied and the part kept at rest. Comment. — (1) No painful symptom nor septic infection has followed any of the cases except in one instance where the patient passed out from under the observation of the author of the operation. (2) Especial care is advised in the ca.ses of angeiomata of the neck and scalp, because of oedema. (3) Xo more than from el; dissecting forceps; artery- clamp forceps; funnel; rubber tube; bulbous-pointed cannula; aneurism- needle; ligature; suture; needle and holder; constrictor for arm; gauze com- press, cotton and bandage. Operation. — The most prominent vein at the bend of the elbow is chosen (see Phlelxiiomy, page 126). If the vein be prominently marked, incise directly over and parallel with it. If not marked, incise obliquelv across the known course of the median basilic vein, the incision running parallel with the direction of the bicipital fascia. Proceed carefully until the vein is located. Expose from 2.5 to 4 cm. (i to i^ inches) of the vein. Pass two catgut ligatures beneath the vein, about 2.5 cm. (i inch) apart — and tie the distal one permanently (Fig. 71). With a pair of sharp-pointed scissors, curved on the fiat, an oblique incision is made through one-half of the vein, between the two ligatures, the apex of the " V " pointing distally. Into this INTRAVENOUS INPL'SION OF NORMAL SALT SOLUTION. 13 1 oblique opening into the vein, the cannula (after seeing that no air is in the instrument) is introduced — and the proximal ligature is tightened about it with a friction-knot. Through this is allowed to flow, by static pressure, as much lluid as is indicated (generally from one to six pints). The cannula is then withdrawn — the proximal ligature is tightened and tied permanently Fig. 71. — INTRAVENOI'S IxFL'SION OF NoR.MAL SALT SoLL'TIo.N : — A. Bandage tourniquet ; H, Median basilic vein; C, Distal (to heart I ligature tied about vein ; D, Proximal (to heart) ligature loosely placed and ready to be tied about vein ; E. Forceps grasping tongue of wound in vein just made by curved scissors ; F, tip of cannula about to enter vein and around which ligature will be tied ; G, Stop-cock. — and the vein completely severed. The wound is sutured and the dressing a])plied. Comment. — The fluid may be thrown into an open vein in a stump — or any convenient vein in a wound may be opened. The basilic vein itself may be used — or the internal saphenous. CHAPTER III. OPERATIONS UPON THE LYMPHATIC GLANDS AND VESSELS. SURGICAL ANATOMY OF THORACIC DUCT. Course and Relations. — (i) Abdominal portion: — (from origin to dia- phragm) ; — Begins in abdomen al receptaculum chyli, on anterior surface of second lumbar vertebra, lying behind and to right side of aorta and between aorta and right crus of diaphragm. At aortic opening in diaphragm (in front of twelfth dorsal vertebra) it still lies to right of aorta and has vena azygos major to its right. (2) Thoracic portion : — (from diaphragm to superior thoracic opening); — Runs up ])osterior mediastinum between aorta and vena azygos major, in front of sixth to twelfth dorsal vertebrae. Opposite to tilth dorsal vertebra it passes to left behind esophagus and aortic arch to enter superior mediastinum, whence it emerges through superior thoracic opening into root of neck, (a) In Posterior Mediastinum (from below upward) — Anteriorly ; pericardium ; esophagus; arch of aorta. Posteriorly ; si.xth to twelfth dorsal vertebn-e; anterior common ligament; right inferior intercostal arteries; vena azygos minor (sometimes one of left middle inter- costal veins and vena azygos tertia). Left; thoracic aorta. Right; vena azygos major; right pleura, (b) In Superior Mediastinum; — anteriorly; first part of left subclavian artery. Posteriorly; upper dorsal \ertebra? (first to fifth.) Left; left pleura. Right; oophagus. (3) Cervical por- tion : — (from superior thoracic opening to termination) ; — From superior thoracic opening it ascends on left side of neck to level of seventh cervical vertel^ra — curxes thence downward, forward, and outward, arching over apex of left pleura — passing in front of subclavian artery, scalenus anticus muscle, vertebral vein — and behind left internal jugular vein, and behind and then externally to left common carotid artery — and, receiving left jugular lym])hatic trunk, empties into left innominate vein at junction of left internal jugular and left subclavian veins. Course and Relations of Right Lymphatic Duct.— .About 1.3 to 2 rni. (i to J inch) in length— formed by union of subclavian and jugular lymjihalic ducts — pa.sses downward and inward — and empties into venous circuLition at junction of right internal jugular and subclavian veins. SUTURE OF THORACIC DUCT. Description.— Suture of the thoracic duct is indicated in wounds of the duct (iccurring from external injury, or in the course of an operation. Operation.— The method of suturing the thoracic duct is similar to that employed in suturing a vein (see Phleborrhaphy, page 126). Having comjjleted the technic of suturing the duct itself, the neighboring tissues should be drawn over and sutured about the wound in the" duct, to aid in closing and reinforcing the sutured site— and the overlying skin should be 132 SURGICAL ANATOMY OF ANTEROLATERAL ASPECT OF NECK. 133 sutured throughout and pressure appHed. Minimum nourishment should be administered to the patient, to keep the duct as empty as possible until union of the wound has occurred. Comment. — If possible, the right duct should be similarly dealt with. LIGATION OF THORACIC DUCT. Description. — The thoracic duct, where completely severed by accident, has been liguted, and recovery has followed — although there has been a question as to whether, in such cases, a branch of the main duct has not existed and maintained the circulation. Suturing, however, is alwavs prefer- able to ligation, where possible. Where ligation is performed, the technic is the same as that for ligating a vein (pages 127 and 128). Comment. — The right lymphatic duct may also require ligation if its divided ends be discovered in a wound. SURGICAL ANATOMY OF ANTEROLATERAL ASPECT OF NECK. Boundaries of Antero-lateral Aspect of Neck. — Superiorly : lower border of btidy of inferior ma.xilla, and imaginary line from angle of inferior maxilla to mastoid process. Interiorly : upper Iwrder of clavicle. Ante- riorly : median line of neck. Posteriorly : anterior border of trapezius. Subdivisions of Quadrilateral Surface of Neck. — (a) Anterior Triangle — divided, by digastric muscle above and anterior belly of omohyoid below, into submaxillary, superior carotid, and inferior carotid triangles, (b) Posterior Triangle — divided, by posterior belly of omohyoid, into occipital and subclavian triangles. Anterior Triangle. — Boundaries, anteriorly: median line of neck, from chin to sternum. Posteriorly : anterior margin of sternomastoid muscle. Superiorly: lower border of body of inferior maxilla, and line from angle of inferior maxilla to mastoid process (base). Inferiorly : at sternum (apex). This triangle is subdivided into submaxillary, superior carotid, and inferior carotid triangles. Submaxillary Triangle. — Boundaries : Superiorly — lower border of inferior maxilla, and line from angle of inferior maxilla to mastoid process. Inferiorly — posterior belly of digastric and stylohyoid, .\nteriorly — anterior belly of digastric (or middle line of neck). Coverings: integument; super- ficial fascia; platysma; deep fascia; branches of facial nerve; branches of superficialis colli nerve. Floor: anterior belly of digastric; mylohyoid; hyoglossus. Contents : Muscles — styloglossus, stylopharyngeus. Ligaments — stylomaxillary (separating anterior from posterior part of triangle). Ar- teries — external carotid, posterior auricular, temporal, internal maxillary, mylohyoid branch of inferior dental, facial with submaxillary and submental branches, internal carotid. \'eins — internal jugular, facial, submaxillary. Nerves — facial, pneumogastric, glossopharyngeal, mylohyoid branch of in- ferior dental. Other Structures — parotid gland, submaxillary gland, lymph- atic glands. Superior Carotid Triangle. — Boundaries: Superiorly — posterior belly of digastric. Inferiorlv — anterior belly of omohyoid. Posteriorly — anterior border of sternomastoid. Coverings: integument; superficial fascia; pla- tysma; deep fascia; branches of facial nerve; branches of superficialis colli T^4 OI'KKATKiXS rPl)X TllK LVMI'IIATIC GI.AXDS AND VESSELS. nerve. Floor: parts of thyrohyoid; hyoglossus; inferior constrictor of pharvnx; middle constrictor of pharynx. Contents: Arteries— common carotid; internal carotid; external carotid; superior thyroid; lingual; facial; occipital; ascending pharyngeal. \'eins — internal jugular; superior thyroid; lingual; facial; occipital (sometimes); ascending pharyngeal. Nerves — descendens hvpoglossi; hypoglossal; pneumogastric; sympathetic; spinal accessory; superior laryngeal; external laryngeal. Other Structures — larynx; pharynx; lymphatic glands. Inferior Carotid Triangle. --Boundaries : Superiorly — anterior belly of omohvoid. .\nteriorly— middle line of neck. Posteriorly — anterior margin of sternomastoid. Coverings: integument; superficial fascia; platysma; deep fascia; descending branch of superficialis colli nerve. Floor: scalenus anticus (superiorly and externally); longus colli (inferiorly and internally); rectus capitis anticus major (between and sujjeriorly) ; vertebral artery and vein (between and inferiorly). Contents: Muscles — sternohyoid; sterno- thyroid. Arteries — common carotid (not strictly); inferior thyroid; vertebral. Veins — internal jugular. Nerves — ^pneumogastric; descending filaments from loop between descendens and communicans hvpoglossi; recurrent laryngeal; sympathetic. Other Structures — larynx; trachea; thyroid gland; lymphatic glands. Posterior Triangle. — Boundaries : Anteriorly — posterior border of sternomastoid. Posteriorly — anterior border of trapezius. Sujieriorly — occiput (ai)ex). Inferiorly — superior border of clavicle (base). This triangle is subdivided into the occipital and subclavian triangles. Occipital Triangle. — Boundaries : Anteriorly — posterior border of sternomastoid. Posteriorly — anterior border of trapezius. Inferiorly — posterior belly of omohyoid. Coverings: integument; superficial fascia; platysma; deep fascia. Floor: splenius capitis; levator anguli scapulas; middle scalenus; posterior scalenus. Contents : .\rteries — transversalis colli. Veins — transversalis colli. Nerves — spinal accessory; descending branches of cervical plexus. Other Structures — lymphatic glands. Subclavian Triangle.— Boundaries :— Posteriorly — posterior belly of omohyoid. Inferiorly — upper liorder of clavicle. Anteriorly — posterior border of sternomastoid (base). Coverings : — integument; superficial fascia; platysma ; deep fascia ; descending branches of cervical plexus. Floor : — first rib. first serration of serratus magnus. Contents : — Arteries — subclavian (third part); suprascapular; transversalis colli. \'eins — subclavian (some- times); suprascapular; transversalis colli; external jugular; small vein from cephalic to external jugular. Nerves — brachial plexus, small nerve to sub- clavius. Other Structures — lymjahatic glands. Lymphatic Glands of Head and Neck.— Consist of superficial and deep glands. (A) Superficial glands of head and neck: — Consist of transverse and vertical sets, (i) Transverse set of superficial glands: — Extend transversely from occiput along mastoid process, zygoma, and lower border of jaw, to symphysis menti, and comprise following groups; — (a) Oc- cipital or Subocci])ital — below sujjcrior cur\ed line of occipital bone, between skin and insertion of complexus muscle, (b) Posterior Auricular, or Sterno- mastoid— behind ear, between skin and insertion of sternomastoid. (c) Parotid — in front of ear, between skin and jiarotid gland, some being embedded within parotid gland, (d) Buccal — on surface of buccinator, between it and skin, (e) Submaxillary — in digastric triangle, between skin and mylo- hyoid and hyoglossus. (f) Suprahyoid— in middle line, between anterior bellies of digastric, between skin and mylohyoid. (2) Vertical set of super- REMOVAL OF LYMPHATIC GLANDS OF NECK. 135 ficial glands (superficial cervical chain) : — (a) Anterior — in front of neck, between hyoid bone and sternum, and between skin and superficial muscles, (b) Middle (superficial cervical chain) — chiefly along e.xternal jugular vein, mainly in posterior triangle of neck, between platysma and deep cervical fascia, (c) Posterior — over trapezius, between it and skin. (B) Deep glands of head and neck: — Comprising those of head and neck. (1) Those of head : — Consisting of following groups; — (a) Lingual — on external surface of hvoglossus and geniohyoglossus. (b) Internal Maxillary — on lateral aspect of pharynx, behind buccinator muscle, (c) Posterior Pharyngeal — between posterior surface of pharynx and rectus capitis anticus major, near base of skull. (2) Those of neck : — Consisting of following sets; — (a) Superior set — along internal jugular vein, from base of skull to level of thyroid cartilage, (b) Inferior set — along internal jugular vein, from thyroid cartilage ta near clavicle. REMOVAL OF LYMPHATIC GLANDS OF NECK. General Considerations. — In the case of diseased cervical glands, an operation may be undertaken — (1) for the removal of one or a few defined glands, in one or more of the regions of the neck, in which case a single or .several incisions, more or less limited, are so placed as most readily and safelv to expose the involved glands; — or (2) for the removal of glands widely, deeplv, and indistinctly disseminated throughout the antero-lateral aspect of the neck, in which case one or more extensive incisions are necessary, both for the removal of the glands and in order to give room in which to safeguard important structures during their removal. Removal of dis- seminated cervical glands will be first described — and removal of isolated glands will he referred to under Comment. Indications for Removal of Cervical Lymphatic Glands. — Chronic tubercular adenitis (most frequently); acute non-tubcrcular suppurative adenitis; enlargement secondarily from neighboring malignant growths. Preparation. — Shaving of all hairy parts at site of and bordering upon field of operation. Position. — Patient supine; shoukiers raised; neck resting over a support, to render it prominent; head so turned as to increase prominence, length, and width of neck, and in order to drag glands out from under protecting tissues. Surgeon on side of operation; assistant opposite. Landmarks. — The triangles of the neck. Instruments. — Scalpels; scissors, straight, curved, blunt and sharp; dissecting forceps; toothed forceps; artery-clamp forceps; blunt dissector; retractors; tenacula; grooved director; aneuri-m needle; needles; needle- holder; sutures; ligatures; sterilized water on hand to flood neck in case of opening large vein in an inaccessible locality. Incision. — Various forms of incision have been used, singly or combined. Where the entire antero-lateral aspect of the neck is to be exposed, a X-shaped incision (Fig. 72) may be used — BC extending from over the mastoid process to the interval between the sternal and clavicular attachment of the sterno- mastoid, passing down the middle of the sternomastoid or along its anterior border — B\ extending transversely forward from the upper end of the oblique incision to the angle of the jaw, and thence along the lower border of the jaw to the symphysis — CD extending transversely outward along the upper border of the clavicle, as far toward the acromioclavicular articulation as necessary. If only the anterior triangle of the neck be involved, the por- 136 OPERATIONS UPON THE LYMPHATIC GLANDS AND VE:SSELS. tion ABC of the incision is alone used — if the posterior triangle, the portion BCD. Operation. — (1) Incise directly through skin, superficial fascia, platysma, and deep fascia — the diagonal portion of the X-shaped incision being first made; that is, the portion over the anterior border of the sternomastoid. Sever the external jugular vein between two ligatures. Branches of the superficialis colli nerve will be cut, but the auricularis magnus and occipitalis minor should be retracted backward, if exposed. This incision is carried down to and exposes the whole length of the sternomastoid muscle. (3) Carry the upper incision transversely downward to the angle of the jaw, FiR. 72.-IN, anterior bordci • origins of stem.. i its lower border . Anterior triangk- Entire antero-latcral aspect removing r,H. parallel with poste oblique in l..wer part "f :posed by j-iaterai aspect oi neck, by raising bolli ilated groups of glands; EF, Incision p: with iiosterior border; IJ, Transverse obliq II Mir CrANDS OF Cervical RKr,ioN:-BC, Line over 'I'l I'l --s to interval between sternal and clavicular "Hi )>ii'. < ss to angle of jaw, and thence forward along iLir . 11 1 iLulation outward along upper hnnh-r r.f clavicle, ng llap ABC; Posterior triangle, bv r.ii^iir.; II. i|. I!CD; illg both flaps. Following incisions in.n 1., iis, d for •'-'- -Ilel with anterior border ..i st. rii..Mi.isioid ; upper part of neck; KL. Transverse and then forward along the lower border of the inferior maxilla toward the symphysis, passing through the skin, superficial fascia, platysma, and deep fa.sc!a— and exposing, without injury, the parotid gland, facial nerve, tribu- taries of lemijoromaxilktry vein, facial artery and vein, submaxillarv and submental glands. The facial artery and vein may be divided between two ligatures, if necessary. (3) The lower incision is' now carried transversely along the upper border of the clavicle, as far toward its outer end as necessary —passing through skin, superficial fascia, platysma, and deep fascia- dividing some of the descending superficial branches of the cervical plexus and a few minor vessels. (4) Having now completed these three incisions. REMOVAL OF LYMPHATIC (;LAXDS OF \ECK. 137 two triangular flaps are carefully dissected up and turned aside — an anterior flap (ABC), ha\ing the same boundaries as the anterior triangle of the neck, is turned forward, hinging on the anterior median line of the neck — and a posterior flap (BCD), having the same boundaries as the posterior triangle of the neck, is turned backward, hinging on the anterior margin of the tra- pezius (or on a line posterior to that, if the lower transverse incision have been extended posteriorly to the acromioclavicular articulation). Thus, the superficial parts having been turned aside, the entire antero-lateral quadri- lateral surface of the neck is exposed on a plane with the important structures and in easy access to those structures. (5) All glands are now dissected out, together with their surrounding connective tissue — being sought in the locali- ties indicated in the above summary (see Lymphatic Glands of Head and Neck, page 134) — guarding, at the same time, the important anatom-ical structures enumerated under Surgical Anatomy of the Triangles of the Xeck. (6) If avoidable, the sternomastoid should not be cut — it generally being possible, in such a free exposure, to retract it alternately well forward and backward in order to remove the glands partly or entirely covered by it, slightly flexing the chin on the sternum to lessen tension, ^\'here, however, it proves a barrier to thorough and safe work, it should be unhesitatingly severed — the emergence of the spinal accessory nerve from its posterior border being exposed, and the muscle divided trans\'ersely below the nerve The up])er end of the muscle is then turned upward and backward with the uninjured nerve, and the lower end downward and forward — and the important structures beneath it thus easily brought to view. (7) In com- pleting the operation, the cut ends of the sternomastoid should be carefully sutured with interrupted buried catgut sutures. The flaps are now turned back into ])lace and sutured throughout — the flaps being sutured to each other first, then along the superior transverse line, and, last, along the inferior transverse line — the wound being closed throughout with silkworm-gut or silk — and firm pressure, to occlude dead spaces, made in the dressing. The neck and head are steadied in some form of retentive apparatus until union has occurred. Removal of Isolated Lymphatic Glands of the Neck. — These isolated glands will belong to one of the groups of superficial or deep glands given, with their relations, upon a ]jreceding page. The position, direction, and extent of the incision for their exposure will be determined by the special group of glands involved and the extent of the involvement — the general rule being that the incision is so placed as to reach the site most readilv and with greatest safety to neighboring structures — and may be a single vertical, transverse, or oblicjue straight incision, making an opening whose lips have to be retracted to expose the parts; — or a combination of these; — or a curved incision, thereby forming a flap, which is temporarily turned back. The two most generally used forms of incision, however, are those which are mere or less parallel with one of the borders of the sternomastoid (Fig. 72, EF or GH) — or more or less parallel with the natural obliquely transverse crease crossing the neck about on a level with the h\'oid bone, in the cleax'age line of the skin (Fig. 72, IJ or KL). The incision may be placed over the submaxillary, superior carotid, or inferior carotid triangle, of the anterior triangle of the neck, or over the occipital or subclavian triangle, of the posterior triangle — or over the posterior aspect of the neck, between the anterior border of the trapezius and the posterior median line, and between the superior border of the scapula — or may involve several triangles. Comment. — (i) Great care is necessary in removing glands from thin- i;,S OI'KKATKIXS LI'ON THE LYMPHATIC GLANDS AND VESSELS. walled veins. Should a vein be wounded, the opening should be caught up instantly and laterally ligated, if the wound be appropriate, or sutured, or even transversely ligated. If so situated that closure cannot be immediately made, the part should be flooded with water, so that water stands over the open vein, to prevent the drawing-in of air until the vein can be secured. (2) The important nerves are to he particularly guarded. (3) The arteries and arterial hemorrhage give far less concern than the veins and venous hemorrhage. (4) It is better to dissect the glands out in masses or chains, together with their adherent connective tissue — invisible, impalpable g'ands being thus more thoroughly removed. (5) Glands should be removed w-ith their capsules intact. (6) The sternohyoid and omohyoid may also be divided and subsequently sutured. (7) All bleeding should be immediately con- trolled as encountered, and ligated as soon as convenient. SURGICAL ANATOMY OF AXILLARY REGION. Description. — The a.xilla is a pyramidal space between the upper lateral wall of thorax and inner wall of arm — its apex corresponding with interval between first rib on inner side, cla\'icle in front, and upper edge of scapula behind; — its base, broad at chest and narrow at arm, is com|)osed of skin and dense fascia, extending between inferior border of pectoralis major in front, and inferior border of latissimus dorsi behind. Boundaries. — Anteriorly — pectoralis major (throughout) ; pectoralis minor (its center). Posteriorly — subscapulars (above); teres major and latissimus dorsi (below). Internally — first to fourth ribs; first to third intercostal muscles; serratus magnus. Externally — humerus; coracobrachi- alis; biceps. Contents. — Arteries : — axillary (along external wall, nearer anterior than posterior boundary); superior thoracic; acromial thoracic; long thoracic; alar thoracic; subscapular; anterior circumflex; posterior circumflex. Veins : — axillary (to inner side of axillary artery) ; receiving vena; comites of brachial artery and tributaries of branches of axillary arterv. Nerves: — brachial plexus lies to outer side of first part of axillary artery; — the second part of axillary artery has the outer, inner, and posterior cords of plexus in the rela- tions expressed by their names;— the third part of the arterv has, anteriorlv, inner head of median nerve; posteriorly, musculospiral and circumflex; externally, median, musculo-cutaneous; internally, ulnar, internal cutaneous, lesser internal cutaneous. Posterior thoracic (on serratus magnus). In- tercosto-humeral. External and internal anterior thoracic, crossing in front and behind axillary artery respectivelv. Glands : — see below. Axillary Lymphatic Glands. ~-.\re arranged in four groups: (a) .\xillar\ glands proper — median set; three or four in number; along axillary artery and vein, (b) Pectoral glands; inner or anterior set; four or five in number; along long thoracic artery, below great pectoral muscles and on serratus magnus. (c) Subscapular glands— external or posterior set; two in number; along subscapular artery, under latissimus dorsi. (d) Subclavian or infra- clavicular — superior set; two in number; near cephalic vein; just below clavicle in fossa under pectoralis major and deltoid, upon costocoracoid membrane. Axillary Lymphatic Trunk.— Efferent trunk from above sets of glands — runs upward along subclavian vein — emptying into thoracic duct on left, and into right lymphatic duct on right. REMOVAL OF AXILLARY LYMPHATIC GLANDS. 139 REMOVAL OF AXILLARY LYMPHATIC GLANDS. Description. — The removal of the axillary glands is clone, in the majority of cases, in connection with the removal of neighboring malignant growths, especially those involving the breast — and, in such cases, the incision for exposing the axillary region is merely a prolongation into the axilla of the incision for the original operation. The steps, therefore, of the operation for the removal of these glands will be found sufficiently described under the operations for the radical removal of the breast (pages 5S2 to 5^5). Where it is planned to remove enlarged ax- illary glands alone and as a distinct operation, the incision is placed over the involved glands (Fig. 73). SURGICAL ANATOMY OF SCARPA'S TRIANGLE. Description. — .\ triangular area just below fold of groin. Boundaries. — Base (above) ; Poupart's ligament. Externally; sartorius. Internally; adductor longus. .Apex (below) ; junction of sartorius and adductor longus. Roof. — Skin; superficial fascia; fascia lata. Floor. — (From without in- ward.) Iliacus; psoas; pectineus; adductor brevis; adductor longus. Contents. — -Arteries; common femoral (from middle of base to apex); superior epigastric; superfi- cial circumtlex iliac; superficial ex- ternal pudic; deep external pudic; profunda femoris. \"eins; femoral (to inner side of artery); profunda femoris; tributaries of branches of femoral; internal saphenous. Nerves; anterior crural (to outer side of artery) ; crural branch of genitocrural; external cutaneous. Lymphatics; superficial and deep glands. Inguinal Lymphatic Glands. — Consist of two following sets; (1) Super- ficial Glands; ( )l)li(iuc or Inguinal Set — along Poupart's ligament, u]ii)n fascia lata. \'ertical or Saphenous Set — around saphenous opening and ujion fascia lata. (2) Deep Glands; along upper part of femoral vessels, one or jnore being within femoral canal. 73. — Incision for Exposing "ic Glands : — Passing bttwt pectoral muscles, in front, and the scapula posteriorly, to which may be added one c cisions at right angle, extendinij either in behind the main incision. I40 (M'KRATIONS UPON' •rilE l.VMI'llATir GLANDS AND VESSELS. REMOVAL OF INGUINAL LYMPHATIC GLANDS. Description. — The operation will differ according to site and amount of glandular involvement— and the lines of incision are given accordingly. Indications.— Glands enlarged or broken down as a result of venereal disease; tubercular glands; simple, chronic, and suppurative adenitis; malig- nant involvement. Preparation. — Groin shaved. Position. — As for ligation of femoral artery at base of Scarpa's triangle (pa.ge Q5). Landmarks. — Given under Sur- gical .\natomy of Scarpa's Triangle. Instruments. — As for removal of cervical glands (page 135). Incisions. — (i) Where the ob- lique (superficial) set of glands are involved — an incision may be made parallel with and just below Pou- part's ligament, wdth its center over the enlarged glands (Fig. 74, .\). (2) Where the x'ertical (superficial and deep) sets are involved — the in- cision is made along the course of the femoral artery, with its center ()\er the enlarged glands (Fig. 74, B). (See ligation of comrrion fem- oral at base of Scarpa's triangle, page 95.) (3) Where all three sets are involved — the incision may be a combination of the above two, being somewhat T-shaped. Operation. — Divide skin and superficial fascia in the direction or directions indicated above. The superficial vessels encountered are ligated. The superficial glands (ob- lique and vertical sets) will be found upon the fascia lata, in the posi- tions indicated. To reach the deep glands (lying along the great vessels) the fascia lata is incised in the line of the femoral artery (as for ligation of that artery). Important structures are to be avoided and the glands sought along the course of the artery and vein. The general principles mentioned under the removal of cervical lymphatic glands are applicable here — and elsewhere, wherever glandular tissue is removed. Fig. 74.— Incisions for Expn Lymphatic Glands:— A, Obliqui below find parallel witli Poupart' oblique superficial set of jjlainis ; cision over fcuioral artery, for y i and dee]) set.s. A T-shaped iucisii. by uniting these, where all three- ^^ l CHAPTER IV. OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. Note. — The operations which may be performed upon Nerves, Plexuses, and Ganglia will be first described — and then the operations for the exposure of the more important nerves, plexuses, and ganglia will be given. Having exposed a nerve, any of the operations about to be described may be applied to it, as indicated. NEUROTOHY. Description. — Section of a ner\e. Neurotomy may be transverse {e. g., as when performed for neuralgia of a sensory nerve, or spasm of a motor nerve); — or longitudinal (e.g.. as done in some cases of neurorrhaphy and neuroplasty). Indications. — Neuralgia of sensory nerves; spasm of motor nerves; preliminary to neurorrhaphy or neuroplasty. Preparation — Position — Landmarks — Surgical Anatomy —Incision. — Determined by the special nerve involved. ,^!: ^^1 ^^S^^TOWSS**** F'g- 75- — NErROToMV of Supraorbital NERVt Operation. — Having exposed and isolated the individual nerve, it is lifted from its bed by forceps "and divided with a scalpel or scissors. The cut ends are allowed to fall back into place — or, better, should be so dropped back into the wound as to make re-union unlikely. The wound is closed as usual. No s])ecial after-treatment is carried out (Fig. 75). Comment. — Chiefly applicable to smaller sensory nerves — and, rarely, smaller mott)r nerves. Not generally successful in neuralgias. 141 14-2 OPERATIONS UPON THE NERVES. PLEXUSES, AND GANGLIA. NEURECTOMY. Description. — Exxision of a nerve. Neurectomy may be partial or com- plete. .\s ordinarily performed, only a small part of the length of the nerve is remoxed. Preparation — Position — Landmarks — Surgical Anatomy — Incision. — Determined by the special nerve. Indications. — Neuralgia of sensory nerves; spasm of motor nerves. "^"VlW***^ Fig. 76. — Nei-recto Operation.— The nerve having been exposed and brought well into the field, is lifted out of its bed with forceps — and from 2 to 3 cm. (i to ij inches) of its trunk is excised with scalpel (preferable to scissors, which partly crush). The ends are then allowed to drop back into position— and the wound is closed (Fig. 76). Comment. — Total excision is most frequently done liy avulsion (page 143). NEURECTASY. Description. — Nerve-stretching. Indications. — Neuralgia of sensory and sj)asm of motor nerves. Preparation— Position— Landmarks Surgical Anatomy— Incision. — Determined by the ner\e ojierated ujxin. Operation.— The ner\e is freely exposed and separated bv blunt dis- section sufficiently for manipulation. Small nerves are stretched by means of a nerve-hook inserted beneath them. Large nerves are stretched by being grasped between thumb and finger— the nerve is steadily and evenly pulled from its center for about five minutes— then from its periphery for about five minutes. The extremes of force emjjloyed mav be represented by a pull of a half-pound for the supraorbital— and from' thirty to sixty pounds (according to the judgment of the operator) for the sciatic. The' manipu- lation is done with as limited d'sturbance to the surrounding structures as possible. After the stretching, the nerve is dropped back into place and the incision closed. In the after-treatment, the part should be immobilized until union of the wound occurs. Temporary paralyses of motion and sensation are to be expected (Fig. 77). NERVE AVULSION. 143 Fis. 77. — Newrectasv of Infraorrital Nervk. Comment. — Sensory nerves seem more dulled by traction in a direction away from the cord — motor nerves more dulled by traction toward the cord. NERVE-AVULSION. Description. — The tearing away of a nerve from its central and peripheral connections. Indications. — Neuralgia. Chiefly used upon branches of the fifth nerve. Preparation —Position — Landmarks — Surgical Anatomy — Incision. — Determined bv the special nerve. Fig. 7S. — Nerve-avi'lsion of Inf Operation. — Having exposed the nerve involved, it is grasped by catch- force[)s (t'lrmly, but not strongly enough to crush and break it) — and then slowly wound around the forceps (by twisting the latter between the fingers) — until the nerve is torn away from its connections, both proximally and distallv. Branches of the nerve are also sometimes avulsed, to a greater or 144 OPERATIONS UI'ON THE NERVES, PLEXUSES, AND GANGLIA. less extent along with the main trunk — as well as a [lart or the whole of a ganglion. The nerve may, also, be partly cut — either distally (generally) or peripherally. The wound is closed throughout, in the usual manner (Fig. 78). NEURORRHAPHY. Description. — Suturing of nerve which has been partiallv or entirelv divided. Neurorrhaphy may be primary, or immediate, where the nerve is sutured at once, — or secondary, where the suturing is done subsequent to repair of injury. Indications. — Repair of injurv to nerve. Neuroplastv. Preparation — Position — Landmarks — Surgical Anatomy — Incision. — Determined bv the nerve involved. Operation of Primary, or Immediate, Neurorrhaphy. — The severed nerve-ends are e.xposed in the wound and brought well within reach. See if they be cleanly cut. If not, gently grasp them with forceps and cut tliem cleanly, and preferably transversely, with a sharp knife, with a minimum sacrifice of nerve-tissue. The ends are brought and held in apposition, in their normal relations, anterior aspect to anterior as]ject, and the like. If Figs. 79-83.— Mi-;rHoDS passing tlirough e nt'r\-e-sheaUi only. the ends cannot be approximated, flex or extend the limb to increase the length, or stretch both ends gently (preferably grasping them with the fingers). It is desirable that there should be no tension upon the sutures. The junction is made with a fine cambric needle threaded with fine chromic catgut and held in a needle-holder. One of several methods of suturing may be adopted; —(a) The sutures may be passed entirely through the sheath and nerve, in two or more directions, and about 5 mm. (i inch) from the ends. The needle passes from before backward through the entire thickness of the proximal end— then similarly through the distal end, from behind forward— and the suture is tied lightly, so as not to have tension. A second suture may be ajjplied antero-posteriorly, or laterally — and as many as seem needed accurately to coapt the ends. This is the most general' method of nerve- suturing (Figs. 79-81, A, 15, C). (b) Sutures may be passed through the NEURORRHAPHY. 145 nerve-sheath alone, encircling the nerve proper. This is the preferable operation — l>ut is possible only in large nerves (Figs. 82-S3, D, E). (c) Part of the sutures may pass thnugh the nerve and sheath (as in a) — and part through the sheath only (as in b) (Figs. 84-S6, A, B, C). (d) After Figs. S4-SS.— Methods of Nerve Suturing :— II.— -\. B, Sutures passing through sheath and part of nerve; C. Sutures through sheath, reinforced by relaxation-suture through entire nerve; D, Nerve cut obliquely and united by suture through sheath and part of nerve ; E, Same with rela.xation- paring the larger end, it may be split down its center for about 1.3 cm. (i inch) — the smaller end maybe beveled on tvvo sides and sutured between the lips of the split end (Fig. 93, A), (e) One end may be beveled on its Figs. S9-92.— Methods of XERVE-strvRlsc :— III— .^. Reinforcing through-and-through suture ■ lateral suture through loops ol first suture; B, C. D. Union by approximation of lateral aspects of rr\-e, after freshening. upper surface, the other on its lower surface — the two freshened surfaces are then placed in contact and sutured through and through (Figs. 87 and 88, D, E). This requires a greater length of nerve than some of the other methods. Other methods are shown in Figs. 89 to 92, and 94 and 9:5. 146 OPKKATIONS I'I'OX THE NEKVKS, PLEXUSES, AM) GANGLIA. Having completed the union of the nerve-ends, the wound is sutured and the limb immobilized so as to minimize tension for about ten days — the part is then gently massaged daily and the splint reapplied between times and not removed for about six weeks. Primary union is particularly to be sought. The restraining splint should be such as will hold the part so that the nerve will he rela.xed. Operation of Secondary Neurorrhaphy. — Having applied Esmarch's bandage, one may cut directly down upon the supposed site of the nerve -ends. It is better, however, deliberately to incise for and e.xpose both pro.ximal and distal nerve-trunks, above and below tlie involvement, on anatomical grounds. Much difficulty may be e.xperienced in finding the nerve-ends, unless traced down and upward, as the case may be, from the nerve-trunks. The proximal end is easier to find, and apt to be bulbous and sensitive. The distal end is apt to be atrophied. Sufficient freeing of the nerve-ends to enable them to meet is necessary. While in primary suturing the se\ered ends may or may not require trimming before suturing, in secondary suturing they are, in ad- dition to being freed from connective tissue, always to be excised. Having identified the nerve-ends, dissect away all intervening fibrous tissue. With a sharp knife cut away trans- versely the proximal end until healthy nerve tissue is reached. In the case of the distal end, simply cut away enough of the upper end to afford good ap- proximation (for degen- erative processes will have extended far down this end under anv cir- cumstances). If the ends can now be made to meet without too mucli ten- sion, they are sutured together by one of the methods described under primary neurorrhaphy. If greater length be necessary, as is almost invariably the case, it may generally be gotten by first carefully stretching the ends -after which they are united by suture. If sufficient length cannot be thus secured, neuroplasty must be done (page i47). Following secondary neurorrhaphy the wound is closed, the limb splinted, and the same after-treatment carried on as after the primary operation— although results are not to be expected so soon. Restoration of function may require from one to two years. Comment.— Where stretching is resorted to to gain length in secondary suturing, it should be ajjplied before excising tlie nerve-ends— traction being made upon the nerve-ends themselves, which are afterward removed. .\nd if tension be too great upon the sutured ends, rela.xation-sutures mav be applied above and below the line of finer approximation sutures. w Figs. 93-95.— Methods of NERVE-SL-TVRiNt; iiig of beveled end between lips of split end ; B, t ing sound upper and lower portions of nerve suturing' contracted portioTi. -IV.— .\, Sutur- Mellu.il of unit- by splitting and NEUROPLASTV. 147 NEUROPLASTY. Description. — The union of severed nerve-ends by processes of plastic elongation of the nerve itself, — or by the interposition of nerve or other Figs. 96-99. — Nel'Roplasty : — I. — A. B.Union by splitting both eiuls of nei enci-to-end ; C. D. Same, with split ends united lateral id uniting split ends material — in cases where the loss of nerve-substance is so great that the severed ends cannot be brought and held together by the ordinary methods Figs. 100-103.— Neukoplasty ;— II. — A, Splitting < to lateral aspect of opposite entire end ; B. Same, wit! of bulbous ends. id. with union of lateral aspect of split end n end-to-end ; C, D, Same as in B, in case Figs. 104-106. — N splitting both ends, end; C, liiterpolatic LASTV:— III.— A. B. Doiibly inion of split ends end-to- 148 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. of suturing. The object sought is the supplying of a substance between the cut ends along which the nerve-fibers may grow from the proximal to the distal end (as the tendrils of a vine grow along a trellis) Indications. — Where, in primary operations, considerable nerve-substance has been de- stroyed by the cause of the in- jury, — or, in secondary opera- tions, the retraction of the sev- ered ends has been \'ery great — so that by no other means can the ends of the nerves be brought and kept together. Preparation — Position — Landmarks — Surgical Anat- omy — Incision. — Determined by the special operation. Operation. — Having ex- posed and isolated the severed ends, and, in the case of secon- dary operations, freed them from connective tissue and freshened them by partial excision, one of the following means of bringing and holding the ends in contact is resorted to: — (a) .\t points as far from the ends of the nerves as indicated by the length of the intervening space to be filled, divide each nerve half- way, transversely — split each end back to within about 6 mm. (J inch) of its end — bend the two cut portions to- ward each other — and suture them end to end, or laterally (Figs. 96-99, A, B, C, D). In filling smaller gaps, one trunk only may be split — bent back to the other end — and both freshened and sutured (Figs. 100 and loi. A, B). (b) Sections of nerves from a freshlv amputated human limb, or from the lower animals, may be interposed in the gap and sutured at both ends by one of the methods given under neu- rorrhaphy. This interposed part does not grow, but onlv serves the role of a trellis (Fig. io6, C). (c) A solid cyl- inder of decalcified bone may be in- terposed and sutured to the ends of the nerves, (d) Strands of fine catgut may be made to bridge the interval, as a guide to the new nerve-fibers (Fig. 107, A), (e) The i)roximal and distal ends of the nerve may be enclosed in a hollow cylinder of decalcified bone (Figs. 108 and lo-), B, C). (f) Proceed as in Fig. 104, .\— then shift the 107-ioa.— Nei-roplasty :— IV.— A, nion by strands of gut alone; B, C, Same, enforced with decalcified bone cylinder. NEKVE-GKAKTIN'G ; NERVE-IMPLANTATION. 149 cut ends laterally, and approximate as shown in Fig. 105, B. (g) Com- bine methods (d) and (e) — the combined method of bridging with catgut and enclosure in decalcified bone tube. One end of the catgut bridge is slipped through the tube, sutured to the other end, and drawn back within the tube (Figs. 108 and [09, B, C). (h) Shortening of the limb, by resec- tion of its bone or bones, to allow of approximation of the ends of the nerve. (The musculospiral has been thus successfully treated.) Of the above methods, method (a) is the one most generally used. Having com- pleted the neuroplastic operation, the wound is closed and the part immo- bilized in a position to relax the nerve. NERVE-GRAFTING; NERVE-IMPLANTATION. Description. — The grafting of the ends of an injured ner\e into the trunk of a neighboring nerve — the severed upper end being grafted into the intact nerve at a point opposite its level, above — and the severed lower end grafted into the intact trunk opposite its level, below — that is, at points where they can be conveniently brought into contact with the sound nerve. The object sought is to switch the interrupted nerve-stream, or nerve-impulse, from the proximal end of the cut nerve into the neighboring sound nerve — thence to have it conveyed along this used nerve down to the point where Figs. 110-113.— Nervk-grafting :— I. — A, B, Engrafting of freshened lower end of divided median -ve ( for instance y upon intact ulnar nerve ; C, D, Engrafting of freshened upper and lower ends of ided median nerve upon intact uhiar nerve. the distal end of the cut nerve is sutured to the utilized nerve — and thence returned to the original nerve and transmitted along the distal portion of the cut nerve to its final distribution, as though no interruption to its normal course and transmission had occurred. An illustration would be a divided median nerve and an intact ulnar nerve — where the upper end of the median ner\-e is sutured to the upper part of the ulnar — and the lower end of the median to the lower part of the ulnar (Figs. 112 and 113, C, D). The object finally sought is to have nerve-fibrils grow down this nerve from the proximal ISO OPERATIONS UI'OX THE NERVES, PLEXUSES, AND GANGLIA. cut end to the distal cut end. The method is of limited application, because of the necessity of finding large nerves in close proximity — the upper ex- tremity being about the only locality in which the method can be utilized (Figs. 114 and 115). Preparation — Position — Landmarks — Surgical Anatomy — Incision. — Determined by the individual operation. Operation. — E.xpose, isolate, and excise the proximal and distal ends of the severed nerve, supposing it to be a .secondary case. Also through Figs. 114 ami lis.— Nerve-grafting :— II.— A ^o left). Showing ulnar and niedi; at diBeienl heights; B (to right). Union of upper end of median to lower end of uln engrafting of upper end of ulnar and lower end of median into this new trunk the original incision, expose the neighboring nerve upon which the grafting or implantation is to be made. By means of curved scissors, remove a limited portion of its sheath, on the lateral aspect of the nerve, at the sites where the upper and lower severed nerve-ends are to be grafted. The obliquely or transversely divided ends of the involved nerve are to be sutured to the denuded lateral aspect of the intact nerve, above and below, bv fine chromic sutures passing through the sheath of the nerve-ends, on the one hand, and through the sheath and part of the thickness of the intact nerve at the INTRAXEURAL IXFILTRATIOX FOR REGIOXAL AXESTHESIA. 151 bared sites, on the other hand. Having completed the nerve-suturing, if the neighboring parts have been disarranged, these should be rearranged — bv buried catgut sutures, if necessary. The wound is then closed throughout. The part should be immobilized in a position of relaxation of nerve-tension until union has occurred — and subseijuently treated as described under neurorrhaphy. Comment. — The intact nerve may be split at the two places to receive the freshened severed ends. It seems to make no difference whether a sen- sorv nerve be grafted to a motor or to a mixed nerve — or vice versa. OPERATION FOR RELIEF OF NERVE COMPRESSED BY BONY OR FIBROUS CICATRICIAL TISSUE. Description. — Nerves are sometimes involved and pressed upon in the processes of repair following injury of bones and soft parts, or in the processes of disease, and eventually become so firmly compressed as to have their function impaired — in which case an operation to free them for pressure is indicated. Position — Landmarks — Incision. — Dependent upon nerve involved. Operation. — The steps of the operation will be determined by the position and nature of the compression. Where fibrous cicatricial tissue surrounds the nerve, the mass is to be exposed by dissection — the nerve is to be isolated either above or below the mass and is to be followed through it and dissected out from it. The cause of compression, as far as possible, is to be removed, so as to avoid a recurrence. Where a bony callus surrounds the nerve, this is to be reached by the safest route through the muscular planes — the nerve being similarly isolated above and below the mass — and freed through it. It is often necessary to chisel away as much of the callus as imprisons the nerve — and in order to render a recurrence of compression unhkely. The wound is closed as usual. Comment. — Nerves may be compressed by growing tumors — their reUef being determined by the treatment adopted for the tumor. INTRANEURAL INFILTRATION FOR REGIONAL ANESTHESIA. Description. — The injection of a sterilized anesthetic solution into a nerve-trunk. The injection may be made at the site of the proposed opera- tion, or al)(5\e the site. Indications. — To produce anesthesia in the region supplied by the nerve, for the purpose of operating at any magnitude. Especially indicated in those portions of the body which may be more or less isolated, — and in those cases in which general anesthesia is contraindicated. Position — Landmarks — Incision. — Determined by the special opera- tion. Operation. — The anesthetic fluid may be injected at the site of operation or above it; — (a) Where the Injection is made into the Nerve-trunk above the site of Operation — the anesthesia being produced in the region supplied by the nerve: — (Suppose the injection be made into the sciatic nerve, for amputation of the leg) ; To prepare the way for the incision, anesthetize the skin by intradermal infiltration — and the connective tissue by subdermal (subcutaneous) infiltration. Expose the sciatic nerve above the bifurcation 152 OPERATIONS L'POX THK XKRVES. PLEXUSES, AND GAXGI.IA. into internal and external popliteal and isolate it sufficiently for manipulation. Insert the needle of the syringe through the sheath of the nerve and into and among its fibers — and slowly inject the anesthetizing fluid (the amount determined by the nature of the solution and size of the nerve) until the entire extent of a transverse section of the nerve has been infiltrated or "blocked" Fig. 116.— Intraneural Infiltration for Regional Anfsthesia -.—The great sci iiig here infiltrated. (Fig. n6). If this single injection be considered sufficient to last throut'hout the operation, the wound may be at once clo^^ed— otherwise it is temporarilv packed with gauze. The limb is elevated and exsanguinated bv n. with first division passing through sphenoidal fissure ; second, through foramen rotundum ; third, through foramen ovale ; B, Middle meningeal artery passing through foramen spinosum ; C, Position of cavernous sinus; D. Position of common carotid. The third nerve (above) and fourth nerve (below) are seen passing between the first division of the fifth nerve and the ca\-ernous sinus. The dura mater forming Meckel's space is not here shown. E, Floor of middle fossa. the brain are now separated from the middle fossa of the skull. This is done in the direction toward the apex of the petrous portion of the temporal bone, and is accomplished by the fingers or a piece of gauze, or by a curved, blunt elevator. Sometimes the dura is considerably torn, and sometimes the artery is torn whether the dura is or not, reqiuring temporarv packing of .the bony groove to control the hemorrhage, where ligature is imi)ossible. 158 OPERATION'S UPON THE NERVES, PLEXUSES, AND ClANGLIA. Injured dura should be sutured wherever possible. (8) The three divisions of the nerve are now seen and are traced back from their foramina. The positions of the carotid artery and cavernous sinus are located as nearly as possible, for the purpose of guarding them. (9) Isolate and cut the first, second, and third divisions close to the sphenoidal fissure, foramen rotundum, and foramen ovale, respectively. Secure the pro.ximal ends of the severed nerves with forceps or silk, and, practising traction upon them, trace them back to the gasserian ganglion — after incising the dura mater over them. Then, raising the ganglion from its bed, sever its connections with the brain close to the dura mater, and, if possible, without including or injuring the motor root. (10) At the end of the operation the dura and cerebral convolu- tions are allowed to fall into place — the flap of bone and soft parts is turned up — and sutures applied to skin and muscles. Comment. — (1) The width of the basal line of bone may be decreased by rongeur forceps, thus increasing the likelihood of a clean, transverse breakage — or a Gigli saw may be conducted under the bone at its base and made partlv to divide it. (2) In the use of either chisel or saw, the inner tablet of the skull may be left uncut in two or three places, over a limited extent, so that when the flap is broken back, these parts of the vitreous are hft as shelves for the flap to rest upon when turned back into place. (3) Bleeding mav be so great as compel one to pack and finish the operation in two stages. (4) The advisability of removing the first di\ision is doubtful, because of the trophic changes which follow in the eye. The first division is never involved alone. (5) The motor root should always be left undisturbed, if possible — to avoid paralysis of the muscles of mastication. It is more apt to be injured if the dura be opened over the ganglion and the sensory root be cut between the ganglion and the pons. When possible it is best to cut the second and third divisions close to the foramen rotundum and foramen ovale respectively — dissect them back to the ganglion, and remove the parts of the ganglion corresponding to these divisions, leaving untouched the first division, with its corresponding ganglion and the motor root. (6) If the first di\ision be removed, with the corresponding part of the ganglion, especial care is needed not to harm the cavernous sinus and the nerves to the eye — to aid in avoiding which, the second and third divisions should be removed first to give more room. If the first division be accidentally severed, leave the lacerated end as near the remains of the ganglion as possible. (7) If much oozing follows packing, wick or gauze drainage is indicated for twenty- four or forty-eight hours. (8) The chief dangers of the operations are — injury to internal carotid and cavernous sinus; laceration of brain; injury to nerves of eye (third, fourth, and ophthalmic division); hemorrhage from middle meningeal artery. (9) In Horsley's method of intracranial exposure of the gasserian ganglion a large soft flap is turned down from the temporal region, the underlying bone is removed bv trephine and bone forceps (not to be returned), the temporosphenoidal lobe exposed, the dura incised, the ganglion exposed, and the root cut on the proximal side of the ganglion. EXTRACRANIAL EXPOSURE OF GASSERIAN GANGLION AND THREE DIVISIONS OF FIFTH NERVE. ROSE'S METHOD. Description. — The ganglion is approached through the pterygomaxillary fossa, the zygoma being temporarily and the coronoid process of the inferior EXTRACRANIAL EXPOSURE OF GASSERIAX GANGLION. 159 maxilla permanently resected, and the trephine applied to include the anterior and outer portion of the foramen ovale. Preparation. — Head shaved; eyelids stitched together with horsehair or other sutures. Position. — .\s in preceding operation. Landmarks. — Outer canthus of eye; zygomatic arch; meatus auditorius e.xternus; angle and horizontal ramus of lower jaw. Incision. — Begins near outer canthus of eye. about 1.3 cm. (^ inch) below the external angular process of the frontal — passes backward along the upper border of the zygoma to its posterior extremity — thence downward just in front of ear to the angle of the jaw — thence forward along the horizontal ramus of the jaw to the facial vessels. Operation. — (1) Reflection of the Skin Flap; — Incise through skin and fascia only, along the above line. Raise this semicircular skin tlap without harming the facial nerve or Stenson's duct. (2) Exposure of the Pterygoid Space; — Incise down through the periosteum for the entire length of the zygoma, and detach the periosteum. Drill (for later wiring of the bones) two holes through the zygomatic process of the malar, and two through the root of the zvgoma. Divide the bone (downward and forward) between the two anterior holes — and also between the two posterior holes. Displace the zygoma downward and backward, bringing the masseter with it (dividing the necessary muscle-fibers). The coronoid process is exposed and cut obliquely downward and forward, as low as possible, then turned upward, and, together with tendon, cut away (there being no object in retaining it, as it would waste with the other muscles of mastication supplied by the motor fibers of the third division). (3) Exposure of the Foramen Ovale; — Expose the internal pterygoid Viy removing the overlying fat and connective tissue. The internal maxillary artery, which is generally found upon the muscle, is divided between two ligatures. The inferior dental and lingual gustatory nerves are sought at the lower border of the external pterygoid, cut, and their proximal ends tied with silk, to serve as guides. Expose the foramen ovale on the under surface of the great wing of the sphenoid, by partly cutting away and partly retracting away (by scraping) the external pterygoid — thus exposing both the great wing of the sphenoid and the external pterygoid plate. The foramen ovale is sought by following up the silk liga- ture, drawing the nerves of the third division taut, and also by the finger feeling in its known position, a little behind and external to the external pterygoid plate, remembering that just to the inner side and behind the foramen ovale lie the eustachian tube and the middle meningeal artery about to enter the foramen ovale. Bleeding is apt to be considerable here, espe- cially from the veins of the pterygoid plexus and from veins passing through the foramen ovale between the pterygoid ple.xus and the cavernous sinus. This hemorrhage is controlled by gauze packing. (4) Opening the Base of the Skull; — .\ small, long-handled trephine is placed just in front and to the outer side of the foramen ovale, so that the margin of the foramen is included in the disc of the bone to be removed. (5) Division of Nerve- trunks and Partial Removal of the Ganglion; — The trephine-opening having been cleared and sufficiently enlarged by chisel or forceps, the surgeon follows, by means of the silk ligature, the third division up to the ganglion, which is loosened from its bed and the second and third divisions freely resected — the first being left undisturbed. (6) Closure of the \\'ound; — The wound having been irrigated with i : 4000 bichlorid, dried and dusted with iodoform, the previously drilled zygoma is wired, the temporal fascia sutured to the l6o OPERATIOXS UroN THE NERVES, PLEXUSES, AND GANGLIA. cut margin of the fascia over the zygoma, and the wound closed without drainage!^ The evelid stitches are removed in three or four days. Comment.— (I ) The operation may be performed in two stages. (2) The coronoid process may be drilled (for wiring) before cutting. (3) The extracranial method of exposing the ganglion is preferable. SURGICAL ANATOMY OF SUPRAORBITAL BRANCH OF FRONTAL NERVE. Description. — Passes forward from bifurcation of frontal nerve and leaves orbit through supraorbital notch (or foramen) — and, giving off palpebral branches, ascends vertically upward close to bone, beneath orbicularis pal- pebrarum and occipitofron'talis to forehead, where it divides into cutaneous and pericranial branches. The supraorbital vessels lie on its outer side. EXPOSURE OF SUPRAORBITAL BRANCH OF FRONTAL AT SUPRAORBITAL FORAMEN. Position. — Patient supine; head slightly elevated. Surgeon on side of operation, or above head. Landmarks. — Sujiraorbital notch (or foramen) — which, if not easily felt, lies at junction of inner and middle thirds of supraorbital margin. Incision. — Transverse, about 2.5 cm. (i inch) in length, along supra- orbital margin, with center over position of supraorbital notch (or foramen) — the eyebrow having been previously shaxed. Operation. — Having steadied the brow by the first finger of left hand (which also draws up the soft parts so as to hide subsequent scar) and de- pressed lid with left thumb, carry the above incision through skin, fascia, and orbicularis palpebrarum — when the nerve will be found upon the peri- osteum, accompanied by its vessels. SURGICAL ANATOMY OF SUPERIOR MAXILLARY BRANCH OF TRI- FACIAL AND MECKEL'S GANGLION. Description. — .\rises from center of gasserian ganglion — runs forward through foramen rotundum — traverses upper part of sphenomaxillary fossa — enters orbit through sphenomaxillary fissure — thence courses forward along infraorbital groove, accompanied by infraorbital artery, to infraorbital canal — along which it passes to emerge upon face through infraorbital foramen, as the infraorbital nerve, terminating beneath levator labii superioris muscle in a leash of branches. The distance of infraorbital foramen from foramen rotundum is about 5 cm. (2 inches). Sphenopalatine or Meckel's Ganglion. — Placed deeply in spheno- maxillary fossa, beneath superior maxillary nerve, near sphenopalatine foramen. Its relations are: — Superiorly, superior maxillarv nerve; Poste- riorly, sphenoid bone and vidian canal; Externally, internal maxillary artery and external [iterygoid muscle; Internally, vertical jslate of jjalate and spheno- palatine foramen. Comment. — The posterior superior dental is given off from the superior maxillary just before the nerve enters the infraorbital canal — the middle EXPOSURE OF SUPERIOR MAXILLARY XERVE. l6l superior dental, at the back part of the canal — and the anterior superior dental just before its exit upon the face. To insure, therefore, the removal of the origin of the posterior superior dental nerve, the trunk has to be removed as far back as Meckel's gangUon. EXPOSURE OF SUPERIOR MAXILLARY NERVE AND MECKEL'S GANGLION BY THE ANTRAL ROUTE. CARNOCHANS OPERATION. Description. — The superior maxillary nerve is removed from the infra- orbital foramen to the foramen rotundum, together with Meckel's ganglion — by following the course of the infraorbital canal, and removing parts of the anterior wall, roof, and posterior wall of the antrum of Highmore. Position. — Patient supine; head elevated and turned sUghtly to one side. Surgeon on side of operation. Landmarks. — Infraorbital foramen (which is about 8 mm. — J inch — below the infraorbital margin, and on a line drawn from the supraorbital foramen to a point between the two bicuspids of both jaws). Incision. — V-shaped (two sides of an equilateral triangle, each side being about 2.5 cm. — i inch — long), placed with its center over the infraorbital foramen and its two limbs upward. Operation. — (1) This incision is carried to the bone. The flap is then turned up over the closed eye and its apex stitched to the forehead. (2) The infraorbital nerve is isolated at the foramen, cut as long as possible, and tied with silk — to serve as a guide and means of traction. (3) A trephine of about 1.3 to 2 cm. (5 to J inch) in diameter, or a chisel, is now applied to the cleared bone, and a portion of bone removed including the foramen in its upper half — and the mucous membrane of the antrum is incised. (4) The upper portion of the posterior wall of the antrum is similarly removed over an area of about 6 mm. {\ inch), either by trephine or chisel. (5) The mucous membrane covering the roof of the antrum is now divided in the direction of the infraorbital canal, followed by breaking away the bony tioor of the canal, which may be done by chisel or stout scissors, while practising traction upon the nerve as a guide. (6) By this means, and by the use of long slender scissors and dissecting forceps, the nerve is freed back across the spheno- maxillary fossa to the foramen rotundum, until it hangs freely exposed. (7) Effort should be made to recognize Meckel's ganglion at this stage, locating it as definitely as possible. Considerable bleeding may be expected at this period of the operation — hemorrhage being controlled chiefly by pressure. .\rtificial illumination should be used. The nerve, while slight traction is being applied, should be divided at the foramen rotundum and from its sphenopalatine branches. The nerve and ganglion are then withdrawn. (8) The soft parts are now sutured — and, if much oozing occur, temporary drainage is to be provided for through the lower angle of the wound, or tem- porary packing may be necessary, with subsequent suturing of the lower part of the wound. Comment. — (1) .\ T-shaped incision may be used — the horizontal jxirtion being placed under the lower margin of the orbit, and the vertical portion running down on the cheek to near the mouth. Or a r -shaped incision may be used — the horizontal portion along the orbit, and the vertical portion in the nasolabial groove. Probably the best incision is a long trans- verse one below the orbital margin, with strong retraction. (2) When l62 orKRATIONS irON THE NERVES, PLEXUSES, AND GANGLIA. Meckel's ganglion is removed, the vidian nerve is paralyzed and therefore the motor branches to the palate muscles. EXPOSURE OF SUPERIOR MAXILLARY NERVE AND MECKEL'S GANGLION BY THE ORBITAL ROUTE. Description. — After subperiosteally displacing the contents of the orbit from the infraorbital canal and removing the roof of the canal, the nerve is followed back to and beyond Meckel's ganglion and cut at the foramen rotundum. Position. — As in the above operation. Landmarks. — Infraorbital margin and infraorbital foramen. Incision. — Curved incision along lower margin of orbit over infraorbital foramen — extending from near internal angular process to external angular process of frontal. Operation. — Carry the incision to the bone throughout. Isolate the nerve — cut as long as possible — and attach a stout piece of silk to the proximal end as a guide and means of traction. The bone between the infraorbital foramen and infraorbital margin is removed by trephine or chisel, exposing the anterior portion of the infraorbital canal. The periosteum of the floor of the orbit is raised along the orbital margin with a periosteal elevator — a spatula or retractor is placed beneath this and the tissues of the orbit are held out of the way. The roof of the canal is next broken down with a fine chisel, or other instrument — bleeding being controlled by pressure — and the nerve lifted out of its bed by traction on the ligature — and is then traced back with delicate instruments to the foramen rotundum and removed, together with Meckel's ganglion and its terminal filaments. The orbital contents are then allowed to fall back into place and the skin incision sutured. Comment. — It is exceedingly difficult, and probably impossible, actually to leach the ganglion by this method, esyjecially without wounding the eve- structures. It is also difficult to make the section far enough back to include all the dental nerves. EXPOSURE OF SUPERIOR MAXILLARY NERVE AND MECKEL'S GANGLION BY THE PTERYGOMAXILLARY ROUTE. BR.M'N-I.OESSKN OPERATIO.V, Description. — The nerve and ganglion are reached in the pterygo- maxillary fossa by temporarily resecting the zygoma, turning it and the masseter muscle downward, firmly retracting the temporal muscle backward, and following the posterior surface of the superior maxillary bone into the pterygomaxillary fossa. Position. — Patient supine; head on one side and elevated; surgeon to right for both sides. Landmarks. — External angular process of frontal; zygoma; jjosterior border of ascending ramus of lower jaw. Incision. — 15egins at external angular process of frontal, passes downward and backward along upper border of zygoma to tragus of ear, thence down- ward in front of ear along posterior margin of inferior maxilla to angle of lower jaw. Operation. — (i) This incision (the region having been shaved) passes EXPOSURE OF INFRAORBITAL NERVE. 163 onh' through s!dn and superficial fascia — and the ifap of integumentary tissues thus raised by dissection is turned forward and temporarily attached to the nose by suture. (2) An incision is made along the zygoma, passing to the bone, which is then exposed subperiosteally. Two holes are drilled (for wiring the bone later) through the malar bone on a line with a continua- tion of the upper part of its posterior border, and two through the zygoma near its root. The zygomatic arch is then sawed through between the two anterior drill-holes and between the two posterior drill-holes, directing the saw from without inward at the two ends (forming a beveled shelf for the arch to rest upon when replaced). The temporal fascia has been freed along its upper border in exposing the arch — and now the entire arch is turned down, with its attached masseter, cutting whatever fibers of that muscle are still holding the arch in place. (3) At this stage the mouth -is opened with a gag and the lower jaw depressed, to carry downward and backward the coronoid process, with its temporal attachment — at the same time drawing backward with retractors the temporal muscle and tendon from the anterior portion of the temporal fossa. If this do not give sufficient exposure, the anterior part of the muscle and tendon is divided transversely. (4) The pterygomaxillary tissure is thereby exjjosed — and the internal ma.xil- lary artery and vein are seen entering and leaving the pterygoma.xillary fossa through this fissure and are both ligated. The superior ma.xillary nerve is found leaving the foramen rotundum and is brought forward by means of a nerve-hook. The nerve and Meckel's ganglion can be more thoroughly exposed, at this stage of the operation, by chiseling away the spur of bone at the base of the external pterygoid plate, projecting outward and forward across the pterygomaxillary fissure and partially blocking the entrance to the pterygomaxillary fossa — and then both nerve and ganglion can be hooked forward. (5) In concluding the operation, the temporaril)' removed zygomatic arch is wired at both ends where prexiously drilled. If the temporal muscle have been partly severed, this is sutured. The tem;)c)ral fascia is sutured to the cut margin of fascia over the zygoma. The skin incision is closed as usual. Comment. — (1) If the infraorbital nerve be exposed at its emergence upon the face from the infraorbital foramen and be severed, then by traction ujjon the nerve hooked up in the sphenomaxillary fossa the entire length of the infraorbital nerve may be drawn out of the canal backward and all its dental branches torn across in their bony canals. (2) This operation is similar, in principle, to Rose's method of exposing the gasserian ganglion — and the chief indication for its use is where it is found desirable to expose the inferior maxillary at the foramen ovale, as well as the superior maxillary, with Meckel's ganglion, at the foramen rotundum. To expose the superior maxillary and Meckel's ganglion alone, the antral or the orbital route would be preferable; — and to expose all three roots, or the second and third, the Hartley- Krause or the Rose operation, especially the former, would be better. EXPOSURE OF INFRAORBITAL NERVE AT INFRAORBITAL FORAMEN. Position. — Patient's head slightly elevated. Surgeon to side of operation. Landmarks. — Infraorbital foramen — which, if not palpable, lies about 8 mm. (J inch) beiow infraorbital margin, and on line from supraorbital foramen to a point between the two bicuspids in both jaws. 164 OPKKATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. Incision. — About 2 cm. (J inch) in length, over the infraorbital foramen, parallel with the margin of the orbit. Operation. — Skin, fat, and orbicularis ijaljjebrarum are incised. The levator labii superioris is exposed and also incised. The nerve is found at its emergence from the foramen. Comment. — The infraorbital nerve may be exposed through the mouth, without scarring. Having made the gingivolabial fold tense, an incision is made through the mucous membrane and periosteum along the line of reflec- tion from the upper lip to the superior ma.xilla. The soft parts are then dissected away from the bone along the canine fossa, subperiosteally, and firmly retracted upward — until the infraorbital foramen is reached. Note. — For the Anatomy of the Infraorbital, see the Superior Maxillary nerve. SURGICAL ANATOMY OF INFERIOR MAXILLARY BRANCH OF TRI- FACLAL AND THE OTIC AND SUBMAXILLARY GANGLIA. Description of Inferior Maxillary. — Formed of two roots — a large sensory root from the inferior angle of gasserian gang ion — and a small motor root which passes under the ganglion and unites with the sensory root just after it has passed through the foramen ovale — both roots passing through the foramen separately. The nerve divides into anterior and posterior divi- sions 3 to 4 mm. (J inch, about) beneath the base of skull and under cover of the external pterygoid — the former receiving the greater part of the motor root and the latter the greater part of the sensorv root. Ganglia. — (1) Otic (Arnold's) Ganglion; — situated immediately beneath foramen ovale, having inferior maxillary nerve on its outer side, the eustachian tube on its inner side, and the middle meningeal artery on its posterior side. (2) Subma.xillary Ganglion; — placed between mylohyoid and hyoglossus muscles, above deep portion of submaxillary gland, and at outer side of Wharton's duct. Note. — Foramen ovale lies on a line connecting the eminentia articularis, at root of zygoma, of one side, with that of the other, and about 3 cm. (if inches) from the eminentia — and is directly posterior and a little external to the external pterygoid plate. The middle meningeal arterv enters the foramen spinosum just behind the foramen ovale. (3) The internal maxillary artery, in its second part, runs forward and upward on outer surface of external pterygoid muscle. (4) The pterygoid plexus of veins lies on the external pterygoid muscle. EXPOSURE OF INFERIOR MAXILLARY NERVE AT FORAMEN OVALE —OR OF SUPERIOR MAXILLARY NERVE AT FORAMEN ROTUNDUM. MIXTER'S OPERATION. Description. — Mixter's operation consists in a temporary excision and downward displacement of the zygomatic arch, with the attached masseter — followed by a backward displacement of the temporal muscle, to reach the superior maxillary nerve and foramen rotundum — and a forward dis- placement of the muscle to reach the inferior maxillary and foramen ovale. The inferior maxillary nerve may be exposed at its origin by any of the opera- tions exposing the gasserian ganglion, either intracranially or extracraniallv. EXPOSURE OF INFERIOR MAXIIl.ARV NERVE. 16$ Position. — Patient on back; head elevated and turned to one side. Surgeon on side of operation, or to right for both operations. Landmarks. — Zygoma; temporal ridge. Incision. — Curved, with convexity upward — beginning about 1.3 cm. (^ inch) below malar portion of zygomatic arch and passing upward along posterior margin of malar bone and external angular process of frontal bone, to commencement of temporal ridge — thence follows lower temporal ridge to opposite anterior margin of ear — and then curves downward to pass in front of ear and ends about 1.3 cm. (^ inch) below root of zygoma. Operation. — The above incision is made through the shaved skin and through the fascia — and this flap is turned downward, guarding Steno's duct. The temporal artery is ligated, unless it can be displaced backward. The zygomatic arch is e.xposed subperiosteally and sawed through in front and behind, beveling from without inward — and guarding against opening the inferior maxillary articulation behind. The zygoma, attached masseter, and fatty connective tissue are now well retracted downward. The temporal muscle and its attachment to the coronoid process become theieby well e.xposed — and are manipulated in accordance with the structure sought: — (a) To Expose the Superior Maxillary Nerve and the Foramen Rotundum: — The temporal muscle and tendon are firmly retracted posteriorlv, by a broad, smooth retractor, aided by an assistant's depressing the jaw — the surgeon being guided by the posterior wall of the superior maxillary bone and the spur of bone projecting forward and outward from the base of the external pterygoid plate. This spur is chiseled aw-ay to better expose the foramen rotundum, if necessary — the chiseling being done in a forward and slightly inward direction, to avoid going into the middle fossa of the skull. Having removed this spur, the superior maxillary nerve is to be found crossing the pterygomaxillarv fossa from the foramen rotundum to the infraorbital foramen, with Meckel's ganglion beneath it, and near the sphenopalatine foramen, (b) To Expose the Inferior Maxillary Nerve and Foramen Ovale: — The temporal muscle and tendon are now firmly retracted forward (the jaw being now closed to carry the coronoid process forward) — the surgeon being guided to the foramen ovale by its position just posterior and external to the base of the external pterygoid plate, at a distance of about 3 cm. (i^ inches) internal to the anterior margin of the posterior attachment of the zygoma and slightly posterior to this line drawn directly inward. On the way inward the internal maxillary artery is met on the external pterygoid muscle and ligated. The pterygoid plexus of veins also lies upon this muscle. The external and internal pterygoid muscles can generally be displaced by retrac- tion without necessitating their incision. The foramen ovale is usually recognized by the tip of the finger and the nerve is exposed emerging from it and drawn forward by a hook. Free hemorrhage may necessitate packing one part of the wound while working in another. In concluding the operation for exposure of either structure, the zygoma is replaced and the flap turned back into position. Comment. — (i) If the zygoma be drilled anteriorly and posteriorly and then sawed between each pair of drill-holes, it may be subsequently wired. (2) If sufficient room cannot be gotten by retraction of the temporal muscle and tendon, it may be divided in part, transversely — the anterior portion being cut to reach the foramen rotundum — and the posterior portion in order to reach the foramen ovale. The muscle should be sutured on completing the operation. (3) The coronoid process could be drilled, sawed between the drill-holes, and the coronoid tip and temporal attachment turned l60 (IPKRATIONS LPON THE NERVES, PLEXUSES, AND GANGLIA. upward— to be afterward wired back in place. (4) As much of the pterygoid muscles (especially the external) may be divided, or drawn away from its origin at the sphenoid, as needed. But the less the detachment of the temporal and pterygoid muscles, the less the involvement of the jaw articulation subsequently — e.xcept that caused by paralytic atrophy if the motor part of the third division be cut. (5) The motor part of the inferior maxillary is to be avoided if possible — but is generally unavoidably included in the destruction of the sensory portion. SURGICAL ANATOMY OF INFERIOR DENTAL NERVE. Description and Relations. — .\ sensory nerve — a branch of inferior maxillarv nerve, passing down under cover of external pterygoid muscle, it descends to outer side of internal pterygoid, to interval between ramus of inferior maxilla and internal lateral ligament, to dental foramen — accom- panied by inferior dental artery and having lingual nerve in front and internal to it. The mylohyoid branch is given ofif just before the nerve enters the dental canal, and the mental branch at its exit at the mental foramen. The dental foramen is surrounded by the lingula of Spix, to which is attached the internal lateral ligament, the groove for the mylohyoid nerve being just behind it and the attachment of the internal pterygoid muscle reaching to its base. The inferior dental vessels pass along behind and outside the nerve. The internal maxillary artery passes safely above the dental foramen. EXPOSURE OF INFERIOR DENTAL NERVE IN MOUTH I'.ARANICINI'S INTR.ABUCCAl. .METHOD, Position. — Patient supine; head slightly raised; gag in opposite side of mouth; cheek of operated side held open bv retractors and commissure of mouth drawn backward. Surgeon faces patient and stands on his right for both operations. .\ head-mirror should be used. Landmarks. — .\.scending ramus of jaw; spine of Spix; internal ptervgoid muscle. Incision. — .About 2.5 cm. (i inch) in length — along anterior border of ascending ramus of inferior maxilla, about 7 mm. (\ inch) to inner side of sharp anterior border of coronoid process, and ending over the spine of Spix. Operation. — Having incised and detached the mucous membrane and periosteum, feel for the spine of Spix — cutting the internal lateral ligament with scissors if necessary in order to expose the nerve entering the foramen — which is then isolated and drawn forward. The inferior dental artery lies in close contact and should be avoided. In completing the operation, it is better to close the incision with sutures — though these are often omitted. Comment. — Expose the dental foramen that the lingual may not be taken for the inferior dental nerve. If possible, avoid injuring the internal lateral ligament, which is attached to the spine of Spix. EXPOSURE OF INFERIOR DENTAL NERVE. 167 EXPOSURE OF INFERIOR DENTAL THROUGH ASCENDING RAMUS OF INFERIOR MAXILLA. Description. — The outer asjject of the lower jaw is exposed and the nerve reached by trephining the bone. Position. — Patient's head turned to one side and slightly elevated. Surgeon on side of operation. Landmarks. — The four borders of the ascending ramus of the inferior maxilla. Incision. — Curved, circumscribing the angle and lower half of ascending ramus of lower jaw — the transverse curve being just above the lower margin — and the vertical limbs corresponding with the anterior and posterior borders. Thus Sten.son's duct escapes and but few branches of the facial nerve- are injured. Operation. — This incision is first carried through skin and superficial fascia, when whatever nerves are in line of incision are retracted (especially the buccal and supramaxillary) — then through masseter and periosteum to bone. The soft parts are now freed from bone subperiosteally and retracted strongly upward, gaining room by this upward retraction without harm to the facial nerve or .Stenson's duct. \ window of bone, having its center corresponding with this quadrilateral surface of bone, is then removed with the trephine or chisel (a disc about 1.3 to 2 cm. — ^ to J inch — in diameter), remembering that the lower and anterior part of the ascending ramus is much thicker than the upper and posterior, .\pproach the nerve and accom- panving artery with care, elevating, rather than chiseling or trephining, the last thickness of bone. The nerve is then isolated in its canal. Comment. — (•) The nerve can be reached at its entrance into the dental canal and traced up to the foramen ovale by an extension of this operation, by widening the sigmoid notch. The incision passes through skin and superficial fascia only — beginning at the middle of the zygoma, passing backward and downward in front of the tragus to the angle of the jaw, and thence forward to a point just posterior to the facial artery. Raise this flap of skin and superficial fascia as far as the anterior border of the masseter and turn it forward. Expose Stenson's duct and edge of the parotid gland (sufficientlv to gUard them). Divide the masseter and overlying deep fascia down to the bone in a transverse direction, and between Stenson's duct above and the highest branch of the facial nerve below. Free the muscle from the bone at the sigmoid notch and just below. •'Vpply the trephine so as to leave a slight bridge of bone between the sigmoid notch and the trephine- opening — and subsequently cut this bridge away with bone-forceps. Expose the inferior dental nerve and artery — ligate the artery and also the internal maxillary artery (upon the external pterygoid muscle) if necessary. Secure the nerve with silk ligature, and. by traction on silk, follow the nerve to the foramen ovale, retracting the external pterygoid upward (or divide it). Sever the nerve as high and as low as possible. The lingual nerve, lying further forward and inward, may be also reached at the same time. (2) The entrance to the inferior dental canal may also be reached from the inner aspect of the inferior maxilla — bv making an incision around the angle of the jaw, corre- sponding with the insertion of the masseter, and raising the soft parts from the inner surface of the bones subperiosteally to the dental foramen — the mouth cavity not being opened (Liicke-Sonnenburg operation). (3) The operation of exposing the inferior dental nerve through the mouth is to be preferred, as being less disfiguring — although probably more difficult. OrERATIONS UPON' THE NERVES, PLEXUSES, AM) GANGLIA. EXPOSURE OF INFERIOR DENTAL NERVE AT MENTAL FORAMEN, FROM WITHIN MOUTH. Description. — The lower lip is everted and an incision made over the site of the mental foramen. Position. — Patient supine; head supported and to one side. Surgeon on side of operation, or on right for both operations, .\ssistant draws lower lip well downward. Landmarks. — A line drawn over the supraorbital foramen and between the two bicuspids of both jaws will cross the infraorbital and mental foramina — the mental foramen, in the adult, generally lying midway l)etween the upper and lower borders of the jaw proper (e.x elusive of teeth). Incision. — Transverse, through mucous membrane along line of its reflection from lower lip to inferior maxilla, with its center between the two bicuspids, the lower lip being firmly drawn downward. .A vertical incision may be made instead of the transverse. Operation. — This incision passes through periosteum to bone, upon slight downward freeing of which the nerve is found emerging from the mental foramen. Comment. — An incision could be made from without, through the tissues of the chin, over the position of the foramen, in the direction of the fibers of the facial nerve, if the matter of scarring be not taken into account. SURGICAL ANATOMY OF LINGUAL (GUSTATORY) NERVE. Description and Relations. — A nerve of common sensation — branch of posterior division of inferior maxillary nerve. Descends under external pterygoid, to inner side and anterior to dental nerve, a cord generally con- necting the two, and being joined near origin by chorda tympani. The nerve then passes between internal pterygoid muscle and ramus of lower jaw — inchning inward to side of tongue, and, passing over attachment of superior constrictor of pharynx to the lower jaw and the styloglossus muscle, above the deep part of sulsmaxillary gland, is continued forward between mucous membrane of mouth and mylohyoid muscle and lies on its origin close to bone — then runs between mylohyoid and hvoglossus — crosses below Wharton's duct, and passes along side of tongue, under mucous membrane, to apex. Comment. — On widely opening the mouth, one can feel the ptervgo- maxillary ligament, as a prominent ridge behind the last molar. The nerve is generally to be felt behind the pterygomaxillary ligament, about 1.3 cm. (i mch) posterior and inferior to the last molar, lying just beneath the mucous membrane. EXPOSURE OF LINGUAL (GUSTATORY) NERVE IN THE MOUTH. Position. — Patient on back; head slightly raised; gag in opposite side of mouth; cheek of operated side held open by retractors; tongue of patient drawn out and to opposite side by assistant. Surgeon stands on patient's right for both operations, and uses a head-mirror. Landmarks. — Ramus of jaw; ptervgomaxillary ligament; last molar tooth. EXPOSURE OF FACIAL NERVE IN FRONT OF MASTOID PROCESS. 169 Incision. — \"ertica!, about 2.5 cm. (i inch) in length, placed in fold of mucous membrane midwa}' between tongue and gum, with center on level with last molar. The nerve lies about at the junction of the upper and middle thirds of a line from the crown of the last molar to the angle of the jaw. Operation. — Having incised in the above line, the nerve is found just beneath the mucous membrane, prior to dipping under the mylohyoid muscle — and is isolated and drawn forward by a hook. Comment. — The lingual nerve may be reached from outside the mouth by e.xcising a part of the inferior maxilla, at the junction of the alveolar process and the ascending ramus (Loebker). Or it may be reached by dissecting up under the internal surface of the inferior ma.xiila, displacing the sub- maxillary gland, dividing the posterior portion of the mylohyoid and finding the nerve under the posterior portion of the sublingual gland (Luschka). SURGICAL ANATOMY OF FACIAL NERVE. Description. — Arises, superficially, at upper end of medulla oblongata, in groove Ijctween olivary anci restiform bodies — passes, in company with auditory nerve, forward and outward to internal auditory meatus, which it enters with auditory nerve, the ]jars intermedia intervening between the nerves. At the bottom of meatus, the facial nerve enters aqueductus Fallopii, which it follows to its emergence at the stylomastoid foramen — thence passes downward and forward through substance of parotid gland — crosses external carotid artery and divides behind ramus of inferior maxilla, opposite upper margin of digastric muscle, into two chief branches: — (i) Temporofacial, running upward and forward through parotid gland, crossing external carotid artery and temporomaxillary vein and passing over neck of condyle of jaw, and dividing into temporal, malar, and infraorbital branches, — and (2) Cervicofacial, running downward and forward, through parotid gland, crossing external carotid artery, and dividing, opposite angle of jaw, into buccal, supramaxillary, and inframaxillary branches. EXPOSURE OF FACIAL NERVE IN FRONT OF MASTOID PROCESS. i;.\iMs (ii'KK.x riox Position. — Patient supine; head elevated and to one side. Surgeon to right for both operations. Landmarks. — Anterior border of mastoid process; posterior border of ascending ramus of inferior maxilla. The point at which the nerve is sought being from 6 mm. to 1.3 cm. (|- to i inch) in front of center of anterior border of mastoid process. Incision. — Begins close behind pinna of ear, opposite meatus — passes downward to opposite lobule of ear, and then downward and forward almost to angle of inferior maxilla. Operation. — This incision is deepened through skin and fascia, with care. The i)arotid fascia is incised and the parotid gland is retracted forward. The anterior edge of the sternomastoid is exposed and drawn backward. The posterior belly of the digastric is exposed and the nerve is sought on a line with the upper border of the posterior belly of this muscle and at the point above mentioned — coming from the stylomastoid foramen toward the 1 70 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. surface. The posterior auricular artery and vein will probably need ligating, and some libers of the great auricular nerve will be cut. The internal jugular vein is near the deep part of the wound, but there are no other important vessels anterior to the plane of the digastric (behind which is the external carotid). If necessary, esjiecially in stout subjects, a small transverse incision, passing forward from below the pinna, may be added. SURGICAL ANATOMY OF SPINAL ACCESSORY NERVE. Description and Relations. — (i) Accessory portion passes outward to jugular foramen, where it unites with spinal portion, and is joined to upper ganglit)n of the vagus and sends fibers into its pharyngeal and superior laryn- geal branches and into the trunk of that nerve below the ganglion. (2) Spinal portion, after issuing from jugular foramen (where it unites with accessory portion), passes backward, crossing in front of (sometimes behind) the internal jugular vein, descends obliquely behind digastric and stylo- hyoid muscles and occipital artery to enter upper third of sternomastoid about 5 cm. (2 inches) below tip of mastoid process — perforates this muscle in its second fourth and emerges on level with center of its posterior border — and runs thence obliquely across the occipital triangle, and, entering upper part of lower third of its anterior border, terminates in the deep surface of the trapezius. EXPOSURE OF SPINAL ACCESSORY NERVE AT ANTERIOR BORDER OF STERNOMASTOID MUSCLE. Position. — Patient supine; shoulders slightly elevated; head to opposite side; neck supported. Surgeon on right, for either operation. Landmarks. — Anterior border of upper portion of sternomastoid. Incision. — About 7.5 cm. (3 inches) in length, following the anterior bonier of the sternomastoid, with its center opposite a point about 5 cm. (2 inches) below the tip of the mastoid process. Operation. — Having cut through skin and superficial fasc'a, and opened up the cervical fascia, avoiding the external jugular vein and great auricular nerve, expose the anterior border of the sternomastoid and draw the muscle firmly backward. Recognize the inferior border of the [)osterior belly of the digastric — the nerve will be found passing from beneath it to the sterno- mastoid, crossing the transverse process of the atlas. Avoid branches of the facial nerve (at the upper edge of tlie wound) and the occipital artery (lying over the nerve). Comment. — If only that portion of the spinal accessory be involved which is distal to the sternomastoid, the nerve may be exposed by an incision placed along the posterior border of the sternomastoid, with its center oppo- site the center of the posterior border of the muscle. SURGICAL ANATOMY OF OCCIPITALIS MAJOR BRANCH OF POSTE- RIOR DIVISION OF SECOND CERVICAL NERVE. Description and Relations.— Internal branch of posterior division of second cervical nerve — passes upward across (not contained within) sub- EXPOSURE OF POSTERIOR DIVISIONS OF CERVICAL NERVES. 171 occipital triangle (which is formed by rectus capitis posticus major, superior and inferior oblique) — passing across inferior oblique, between it and com- plexus — piercing the complexus and trapezius near their cranial attachments — ascending over back of head with occipital artery, lying on its inner side, and dividing into two branches to supply scalp. EXPOSURE OF OCCIPITALIS MAJOR NERVE BENEATH THE COM- PLEXUS. Position. — Patient on side; face turned as far forward as possible, to make lateral occipital region prominent. Surgeon stands behind patient. Landmarks. — Spine of a.xis; posterior border of sternomastoid. Incision. — Transverse, passing from spine of axis directly outward to posterior edge of sternomastoid. Operation. — Divide, in order, skin, fascia, trapezius (ascending upward and inward), splenius capitis (ascending upward and outward), and com- plexus (ascending vertically). Beneath this last muscle the suboccipital triangle is exposed — and the nerve is found passing upward and inward around the inferior oblique which forms the lower boundary of that triangle. The small occipital nerve will be exposed at the outer portion of the more superficial part of the incision. Comment. — The nerve is here reached before it pierces the complexus and before coming in relation with the occipital artery. It may be reached more superficially where it pierces the outer border of the trapezius im- mediately below the superior curved line. But the lower exposure is better, as giving control of a greater number of branches. EXPOSURE OF POSTERIOR DIVISIONS OF FIRST. SECOND, AND THIRD CERVICAL NERVES. kei:n"s I ii'i:K.vnox. Description. — The posterior divisions of the first, second, and third cervical nerves have been exposed and excised in spasmodic torticollis — supplying, as they do, the posterior rotator muscles of the neck. Position. — Patient turned to one side; neck made prominent. Surgeon at ])atient's back. Landmarks. — Middle line of neck; external occipital protuberance. Incision. — From 6 to 7.5 cm. (2^ to 3 inches) in length and transverse in direction — passing outward from the middle line of the neck, at a point about 4 cm. (ij inches) below the external occipital protuberance. Operation. — Divide, in the Une of incision, the skin, fascia, trapezius, and piisterior border of the splenius capitis, until the complexus is reached, after which the nerves are separately isolated: — (1) Find the occipitalis major nerve (internal branch of posterior division of second cervical nerve) emerging from the complexus and about to enter the trapezius. Divide the complexus transversely, on a level with the nerve. Follow the nerve to the common trunk of the posterior division (before the external and internal branches are given off). Thus the second cervical nerve is exposed. (2) Recognize the suboccipital triangle, — bounded, above and internally, by the rectus capitis posticus major (from spinous process of axis to superior curved line of occiput), — above and externally, by obliquus capitis superior (from upper 172 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. surface of transverse process of atlas to occipital bone, between curved lines, and external to complexus), — below and externally, by obliquus capitis inferior (from apex of spinous process of axis to lower and back part of trans- verse process of atlas). Within this triangle lies the suboccipital nerve (posterior division of first cervical nerve), which does not divide into internal and external branches — lying close to the occiput and behind the vertebral artery. Trace it as near to the spine as possible. Thus the first cervical nerve is exposed. (3) The external branch of the posterior division of the third cervical nerve is found about 2.5 cm. (i inch) lower down than the occipitalis major (page 171) and under the complexus. It is to be followed to the common trunk of the posterior division. And thus the third cervical nerve is exposed. Comment. — This operation has been modified by making a vertical incision from the occiput downward, about 4 cm. (lA inches) outside of the median line — passing through the trapezius, edge of the splenius, and then through the complexus. Also, the second and third divisions may be divided without the first. SURGICAL ANATOMY OF BRACHIAL PLEXUS OF NERVES. Formed by. — Fasciculus from anterior branch of fourth cervical, anterior branches of fifth, sixth, seventh, and eighth cervical, and greater part of anterior branch of first dorsal. Extent and Position. — From lower part of side of neck to lower part of a.\illary space, dividing, opposite the coracoid process, into numerous trunks, and giving olT its terminal nerves at the lower axillary boundary, Relations. — (1) In neck: — First, hes between anterior and middle scaleni and at outer border of former muscle; — then partly behind and partly above and external to third part of subclavian artery, in the posterior triangle of neck, crossed by posterior belly of omohyoid; — then behind clavicle and subclavius muscle, upon first serration of serratus magnus and subscapularis muscles. (2) In axilla : — Lies to outer side of first portion of axillary artery, being covered by pectoralis major — then surrounds second portion of artery, covered by the pectoralis minor and resting upon subscapularis muscle, one cord lying to inner side, one behind, and one to outer side of vessel. The third part of the artery has the internal cutaneous and inner head of median nerve in front; circumflex and musculospiral behind; ulnar and lesser internal cutaneous on inner side; and trunk of median and musculocutaneous on outer side. EXPOSURE OF BRACHIAL PLEXUS IN NECK. Position. — I'aticnt upon back, near edge of tal:)le; thorax raised; head extended and turned to opposite side; arm drawn downward and behind back. Surgeon stands in front of right shoulder, in operating upon either side. Landmarks. — Stcrnomastoid ; trapezius. Incision. — \"ertical, in posterior triangle of neck — beginning about 9 cm. (3^ inches) above clavicle and passing downward to within about 1.3 cm. (^ inch) of middle of clavicle, parallel with anterior border of trapezius, but nearer posterior border of sternomastoid. Operation.— Having divided skin and platysma, the external jugular EXPOSURE OF MUSCULOCUTANEOUS NERVE. 173 vein is either ligated and cut between two ligatures, or retracted. Some of the descend ng branches of the cervical plexus are apt to be incised, generally the supraclavicular. Incise the deep cervical fascia. Recognize the outer border of the anterior scalenus and retract inward. Retract the posterior belly of the omohyoid downward and e.xpose the brachial plexus by dissection. Avoid the transversalis colli artery and vein crossing the middle of the plexus. Identify the cords of the plexus by following with finger to the interval between the anterior and middle scalenus muscles. SURGICAL ANATOMY OF CIRCUMFLEX NERVE. Description. — One of terminal branches of posterior cord of brachial plexus, lying, at first, between axillary artery and subscapularis muscle, it passes downward and outward to lower border of that muscle, accompanied by posterior circumflex artery — it then winds backward and outward around the surgical neck of humerus, through the cjuadrilateral space bounded by teres minor above; teres major below; long head of triceps internallv; and neck of humerus externally — and divides into upper and lower branches. EXPOSURE OF CIRCUMFLEX NERVE ON BACK OF ARM. Position. — As for exposure of ulnar nerve just above inner condyle of humerus (page 175). Landmarks. — Angle made between posterior scapular muscles and pos- terior border of deltoid — by pressing latter muscle toward neck of humerus. Incision. — Made in long axis of limb and placed over above interval. Operation. — Expose and draw forward the posterior border of the deltod, exposing the teres m'nor above and long head of triceps internally. In the angle formed by the last two muscles the circumflex nerve, accom- panied by the posterior circumflex artery (lying below), is seen coming out from before backward through the quadrilateral space and curving around the surgical neck of the humerus to enter the under surface of the deltoid. SURGICAL ANATOMY OF MUSCULOCUTANEOUS NERVE. Description. — Arising from outer cord of brachial plexus opposite lower border of peitoralis minor, it runs downward and outward, perforating the coracobrachialis and passing obliquely across the arm between the biceps and brachialis anticus to outer side of biceps a little above the elbow, where it perforates the deep fascia, passing behind the median cephalic vein, and divides into anterior and posterior cutaneous branches. EXPOSURE OF MUSCULOCUTANEOUS NERVE IN UPPER PART OF ARM. Position. — .\s for exposure of ulnar nerve just abox'e inner condyle of humerus (|)age 175). Landmarks. — Upper internal bicipital sulcus. Incision. — Along inner margin of biceps, beginning at prominence of coracobrachialis and passing downward. 174 ol'KRATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. Operation. — Having incised the superficial structures, the biceps muscle is exposed and drawn outward. The nerve is found penetrating the outer border of the coracobrachialis, covered by the biceps. SURGICAL ANATOMY OF MEDIAN NERVE. Description. — (a) In .\rm; .\rises by a root from inner and one from outer cords of brachial ple.xus, which embrace a.xillary artery, uniting either in front or to outer side of the vessel. Descends arm on outer side of brachial artery at first — then crosses in front of the middle of artery (though some- times passing behind) — thence downward on inner side of artery to elbow — where it is separated from elbow-joint by brachialis amicus muscle and is covered bv bicipital fascia, (b) In Forearm; Passes between two heads of pronator radii teres and descends between fle.\or sublimis and profundus digitorum to about 5 cm. (2 inches) above the annular ligament of wrist, where it lies beneath the fascia, between the tendons of the fle.xor sublimis digitorum below, the palmaris longus internally, and the flexor carpi radialis externally (or rather more under the palmaris longus). (c) In Hand; It enters palm beneath the annular ligament and rests upon flexor tendons, covered by fascia and superficial palmar arch. EXPOSURE OF MEDIAN NERVE IN MIDDLE OF ARM. Position. — Patient's arm is extended and abducted, with hand supine. Surgeon stands on outer side of right limb, cutting from above downward; and between body and left limb, cutting from above downward (or on outside of left limb, cutting from below upward). Landmarks. — Inner edge of bicipital muscle. Incision. — .\long inner edge of biceps, in middle of arm — about 4 cm. (2^ inches) in length. Operation. — Divide skin and connective tissue. Avoid internal cutaneous nerve and basilic vein. Clearly expose inner edge of biceps muscle and draw the muscle to the outer side, when the median nerve is found crossing the brachial artery from the outer toward the inner side (or sometimes passing beneath the artery). EXPOSURE OF MEDIAN NERVE AT BEND OF ELBOW. Position. — .\s above. Landmarks. — Groove between biceps and pronator radii teres muscles. Incision. — Between inner margin of biceps and outer margin of pronator radii teres, somewhat nearer the former, with center of incision opposite the fold of the elbow, and being about 5 cm. (z inches) in length. " Operation. — This incision will, in the usual disposition of the veins at the elbow, pass to the outer side and nearly parallel with the median basilic vein, which should be retracted inward. Incise the bicipital fascia in a line with the skin-cut. The median nerve lies just to the inner side of the brachial artery and its vena? comites — all lying upon the brachialis anticus. Gut- suture the bicipital fascia in closing the wound. EXPOSURE OF ri.NAR NERVE. 175 SURGICAL ANATOMY OF ULNAR NERVE. Description. — (a) In Arm; Arises from inner cord of brachial plexus, between axillary artery and vein, and passes down arm on inner side of axillary and brachial arteries to middle of arm, covered only by skin and fascia — thence diverges to cross inner head of triceps obliquely — pierces internal intermuscular septum and descends posterior to that structure, together with inferior profunda artery, which is upon its outer side, (b) .At Elbow; Occupies groove between olecranon and internal condyle, resting upon posterior surface of latter (rarely upon anterior surface), and enters forearm between two heads of tiexor carpi ulnaris. (c) In Forearm; Passes vertically down ulnar side, upon flexor profundus digitorum, its upper half covered by tlexor carpi ulnaris, its lower half by skin and fascia (the nerve here lying external to flexor carpi ulnaris). The ulnar nerve lies, throughout, to the ulnar side of the ulnar artery — the upper third lying considerably to the inner side, and the lower two-thirds near to the inner side. The dorsal cutaneous branch passes posteriorly between 5 and 7.5 cm. (2 and 3 inches) above the wrist, (d) .\t Wrist; Crosses front of annular ligament between ulnar artery and pisiform bone, a little internal and posterior to the artery, and immediately divides into superficial and deep palmar branches. EXPOSURE OF ULNAR NERVE ABOVE MIDDLE OF ARM. Position. — As for median nerve in middle of arm (page 174). Landmarks. — Brachial artery, which is parallel with and to outer side of the ner\ e for the upper half of the arm. Incision. — From 5 to 7.5 cm. (2 to 3 inches) in length, with its center just abo\e the middle of the arm — running parallel with and about 1.3 cm. (j inch) to inner side of line of brachial artery (the line for the ligation of t le midd.e third of the brachial artery passing along the inner margin of the biceps muscle). Operation. — Incise skin and fascia, which here alone cover the nerve. .\void the basilic vein and the venae com!tes of the brachial artery — also the internal cutaneous nerve to the outer, and the lesser internal cutaneous nerve to the inner side. The ulnar nerve is found di\erging from its course parallel with the inner side of the brachial artery to pass obliquely across' the inner head of the triceps to pierce the internal intermuscular septum. EXPOSURE OF ULNAR NERVE JUST ABOVE INTERNAL CONDYLE OF HUMERUS. Position. — Patient upon back at edge of table. Assistant stands on side opposite one to be operated, and, grasping patient's wrist, with patient's hand prone, draws his (patient's) arm and forearm across the chest, thus exposing its posterior surface to the operator — who stands upon the side to be operated, cutting from elbow toward shoulder on both sides. Landmarks. — Olecranon; internal condyle of humerus. Incision. — .About 5 cm. (2 inches) in length, extending from a point aiiout 1.3 cm. (h inch) above (to proximal side of) internal condvle and midway between internal condyle and olecranon, upward toward a point at inner 176 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. side of brachial arten' opposite the insertion of the coracobrachialis muscle (about center of arm). Operation. — Incise skin and fascia in above Hne — when the nerve will be found upon the posterior surface of the internal intermuscular septum, with the inferior profunda artery upon its outer side. Comment. — If the incision were to e.xtend over the internal condyle, the nerve would be found lying upon the posterior surface of the base of the inner condyle of the humerus, close to the bone and along the inner edge of the triceps. SURGICAL ANATOMY OF MUSCULOSPIRAL NERVE. Description. — Arises, in common with circumflex nerve, from posterior cord of brachial plexus — descends arm behind a.xillary and brachial arteries and in front of tendons of latissimus dorsi and teres major, and winds around humerus in musculospiral groove, from inner to outer side, with superior profunda artery, lying between the internal and external heads of the triceps. Arriving at outer side of arm, it pierces the external intermuscular septum about midway between insertion of deltoid and tip of external condyle (namely, at lower third) and descends between supinator longus and brachiahs anticus to front of external condyle, where it divides into radial and posterior inter- osseous nerves. EXPOSURE OF MUSCULOSPIRAL NERVE BELOW MIDDLE OF ARM. Description. — The ex[)osure is here made upon the external aspect of the arm and the nerve is reached anterior to the external intermuscular septum. Position. — Same as for ulnar nerve just above internal condyle (page 175). The surgeon may also stand so as to cut from shoulder toward elbow. Laxidmarks. — Insertion of deltoid (about middle of arm) ; external condyle of humerus; upper border of supinator longus. Incision. — .About 6 to 7.5 cm. (2^ to 3 inches) in length — crcssing obliquely the outer surface of the lower third of the arm — so placed that its center will be midway between the deltoid and the external condyle — and so that its obliquity will follow the line of the upper border of the supinator longus. Operation. — Having incised skin and fascia, avoiding cephalic and median cephalic veins, identify the internal border of the supinator longus. Draw this muscle to the outer side, so as to expose the interval between it and the brachialis anticus — where the nerve will be found close to the bone, accompanied by a branch of the superior ])rofunda artery. Comment. — Exposure of the nerve at its bifurcation into radial and posterior interosseous may be accomplished (if not performed as a separate operation) by continuing the above incision downward. SURGICAL ANATOMY OF RADIAL BRANCH OF MUSCULOSPIRAL NERVE. Description.— Anterior subdivision of musculospiral. At first lies a short distance to radial side of radial artery, but gradually approaches it SURGU AI. ANATOMY OF THE INTERCOSTAL NERVES. 177 closely and runs parallel with it, on its outer side, covered by supinator longus — running along anterior border of extensor carpi radialis brevier and resting on supinator brevis, insertion of pronator radii teres, and radius. About 7.5 cm. (3 inches) above the wrist the nerve quits the artery, passes backward beneath the tendon of supinator longus, and, piercing the deep fascia, divides into external and internal branches. SURGICAL ANATOMY OF POSTERIOR INTEROSSEOUS BRANCH OF MUSCULOSPIRAL. Description. — Posterior subdivision of musculospiral. Passing down- ward in interval between brachiahs anticus and extensor carpi radiaHs longior, winds around outer side of radius to back of forearm, passing between super- ficial and deep layers of supinator brevis muscle. Thence it enters the cellular interval between the superficial and deep layers of the muscles at back of forearm, passing onto the interosseous membrane at lower third of forearm — and thence under cover of tendons of extensor communis digi- torum to back of wrist, where it swells into a gangliform enlargement. EXPOSURE OF RADIAL OR POSTERIOR INTEREOSSEOUS BRANCH OF MUSCULOSPIRAL. AT THEIR COMMENCEMENT. Position. — As for the median nerve in middle of arm (page 174). Landmarks. — External bicipital sulcus. Incision. — .\long anterior margin of supinator longus muscle, in external bicipital sulcus — center of incision corresponding with external condyle. Operation. — Incise skin and fascia. Avoid median cephalic vein and musculocutaneous nerve. Retract supinator longus to outer and brachialis anticus to inner side — between which two structures the beginning of the radial and of the posterior interosseous will be found, accompanied by a branch of the superior profunda artery. Comment. — This is, practically, a continuation of the operation for the exposure of the musculospiral below the middle of the arm. SURGICAL ANATOMY OF THE INTERCOSTAL NERVES. Description. — (a) Pectoral Intercostal Nerves : — Pass outward, as the anterior divisions of the dorsal nerves, in front of superior costotransverse ligaments, levatores costarum, external intercostal muscles, covered (to angle of ribs) by pleura and endothoracic fascia. They then approach upper part of each intercostal space to accompany intercostal vessels, in groove of rib above, to front of chest — the nerve lying below the vessels. Between angle of rib and middle of rib they lie between internal and external inter- costal muscles, giving off, a little posterior to middle of the ribs, the lateral cutaneous branches — which latter branches pass through external intercostal and serratus magnus muscles about center of ribs and divide into anterior and posterior branches. The main trunk of the intercostal nerve continues forward among fibers of internal intercostal muscles to costal cartilages — thence passes between internal intercostal muscles and pleura, crossing in front of internal mammary artery and triangularis sterni muscle — to pierce 178 OPERATION'S UPON THE NERVES, PLEXUSES, AND GANGLIA. internal intercostal muscles and pectoralis major and end in the anterior cutaneous branches, (b) Abdominal Intercostal Nerves : — Take the same course (as the anterior divisions of the dorsal nerves) as the pectoral inter- costals, from their origin to ends of intercostal spaces in which they lie — thence they run between the slips of origin of diaphragm to enter the abdominal wall, each nerve (from seventh to ninth, inclusive) crossing behind cartilage of rib below. In the abdominal wall they pass between internal oblique and transversalis, diverging from each other as they go forward, to outer edge of the rectus — and, piercing posterior layer of rectal sheath, rectus itself, and anterior layer of sheath, they supply rectus and sheath and end in the anterior cutaneous nerves near the linea alba. Comment. — (1) The exceptions in the distribution of the anterior divi- sions of the first, second, and twelfth nerves are not mentioned in the above descriptions. (2) The upper si.x dorsal nerves form the pectoral intercostal nerves — the lower six, the abdominal intercostals. (3) The final distribution of the lower dorsal nerves is as follows; — sixth, to pit of stomach; seventh, to lower end of ensiform cartilage; eighth, over the middle linea transversa; tenth, to the umbilicus; twelfth, midway between umbilicus and pubis. EXPOSURE OF INTERCOSTAL NERVE BETWEEN ANGLE AND MIDDLE OF RIB. Position. — Patient on side. Surgeon either in front or at back of patient. Landmarks. — .\ngle and lower border of rib. Incision. — Parallel with and just below lower border of ril), and lying between the angle and middle of rib. Operation. — Having incised skin, fascia, and external intercostal muscle, separate the cut edges of the external intercostal muscle and seek for nerve in the intermuscular plane between external and internal intercostals, near the lower border of the rib above. The nerve may be drawn down into view from the groove in the lower border of the rib by means of a nerve-hook. If necessary, bite out a half-button of rib subperiosteally with rongeur forceps, fully exposing the nerve and intercostal vessels, when the latter may be divided between ligatures, if necessary. SURGICAL ANATOMY OF ANTERIOR CRURAL NERVE. Arises from second, third, and fourth lumliar nerves and descends through fibers of psoas muscle — emerging from lower part of its outer border, and descending beneath Poupart's ligament into thigh, beneath the iliac fascia, in groove between psoas and iliacus, being separated from femoral artery on its inner side by the psoas. It divides below Poupart's ligament into an anterior division, passing in front of the external circumflex vessels — and a posterior division, passing behind these vessels. EXPOSURE OF ANTERIOR CRURAL NERVE, BELOW POUPART'S LIGAMENT. Position. — Patient on back; limb extended and rotated slightly outward. Surgeon to outer side of right limb, and to inner side of left or on right. EXPOSL'RE OF GREAT SCIATIC NERVE. 179 leaning over body; or on outer side of left limb, cutting from below up- ward) . Landmarks. — Middle of Poupjart's ligament. Incision. — Vertical, about 5 cm. (2 inches) in length, carried downward from a |)iiint about 1.3 cm. (J inch) e.xternal to center of Poupart's ligament. Operation. — Incise skin and superficial fascia. Crural branch of genito- crural nerve may be met running down the thigh. The superficial circumflex iliac vessels will lie across the incision. Flex the thigh to relax the muscles. The nerve will be found lying to the outer side of the femoral artery, in the groove between the iliacus and psoas muscles. EXPOSURE OF OBTURATOR, SUPERIOR GLUTEAL, AND PUDIC NERVES. The operations for the exposure of the obturator nerve at the t'.iyroid foramen, the superior gluteal nerve upon the buttock, the pudic nerve upon the buttock, and the pudic nerve in the perineum, are. practically, the same as the operations for the ligation of the obturator artery at the thyroid foramen (page 85), the gluteal artery upon the buttock (page 89), the internal pudic artery upon the buttock (page 88). and the internal pudic artery in the perineum (page 88), respectively. SURGICAL ANATOMY OF GREAT SCIATIC NERVE. Description. — Continuation of lower cord of sacral plexus — leaves pelvis by great sacrosciatic foramen, below pyriformis — descends from hollow between great trochanter and tuberosity of ischium down back of thigh, to about its lower third, where it divides into external and internal popliteal nerves (the division often occurring higher). The great sciatic nerve rests, from above downward, upon the ischium, gemellus superior, obturator internus, gemellus inferior, quadratus femoris and adductor magnus, — and is covered bv, from above downward, the skin, fascia, gluteus maximus, biceps, and small sciatic nerve. It has the sciatic artery to its inner side, and small sciatic nerve superficial to it above, and to its inner side as it (the small sciatic nerve) descends the thigh. EXPOSURE OF GREAT SCIATIC NERVE AT LOWER BORDER OF GLUTEUS MAXIMUS. Position. — Patient turned upon side sufficiently to expose field of opera- tion. Surgeon on side of operation, cutting downward on left side, and upward on right. Landmarks. — Lower margin of gluteus, which is below fold of buttock; tubfr(isit\- of ischium; great trochanter. Incision. — Begins over gluteal fold and jxisses vertically downward for a distance of 7.5 to 10 cm. {3 to 4 inches), with center of incision over low^er margin of gluteus maximus and placed midway between tuberosity of ischium and great trochanter — although the nerve lies a little nearer the former than the latter, for by this incision the hamstring muscles are more easily retracted. Operation. — Having incised skin and fatty areolar tissue, the small sciatic nerve and cutaneous vessels are encountered. Expose the lower edge l8o OPERATIONS UPON THE NERVES, PLEXUSES. AND GANGLIA. of the gluteus maximus, running downward and outward, and retract upward. Find and retract the hamstring muscles inward, bending the knee to aid the retraction. The nerve is found a Httle nearer the tuberosity of the ischium than the great trochanter and under the outer edge of the biceps muscle. SURGICAL ANATOMY OF INTERNAL POPLITEAL BRANCH OF GREAT SCIATIC NERVE. Description. — The larger branch of the great sciatic. Extends from bifurcation, at lower third of thigh, through middle of popliteal space to lower border of pophteus muscle, where it becomes the posterior tibial nerve. It is covered, above, by hamstring muscles; in the middle, by skin and fascia; and below, by heads of gastrocnemii. The pophteal vein intervenes between the nerve superficially, and the artery deeply. In the upper popliteal space the nerve hes external to the popliteal artery and vein ; at the level of the knee, the nerve crosses these vessels; and in the lower popliteal space the nerve hes to the inner side of the vessels. EXPOSURE OF INTERNAL POPLITEAL NERVE AT LOWER PART OF POPLITEAL SPACE. Position. — Patient rests on shoulder and side of chest, as nearly prone as anesthesia will allow; limb extended. Surgeon to outer side of left, cutting downward; and to inner side of right, cutting downward (or to outer side, cutting upward). Landmarks. — Heads of gastrocnemii muscles. Incision. — Begins opposite the center of the popliteal space and passes vertically downward for about 9 cm. (3^ inches), between the two heads of the gastrocnemii. Operation. — Having divided skin and superficial fascia, avoid external saphenous vein and nerve at the outer and lower part of the wound. Expose the heads of the gastrocnemii and open up, by blunt dissection, the interval between them, retracting the heads of the muscle to their respective sides. The nerve will be found the most superficial of the imjjortant structures in the popliteal space. SURGICAL ANATOMY OF POSTERIOR TIBIAL NERVE. Description. — The direct continuation of internal popliteal nerve. Extends from lower border of popliteus muscle to interval between internal malleolus and heel, where it divides into internal and external plantar nerves. It is covered, aljove, by gastrocnemius, plantaris, soleus, and intermuscular deep fascia; and, below% by only skin and fascia. It rests upon (its anterior relations are), above, tibialis posticus; and, below, flexor longus digitonim. It lies to inner side of posterior tibial artery above, but soon crosses it and runs on its fibular side to ankle. EXPOSURE OF POSTERIOR TIBIAL BETWEEN ORIGIN AND ANKLE. The operation for the exijo^urc of the posterior tibial nerve at its origin is, practically, the same as that for the exposure of the internal pojjliteal at EXPOSURE OF EXTERNAL POPLITEAL NERVE. l8l the lower part of the popliteal space (page i8o). The posterior tibial nerve in the leg may be exposed by the same operation as would expose the posterior tibial artery at the same level (page 112). EXPOSURE OF POSTERIOR TIBIAL NERVE BEHIND INTERNAL MALLEOLUS. Position. — Patient on back; knee fle.xed ; leg resting on outer side. Sur- geon stands facing either foot, cutting from above downward. Landmarks. — Internal malleolus; tendo Achillis. Incision. — Curved, about 5 cm. (2 inches) in length, made about 1.3 cm. (2 inch) behind and parallel with the internal malleolus, beginning just in front of tip of malleolus and extending upward in a line midway between internal malleolus and tendo Achillis. Operation. — Directing the knife toward the tibia, divide skin, superficial fascia, and annular ligament. The order of the structures met behind the internal malleolus, from within outward, is, tibialis posticus; fie.xor longus digitorum; posterior tibial artery, vein and nerve; flexor longus hallucis. The nerve is therefore sought between the tendons of the flexor longus digi- torum and flexor longus hallucis. SURGICAL ANATOMY OF EXTERNAL POPLITEAL (PERONEAL) BRANCH OF GREAT SCIATIC. Description. — Smaller branch of great sciatic. Enters superior angle of popliteal space and passes obliquely along outer side of this space to head of fibula, lying near inner border of biceps (lying beneath skin and fascia, behind head of fibula, to inner side of biceps tendon). The nerve leaves the popliteal space in interval between biceps tendon and outer head of gastrocnemius — winds around neck of fibula between bone and peroneus longus muscle — and, piercing origin of latter muscle, divides into anterior tibial, musculocutaneous, and recurrent articular nerves. EXPOSURE OF EXTERNAL POPLITEAL BEHIND TENDON OF BICEPS. Position. — Patient on uninviilved side, rolled into slightly prone position; leg extended. Surgeon stands facing back of patient's knee. Landmarks. — Tendon of biceps; head of fibula. Incision. — .\bout 4 to 5 cm. (15 to 2 inches), along posterior edge of tendon of biceps, extending from over the prominence of the external condyle of the femur toward the posterior border of the head of the fibula. Operation. — Divide skin and deep fascia. Expose the biceps tendon. Flex the knee to relax the tendon and search for the nerve near the attachment of the biceps tendon to the head of the fibula, near the outer edge of the gastrocnemius. l82 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. SURGICAL ANATOMY OF ANTERIOR TIBIAL BRANCH OF EXTERNAL POPLITEAL. Description. — One of the terminal branches of the external popliteal. Commences between fibula and peroneus longus — pierces septum between peronei and extensors — passing obliquely beneath extensor longus digitorum to forepart of interosseous membrane. Runs forward on interosseous mem- brane between extensor longus digitorum and tibialis anticus, in upper part of leg — and between tibiahs anticus and extensor longus hallucis, lower down. Passes under anterior annular ligament and ends in front of bend of ankle in external and internal branches. The anterior tibial nerve reaches the fibular side of the tibial artery at the junction of the u[)per and second fourths of the leg, thence lies in front of the artery to the ankle, and thence generally lies to its outer side. EXPOSURE OF ANTERIOR TIBIAL NERVE NEAR ORIGIN. Position. — Patient supine and inclined to uninvolved side; hip slightly fiexed and rotated inward, so that knee rests upon inner aspect. Surgeon stands behind either limb, cutting from above on the right, and from below on the left. Landmarks. — Outer tuberosity of tibia; head of fibula. Incision. — Begins opposite the most external ]jart of the tibial tuberosity, and about 1.3 cm. (i inch) anterior to the head of the fibula, and jia.sses downward for 5 to 7.5 cm. (2 to 3 inches). Operation. — Having incised skin and fascia, the intermuscular septum between peroneus longus and extensor longus digitorum is sought, running obliquely downward and forward, and is opened up by blunt dissection. The anterior tibial nerve (and also the musculocutaneous nerve) is found deep in this internmscular interval, running downward and inward, below the fibular head and covered by the extensor longus digitorum (the musculo- cutaneous running vertically downward). Comment. — The anterior tibial nerve may be exposed at any point on the leg below its upper fourth, by the same operation as would expose the anterior tibial artery at the corresponding level (page 105). SURGICAL ANATOMY OF THE CERVICAL SYMPATHETIC GANGLIA AND CORD. Description. — The cervical portion of the gangliated cord lies deeply in the neck, embedded in the fascia between the muscles covering the front of the vertebral column l)ehind, and the carotid sheath in front — and consists of three ganglia, together with the connecting cord: — (a) Superior Cervical Ganglion (largest) — lies opposite second and third cervical vertebra? (some- times, fourth and fifth) — rests upon rectus capitis anticus major, posteriorly, — has internal carotid artery and internal jugular vein, anteriorly, — and pneumogastric nerve, externally, (b) Middle Cervical Ganglion (sometimes wanting) — opposite sixth (or seventh) cervical vertebra — upon, or close to, where the cord crosses the inferior thyroid artery, (c) Inferior Cervical Ganglion — between base of transverse process of seventh cervical vertebra and neck of first rib, lying between subclavian and vertebral arteries. TOTAL EXCISION OF CERVICAL SYMPATHETIC. 183 TOTAL EXCISION OF CERVICAL SYMPATHETIC GANGLIA AND CORD. JIJXNESCOS IH'EKATIOX. Description. — The cervical sympathetic ganglia and cord have been inciscil, partially excised, and totally excised — chiefly for exophthalmic goiter and epilepsy — and also in hysteria, chorea, tumors of the bram, and glau- coma. The cord and one or both upper ganglia of one or both sides have been removed, — or both upper ganglia of both sides, with mtervening cords, — or both cords with all the ganglia of one or both sides. The removal of the cord and ganglia of one side will be described below. Position. — Patient supine; shoulders and head raised and latter turned to op])osite side; neck, shaved, rests upon a narrow support (to render promi- nent). Surgeon to right, for both sides. Landmarks. — Mastoid process; posterior border of sternomastoid; clavicle. Incision. — Beginning opposite the posterior margin of the mastoid pro- cess, passes downward along the posterior border of the sternomastoid to just below the clavicle. Operation. — Incise skin, superficial fascia, and platysma. Divide the external jugular vein between two ligatures. Displace the sternomastoid inward (or it may be split longitudinally near its posterior border and the parts retracted laterally). E.xpose the common sheath of the vessels by blunt dissection. Lift the carotid sheath, unopened, upward and retract it inward — when the cervical cord and superior and middle cervical ganglia will be exposed, lying upon the prevertebral muscles. Having well retracted the structures to that side toward which most easily displaced, isolate the trunk of the cervical sympathetic near the center of the incision. Follow it up to the superior ganglion, divide the communicating branches of the ganglion with delicate scissors, and remove the ganglion with fine forceps. Practising slight traction upon the distal end of the trunk, trace the cord down to the middle ganglion, which is similarly removed — carefully guarding, throughout, all important adjacent structures. Continuing gentle traction upon the cord, just sufficient to follow it, trace the main trunk down behind the clavicle to the inferior ganglion. Guard the spinal accessory nerve in the upper part of the neck — the nerves of the cervical plexus in the middle of the neck — the thyroid and vertebral vessels, recurrent laryngeal and phrenic nerves and pleura in the lower part of the neck — and the thoracic duct on the lower left side. In closing the operation, approximate the separated muscles with buried gut sutures — and close the superficial wound in the usual manner, unless temporary drainage be indicated. CHAPTER V. OPERATIONS UPON THE BONES. OSTEOTOMY IN GENERAL. Definition. — Any division of bone by cutting instrument. Indications. — Deformities of bones and joints (such as result from congenital conditions); diseases of bones and joints, followed by weakening of bone and subsequent curvature or angularity; malunion following fracture; ankylosis. Varieties. — (a) Linear Osteotomy; Simple division of bone in its con- tinuity, by simple transverse, oblique or vertical section-line (e. g., linear osteotomy of neck or shaft of femur for faulty ankylosis), (b) Cuneiform Osteotomy; Removal of a wedge-shaped piece of bone in its continuity {c. g., cuneiform osteotomy for bent tibia), — or from, or including, one of its ends (e.g., cuneiform osteotomy of a joint for ankylosis), (c) Osteoarthrotomy; Though not a distinct variety of osteotomy, may be considered as an inter- articular osteotomy, linear or cuneiform. General Manner of Performing Osteotomy as to the Instrument. — Osteotomy, in general, may be performed with an osteotome, an instrument ground evenly from both sides, and graded upon the handle to indicate depth of section, — with a chisel, an instrument beveled from one side only, and similarlv graded U].)on handle, — or with a special saw. General Manner of Performing Osteotomy as to Method of Opera- tion. — (a) Open ^lethod; in which the site of the bone-section is exposed to view by a preliminary operation, (b) Subcutaneous or Submuscular Method; in which the site of bone-section is reached through the smallest, simplest incision and the bone divided out of sight and by the sense of touch. Cuneiform osteotomy is nearly always done by the open method. Linear osteotomy may be done by the subcutaneous or by the open method — the form.er being more frequently done — the latter being preferable where the safety of the parts can be better preserved by first e.xposing them. Cuneiform osteotomy should be done subperiosteally where possible, and when not contraindicated (as by disease). Linear osteotomy should be done sub- periosteally when performed by the open method, if possible and not contra- indicated. Linear osteotomy is usually performed with an osteotome or a saw. Cuneiform osteotomy is generally done with a chisel (sometimes with a saw). Instruments Used in Osteotomy.— Rubber tourniquet; scalpels; tenotomy knives; hemostatic forceps; dissecting and toothed forceps; scissors, curved and straight, sharp and blunt; retractors; chisels, various sizes and widths; osteotomes, various sizes and widths; mallets, preferably of wood; saws, especially of the osteotomy ty[)e (with narrow blade and with cutting part only at end, and with blunt point and large handle), and also chain- saws, Gigli saws, and butcher saw; periosteal elevators, curved and straight; rugines; raspatories; blunt dissector; bone-holding forceps; bone-cutting forceps; needles, straight and curved; needle-holder; chromic and plain 184 LINEAR OSTEOTOMY BY THE SfBCLTANEOUS METHOD. iSs gut; silkworm-gut and kangaroo tendon; bone-drills; silver wire; pegs and nails, ivory and metallic; sand-bag (for part to rest upon and dissipate the jar). Preparation of Patient. — The part shaved. Position. — The position of patient, surgeon, and assistant will be deter- mined by the special operation. LINEAR OSTEOTOMY BY THE SUBCUTANEOUS METHOD. Steps of Operation Preparatory to Division of Bone.— Having ex- sanguinated the limb Ijy elevation, tnUowed by the application of a rubber tourniquet (which may generally be dispensed with), the portion of the limb involved is placed upon a sand-bag (previously damp- ened and covered with several layers of wet, sterilized tow- els, to prevent the fly- ing of dust), which forms a yielding bed into which the part may he moulded and in which it may re- ceive the jar of the blows from the mal- let. An incision, just long enough to ad- mit the osteotome or saw, is made over the site of the bone- section. The incision is as limited as pos- sible, and so placed as to reach the bone bv the most direct and safest route, and with the least danger to important struc- tures. It should be, where possible, in a line with the over- lying muscle-fibers — should avoid vessels and nerves — and is generally parallel with the bone. This incision is usually made directly to the bone with one stroke — it being impossible, from the small size of the wound, to recognize the intermuscular planes, or the bone's exact level, if at any depth from the surface. Hav- ing made a path to the bone, the remaining steps of the operation will de- pend upon the instrument with whicli the division of the bone is to be made. Division of Bone with Osteotome. — Having made the incision through the soft parts with a knife, the knife is not withdrawn but allowed to remain in situ as a guide — upon this an osteotome (somewhat narrower than the Fig. 121. — Linear Osteotomy by the Svbcutaneovs Method: — A. Linear osteotomy of anatomical neck of femur with saw; B, Linear osteotomy of surgical neck of femur with osteotome. l86 OPEKAIIONS LI'(JX THE BONES. bone to be divided) is introduced, entering the wound with the length of its cutiing-edge corresponding to the length of the wound. It is carefully passed down, in contact with the knife, to the bone, and the knife withdrawn. The osteotome, constantly held in contact with the bone, is now turned with its cutting-edge in the direction of the desired bone-section (which is generally at a right angle to the incision of the soft parts). In the act of turning the osteotome into position, the soft parts are levered away by the blunt sides of the instrument, and the bone is hugged, but care is used not to detach the periosteum (which the knife-incision may have cut) (Fig. 121, B). The osteotome is held in the surgeon's left hand near its cutting end — being grasped in his full hand, the ulnar margin of his hand resting on the patient's limb to steadv the instrument. The instrument should cut away from important structures, and preferably toward the surgeon. After each stroke of the mallet, the osteotome should be shifted, traveling back and forth in the line of section, that it may not bind in any one place. In section of thick bones, if the instrument bind, it is withdrawn and a thinner (not narrower) one is introduced — and subsequently a still thinner, if necessary. Progress through the bone is determined by the skilled sense of touch. The section should be evenlv made, as to depth, completely across the width of bone, traveling back and forth, no two blows being made in one site. Never remove the instrument from the groove in the bone when once the section has been commenced (unless a larger instrument catches in the section and has to be replaced by a thinner one), for it is often hard to regain the groove. The last portion of bone on the far side of the section, when important structures ■ are just beyond, need not be cut with the osteotome, but may be bent or liroken subsequently by manipulation of the limb. Division of Bone with Saw. — A special osteotomy saw, generally of the Adams type, is used. The operation is very similar to that just described, except in the substitution of the saw for the osteotome. The skin incision is placed as in the above operation, but is made with a tenotome instead of an ordinarv knife — usually cutting in the line of the muscle-fibers and in the axis of the limb. When the bone is reached, the blade of the tenotome is turned so as to cross the bone transversely and is made to cut a path for the saw across the bone — the non-cutting part of the handle of the tenotome doing no harm to the soft parts between the bone and wound of entrance. When the way for the saw has been prepared, the tenotome is left in situ as a guide. Upon this the blade of the saw is introduced down to the bone and its cutting part pushed on across the portion of bone to be divided (Fig. 121. \). The bone is to be sawed with short strokes, guarding against thrusting the point of the saw into the soft parts, especially at the beginning and ending of the section. The section may be nearly made with the saw and com])leted liy manual bending or breaking. After-treatment. — Following osteotomy, the limb, or part, is in a con- dition of comjxjund fracture made under the most favorable circumstances. Some form of splint, or a plaster-dressing, must immobihze the limb and keep the ends of the bones in apposition. The wound is closed by suture — no drainage being u.sed in clean cases. Comment. — (i) In division by an osteotome, the osteotome itself is sometimes used to cut its way through the soft parts, instead of knife. (2) When the bone-section is nearly complete, bending is especiallv applicable in young, tender bones. (3) The section of the bone should generally be completed by instrument, and not by breaking, as a splinter of bone may do damage to adjacent parts. CUNEIFORM OSTEOTOMY. LINEAR OSTEOTOMY BY THE OPEN METHOD. Steps of Operation Preparatory to Division of Bone. — The site of the bone-section is exposed by an incision so placed as to reach the bone most readily and safely, seeking an intermuscular plane where possible. Having passed through skin, fascia — and through or between muscles — the soft parts are opened up and retracted to either side — and the region of bone fully exposed to view. Where it is possible to do so, and where it is not contraindicated, the periosteum is incised in the long axis of the bone, freed from its circumference, and retracted with the soft parts. The bone-section mav then be maro.\lv :—Ol the tend., .^chillis. The wound is entirely closed and the limb dressed upon a splint, or the part immoljilizcd (Fig. 162). Subcutaneous Tenotomy.— The tendon is here divided subcutaneously, through the smallest possible wound. Having put the tendon upon the stretch, to render prominent, an incision is made parallel with and just to one side of the tendon to be cut, and so placed as to do the least damage to other structures in the neighborhood. The incision is first made with a sharp tenotome, through skin and fascia down to the tendon — upon this as a guide the blunt tenotome is passed sidewise (the sharp one being withdrawn). The tenotome is then insinuated beneath the tendon, which it closely hugs throughout. Sometimes temjjorary relaxation of the tendon will aid the passage of the knife beneath it. The cutting-edge of the tenotome is then turned outward— the tendon put upon the stretch— the forefinger of the TENORRHAPHY. 213 left hand being placed over the site of section as a guard and guide — and the tendon cut by a short sawing movement, the last fibers being cut carefully as the tendon is felt to yield. The knife is finally withdrawn upon its side. The wound is sutured and the limb dressed upon a splint (Fig. 163). Comment. — (1) In simple sections where the tendons are easily accessible and the neighboring parts are not important, subcutaneous tenotomy may be done. Where the opposite conditions exist, open tenotomy should always be practised. {2) In doing subcutaneous tenotomy, the tenotome is some- times inserted between skin and tendon and the section made inward upon the tendon — which is more dangerous than cutting from beneath the tendon outward. TENORRHAPHY. Description. — Suturing of tendon. In recent cases the ends of the tendons can ordinarily be appro.ximated without great difficulty. In old cases if the ends cannot be approximated and sutured after freshening them by Figs. 164-167. — Tenorrhaphy: — A, Single suture through entire thickness of tendon; B. Two ures entirely through tendon, in opposite directions; C, Peripheral sutures; D. Woelfler's quilt trimming, some method of lengthening must be used — and if their union cannot be accomplished by lengthening, transplantation to adjacent tendons mav be resorted to. Varieties. — Primary, when the tenorrhaphy is done near the time of injury. Secondary, when done after healing. Operation. — In recent cases an already existing wound may be present (except in such cases as subcutaneous rupture of a tendon) — and where a wound is present, this is simply enlarged and the tendon more fully exposed and the ends isolated. Where no wound exists at the time of the tenorrhaphy, the main tendon and its ends are exposed by an incision which reaches the site by the safest and simplest route. In primary tenorrhaphy the ends may require no trimming, especially in clean cuts, — or but slight trimming. In secondary tenorrhaphv, a transverse or oblique section of the tendon ends is always necessary, prior to suturing. In either case, the opposite ends of 214 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. the tendons are brought well into the wound and approximated. Chromic catgut and kangaroo tendon are the best materials for uniting the ends. Several methods of suturing are used — the chief of which will be here de- scribed: (a) Interrupted sutures passing transversely through upper and lower ends of divided tendon (Figs. 164 and 165, letters A, B); — A straight needle enters the pro.ximal surface of the upper portion and passes transversely through its thickness, about 8 mm. or 1.3 cm. (from § to A inch) from the cut margin — emerges at same level upon distal surface — crosses the gap — enters the distal surface of the lower portion, from 8 mm. to 1.3 cm. (^ to h inch) from the cut end — passes transversely through — emerges at same level on pro.ximal surface. The two ends of the suture are drawn upon until the tendon ends are approximated, and are then tied. When the tendon-ends have been cut obliquely, the sutures are so passed as to cross the line of division at a right angle (Fig. 173, B). (b) Interrupted mattress sutures; — A curved needle enters the proximal surface of the lower portion, about 8 mm. (^ inch) from its end — passes axially through two-thirds of the thickness Figs. 16S-171.— Tenorrhaphy; — .A, Mall of the tendon — emerges on the cut margin — crosses the gap to the upper portion— enters the cut margin about two-thirds its thickness from the prox- imal surface— emerges about 8 mm. (J inch) above the end— passes over the outer surface of the upper portion of the tendon for from 8 mm. to 1.3 cm. (J to ^ inch) — again enters the upper portion on a level with the point at which it has just emerged from the upper portion — passes through about two-thirds its thickness — emerges on the cut margin — crosses the gap to the lower portion — enters its cut margin about two-thirds its thickness from the pro.ximal surface — and emerges on the proximal surface on a level with the original entrance — when the two ends of the tendon are drawn upon until the cut surfaces come well into contact and are then tied (Figs. 168 and 169, A and B; and Fig. 167, D). (c) Peripheral longitudinal coaptation sutures;— A curved needle enters the lateral surface of the upper portion, about 8 mm. or 1.3 cm. (J to i inch) from the cut edge— passes longitudinallv through the tendon and emerges on the cut margin about 6 to 8 mm. (| to | TENORRHAPHY. 215 inch) from the lateral surface — crosses the gap — enters the cut margin of the lower portion, from 6 to 8 mm. (j to ^ inch) from the lateral surface — passes longitudinally through the muscle and emerges on the lateral surface, about 8 mm. to 1.3 cm. (^ to 5 inch) from the cut margin. The upper and lower ends of the sutures are now tied, approximating the tendons. These sutures are repeated at intervals of about 8 mm. to 1.3 cm. (^ to ^ inch) around the entire circumference of the tendon (Fig. 166, C). (d) Lateral knotted sutures; — A curved needle enters the lateral surface of the upper portion about 8 mm. to 1.3 cm. (^ to ^ inch) from the cut margin — passes transversely through the tendon tissue for about 8 mm. to 1.3 cm. (5 to ^ inch) in width, and 8 mm. (J inch) in depth — and emerges on the level of entrance. The two ends of the suture are now tied, care being taken to but slightly, if at all, pucker the tendon — and one end of the suture is then cut short The same kinci of suture is applied immediately below, in the lower portion of the tendon, and one end of the suture similarly cut short. The two long ends of the sutures are then tied together, thus appro.ximating the two ends of the tendon. As Figs. 172-174.— Tknorrhaphv :— a, Reinforcing or relaxation suture, applii suturing (shown with first turn of knot); B, Suturing of obliquely divided en through-and-through suture by lateral suture through loops of first suture. many of these pairs of sutures are introduced as necessary (Figs. 170 and 171, C and D). The extreme margins of the tendon-ends may be further sutured, between these sutures, by method "c." (e) Relaxation sutures; — In any of the above forms of primary or coaptation sutures, one or more relaxation sutures of heavy catgut may be applied, passing transversely through the entire thickness of the tendon considerably above and below the primarv sutures — and tied tightly enough to take the chief tension, and thus free the primary sutures from strain (Fig. 172, A), (f) Combination of the interrupted mattress (method "b"), or lateral knotted sutures (method "d"), with relaxation sutures (method "e"). Of these various method-^, either method "a" or "b" is probably most generally applicable — the former especially in smaller tendons and the latter in larger. Having united the tendon-ends, the wound is closed and the limb put up upon an immobilizing splint. 2l6 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. Comment. — (i) While a constrictor is not generally necessary, its use is ordinarily advisable. (2) Some surgeons prefer to e.xpose the parts by a curved incision, beginning and ending over the tendon, above and below the rupture, but not over the rupture — so that there may be no possibility of adhesion between the tendon cicatri.x and the skin cicatrix. (3) The ends of the tendons often form adhesions to their sheaths, and must be freed before they can be brought together. (4) All tendon-sheaths opened to e.xpose tendons must be repaired with catgut. (5) The upper end of the divided tendon retracts further, and is harder to find, than the lower. The upper end retracts more because of the more active shortening of the proximal end of the muscle. It may be found, in hard cases, by "milking" the tendon- sheath downward — or by incising over the tendon higher up and tracing downward — or by incising the sheath in the lower part of the wound and tracing upward. The upper end of the tendon may sometimes be brought into view by extending the fingers or toes, the fibro-serous vincula pulling down the adjacent tendons. The lower end is generally not hard to be found — when hard, incise over the sheath lower down and trace upward — or pass a probe into its sheath from below and protrude it upward. (6) If the two ends cannot be found, one end must be tran.splanted into a neigh- boring tendon of the same group or function (see transplantation and grafting of tendons, pages 221 to 223). (7) The limb is put up so as to relax the tendon and muscle fully, and held so in a splint during union. Aher union has occurred, passive and active movements are begun early and persisted in — in order to prevent adhesion of tendon to sheath, and to get full range of movement. (8) It will be seen by comparing the illustrations of Neuror- rhaphy (pages 144 to 146) that many of the methods used in uniting nerves are applicable to the union of tendons. TENDON-LENGTHENING. Description. — Tendon-lengthening, sometimes called tendoplasty, is ap- plied to the lengthening of shortened tendons, or to the union of severed tendons, by proces,ses of plastic elongation. Varieties. — Tendon-lengthening may be required in two classes of ca.ses; — (I) \\'here the tendon is intact but shortened; — (2) Where the tendon has been severed and the divided ends have retracted. As to the time of per- forming the operation, tendon-lengthening may be either primary (done near the time of injury), or secondary (when done after retraction and healing). Operation. — Much that has been said under Tenorrhaphy, as to the exposure of the tendon, is equally applicable here — (see 0])eration, page 213, and Comment, page 216). Having exposed the shortened tendon, or the retracted tendon-ends, in the wound, one of several methods of lengthening may be applied — the chief of which will be here described: — (a) Operations for lengthening shortened intact tendons:— (1) By long oblique division of tcnflon, with gliding of beveled ends;— The obliquity of the division will determine the amount of lengthening — the ends being slid past each other far enough to still leave sufficient substance for union — and then the ends are sutured by several transverse sutures of chromic gut or kangaroo tendon. An oblique incision of 5 cm. (2 inches) will furnish a lengthening of from 2.5 to 4 cm. (i to li inches) (Fig. 176, B). (2) By central longitudinal splitting of tendon with transverse division of the split ends and their approximation, surface to surface; — Having split the shortened tendon TENDON-LENGTHENING. m 1 1 I' I ' '|i[ 217 Figs- I75-'7S. — THNDON-I.ENGTHENlNr. ; — A, Splilling tendon t suturing ends laterally ; B. Splitting and suturing tendon obliquely Lusversely and longitudinally and C, Splitting tendon obliquely and one end obliquely and longitudi- nig Figs reinfo tudina with sum: ordinary) rQ-iS2.— Tkndon-i.engthening :— A, Splitting one end longitudinally and transversely, where bent, and suturing split end into opposite unsplit end ; B. Splitting both ends longi- id transversely, reinforcing where bent, and suturing sjilit portions end to end : C, Same, ng of split portions laterally ; D. Same as last, with different sutures (lateral knotted and 2lS OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. down its center, as far as necessary to furnish the needed length, the ends of the split portion are divided transversely, or shghtly obliquely, in opposite directions. They are then glided past each other and fastened laterally near their ends by two or more sutures passing through their com- bined thickness (Fig. 175, A). (3) By central longitudinal splitting of tendon with transver.se division of the split ends and their approximation, end to end; — Somewhat similar to the method just described, except that the extreme ends of the split portions are sutured end-to-end, rather than surface-to- surface (Fig. 177, C). (4) By zig-zag incisions; — Incisions, transverse to the length of the tendon, are made on opposite sides of the tendon, passing half-way across, and not placed directly opposite each other. .\s many as are deemed necessary are thus placed, and the tendon lengthened bv traction (Figs. 187 and 1S8, A, B). (b) Operations for lengthening shortened severed tendons: — (i) By partially s|)litting one end, twisting the split half I te*il|i ti':' 'v'lj M\ I If' Figs. i83-i,S5.— TEN[)ON-l.ENGTHF.NiNr, :— A, Double splitting of botti ends, re bent, and suturing split portions end-to-end; B. Bridging with gut. or reinforcing C. Bridging with twisted gut ; D. Interpolation witli another lateral knotted sutiir and suturing it to itself and to the end of the opposite end. Calculating the required amount of tendon needed, the upper end of the tendon is partially split, twisted upon itself and sutured to itself — and its free end sutured to the opposite lower end of the unsplit tendon (Fig. 178, D; and Fig. 179, A). (2) By partially splitting both ends, twisting the split portions and suturing them to themselves and to the end of the opposite end. This is the applica- tion to both ends of the principle applied in '• 1 " to one end (Fig. 180, B). (3) By partially splitting both ends, twisting the split portions and suturing them to themselves and laterally to the opposite end (Fig. 181, C). (4) By distance suturing, or bridging, with catgut;— The ends are approximated by lateral knotted sutures, as far as possible, then a continuous catgut suture is run back and forth between the ends and between the lateral knotted TENDON-LENGTHENING. 2iq sutures, partially filling in the gap by catgut strands, upon which lymph and blood are poured, and, together with the catgut, organized (Figs. 184 and 185, B and C; and Fig. 189, C). Following the union of the tendon- ends, the tendon-sheath, if it have been incised or otherwise injured, is re- paired with catgut sutures, as far as possible. In e.xposing the tendon, the sheath should not have been needlessly freed, for the vessels of the tendon reach it through the sheath. The overlying muscles are brought together with buried catgut sutures. The skin-wound is then closed — and the limb immobilized upon a splint, which will insure rela.xation of the part. Passive and active motion should be begun as soon as sound healing has occurred. Comment. — Many of the methods of nerve-lengthening are equally applicable to tendon-lengthening (pages 147 to 149). Not only may tendon-lengthening be accompUshed by processes of plastic elongation in the Figs. 187-189.— Tendon-lengthening :— A. Poncet's accordion method (in case of tendo Achillis) — incisions partly across tendon ; B, Same, sliowing amount of lengthening by traction upon tendon ; C, Bridging with gut. reinforced with decalcified bone-cylinder. sense of bringing into position undetached portions of tendon — but elongation may be also accomplished by the interjjosition of tendon substance, in those cases where the gap is too long to be bridged by other means, as in the similar operation for nerve-lengthening. The two most ordinary ways are the following; — (a) A piece of tendon of the required length and as nearly the desired size as possible, taken from a human being just operated upon, or from a lower animal, is inserted into the interval between the severed ends, which have been freshened, and is sutured to both ends of the main tentlon by longitudinal peripheral sutures, or other method (Fig. 186, D). (b) Half the thickness, and as much of the length as required, of part of the same or of one of the neighboring tendons of the patient is taken, and sutured, as 220 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. above, into the gap. The wound is treated as after other forms of tendon- lengthening. The interpolated tendon probably disappears, as such, after serving as a framework. TENDON-SHORTENING. Description. — The shortening of a tendon for the purpose of increasing the action of a muscle which has become impaired by the elongation of its tendon,— or for the purpose of improving a deformity (as the shortening of the tendo .-Vchillis for talipes calcaneus). Operation. — Having exposed the involved tendon, its shortening may be accomplished in one of several ways; — (i ) By excision of a piece of the tendon, with the union of the resulting ends by one of the methods of tenorrhaphy. (2) By oblique division of the tendon, followed by gliding of the ends in such a way as to lessen the length of the tendon, and the suturing of the ends as wlii -h EF issutur ri lo K L : C, Follow- ). E (cision of port on of tend 3nbytr.ins- ds(i jortion betwet n circular transverse 190-193.— Tendon-shortening : — A, Portion of tendon excised obliquely and severed lulured end-to-end. in direct contact or overlapping (reverse of Fi^. 176, B) ; B, Z-shaped inci- de, followed by excision of E F G H and IJ K L, aft ids of tendon are sutured in form of mortise; followed by mattress-suturing of opposite < here excised). in Fig. 19c, A. (3) By division and shortening of the tendon, followed by the beveling of one end into a wedge, and the splitting of the other end — and the suturing of the wedge into the split portion, thus using up the excess of length (Fig. 192, C). (4) By the figure of Z method (Fig. 191, B);— make a vertical incision down the center of the tendon from F to K, and transverse ones along E F and K L. Having drawn the cut portions apart, shorten each piece by removing the ends at G H and I J. E F and G H are then sutured together, and I J and K L — as well as the vertical line of division. The wound, following the operations for tendon-shortening, is closed and treated as after tendon-lengthening, .'\nother form of tendon- shortening is shown in Fig. 193, D, where a portion of tendon is removed. TENDON-GRAFTING. TENDON-GRAFTING. Description. — Tendon-grafting, tendon-transplantation, or tendon-im- plantation, as the operation is variously termed, is the attachment of the distal end of a divided tendon into a neighboring sound tendon of the same general group or function. The attachment is sometimes made laterally, without the division of the involved tendon Indications. — (i) Those cases in which so much of the tendon has been •destroyed that its reconstruction is impossible — and the damaged tendon Fig. 194. — Tendo.n-grafti.vg :— Of sound extensor of great toe into impaired anterior liliial ; A. Tendon of tibialis amicus; B. Pro.xinial end of extensor proprius hallucis, which has been severed from lower end. C, and engrafted upon anterior tibial tendon; D, Innermost tendon of extensor brevis digitoruni. is therefore grafted to a neighboring tendon (for instance, should one of the four tendons of the fle.xor sublimis or profundus digitorum be too extensively damaged for union of the proximal and distal ends, its distal end may be attached to one of the neighboring sound tendons of the same muscle). (2) Those cases in which a group of muscles, or a single muscle, has been para- lyzed — and one or more of the tendons of the paralyzed group is therefore grafted to a tendon of an unparalyzed group (for instance, if the tibialis anticus were paralyzed and the extensor proprius hallucis intact, the tendon of the tibialis anticus may be grafted upon the latter) (Fig. 194). Where the tendon of the muscle from which the power is to be derived is of comparatively 222 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. little importance functionally, and the paralyzed muscle is of more importance, the entire sound tendon may be diverted into the paralyzed muscle (Figs. 195-198). But where the tendon of the muscle which is to supply the j)ower is more important than the paralyzed tendon, then but a portion of the sound tendon should be diverted into the paralyzed one (Figs. 199-203). Figs. 195-198.— Tendon-graftinc:— I— Where the tendon of the muscle supplying the power is of comparatively little importance (shown on the right, in light), the entire sound tendon is grafted upon the impaired tendon (shown on the left, in dark). (Modified from Vulpius.) Figs. 199-203. -Te ii n directly over it,— or by an incision beginning and ending over the sheath but passing to one side of the sheath throughout the rest of its course, thus en- EXCISION OF TENDON-SHEATHS. 225 abling a skin-flap to be turned to one side, so that when replaced its scar will not fall directh' over the tendon. Having retracted the soft parts, the tendon-sheath is entirely isolated, with care, from the neighboring structures — especially from those forming its bed. The sheath of the tendon is now divided circularly around the tendon, above and below the diseased portion — but without cutting the tendon itself. Having completed the two circular incisions at either end, the sheath is split in the long axis of the tendon — and thus laid completely open — and may be removed in one piece (Fig. 207). Any diseased portions of the contained tendon found, should be scraped. The skin-flap is then united — and the limb put up so as to immobilize the tendon. CHAPTER IX. OPERATIONS UPON THE LIGAMENTS. SYNDESMOTOMY. Description. — Division of ligaments. Generally performed for the con- traction of ligaments occurring as the cause, in whole or in part, of some of the deformities. Operations. — The ligament, or ligaments, at fault may be divided by the subcutaneous or open method — the latter being preferable. In the open method the involved ligaments are exposed by the simplest and safest route — and divided in the same general manner as the division of tendons by the open method — and the wound similarly treated. SUTURING OF LIGAMENTS. The suturing of ligaments is performed upon the same general principles as is tendon-suturing (see page 213). LENGTHENING OF LIGAMENTS. Description. — Lengthening of ligaments which have become shortened through disease or injury — especially in cases of deformity. Operation. — Many of the same methods involved in tendon-lengthening are applicable to the lengthening of ligaments. Where a ligament is attached to a bony prominence, this has been chiseled off and displaced to a neigh- boring site and there nailed (as in the case of the ligamentum patella;, where the tubercle of the tibia has been displaced to the upper portion of the tibia — but with uncertain success). (See Tendon-lengthening, ]jage 216.) SHORTENING OF LIGAMENTS. Description. — Shortening of ligaments which may have become lengthened through disease or injurv. Operation. — Many of the tendon-shortening methods may also be ap- plied to elongated ligaments, .^s in the above operation, where a ligament is attached to a prominence of bone, this may be chiseled from its normal site and nailed to an adjacent site (as in the case of the ligamentum patella?, where the tibial tubercle has been displaced lower down the tibia). Note. — Most of the work done upon Ligaments will be found described in special writings upon orthopedic surgery. (.^Iso see Tendon-shortening, page 220.) 226 CHAPTER X. OPERATIONS UPON THE FASCIA. FASCIOTOMY. Description. — Fasciotomy or a])<)neuri)tomy signifies the division of bands or planes of contracted fascia. Tlie term is used with especial reference to operations upon contracted palmar and plantar fascia, in the deformities of those parts — and in connection with the contracted fascia lata, and the contracted fascia following burns, and the like. Operation. — The division is usually accomplished by the subcutaneous or open method. The general principles of the operations will be here de- scribed — the steps of the special operation will be determined by the anatomy and contraction of the part involved, (a) Fasciotomy by the Subcutaneous Method: — Where the contracted fascia is in the form of narrow Ijands, a sharp-pointed tenotome with a narrow cutting-edge (of about 6 mm., or | inch) is best. Where the fascia is contracted in the form of planes, a sharp- pointed tenotome with a longer cutting-edge is to be preferred. The short- bladed fasciatome, however, is the safer form of tenotome, as far as damaging the neighboring structures is concerned. The instrument is inserted flatwise beneath the fascia — the cutting-edge is then turned toward the contracted fascia, which is rendered further prominent by e.xtending the part, and the special band of fascia is divided against which the knife-edge presses — then another band is sought — new bands appearing to spring into e.xistence as others are cut — the tenotome being carefully pushed in different directions until all the bands are cut. Just before each band is cut, the tip of the surgeon's left forefinger should be placed over the tense band of fascia and make counter- pressure, and thereby serve as a guide of the progress of the knife toward the skin. Sometimes all the bands can be divided through one introduction of the tenotome — in other cases the tenotome is introduced at several sites. The tenotome is sometimes introduced between the skin and the fascia and divides the latter by cutting downward, which is somewhat more risky. When all or nearly all of the ligaments have been divided which the tenotome can detect and reach, the part is fully extended, breaking down the remaining ones if any. The tenotome wound or wounds are then closed by a suture or two and the limb immoljilized in a splint, which is worn for a long period, (b) Fasciotomy by the Open Method : — A number of limited incisions may be made from without inward, through the skin and fascial bands, — or the involved fascial bands may be exposed through a skin-flap which is raised and retracted to one side, or through a long straight incision whose margins are retracted laterally. Following the thorough exposure of the parts, in the last method, the contracted fascia is dissected out wherever present. In either one of the open methods, the part is fully extended after the operation, the skin-wound closed and the part immobilized. Note. — Much of the work done upon the Fascia will be found described in special writings upon orthopedic surgery. CHAPTER X!. OPERATIONS UPON THE BURSAE. PUNCTURE OF BURSAE. Description. — Generally resorted to for exploring the nature of the bursal contents, or for injecting fluid for destroying its secreting surface, or simplv for the evacuation of its contents. Operation. — The needle of the syringe is introduced, with the usual precautions, into the interior of the enlarged bursa — piercing the skin as directly over the cyst as possible and passing by the safest route through, or preferably between, the overlying tissues. The site of the introduction will depend upon the special bursa. INCISION OF BURSAE. Description. — Usually resorted to for the evacuation of pus, or other fluid; or to expose the interior for curettage. Operation. — An incision is made down to the bursal sac — selecting a site where the least im]5ortant structures will be encountered and the sac most readilv reached. The intervening parts having been retracted to one or both sides and the bursa steadied by the surgeon's left forefinger and thumb, its wall is incised with a scalpel — after which the special object of the operation is accomplished. The steps of the operation will depend upon the special bursa. In some cases the incision will pass from the skin directly into the bursal cavity, without any intervening dissection. EXCISION OF BURSAE. Description. — Generally done for the removal of chronicaHy inflamed or diseased bursa? — the majority of the latter cases being tubercular. Operation. — The exposure of the enlarged bursa is accomplished as described under the operation for incision. The surrounding parts having been then drawn well aside, the entire bursal sac is dissected from its bed, partly by blunt and partly by sharp dissection — carefully guarding the neigh- boring structures, and especially those joints with which the bursa may communicate. Whenever possible, the communication with a joint should be closed by suturing together the edges of the neck of the e.xcised bursa. The wound is then closed, or drained, as indicated. 228 CHAPTER XII. AMPUTATIONS. GENERAL CONSIDERATIONS. Definition.— Amputation — the removal of a limb through its continuity. Disarticulation — the removal of a limb at a joint. Indications. — Any injury, disease, or malformation rendering retention of the limb incompatible with life or comfort; — avulsion of limb; compound fracture; compound dislocation; fracture with great comminution of bone; laceration of important vessels; extensive contusion; e.xtensive laceration; gun- shot injuries; aneurism; effects of heat and cold; gangrene; extensive bone disease; tumors; elephantiasis; tetanus; snake-bite; deformities. .Amputa- tions are far less frequent in modern conservative surgery than formerly — limbs now being often saved by excision, and other operations, which were at one time sacrificed. Preparation of Patient. — The constitutional preparation of the patient — and the previous and immediate local antiseptic preparation of the part — are the same as for any major operation. The part should be shaved, where its condition admits of this preparation — and should come to the table with the preliminary dressing in position. Position of Patient, Surgeon, and Assistant. — (i) Patient rests upon back, lying near side of table, and nearer the upper end for amputations of the upper extremity, that the limb may be held out from the table at a right angle; — and nearer the lower end for amputations of the lower extremity, that the limb may be held both out from the table, and also over the end of the table. (2) Surgeon so places himself as to enable him to grasp with his left hand the patient's limb between the saw-line and the trunk — which will place him upon the outer side of the right limbs, and on the inner side of the left limbs (between the table and the left limbs) (Fig. 208). This is the general rule, of almost universal application (and will not be repeated with each operation) — where exceptions occur they will be mentioned with the special amputations. In amputations of the upper part of the left arm and upper part of the left thigh, especially the latter, it may be more con- venient to stand to the outer side of the limb, in which case the left hand grasps the limb below the saw-line. This avoids wedging one's self between the table and the upper part of the limb, which, in the case of the lower limb particularly, cannot be stretched out at a right angle from the table. (3) As- sistant : — grasps the part of the limb, wrapped in an aseptic towel, that is to be removed, standing facing the surgeon, so that he can better steadv the limb against the movements of the saw than if he stood at the end of the limb — his arms being thus parallel rather than at a right angle to the working of the saw. Instruments. — Esmarch's rubber bandage and tourniquet; amputating knives, long and short; scalpels, various; cartilage knives; Catlin knives; saws, ordinary amputating, bow, and butcher; small thin saw, for spiculae of bones; periosteal elevators; metallic retractors (for flaps); linen retractors 229 230 AMrUTATIOXS. (for flaps); broad metallic or ivory spatukc and retractors to hold soft parts out of way; dissecting and toothed forceps; arter\-clamp forceps, numerous; rongeur forceps; scissors, straight and curved, sharp and blunt; tenacula; probes; grooved directors; ligatures and sutures, silk, catgut, plain, chro- mic and silkworm-gut; tendon; needles, straight and curved; needle-holder; Fig. 20S.— h.i.i-sTRATiNG PdsniiiN OF SuRGKoN IN Ampi'tating :— Slaiiding to outer side t riRht, and 10 inner side of left limbs— manipulating knife with right hand, and steadying limb (als retracting soft pans) with left hand placed between saw-line and trunk.— Hands of assistant ar shown in various positions, grasping and supporting part to come away. drainage-tubes; irrigator and irrigation tluid; normal salt solution and in- struments for intravenous infusion; dressings for stump; splint. Special instruments will be mentioned under special amputations. Control of Hemorrhage in Amputations.— Hemorrhage ma\- be con- trolled in one of two general ways— Ijy sonic form of tourniquet or ctinstrictor, or by digital compression. (A) Control of hemorrhage by tourniquet or constrictor :— Several forms of tourniquet control are in use; — (i) Es- march's Broad Rubber Bandage, and Tourniquet of Rubber Tubing or Narrow Band; — These constrictors may be used in two ways;— (a) Use of GENERAL, CONSIDERATIONS. 231 Bandage and Tourniquet (Esmarch Method); — The bandage is appHed from the fingers or toes upward, for example, nearly to the shoulder or hip — the tourniquet is then applied above the bandage — and the bandage re- moved. This saving to the patient of the blood in the limb is more particu- larly indicated when the limb is healthy and the patient anemic — otherwise a patient who loses a limb can also generally afford to lose its proportional amount Fi>;. 209.— Illustrating Methods of Hemorrhage Control:— Wyetli's method by rubber tourniquet and needles, at right shoulder-joint.— Same at left hip-joint.— Ordinary rubber tourniquet and pad at left shoulder-joint, reinforced (kept from slipping) by strips of roller-bandage. — Same, at right hip-joint. — Use of Esmarch rubber tourniquet above left elbow. — Exsanguinalion of limb by Esmarch rubber bandage, followed by application of rubber tubing (or Esmarch rubber tourniquet} above left knee. — Compression of right femoral by Petit type of tourniquet.- Preliminary ligation of left femoral. — Digital compression of main arteries at riglit wrist. of blood (Fig. 209, left leg), (b) Use of Esmarch's Tourniquet Alone; — The limb is held elevated for about three minutes (this empties the veins mechani- cally and causes the arteries to contract reflexly, thus lessening the blood to the limb; but if the elevation be too long, the arteries recover, dilate, and let in more blood) — and, during the time of this elevation, a healthy limb may be massaged downward to aid exsanguinalion — the tourniquet alone is then 232 AMPL'TATIOXS. applied as liigli up the limb as indicated for the special operation, no form of bandage having been previously ajjplied (Fig. 209, left arm). In operating any- where below the elbow or knee, the constriction should be applied just above the elbow or knee, — and in amputating anywhere above the elbow or knee, the con- striction should be applied as near the trunk as possible. This is the general method of hemorrhage control in the majority of cases. The objections which have been urged against the Esmarch bandage and tourniquet, or tourniquet alone, are — the increased bleeding following the operation, from temporary vasomotor paralysis; the possible lowered vitality of the com- pressed parts; occasional temporary paralysis of nerve-trunks from pressure; and the possibility of forcing pathological products into the body. The great advantage over these disadvantages, however, is that it controls all bleeding — and its use, therefore, is advisable in spite of the disadvantages. (2) Tourniquet of the Petit Type; — The entire limb is compressed, with special pressure over the main artery (Fig. 20Q, right thigh). (3) Tourniquet of the Signorini Type; — No circular constriction is used — a pad on one arm of the tourniquet compresses the artery against a counter-pad on the other arm of the tourniquet opposite or beneath the limb or body. (B) Digital compression of the main artery : — Compression is generally made through the skin — but may be made directly upon the main vessel through an incision made immediately over it (I''ig. 209, right hand). The office of hemorrhage- control by digital compression is sometimes delegated to a single individual in a hospital. Note : — Special methods of controlling the circulation will be mentioned in connection with special amputations, especially those about the shoulder- and hip-joints (Fig. 209, shoulders and hips). THE GENERAL TECHNIC IN AMPUTATING. LOCATION OF LINE OF BONE-SECTION, OR DISARTICULATION. The determination of the saw-line in an amputation, or the disarticula- tion-line in a disarticulation, is the first step — generally marking the upper limit of the operation — and is the necessary guide to the subsequent steps. Level at Which the Bone, or Bones, are to be Sawed.— Is to be deter- mined by the individual case —and its position should be such that enough healthy tissue will be pro\ ided for. between the saw-line and the upper limit of the diseased or injured tissues to be removed, to furnish ample covering of soft parts to protect the stump without undue tension. Level of Joint-line at which Disarticulation is to be Done.— The position of the articulation-line is, of course, fixed — it is only necessary to recognize it anatomically — and to determine whether sufficient sound tissue intervenes between joint-line and upper limit of the parts to be removed to afford covering satisfactory in quantity and quality to protect the stump. Otherwise the disarticulation will have to be converted into an amputation at a higher level. Relation of Saw-line to Length of Flap, and Vice Versa.— While the position of the saw line determines the amount of tissue (and, conse- quently, length of flap or flaps or of circular covering) which will be required to cover the sawed bone— so also does the choice of the method of amputation to be used largely determine the amount of bone to be sacrificed (and, con- sequently, the length of the resulting limb)— for (a), In circular amputations and amputations by equal flaps, the minimum amount of bone is sacrificed; and (b). In amputations by a single flap, the maximum amount of bone is sacrificed. LOCATION OF LIMITS OF SKIN" INXISIOXS. ^33 LOCATION OF LIMITS OF SKIN INCISIONS. A total covering of soft parts equivalent to i^ diameters of the limb at the saw-line is the general rule of allowance. It is necessary, therefore, to determine the lower limit of the skin incision, as this forms the lower limit of the total covering. This limit may be determined accurately or approx- imately. In Circular Amputations. — (a) .\ccurately; — Find the circumference of the limb at the saw-line by means of a metallic tape-line (say. 15 cm., or 6 inches) — one-third of the circumference will give the diameter (say, 5 cm., or 2 inches). Therefore, to furnish ij diameters (say, 7.5 cm., or 3 inches) the lower limit of the skin incision would have to be 3.8 cm., or i^ inches, below the saw-line, (b) .\ppro.\imafely; — Place the thumb at the saw-line on the anterior aspect of the limb (the nail facing the junction of the limb with the trunk) and the tip of the index-tinger immediately opposite on the posterior aspect of the limb (without compressing the soft parts). Now, keeping the thumb where first placed, and keeping the distance between the tip of the thumb and tip of the index unchanged, rotate the hand around (making these two fingers act as the two arms of callipers) until the tip of Fig. 210. — Relation of Skin Incision to Saw-line: — Methods of amputation by equal flaps, circular covering, and unequal flaps are shown each to furnish a covering of i^ diameters of limb at saw-line. the index rests upon the anterior aspect of the limb in a vertical line below the tip of the thumb. The distance between the thumb-tip and the finger-tip will be the diameter of the limb at the saw-line — and three-fourths of this measurement will insure a covering of the requisite ij diameters of the limb. In calculating the covering in the circular method of amputating, it is to be remembered that as the circular covering will be sutured in a straight line, either from before backward or from side to side, practically the covering may be regarded as being furnished by two aspects of the limb, either the front and back or the two sides — that is, as though furnished by two equal flaps (Fig. 210). In Equal Flap Amputations. — Same as for the circular method, whether calculatcfl accuratelv or ajujroximately (Fig. 21c). In Unequal Flap Amputations. — (say the anterior twice as long as the posterior fl.ip) ; — (a) .Accurately; — Finding the circumference and diameter in the above manner (the measurements being as there given) — the lower limit of the anterior flap would be 5 cm. (2 inches) below the saw-line, and the lower limit of the posterior, 2.5 cm (i inch) below, (b) .Approximately; — Having gotten the measurement of the full diameter marked out on the anterior aspect, as e.xplained above, this will represent the length of the anterior flap — and one-half of this measurement will give the length of the posterior flap (Fig. 210). 234 AMPUTATIONS. INCISION OF SKIN AND FASCIA. In general terms, it is considered that the aspects of the limb furnish an average covering of i^ diameters of the limb at the saw-line — whether this covering consist of skin alone, or of skin and muscle combined — and whether furnished by one or more aspects of the limb. In the circular method of amputating, the covering is furnished equally from all aspects of the limb. In the method by equal flaps, it is furnished equally by two aspects of the limb. And in the method by unequal tla];s, the inequality of length may be parceled out in any way indicated, just so the total covering is equivalent to i^ diameters at the saw-line. If the covering be from one aspect alone, as in the single flap or in the elliptical methods, the total diameter and a half comes from that one aspect. Where the amputation is done through a site of maximum contractility of skin and muscles (as through the lower half of AND Fascia in iing up|>L-i , furthe 111 part of lower aspects of Hi the arm, or the lower half of the thigh), a somewhat greater allowance may become necessary (even to the extent of two diameters). Where the ampu- tation is done through a site of minimum contractility of skin and muscles (as through the dense tissues of the palm of hand and sole of foot), a somewhat less allowance than the average may be provided. Manner of Incising Skin and Fascia in Circular Amputations. — ^^■hether a stump is going to be covered by skin alone, or by skin and muscle, the skin is invariably cut first and cut separately. Standing to the outer side of the right and inner side of the left limbs, grasp the part above the level of the skin incision with the left hand and retract the skin upward, either entirely alone or aided by an assistant (the assistant's aid being more necessary in large limbs)— the retraction being evenly maintained throughout. This is done to provide as ample a skin covering for the muscles as possible, for. as the average contractility of the skin involved in an amputation is greater than the average contractility of the muscles involved, if the skin and muscles were divided on the same level it would subsequently be found diflicult, or INCISION OF SKIN AND FASCIA. 23s impossible to make the skin meet over the cut muscles. Therefore this circular division of skin, which has been well drawn up under the knife-cut prior to incising, means an actual division of the skin a little lower than the position of the knife on the limb indicates — but insures having a somewhat fuller measure of skin than if it were cut without retraction. Having thus retracted the skin, take a long knife with a blade one-and-a-half times the diameter of the limb to be remo\-ed — and, holding it in a full hand, like a pruning-knife, pass the arm under the patient's limb and bring the cutting- edge into contact with the upper surface of the limb, the back of the knife being horizontal and pointing upward, the heel of the knife being over the center of the limb, and the point projecting beyond the limb toward the surgeon. Beginning the incision with the heel of the knife, steadily and evenlv draw the knife from heel to point, passing with one sweep of the knife through three-fourths of the circumference (Fig. 211). The knife is then with- drawn and reinserted with its heel at the place of beginning of the incision on the supero-e.xternal surface (in o])erating on the right limbs), and, with one sweep, passes through the remaining fourth of the circumference (Fig. 212). The attempt to make the complete circuit with one sweep is not to be recommended, as the ends of the resulting wound are not apt to be in line, and the wound, generally, imperfectly made. This circular skin incision is sometimes made with a small knife. The assistant can aid the surgeon by rotating the liml) to meet the knife. The blade is held perpen- dicular to the skin throughout. The incision passes through skin and fas- cia, but not into muscles. Owing to the unequal retraction which some- times takes place upon the ditTerent aspects of a limb, it may be necessary to plan one portion of the circular incision upon a lower level than the rest 236 AMPUTATIONS. of the incision — this greater allowance of skin at this site will, however, be drawn up on a level with the rest of the circular incision, owing to the greater retraction there. So that what may appear as an oblique incision, will become circular and upon the same level after the division. Maxmer of Incising Skin and Fascia in Flap Amputations. — .A.s in Incising Skin a.nd Fascia in Flap .Av Fig. 214.— I.N'cisiNc Skin the circular method, whether the covering is to be of skin alone, or of skin and muscles, the skin is invariably cut first and separatelv — and whether the flap be cut from without inward, or from within outward (by transfi.xion). The preliminary steps, as to position, retraction of skin, and general prin- FREEING SKIN AND FASCIA. 237 ciples involved, are the same as in making the skin incision in the circular amputation. When all is ready, the surgeon takes an ordinary scalpel of medium size, and, holding it as a violin-bow, enters its point into the skin vertically, at the upper limit of the base of the flap. The knife passes through skin and connective tissue, and as it travels vertically down one limb of the flap the cutting-edge is lowered until it forms less than a right angle with the surface being cut — when nearly the lower limit of the flap is reached, the knife rounds the corner of the flap — thence passes transversely across that aspect of the limb from which the flap is being taken — then similarly rounds the opposite corner — and thence travels vertically upward to a point cor- responding with the point of beginning (Fig. 213). Care should be exercised that each flap should measure one-half the circumference of the limb at its base, and one-half of the circumference at that part of its free end just above the rounded corners — and that these corners should be very bluntly, and not sharply, rounded (that they should be squarely rounded, as it were), for if they be too much tapered at their free ends, they will cover the stumps with difficulty and unsatisfactorily. Instead of cutting the entire flap with one sweep of the knife, each vertical limb and one corner of the flap should be made with one downward cut of the knife. While all flaps should be prac- tically square, with merely the corners rounded, an exception is made in the method of unequal rectangular flaps of skin and fascia (Teale's method) — the corners of the flaps being here right-angled, instead of rounded (Fig. 214). This is also the case in the conversion of a circular method of amputation into a flap method by two vertical incisions placed laterally — and even here the corners mav be rounded. FREEING SKIN AND FASCIA. Having incised skin and fascia, for either a circular or a flap amputation, the manner and extent of further freeing skin and fascia will depend upon whether the method is to be one of simply skin and fascial covering, or of skin, fascial, and muscular covering for the stump. Freeing Skin and Fascia in Simple Skin and Fascial Covering for Stump. — The skin and fascia, after having been divided, are partly retracted and partly dissected back to the hne of future division of muscles. The edges of skin and fascia (avoiding the separation of the one from the other, as the vessels reach the skin through the fascia) are grasped by the fingers of the left hand, lifted from the muscles, and drawn upward — and, while held in this position, and while under slight tension, the fascia is touched here and there at points where it especially binds along the line of its junction with the muscles and deep fascial planes, bv a scalpel held at a right angle to the surface of the muscles and with its cutting-edge toward the part to be removed — and thus scoring of the skin and consequent damage to its blood-supply are avoided. The skin and fascia are, by this means, raised in one layer from the muscles — and the skin should be raised with all the underlying fascia possible — and the combined skin and fascia should be rai.sed evenly up to the future line of muscle (livi>ion (Fig. 21 y). Freeing Skin and Fascia in Skin, Fascial, and Muscular Covering for Stump. — Special care is here taken not to separate skin and fascia from underlying muscles, any further than simply in the immediate line of original skin incision, and simply for the purpose of allowing of full retraction. The skin and fascia are here not picked up and separated from the muscles — 238 AMPUTATIONS. the only knife-touches necessary being a few where the fascia has not been thoroughly divided and where it is necessary further to divide a fascial attach- ment here and there in order that the skin and fascia mav retract as far as they naturally will unaided by manual retraction — and this is done bv touching the points of binding at the bottom of the original incision, bv the point of a knife held vertical' RETRACTION OF SKIN AND FASCIA. Where Stump-coverings are to be of Skin and Fascia Alone.— Having freed skin and fascia from the underlying parts, as above described, partlv by retraction and partly by dissection, until the line is reached at which the muscles are to be divided, the skin and fascia are further retracted above DIVISION" OF ML SCLES IN CIRCULAR METHODS OF AMPUTATION. 239 this line and are held out of the way by the hands of an assistant, or by re- tractors (Fig. 216). Where the Stump-coverings are to be of Skin, Fascia, and Muscles. — Retraction of skin and fascia from the underlying muscles, other than that which occurs unaided, is not practised. It is sought, on the other hand, to keep in contact, as one layer, skin, fascia, and muscles. DIVISION OF MUSCLES IN CIRCULAR METHODS OF AMPUTATION. In the Ordinary, or Infundibuliform, Variety of Circular Amputa- tion. — (For description, see page 261.) — (a) Division of More Superficial Muscles; — The position of surgeon, manner of holding limb, kind of knife and manner of manipulating it, are all the same as in making the skin incision. Fig. 217.— Division of Mvscles in Infi-ndibii.ar Vakiktv of Circular Ampitation :— I— Di- viding more superficial muscles on level with retracted skin and fascia. The skin and fascia having been circularly incised and allowed to retract, the surgeon grasps the limb above the naturally retracted skin, and further retracts skin and fascia, putting, at the same time, the muscles upon the stretch by this upward retraction of the overlying parts, aided by an assistant in the case of larger limbs. The more superficial muscles are now divided circularlv on an exact level with the retracted skin, by one sweep of a long knife passing, first, through three-fourths of a circle, followed by a second sweep through the remaining fourth (Fig. 217). It is not always possible to divide only and wholly what are generally understood as the superficial layers of muscles — it is onlv meant that one divides, in this first circular division, about one-half of the muscular covering of the limb, the knife sometimes dividing a group of muscles completely and sometimes only partially. To allow for unequal retraction, the muscles may sometimes have to be divided lower on one aspect of the liml) than on another, (b) Retraction of More Super- 240 AMPUTATIONS. ficial Muscles; — This layer of muscle tissue is now retracted as the skin was above it. It is not expected that the first muscle layer includes all and only the superficial muscles, and the deep layer all and only the deep muscles — Amputation :— li- the former includes simply the more superficially placed, and the latter the more deeply placed mu.scles. There is no general use made of the scalpel in freeing the superficial muscle layer, as in the case of separating the fascia and skin from the muscles, but, where indicated, a touch of the knife mav be used to enable the more superficial muscles to be evenly retracted, (c) Division of Deeper Muscles;— Having retracted the divided muscles more superficially placed, the more deeply situated muscles are now circularly divided on a DIVISION OFMUSCLES IN CIRCULAR METHODS OF AMPUTATION. 241 level with the retracted superficial muscles, and in a manner similar to the divi- Fig. 220.— Division of Mi'scles in Modifi and fascia turned back, the more superfici: deeper muscles in the infundibular fashion lATioN — showing flaps of skin knife in the act of di\ idiiig tlie sion of the first layer (Fig. 218). It is to be planned that this circular division of the deep muscles will come down upon the bone sufficiently far below the saw-line to provide for a periosteal flap, (d) Retraction of Deeper Muscles; — This is done preparatory to forming the periosteal covering. Note — it will thus be seen that, having divided skin and fascia lowest of all, the superficial muscles have been divided upon a higher level, and the deep muscles upon a still higher level — forming, thereby, when the bone is sawed, a hollow cone, whose apex will be formed by the sawed bone, whose base will be the margin of skin and fascia, and whose sides will be com- posed of the cut muscles (Fig. 242). In the Circular Amputation " a la Manchette," or Cuff Variety of Circular Amputation. — (I'or descrip- tion, see page 203.) — In this method, all the muscles are divided circularly down to the bone at one level, which is that of the reflected cufi" of skin — cal- culating to come down upon the bone sufficiently far below the saw-line to form a musculo-periosteal covering (Fig. 219). 16 Fig. 242 AMPUTATIONS. In the Modified Circular Amputation.— (For description, see page 264.)— After the flaps of skin and fascia have been retracted, the more super- ficial muscles are divided on a level with the retracted flaps— this layer of muscle tissue is retracted — and the deeper layer is divided upon a level with the retracted superficial la\er— calculating to come down upon the bone far enough below the saw-line to allow for a musculo-periosteal covering (Fig. 220). The division of muscles being, in other words, just as in the ordinary circular amputation. This is the better way of dividing the muscles in the modified circular operation. Where, in the modified circular amputation, the muscles are all divided at one level (that of the retracted flaps), the muscles are di- vided as in the circular am|:)utation a In manchette. In the Oval Method of Amputating. — (For description, see page 265.) — .After having made the oval incision through skin and fascia, the muscles are divided directly to the bone — the knife entering the muscle tissue upon the line of the retracted skin and fascia. Along the queue, or vertical portion of the oval, which begins at. or just above, the saw-line, or disarticulation- line, the two lines of incision will coincide — parting below to follow the outlines of the oval — and meeting at the mid-point behind (Fig. 221). In the Racket Method of Amputating. — (For description, see page :?66). — The principle here is the same as in the oval method. DIVISION OF MUSCLES IN FLAP METHODS OF AMPUTATION. In Amputating by Single Flap of Skin and Muscle. — (For description, see page 267.) — The skin-and-fascia flap having been outlined and incised, the muscles are cut, preferably from without inward (or may be cut from within outward, by transfixion), beveling inward, on a line with the retracted skin-and-fascia flap — the incision coming down upon the bone suflficiently far below the saw-line to provide for a musculo-periosteal covering (Fig. 222). In Amputating by a Single Skin-flap. — (For description, see page 26q). — Having retracted skin-aiid fascia flap, the muscles are divided cir- cularly at the saw-line, or disarticulation-line. In Amputating by Equal Flaps of Skin and Muscle. — (For description, see page 269.) — Same as by single flap of skin and muscle (Fig. 223). In Amputating by Equal Flaps of Skin. — (For description, see page 270.) — Same as by single skin flap. In Amputating by Unequal Flaps of Skin and Muscle. — (F'or de- scription, see [)age 271.) — Same as l>v single flaj) of skin and muscle. In Amputating by Unequal Flaps of Skin. — (For description, see page 272.) — Same as by single fla[) of skin. In Amputating by the Elliptical Method. — (For description, see page 273.) — .As this may be considered a variety of single flap amputation (of either skin alone, or of skin and muscle combined), the manner of dealing with the muscle is here the same as in that ojjeration. In Amputating by Teale's Method of Unequal Rectangular Flaps of Skin and Muscle. — (I'or descri|iticin, see page 272.) — Upon the line of the retracted skin and fascia, the muscles are cut through the periosteum along the two vertical lines. The muscles are then cut through the [jeriosteum transversely along the free margin of the retracted skin and fascia representing the end of the longer flap — all of the soft parts are then dissected up above the lower limit of the shorter flap, when the muscles opposite its lower limit are transversely divided through periosteum to bone. DIVISION OF MUSCLES IN FLAP METHODS OF AMPUTATION. 243 Method of Cutting Flaps from Without Inward. — In this method the flaps are cut by dissection, as it is sometimes called. The incision out- lining the flap having been made through skin and fascia, the surgeon, standing to the outer side of right limbs and inner side of left limbs, and grasping the limbs between savv-hne and trunk, proceeds to cut the muscle portion of the flap. A scalpel is made to cut the muscles along the line of retracted skin-and-fascia flap, the point of the knife entering the muscles at the upper limit of one of the limbs of the skin- and-fascia flaps — follows this margin vertically downward, passing deeply through the muscles — as the free border is approached, the knife is given a direction obliquely inward, so as to broadly and thickly bevel the muscles here, leaving them thinnest (though not thin) along this aspect of the flap — continu- ing the beveling process across the entire transverse width of the free end of the flap and well around its bluntly rounded corner — thence the knife passes ver- tically up the opposite limb of the flap, sinking deeply into the muscles, though the I)one need not be fully reached in the vertical cuts at the first stroke (Fig. 224). As in cutting skin-flaps, the entire incision need not be made at one stroke of the knife — but is better made in two strokes from above downward. The surgeon now grasps the partly cut flap with the fingers of his left hand, and, while draw- ing it away from the bone, proceeds to fashion the rest of it along the same lines upon which it was begun, beveling it toward the bone by successive cuts of the knife — planning that the base of the flap will contain the full thickness of the soft parts covering the bone — and calculating that the knife will come down upon the bone (or bones) far enough below the saw-line (or disarticula- tion line) to provide a musculo periosteal (or capsulo-periosteal) covering. Where two flaps are cut, the second is cut in the same general manner. Care should be taken that the muscles are thickly and bluntly beveled, else a thin, ill-nourished ending to the flap is apt to be left. Xo attempt is made to bevel the upper part of the sides of the flap (the vertical portions) — the beveling beginning only just above the rounded corners. By cutting on a line with Fig. 222. — Division of Muscles in A.mputation by Single-: Flap Method. 244 AMPl'TATIONS. the retracted skin, ample covering; of the muscle-portion of the flap by the skin-and-fascia ])ortion is ])rovided (I''ig. 220- Method of Cutting Flaps from Within Outward. — In this method the flaps are cut by transfixion. The skin and fascia should always be cut first and from without inward, as the first step of every flap (as well as of every other kind of) amputation — no matter what the method of doing the Fig. 223.— Division o other steps of the operation. If this be not done, the muscles and skin will necessarily be cut upon the same, or nearly the same, level — with the inevitable result that there will he a deficiency of skin to cover the muscles, owing to the greater retraction of the former. Having, therefore, cut the skin and fascia flap from without, the surgeon proceeds to cut the muscles by trans- fixion. A long knife is taken, having a length equal to at least one-and-a-half diameters of the limb at the site in question. Marking the saw-line with Fig. 224. — METHt; Cl"TTING FROM \Vr the thumb of the left hand, the point of the long knife (whose sides look upward and downward and whose edge points toward the extremity to be removed) is entered directly in the center of the lateral aspect of the limb (where the flaps are to be taken from the anterior and posterior aspects of the limb) and opjiosite the saw-line. The knife-point should be so placed and pointed as to avoid im[)ortant vessels. The knife is then carefully pushed directly forward, until its point strikes the center of the lateral aspect of the hone (or, if two bones, of that one nearer the operator)— the handle is DIVISION OF MUSCLES IN FLAP METHODS OF AMPUTATION. 245 then lowered while the forward progress of the knife continues, so that its point is made to hug the bone closely until its upper margin is reached — the handle is then raised so as to cause the point to sink and follow, as nearly as possible, the surface of the bone (or bones) on the opposite side (which, naturally, can be less closely followed than the nearer quadrant of the bone's circumference). When the knife's point is felt to have reached a point on the far side of the limb corresponding with the center of the bone, the handle is then lowered to a horizontal position and the knife thrust on forward until it protrudes through the skin on the far side of the limb. The surgeon stops here a moment to calculate the line along which the cutting-edge of the knife is to emerge — the guide to which being the line of the retracted skin flap. \A"ith a slow back-and-forih sawing movement, the knife is made to cut its way forward — hugging the bone (or bones) closely throughout the greater portion of its wa\' — until near the free end of the flap, when it is made to round its way out in such a manner as to cut a thickly beveled edge of muscle on Fig. 225. — Method op Raisi.sg Flaps of Skin and Misci.e bv Cutting from Within Outward (by Transfixio.n)— cutting upon the line of retracted skin and fascia, which have been previously divided. a line with the retracted free edge of skin (Fig. 225). In cutting a second flap from the opposite aspect of the limb, the first flap is retracted out of the way — the knife then passes over the cut surface of the muscle along exactly the same course as in beginning the transfi.xion of the first flap — until its point strikes the center of the lateral aspect nearer the surgeon (at exactly the same point as in the first manccuvre). The handle is now raised, to cause the point to follow down the lower quarter of the circumference of bone nearer the operator — when its lower margin is reached, the handle of the knife is lowered and the knife pushed forward, until the inferior surface of the bone (or bones) is passed. The handle is now still further lowered and the knife pushed forward, so as to cause the point to follow the further inferior quarter of the bone and emerge opposite the center of its lateral aspect. But as this mana'uvre is diflScult to accomplish, the surgeon generally aids the knife with his left hand, by partly guiding it and partly depressing the remaining soft parts on far side below the point of the knife so that its edge escapes them. Then with a similar back-and-forth movement, at first hugging the bone, the knife is made to cut its way out on a line with the retracted skin-flap. In order to 246 AMPUTATIONS. avoid cutting the muscle-flaps too narrow and too thin, it is necessary to hug the bone (or bones) until about three-fourths of the flap is cut and then abruptly round out to the line of the retracted skin flap. Great care is also necessary to avoid piercing the main vessels in making the transfi.xioii — and to avoid splitting them (whether at first transfi.xed or not) in cutting forward to form the flap. Therefore, it is sometimes necessary, when forming flaps by transfi.xion, to so plan them that they will not be precisely antero- posterior, or lateral — but will be so formed as to be least likely to contain split vessels. Considerable tissue at the base of the flap often escapes division in cutting by transfi.xion and has to be cut subsequently. The method of transfixion rnav be varied by not passing the knife so closely to the bone — that is, bv transfixing the more superficial muscles only, retracting these, and then cutting the deeper muscles circularly at the saw-line. A further modification of the transfixion method consists in cutting through skin-and- fascia flap from without — then transfixing the apex of the muscle-flap — and dissecting uji the remaining soft parts. Comparison of Methods of Cutting Flaps. — (a) The method of cutting from without inward enables a fla]) to be cut with greater precision — makes the wounding and splitting of the main vessels unlikely — and provides for a more accurate calculation of covering for the stump, especially as to the relation between the amount of skin and muscle covering. It is the method to be chosen in the great majority of cases, (b) The method of cutting flaps from within outward (transfixion) is a convenient method in very large limbs, and in some special amputations, and where speed is necessary. Flaps thus cut are apt to have their arteries injured — are apt to be too thinly beveled at their free ends — are apt to be too narrow throughout, and too pointed at their ends — and, generally, less judgment can be exercised in their fashion- ing. Even in the larger limbs a flap can be more satisfactorily cut from without inward than by transfi.xion. Even where transfixion is used, how- ever, the skin and fascia should invariably be cut from without — and the knife should come out on a line with this retracted skin. FREEING AND RETRACTING OF MUSCLES. In Ordinary Circular Method. — After the division of the more super- ficial muscles by the circular sweep of the knife, it may be found that here and there these muscles are not divided to an equal depth. Such unequal division, wherever found, is completed bv a few strokes of the edge of a small knife. This layer of muscles is then retracted upward until the level is reached for the circular (li\ision of the deeper muscles. In Circular Amputation a la Manchette. — Here the muscles are divided directly to the bone, on the line of the reflected cuff, and no special freeing or retraction of the muscles is done, until ready to make the musculo- periosteal covering. In Modified Circular Amputation. — The muscles are here freed and retracted as in the ordinary circular amputation. In Oval Method of Amputation. — Here the muscles are divided on the Hne of the i)\al — no freeing or retraction being necessary until ready to make the mu>( ulii |)eriosteal flap. In Racket Method of Amputation. — Same as in the oval method. In Single, or Equal, or Unequal Flaps of Skin and Muscle. — (A) When Cut from Without; — The fingers of the left hand raise the flap away MAKING MUSCULO-PERIOSTEAI, COVERING. 247 from the bone, while the surgeon cuts the vertical limbs of the flap to the bone, and gradually bevels the terminal portion of the flap obliquely upward toward the bone. (B) \\'hen Cut from Within by Transfi.xion; — No freeing or retraction necessary, until ready to make the musculo-periosteal covering. (The fingers of the left hand may grasp up the soft parts of the limb and lift them away from the bone as the knife cuts its wav out.) In Single, or Equal, or Unequal Flaps of Skin.— The muscles are here divided on one level — no freeing or retraction being necessary, until ready to make the musculo-periosteal covering. In Elliptical Method. — The muscles are handled as in an am])utation by a single tla]j of skin anrl muscles. In Unequal Rectangular Flaps of Skin and Muscle (Teale's Method). — The muscles are here handled as in amputation by unequal flaps of skin and muscle. MAKING MUSCULO-PERIOSTEAL, OR PERIOSTEO-CAPSULAR, COVER- ING FOR END OF BONE. Description. — A covering should be provided for the end of the ampu- tated or disarticulated bone, or bones, which will consist of periosteum and overlying muscle, raised as a single musculo-periosteal or periosteo-capsular flap or covering. Care should be exercised in raising this covering, that muscle is not first raised from periosteum and periosteum from bone, but that muscle and periosteum should be raised in one adherent layer. Peri- osteum is absent over cartilaginous surfaces, hence a pure musculo-periosteal covering is not to be gotten in a disarticulation — but as much of the capsule of the joint, which is practically a continuation of the periosteum, should be preserved as possible, and treated in the same way as the periosteum, that the articular end of the proximal bone may be covered. The distinct advantages of a musculo-periosteal covering for the end of the bone are the following; — (1) The muscles being adherent to the periosteum, when a covering of the latter is stitched over the bone, a thicker and more fixed covering to the end of the bone is secured than could be otherwise attained: — (2) The end of the bone being covered by periosteum, adhesion of the soft parts to the end of the bone is far less likely, the parts covering the bone generally remaining freely movable, and are, therefore, both better nourished and are less likely to become painful; — (3) The medullary cavity of the bone being shut off by the musculo-periosteal covering, is much less apt to become involved in any septic process which may arise in the stump. The only objections which can be raised to a musculo-periosteal covering are the time and trouble involved — which should not be allowed to weigh against the practical advantages — nor should the possible formation of osteophytes and proliferation of bone from the turned-over periosteum be seriously regarded. Manner of Providing Musculo-periosteal Covering in all Forms of Circular Amputation, and in all Double-flap Amputations Cut from Without Inward. — Tlie surgeon should [jlan to have his knife pass through the deep layer of muscles surrounding the bone in such a way as to come down through these muscles and upon the periosteum without separating muscles from periosteum (which would also detach the vascular supply of the periosteum), and at such a level on the bone below the saw'-line as to equal a full half-diameter of the bone at the saw-line. In circular amputa- tions this final cut will pass transversely through the muscles, — in flap ampu- 248 AMI'UTATIONS. tations, obliquely through, in the process of beveling. As soon as the peri- osteum is reached in this final incision, all the soft parts are carefully retracted around the whole circumference of bone at this level, especial care being taken not to use force in the retraction, thereby separating muscle from periosteum by dragging the former off of the latter. A circular incision is now made through the periosteum around the entire circumference of bone, at the level of the lightly retracted muscles — cutting the periosteum with especial firmness where closely bound to the linea? aspera?. The peri- osteum is then detached back to the line of the future saw-cut, by means of a periosteal elevator — care being exercised not to push the muscles off the periosteum, but to push the periosteum back from the bone with the muscles attached (Fig. 226). In Flap Amputations by Transfixion. — The knife should be entered just far enough below the saw-line to equal a full half-diameter, or more, of bone at the saw-line. When the flaps are cut, the periosteum is divided circularly at this level — and then the periosteum and muscles are detached back to MrscULO-PER [OSTEAL COVERING— ill the the_ saw-line — or the periosteum may be raised as two small flaps, their incision beginning at the saw-line (Fig. 227). In Oval and Racket Modifications of the Circular Amputation.— The freeing back of the muscles should be stopped at a level equal to a full half-diameter, or more, of the bone below the saw-line— the periosteum is here circularly divided— and the periosteum and muscles detached thence back to the saw-line. In Single-flap Amputations of Skin and Muscle.— The knife comes down upon the Ijone one full diameter, or more, of bone below the saw-line. As the two vertical limbs of the flap have been cut down to the periosteum in the earlier part of the operation, a musculo-periosteal flap is now marked out, haxing a base equal to half the circumference of the bone at the saw-line and a length equal to one full diameter, or more, of the bone at the saw-line. The periosteum and muscles are now detached back to the line of bone-section —all the hitherto undisturbed parts on the opposite side of the limb are now divided transversely to the bone— and the bone sawed. In Flap Amputations of Skin Only.— As the muscles are here divided MAKING MUSCULO-PERIOSTEAL COVERING. 249 circularly, the musculo periosteal flap is provided for just as in the ordinary circular am])utation. In the Elliptical Modification of the Single-flap Method.— The musculo-periosteal covering; is handled as in the single flap of skin and muscle. In Unequal Rectangular Flaps of Skin and Muscle (Teale's Method). — The musculo-[ierioslcal covering is secured as in amputation by unequal flaps of skin and muscle. In Amputating Limbs with Two Bones. — The musculo-periosteal covering for the larger bone is provided as described in the single bone limbs The musculo-periosteal covermg for the smaller bone is provided in the same manner, but will be cut at a higher level (as it is circularly divided, or a flap is cut, which will be equivalent to the smaller diameter of the smaller bone). Where the bones are of the same size, the periosteum is divided at the same level in each case — which may also be done when the bones are of unequal size, the redundancy of periosteum in the case of the smaller bone being subsequently removed with scissors. Fig. 227. — Raisi putating. Note. — The final treatment of the periosteal covering cannot be carried out until after the division of bone. Comment. — (i) It will be seen that in circular amputations and in ampu- tations by double flaps, the musculo-periosteal covering is furnished from the entire circumference of the bone — while in amputations by single flaps, a single flap of musculo-periosteal tissue is raised, the width of which is equal to a half-circumference of bone and a length equal to a diameter of bone. (2) ,ns there is comparatively little retraction of fibrous periosteal tissue, the chief retraction taking place in the attached and overlying muscles, a length for the musculo-periosteal covering of one full diameter of the bone (each side of the bone hereby furnishing one-half diameter) will, therefore, cover the end of the bone, but none too fully — so that this measurement should be made very full. (3) Where it is difficult to detach the musculo- periosteal covering backward after simplv a circular division of the periosteum, two vertical incisions may be made upon the lateral aspects of the bone, from the site of the saw-line to join the circular cut — which will make the detachment easier. These vertical incisions may, indeed, be made in all cases. Even where the vertical incisions are not made in detaching the periosteum, they may be subsequently made before adjusting the periosteal flaps or covering. In the pure flap amputations the muscles have already 250 AMPUTATIONS. been divided to the periosteum, so that the knife easily makes the two vertical incisions in the periosteum. In the circular amputation where it is necessary to add the vertical cuts before sawing the bone (that is, in order to reach the saw-line), the point of the knife may be pushed into the transversely divided muscles, in the long a.xis of the limb, up to the saw-line (which will lie only a half-diameter of the bone above) and cut downward thence to join the circular cut. (4) In the case of the two-bone limbs, the interosseous mem- brane is also freed back in the act of detaching the periosteum. (5) Some hold that the periosteal covering is without value in the adult and actually harmful in the young, owing to the possibility of reproduction of bone render- ing the stump conical. The former is an error of observation. The latter must be very rare, the epiphysis being responsible for the chief increase of length of bone. Fig. 228.— Retr RETRACTION OF SOFT PARTS PREPARATORY TO SAWING THE BONE. All the soft parts overlying the bone having now been divided, from skin to jicriosteum, these soft parts are to be retracted above and out of the way of the saw- line, which should be seen to be clear in its entire circumference before making the bone-section. In Single-bone Limbs. — .\ double- tailed linen retractor is generally used to hold the soft parts back — the two tails of the retractor pass- ing around the bone, thus supporting the soft parts and drawing them upward and out of the way (Fig. 228). Fig. 229. — Retraction Sawing of Bonk— in the c tail retractor is shown above OF Soft Pakts Pri ,se of a double-bone lii SAWING THE BONE, OR BONES. 251 In Double-bone Limbs. — A three tailed linen retractor is usually used — the central tail passing between the bones — the outer of the other two tails on the outer side of the outer bone, and the inner on the inner side of the inner bone (Fig. 229). Comment. — The parts may also be retracted by the hands, or by various forms of metallic or other retractors. SAWING THE BONE, OR BONES. General Considerations. — The surgeon, standing to the outer side of right limbs and to the inner side of left limbs, grasps the limb firmly with his left hand just above the saw-line. An assistant supports the distal portion of the limb, holding it out over the side of the table, and on an e.xact line with the level at which the limb leaves the trunk, in the case of the arm and thigh; and on a level with the surgeon's left hand in the case of the forearm and leg. If he elevates it above the common level, he will bind the surgeon's saw throughout the entire transverse section (because the parallel wal's of the section will tend to appro.ximate), — and if he depresses it below the common level, while he makes it easier for the surgeon to saw, he is apt to splinter the bone just before the section is completed (because the [larallel walls of the section will tend to diverge). In Single-bone Limbs. — The surgeon places the edge of his thurrb- nail dciwn upon the bone immediately above the saw-line, as a guide to the saw, temporarily loosening but not entirely rela.xing his steadying hold with the other fingers and palm upon the limb. Hcilding an ordinary amputating saw in his right hand, he deliberately places its heel against his thumb and knuckles, and directly over the saw-line — and, with a fairly slow but firm and steady movement, he draws the saw backward from heel to point, thus grooving the bone transversely. If this groove be not distinct or deep enough, the first movement (from heel to point) may be repeated. The surgeon now resumes his steadying grasp of the limb with his left hand and proceeds to saw the bone bv slow, even, steady, back-and-forth strokes of the saw, 252 AMPUTATION& traveling the entire length of the saw-blade at each stroke — ^^and avoiding uneven and too rapid sawing, the latter sometimes generating a harmful degree of heat. It is during the section of the latter part of the bone that the assistant is most careful in his manner of holding the limb and the surgeon in his use of the saw. Toward the last the strokes of the saw should be slower, shorter, and lighter, and the limb so balanced that there will be no cross-strain anywhere throughout its length — and thus are the chances of splintering minimized. If indicated, the larger saw may be removed toward the last and the section be completed with a lighter, finer saw, but this is ordinarily unnecessary. As the bones of both single-bone limbs are nearly circular, no beveling of the edges is needed (Fig. 230). In Double-bone Limbs. — The general manipulative method is here the same as in the single-bone limbs. The saw first engages the heavier bone, and, having passed partly through this, is dropped upon the lighter or more movable bone — the section of which latter bone should be first com- pleted, the saw all the while cutting the heavier bone also, which it finally completes alone. Where both bones are of the same size (as the middle of the forearm), the saw grooves the one nearer the operator and is then dropped upon the farther one. Where a bone presents a promi- nent ridge, almost or quite sub- cutaneous (as the anterior border of the tibia), this would become an angular projection after sec- tion of the bone and would be apt to become a prominent point of pressure. To avoid this, this edge of bone should be beveled — which is best done by making an oblique saw-cut from above down- ward, beginning about 1.3 cm. (^ inch) above the saw-hne and pass- ing obliquely into the bone at such an angle as to be about 6 or 8 mm. (^ or J inch) below the level of the bone by the time it has reached the saw-line. Having made this 1.3 cm. (^ inch) oblique saw-cut into the bone, the saw is then withdrawn and is made to traverse the bone transversely along the line of bone-section in the ordinary manner. When the saw, traveling transversely, reaches the short oblique section, the small triangle of bone will drop out — and when the section is completed, the prominent edge of the bone will be found beveled (Fig. 231). Comment. — In the very voung, and especially in amputating those bones which grow chiefly from an upper epiphysis, it is well to saw the bone as high as possible — as subsequent growth from such bones may require reamputation. REMOVING SPLINTERED BONE. If, in the final saw-section, whether by splintering or a transverse snapping of the frail bridge of bone, a fragment of bone is left projecting from the stump, or any other projecting irregularity should appear upon the trans- versely divided bone, this should be removed down to a level with the face of the bone. This is accomplished by grasping the .spicula of bone with bone-holding forceps (such as the lion-j'aw tvpe) and steadving it, while the surgeon removes the spicula with a small, fine saw (Fig. 232). LIGATIXG ARTERIES AND VEINS. 253 Comment. — (i) Bony projections are often crudely crushed off with bone-cutting forceps — this is quickly done and is a temptation — but is not to be recommended, as necrosis of the margin of the bone is more apt to follow crushing than sawing. (2) The splinter of bone may be upon the portion of bone removed — there will then be a corresponding depression, with probably a tearing of periosteum and muscles, upon the bone in the stump — which may require to be evened off. LIGATING ARTERIES AND VEINS. As soon as the bone has been sawed, all the chief arteries and the larger veins should be tied. The arteries are tied in the order of their importance and are sought in their known positions. They have frequently retracted somewhat, so as to be out of sight, and are to be traced by their known rela- tions. The stump should be held in a good position and light — and, if necessary, dried of blood. The cut ends of the arteries are caught by catch- forceps and drawn out of their beds by the surgeon — while an assistant ligates the larger vessels with chromic catgut, tying them with a surgeon's knot. The larger arteries may be tied with the stay-knot of Edmunds and Ballance (page 24). All the vessels should be clamped before any are tied. The larger arteries should be drawn out of their sheath before being tied. The smaller arteries with their sheaths may be included in the ligature. .Arteries which are caught with difficulty with catch-forceps may be taken up with a tenaculum. Very small vessels may be compressed or twisted without ligaturing. The chief veins should be tied — as well as any others which are seen gaping. All vessels should be tied as long as possible — and should be disturbed in their sheath as little as possible. .Arteries bleeding from their osseous canals in the end of the bone cannot be tied, but may be controlled by plugging the vascular canal with a piece of catgut, a piece of sterilized wood, or with Horsley's antiseptic wax, or Halsted's gut-wool — 254 AMTUTATIONS. or a limited portion of the canal may be crushed in upon itself. After all known vessels are tied, the Esmarch, or other constrictor, should be relaxed and all hitherto untied vessels which now bleed are to be ligated (Fig. 233, A, H. and C). Comment. — (1) See that the first knot (friction-knot) does not loosen before the second knot (surgeon's knot) is complete — and that the knot is far enough from the end of the vessel not to slip otT. (2) Where hemorrhage Fig- 23.'i-— Stump after Amputating through Lower Part of Right Leg:— A, Ligation of anterior tibial artery, B, Clamping of posterior tibial artery; C, Hlugging vascular canal of bone with piece of catgut ; D. Cutting off tag of peroneus longus ; E, Cutting anterior tibial nerve short. is apprehended, vessels may be taken uj) immediately after dividing t!ic soft parts, and before even severing the bone. Instead of taking up and tying the vessels seriatim, they may be immediately clamped, one after another, and, if not tied at once, the catch-forceps may be retracted with the tlaps, or with the circular division of soft parts, and the bone sawed, after which the ve.ssels are tied— relaxing the original hold where vessel and sheath are in- cluded and taking up vessel alone. (3) Obstinate oozing may generally be SUTURING OF MUSCULO-PERIOSTEAL COVERING. 255 controlled by ligating en masse — or by douching with hot saline solution, or by pressure. This is the form of hemorrhage which is more apt to occur after the removal of the constrictor. TREATMENT OF NERVES, TENDONS, AND TAGS OF MUSCLE, FASCIA, AND SKIN. (I) .\I1 nerves should be cut as short as possible, to avoid entanglement and pressure in the process of cicatrization — to accomplish which they should be caught by forceps and drawn well out and then cut with scissors and allowed to retract out of sight. Where the flap method has been done and it is likely that an important nerve may be subjected to pressure when the flaps are bent and sutured over the end of the bone, the nerve should be dis- sected out. This is especially the case in the method of single-flap ampu- tation. Nerve ends are apt to become bulbous in any event, but will not be troublesome unless subjected to pressure. (2) .'Ml tendons should be caught with forceps, steadied, and cut short under slight tension. They are difficult to cut unless steadily held and slightly stretched — when they may be cut with scissors or a very sharp knife. Tendon-ends possess low vitality, are apt to slough, fulfil no useful purpose in the stump, and make but poor covering. (3) All tags and irregularities of muscle, fascia, and skin should be evenlv trimmed, so as to conform with the general contour. (Fig. 233, E and D.) TRIMMING OF FLAPS. It is undesirable, and somewhat unsurgical, to make a miscalculation in the length or contour of a flap, which will require any subsequent trimming — but where a flap is distinctly too long, or too large, or misshapen, it is better to do the trimming necessary to make a good fit than to suture it in place as it is. It is held in the left hand and trimmed as one would trim a piece of paper. A flap may be trimmed as a whole — or some individual tissue composing it may be trimmed. RE-AMPUTATION FOR IMPROPERLY MADE FLAPS. It is even more unsurgical, and much more difficult to rectify, to find that so little allowance of covering has been made that the end of the bone either cannot be covered at all, or cannot be covered without a degree of tension calculated to endanger the flaps. In such a case all that one can do is to amputate at a higher level. If only a slight deficiency of covering exist, the end of the bone may be freed of its soft parts by retraction and made to project and then be removed by the saw. Where the deficiency is greater, from one to several inches of the soft parts may also have to be re- moved, as well as the bone. In such a case one proceeds very much as in the original operation, modified by the needs. ADJUSTMENT AND SUTURING OF MUSCULO-PERIOSTEAL OR PERIOSTEO-CAPSULAR COVERING. The first step in the closure of the stump-tissues is the adjustment of the musculo-periosteal covering. It will be remembered that in all circular amputations, and in all double-llap am])utations of skin and muscle, the 2S6 AMPUTATIONS. musculo-periosteal covering was made by a circular division of the periosteum around the bone one-half of a full diameter of the bone below the saw-line (thus furnishing a full diameter), and that the periosteum, with adherent muscles, was then detached in one layer up to the saw-line. Therefore, after the bone is sawed and the soft parts drop down around its cut end, the musculo-periosteal covering will form a hollow cylinder projecting from the lower surface of the transversely sawed bone — the periosteum hanging down around the bone for a depth, appro.ximately, of a half diameter of the bone, the muscles being adherent to its outer side. This cutT of musculo- periosteal covering may be converted into two small flaps by cutting along its lateral aspects with straight-pointed scissors, from its lower free margins up to the bone. The corners of these little flaps may then be slightly rounded, though this is not necessary. These two flaps are then dropped over the end of the bone and their edges are sutured together with catgut, the sutures passing through periosteum and muscles. While the above method makes a neater lit, it is nt)t really necessary that the musculo-periosteal covering should be slit up at all on the sides — it suffices simply to ap- proximate the edges over the bone by a suture running either antero-posteriorly or trans- \ersely. Where the musculo- periosteal covering has been raised in the form of a single flap (as in the amputation by a single flap), this single flap of musculo-periosteal covering is dropped over the end of the bone and its margins sutured to the cut margins of the peri- osteum around the rest of the circumference of bone, including the muscle overlying the perios- teum. Where the bone-section is very small, it is often difficult to adopt any definite plan of making and suturing a musculo-periosteal flap, the per- iosteum being torn in shreds in the process of detachment. In such cases the mass of musculo-periosteal tissue is simply gathered together and sutured over the end of the bone. (Figs. 234 and 242.) QUILTING OF MUSCLES. The muscle tissue which enters into the covering of the bone should, where possible, be appro.ximated and sutured into apposition by buried chromic gut sutures, placed in one or more tiers, by means of either buried simple sutures, or buried quilt- or mattress-sutures. Thus the cut aspects of the muscles are brought into contact, — less tendency for them to retract away from the end of the bone occurs, — in the process of cicatrization they become incorporated in the general pad of covering which forms the etump (even though the muscle tissue itself may be subsequently replaced by fibrous tissue), — there is less chance of adhesions forming between bone and skin, — and, altogether, a fuller, softer, better-formed pad of covering is provided. These advantages more than counterbalance the only two disadvantages — namely, of time and trouble involved. By the process of quilting, muscles QLILTIN"(; OF MUSCLES. 257 ,.— Quilting of Muscles in Circular Method of Amputation; — First tier of sutures has been placed — and is being buried by the second are brought and held in contact until united, which, in the ordinary method of simply dropping muscles over the ends of the bones and depending upon the single line of marginal skin-sutures to approximate, either could not be made to come into contact even temporarily, or, if so, would generally retract apart before union. In Circular (Infundibuliform Variety), Modified Circular, Oval, and Racket Metliods. — After su- turing the niuscuIo-]3eriosteal cover- ing the muscle surfaces are brought into contact immediately over the musculo-periosteallv covered end of bone. The appro.ximation of mus cle tissue over the bone may be made in the way in which the mus- cles most naturally fall. Other things being equal, the approxima- tion should be made so as to cause the suture line to be parallel with the future suture line of the integu- mentary coverings. The first tier of sutures is placed nearer the bone, entering and leaving the muscle tis- sue at such a distance from the bone as to secure an easy ap- pro.ximation of the muscle substance over the end of bone. This first row of sutures, which, if of the simple form, may be either interrupted or continuous, will conceal the end of the bone. A second tier, especially in heavily muscled limbs, or in thin limbs with large muscle flaps, should be applied — being inserted nearer the edge of the muscle tissue than the first — and, when tied, will hide the first row (Fig. 2;^ 5). In Circular Method a La Man- chette. — As the mus- cles are here all divided on one level, and that level is that of the re- tracted skin, skin and fascia alone cover the end of the bone, and no approximation and quilting of the muscles are possible. In All Double-flap Amputations of Skin and Muscle. — The muscles are cjuilted in the same manner as in the ordinary circular (infundibuli- form), the process of muscle-quilting being easier in the double-flap method than in the ordinary circular, as the muscles are adherent to the flaps on either side and are more readily held in approximation while being quilted (Fig. 236). F ig. 236.-Q1 riLTINc; fMi SCI .ES IN Flap Method c IF Ampu- tatic IN :— First tier of bu ried suti h; as bee; 11 placed a i.d tied— and SI i;coiid tier i: i being pi; aced 258 AMrfTATinXS. In All Double Flaps of Skin. — No (juilting of muscles is here possible — as the muscles are transversely divided on a level with the retracted skin- flaps. In All Single Flaps of Skin and Muscle, Including the Elliptical Method. — As the muscles are here divided obliquely on the side of the flap, and transversely on the opposite side, the quilting of muscles is not done as in the above-described methods (where the lateral aspects of the muscles are sutured to lateral aspect, or ends to ends). The lateral aspect of the muscles in the present instance, some of which aspect is made up by the obliquelv beveled muscles, is sutured to the transversely divided muscles on the side of the limb opposite to the flap — and the ends of the muscles in the flap are sutured to the circumferential margin of the transversely divided muscles in the stump. As the base of the flap comes from a full half-cir- cumference of the limb, the bent-over flap is only appro.ximated to the opposite half of the face of the stump. Where this method is used in the neighborhood of an articulation (that is, in a disarticulation) where only tendons pass over and cover the joint, no quilting is possible. It is. therefore, applicable only where muscles cover bones, which, in the case of the joints, is only at the shoulder and hip. DRAINAGE. No drainage is necessary in amjjutating through sound tissue in the continuity of a limb. Temporary drainage (for two or three days) may be instituted in disarticulating through the larger joints — to provide for the escape of the synovial fluid which the remaining synovial surfaces will go on secreting for a time. Where drainage is indicated, it is sometimes better to make a counter-opening than to attempt to drain through a non-dependent suture-line. Drainage may be temporarily used where bleeding in the stump-tissues is feared after prolonged use of an Esmarch, or for other reason. Drains of rubber-tubing, glass, gauze, or bone-tube may be used. SUTURING OF THE STUMP. The suturing of the edges of the wound should be done with silk and by means of interrupted sutures. Where no great tension is likely to occur, silkworm-gut may be used. Catgut is also employed. The parts should come together without tension. The interrupted is to be preferred to the continuous form of suturing, for the parts may be thereby more accurately adjusted — and if it become necessary to open any part of the wound for drainage, or other cause, only the few indicated sutures need be cut. In Circular Amputations. — It is optional with the operator as to whether the soft parts are so appro.ximated as to result in a line of sutures running from before backward, or from side to side. The former is to be preferred, as the lower end of the suture-line (in the recumbent position of the patient) drains the wound by gravity, in case drainage be necessary. Where skin and muscle come evenly to the edge of the wound, both are included in the sutures. \\'here skin is longer than muscle, the sutures which close the wound pass through skin only — the muscles having been appro.ximated by their own buried sutures. In Flap Amputations. — Here the direction of the line of sutures will be determined by the position of the flaps. Where double flaps are taken from the anterior and posterior aspects of a limb, the suture-line will run THE EVUI.UTION" OF AMPUTATION METHODS. 259 from side to side. \Vhere double flaps are taken from the lateral aspects the suture-line will be anteroposterior. Where a single flap is appro.ximated to the opposite side of the limb, its margin is sutured to the opposite half- circumference. Where the margin of the flaps is composed of skin and muscle, both are included in the sutures. Where the skin is longer than the muscle, the skin alone is included in the suturing. In all cases the muscle surfaces are supposed to have been quilted together prior to the final closure of the wound. Comment. — (i) Owing to the. difficulty of equally dividing out the posi- tions for sutures where a large wound is to be brought together, it is well to begin by putting in a central suture and then divide each remaining half of the space into quarters by two other sutures — then these smaller lengths can be sutured with interrupted or continuous suture — the former being better, as, in case it be neces.sary to loosen any suture for suppuration, or otherwise, the entire line need not be loosened. (2) If tension upon the edges be great, a few tension-sutures may be used. DRESSING OF THE WOUND. The wound and stump should be covered with absorbent gauze — the entire stump enveloped in absorbent cotton — which should be snugly bandaged to the end of the stump and the circumference of the limb. A padded poste- rior splint should be incorporated in the outer layers of the dressing, pro- jecting beyond the stump slightly — both to support the part; protect it from injury; and control, or lessen, the muscular starlings which are apt to occur. The stump should rest upon an inclined plane, outside of bed-covering. REMOVAL OF DRESSINGS. If all goes well, the dressings are not remoxed until about the tenth day (or from the tenth to the fourteenth). If a drainage-tube be used, the dress- ings are often changed when that is withdrawn — although it is sometimes withdrawn at the end of the second or third day- -and the dressings not removed until the usual time. THE METHODS OF AMPUTATION. THE EVOLUTION OF AMPUTATION METHODS. The methods of amputation have undergone a slow process of evolution — which may be briefly stated in the following tabular form (modified from Kocher). Circular Incision. — The fundamental tj^De of amputation. Of which there are two varieties, and from which all other methods of amputation may be derived; — (a) Transverse circular incision (Fig. 237, A); (b) Oblique circular incision (Fig. 237, B). Racket Incision. — Formed by the addition of a longitudinal incision to the (ircular incision, (a) If the longitudinal incision be added to the transverse circular incision, the transverse racket incision results (Fig. 237, C); (b) If the longitudinal incision be added to the oblique circular incision, the oblique racket incision results (Fig. 237, D). Nole — The corners of the 26o AMPUTATION'S. racket incision are now tjenerallv rounded off, as in the oval method, the Fig. 237.— Thr Evolution of Amputation Mkthods : — I— .A. Tr.it Oblique circular incision; C, Transverse racket incision; D, Oblique rackel iiicisi.)ii. (Modified from Kocher.) only practical difference between the two, as now usually employed, being that the queue is made longer in the racket method. Oval Incision. — Formed by the shortening of the queue and the rounding- Fig. 23.S.— The Evolution of Amputation METiions :— II— A, Tr;insverse cnal incision; B, Oblique oval incision; C, F.qual rectangular flaps ; 1). I'nequal rectangular fla]is. (Modified from Kocher.) off of the angles of the racket incision, (a) If the angles of the transverse racket incision be rounded, the transverse oval incision results (Fig. 238, A) ; (b) If the angles of the oblique racket incision be rounded off, the oblique oval incision results (Fig. 238, B). ORDINARY CIRCULAR AMPUTATION. 261 Rectangular Flaps. — Formed by two longitudin:il incisions, (a) If the two longitudinal incisions be added to the circular incision, equal rectangu- lar flaps result (Fig. 238, C); (b) If they be added to the oblique circular incision, uncf|ual rectangular flaps result (Fig. 238, D). Rounded Flaps. — Formed by rounding the angles of the rectangular flaps, (a) If the angles of equal rectangular flaps be rounded, equal rounded flaps result (Fig. 239, A); (b) If the angles of unequal rectangular flaps be rounded, unequal rounded flaps result (Fig. 239, B). Elliptical Method. — The position of this method, in the process of evolution, will be described further on (page 273). SUMMARY OF AMPUTATION METHODS. Fundamental Types. — Circular Method; Flap Method. Modern Types. — (a) Circular and its modifications; (b) Flap and its modifications; (c) Irregular methods of amputation. As to Nature of Covering of Stump. — .-Ml methods of amputation are either — (a) Skin Coverings — that is, skin and fascia alone cover the divided muscles and bone, as in the cuff methoil of the circular amputation, and in the simple skin-flap in the flap method of amputation; — or (b) Skin- and-muscle Coverings — where skin, fascia, and muscles, combined and un- separated, including the periosteum, cover the end of the bone, as in the ordinary (infundibuliform) circular amputation, and in flaps of skin and muscle in the flap method of amputation. CIRCULAR METHODS OF AMPUTATING. (a) Ordinary Circular Method — (amputation circulaire infundibuli- forme) ; — (b) Cuff Method of Circular Amputation — (amputation a la man- chette) ; — (c) Modified Circular Method of Amputation — (mi.xed method) ; — • (d) Oval (or Lanceolate) Method;— (e) Racket Method. ORDINARY CIRCULAR AMPUTATION. (AMPCT.ATIOX CIRCII.AIRK IXFUNDlBfLIFORME). General Description. — The soft parts are divided by a series of circular cuts, retraction of the parts taking place between each circular sweep of the knife, so that tlicy are cut partlv through at different levels — the sawed bone formmg the ayiex of the funnel left upon the pro.ximal end of the bone, and the skin margin the base — the distal ])art removed being cone-shaped. Technic. — Stand to outer side of right and inner side of left limbs, so as to grasp limb between trunk and amputation-site. Determine the saw- line. Fix the skin incision at a level below the saw-line equal to J of i^ times the diameter of the limb (or three-fourths of that diameter) at the saw-line (that is. at 11.5 cm., or 4^ inches, below the saw-line, if the diam- eter of the limb at the saw-line be 15.3 cm., or 6 inches) (Fig. 240, A). Grasp the limb just above the line of the skin incision with the left hand and retract the skin upward, aided, if the limb be large, by an assistant. With a long knife, make a circular incision, at the skin-incision line, through skin and superficial fascia, entirely around the limb. Free skin with its superficial fascia from the muscles with their deep fascia, aiding 262 AMPUTATIONS. the separation in the intcrfascial line by touches with a scalpel, where neces- sary. Retract the skin and fascia evenly around the circumference of the limb. Divide the more superficial layer of muscles circularly, on a level with the retracted skin. Retract this more superficial layer of muscles. Divide the remaining deeper muscles circularly on a level with the retracted outer laver of muscles — and planning to come down upon the bone, or bones, far enough below the saw-line to allow of making a musculo-periosteal covering for the bone or bones. Retract the dee])er muscles thus cut. Divide with a stout knife, the periosteum circularly around the bone, or bones, at a di-stance below the saw-line equal to a good one-half diameter of the bone Figs. 240 and 241.— Ordinary ( lNirNi)iHri-Ak) Fora! ni- C'lRcr of incision and bone-section; H, Resulling sulure-line. The skin also applicable to the cuff variety of the circular method. at the saw-line. Push up the periosteum from the bone with periosteal elevator — keeping the muscles adherent to the periosteum. Apply linen (or other) retractors to the soft parts and draw them above the saw-line. Saw the bone, or bones. If splintering occur, grasp the spicula with forceps and remove with finer saw. Allow the soft (larts to drop over the end of bone, or bones, the sawed ends of which will form the apex of a funnel — the bone being covered by periosteum — periosteum by muscle — and muscle by fascia and skin (Fig. 242). Tie the vessels — cut the nerves and ten- dons short — and remove any tags of connective tissue or skin. Suture the musculo-periosteal covering over the end of bone, or bones. Quilt the CCFF METHOD OF CIRCULAR AMPUTATION. 263 muscles together in one or two layers. Suture the skin and fascia antero- posteriorly (Fit,'. 241, B) — and apply the dressing and supporting splint. Resulting Stump. — Evenly covered on all sides hy muscle and skin — the hone being particularly well protected and on a higher level above the surface of the stump than in any other form of amputation. The scar is ter- minal — anteroposterior, if the wound be sutured from before backward, — lateral, if sutured from side to side (Fig. 241, B). Indications. — In limbs more or less evenly surrounded by muscles: — lower part of forearm (sometimes), arm, and thigh. Comment. — (1) Owing to unequal skin retraction in some localities (as the antero-internal aspect of the arm and thigh) the circular incision may have to be planned obliquely and only become circular after the incision — and may also have to be planned lower. (2) A pure ordinary circular (infundibuliform) am- putation is impossible in a limb of rap- idly increasing girth, as it is impossible to retract the soft parts. A single lateral vertical incision through skin and fascia, or double lateral incisions, may become Fig. 243.— .\i-pkvkanck of the parts necessarv in order to free the parts — Following thk i.nfi-.ndibilar For.m of 1 .. ' . . 1 ■ 1 • f r Circular Ampctation ;— .A funnel-shaped when It ceases to be a typical mfundl- „,.;,,. ,^ft proximally, and a cone-shaped buliform amputation. mass disiaiiy. CUFF METHOD OF CIRCULAR AMPUTATION (I'lRtTLAR AMPUTATION A LA MAN'CHETTEi. General Description. — .\ circular division of the skin is made, which is turned over and u]jward upon itself as a cuff — and, upon a level with this retracted cuff of skin and fascia, the muscles are divided to the bone, generally with one circular sweep of a long knife. Technic- -The steps of the operation are similar to those of the ordinary circular amputation Ipage 261) up to the completion of the circular incision through the skin and superficial fascia. The skin and subcutaneous tissue are then turned back upon themselves as a cuff — the freeing being done by means of the lingers of the left hand, aided by touches of a scalpel, until evenly retracted all around. On a level with the retracted cuff, the muscles are circularly divided down to the bone — the site at which this division takes place being such as will allow of ample and easy covering of the transversely divided muscle by the skin and fascia — an average calculation being that about one-third of the total distance from saw-line to line of skin incision should be given to skin and fascia alone. The subsequent steps of the opera- tion, including the musculo-periosteal covering for the bone, being the same as for the ordinarv, or infundibuliform, circular amputation. Resulting Stump. — .\pt to be more or less irregular in contour and not so well ]jadded, owing tn the nature of the parts used for covering. The scar lies as in the ordinary circular amputation (page 262). 264 AMPUTATIONS. Indications. — Mnst frequently used where the soft coverings are more tendinous than muscular: — wrist, lower part of forearm, ankle, and lower part of leg (in thin subjects). Comment. — (i) and (2) The same comments made under (1) and (2) of the last operation app'y equally here (page 263). (3) Owing to the greater proportion of skin in this covering and the division of muscles in one layer, as well as the number of tendons present in the sites where this method is generally used, the covering of the bones is not so satisfactory as in the ordinary circular method. MODIFIED CIRCULAR AMPUTATION iMI.XED METHOD). General Description. — Two equal flaps, composed of skin and fascia, Figs. 243 and 244.— Modi of varying length, and having bases equal to one-half of the circumference of the limb at their upper ends, are cut and dissected up a short distance- followed by a circular sweep of the knife through the retracted superficial muscles— and by a second circular sweep at a higher level, through the re- tracted deeper muscles— and completion of the operation as in the ordinary circular amputation. Technic. — Having fi.xcfl upon the saw-line, and having marked a point below the saw-hne equal to ^ of ih diameters of the limli at the saw-line (that OVAl. METIKJD OF AMPUTATION'. 265 is, three-fourths of the diameter at the saw-line), two equal flaps of skin and fascia (of this length) are planned. These flaps have bases equal to one-half the circumference of the limb at the level of their upper limit — and their length will be ecjual to one-third or one-half of the total distance between saw-line and lowest limit of skin-covering (generally one-third in slender, ill-formed limbs, and often one-half in large, tapering limbs). The flaps are usually lateral ones, but may be anterior or posterior (Fig. 243, A). Retracting the skin with the left hand, begin the incision at one mid-lateral aspect of the limb, at a level above the lowest limit of the skin incision equal to one-third or one-half (as the case may be) of the distance between the saw-line and the lowest limit of the skin incision — pass vertically downward, through skin and fascia, until nearly at the level of the lowest skin incision — thence round forward into the line of lowest skin incision, in a bluntly rounding manner — and complete the opposite end of the same flap in the same manner. Then make the opposite flap in the same way as the first one, corresponding in shape and size. Dissect these flaps of skin and fascia back to just beyond their bases. While the flaps, and the muscles also, are retracted, divide the more superficial muscles circularly — retract these, and divide the deeper muscles similarly — making the usual provision for the musculo-periosteal covering. The operation is completed as in the ordinary circular ampu- tation — the skin and fascial flaps being sewed over the quilted muscles — the bone being at the apex of a funnel which is somewhat shallower than in the infundilniliform variety of circular amputation (owing to the muscles having been di\ided at a higher level). Resulting Stump. — While not covering the end of the bone with quite as thick a padding of soft parts, its general features are the same as thofe following the ordinary circular method. The main part of the scar is terminal, but its ends are apt to be partly lateral (Fig. 244, B). Indications. — This is the form of circular amputation most generally used and is adapted to a greater number of sites than the ordinary circular, nr the cut'f modification of the ordinary method. Comment. — (i) The skin-flaps may be cut of unequal lengths. (2) The muscles may be divided at one level. (3) This form of circular ampu- tation has largely replaced either of the other forms. OVAL METHOD OF AI.IPUTATION. General Description. — .\ modification of the circular method. The skin incision is in the form of an oval, with one of its ends more prolonged and pointed — the .soft parts between skin and bone being divided by cutting from without inward — and the lips of the wound being sutured in a single line parallel with the long a.xis of the wound. Technic. — This amputation being generally used in disarticulations, the upper or pointed end of the oval usually begins just above a ioint-line and upon its outer or anterior aspect — the limbs of the oval parting at an angle sufficient to include the head of the distal bone — and sweeping thence in a curve down the lateral aspects of the limb — passing, finally, transversely toward each other — to meet upon the inner or under surface of the distal limb and at a distance beneath the line of articulation calculated to furnish sufficient covering for the head of the jjroximal one of the bones making up the joint (Fig. 245, \). Having completed the incision through skin and fascia, one of two courses may then be adopted; — (a) The incision may then be deepened 266 AMPUTATIONS. throughout cHrect to the bone, by cutting from without — the deep incision, from the point where the arms or limbs of the oval begin to diverge, following the line of the retracted skin. This is the general method in all of the smaller disarticulations and in most of the larger, (b) Or the joint may be opened by the more vertical part of the incision and, after disarticulation, the muscles may be cut from within outward, on a line w'ith the re- tracted skin. Having tied the vessels, cut the nerves and tendons short, the wound is sutured in its long a.xis (Fig. 245, B) Resulting Stump. — The end of the bone is very fully covered e.xcept where the head or articular end of the pro.ximal bone is disproportionately large. The scar is termino-lateral (Fig. 245, B). Indications. — A form of amjiutation generally used for disarticulating a limb from the trunk, or a smaller limb from a larger limb. The method admits of first opening the joint for investigation before finallv deciding upon amputation — and it also admits of securing the vessels before removing the limb. Comment. — The suture-line mav run antero-posteriorly in one straight line — or the free, lower convex border of the flap may be turned over and sutured to the up]jer angular concavity of the wound. Fig. 245.— Oval Method of , TATloN:— A, Form and position of B, Resulting suture-line. RACKET METHOD OF AMPUTATION. General Description.— A modification of the cir- cular method. The same, in principle, as the o.val am- putation — with the addition of a longitudinal vertical cut prolonged from the apex of the oval forming the "han- dle of a racket" — thus giving a better exposure of joints without sacrifice of tissue and securing a better covering for the bone in the upper part of the wound. Technic. — Practically similar to the oval amputa- tion, except that the queue of the racket begins con- siderablv farther back over and 247,- iitl positic -Racket Method of .Amp n of incision ; B, Resulting ; AMPUTATION BV SINGLE FLAP OF SKIN AND MUSCLES. 267 the head of the ])ro.\imal bone forming the joint — and along this single straight line the knife travels some distance before the arms of the racket begin to diverge. After the beginning of the divergence of the limbs of the racket, the o[)eration is completed as in the oval operation (Fig. 246, A). Resulting Stump. — More satisfactory covering is secured by the racket than bv the o\al method of amputating. The scar is termino-lateral (Fig. Indications. — Disarticulations of the shoulder- and hip-joints, and of the digits from the hand and foot (especially, in the latter instances, where a metatarsal or metacarpal bone is removed with the digit). As in the oval method, but to a much greater extent, does the racket method admit of a pre- liminary examination of the joint through the vertical portion of the incision, before deciding upon amputation. The vessels may also be secured before entirely separating the limb. The muscles in the stump are better ])reserved. Comment. — (1) The queue of the racket should be jilaced, if possible, over an intermuscular septum and be deepened in the se])tum. (2) Ampu- tation by a T-shaped incision is, practically, a form of racket incision. (3) The suture line may run antero-posteriorly (or from the outer to the inner aspect of the part), which is to be preferred. Or the upper portion of the queue may be sutured in this manner and the lower conxex portion of the fiap brought up and sutured to the angular concavity formed by the di- vergence of the lateral limbs of the racket. FLAP METHODS OF AMPUTATING. (a) Single Flap of Skin and Muscles; — (b) Single Flap of Skin; — (c) Equal Flaps of Skin and Muscles; — (d) Equal Flaps of Skin; — (e) Unequal Flaps of Skin and Muscles; — (f) Unequal Flaps of Skin; — (g) Elli])tical Method; — (h) Unequal Rectangular Flaps of Skin and Muscle. AMPUTATION BY SINGLE FLAP OF SKIN AND MUSCLES. General Description. — A method of amputating whereby the stump is covered with a single flap derived from one aspect of a limb — and consists of skin, fascia, and muscles. Such an amputation involves the maximum sacrifice of bone. Technic. — Having fixed upon the saw-line (or line of disarticulation), a point is determined upon below this line, and on that aspect of the limb which is to furnish the flap, which will represent a distance below the saw- line equivalent to li diameters of the limb at the saw-line. A flap is then marked out with a base equal in width to a half-circumference of the limb at the saw-line, and a length equal to ij diameters of the limb at that line. (Fig. 248, A). Grasping the limb as in the ordinary circular amputation, the knife is entered at the far upper end of the base of the flap, at a right angle to the skin — and passes vertically down the mid-axis of the limb to near the lower limit of the flap — where it forms a squarely or bluntly rounded corner to the flap — thence passes transversely along the lower limit of the flap — and completes the opposite limb of the flaj) symmetrically with the first limb. This incision passes through skin and fascia. When this integumentary flap has retracted, the muscles are cut obliquely on a line with its retracted edges, so directing the knife as to bluntly bevel the muscular portion as the knife cuts its way 268 AMPUTATIONS. from without inward and upward. This incision passes obliquely through all the muscles and is planned to come down upon the bone at a distance beneath the saw-line equivalent to a good diameter of the bone at the saw- line, thus providing for a musculo-periosteal covering. The knife is then carried through the periosteum so as to form a musculo-periosteal flap with a base of half the bone at the saw-line and once the diameter. The musculo- periosteal covering is then detached back to the saw-line. Divide the hitherto undisturbed soft parts on the opposite side of the limb by a circular sweep of the knife — passing through the skin and fascia of the half-circumference Figs. 24S and 249.— Ampctation B^• Single Flap or Skin a incisions; B, Resulting sutu a little below the level of tiie base of the single flap — and through the muscles on a level with the base of that flap, including the periosteum. Retract all the soft parts on the pro.ximal side of the saw-line and divide the bone. Suture the musculo-periosteal flap over the bone, the free edge of the periosteal flap being sutured to the half-circumference of the opposite aspect of the bone. Quilt the lateral and terminal aspects of the cut muscles in the flap with the transversely cut ends of the muscles on the opposite side of the limb. Suture the terminal and lateral aspects of the skin of the flap to the trans- versely divided skin of the opposite side. Resulting Stump.— The stump is at first well covered with muscle— and, when this atrojihies, bv the replacing fibrous tissue. The scar is lateral (Fig. 240, B). AMPUTATION BV EQUAL FLAPS OF SKIN AND MUSCLE. 269 Indications. — Cases of injury so destroying the soft parts as to leave those of but one aspect available. Also in such cases as Farabeuf's amputa- tion of the upper third of the leg by a single external flap of skin and muscles, or Dubreuil's disarticulation at the wrist by a single external flap of skin and muscles. Comment. — (i) In all flaps, skin must be longer than muscle. (2) There is sometimes an excess of muscle in a flap, part of which should be removed in the process of beveling — but a fully muscled flap is generally desirable. (3) A flap of skin and muscle is more apt to live and makes a better covering than one of skin alone. (4) While the muscle tissue as such may not remain in the tissues of a stump, the muscle-fibers undergoing atrophy, yet the fibrous tissue matting and padding together of the parts is left in its place. (5) A single flap requires the maximum sacrifice of limb, one side of the limb furnishing the entire covering and the bone being con- sequently divided at a higher level. AMPUTATION BY SINGLE FLAP OF SKIN. General Description. — The features of this operation are practically the same as those of the amputation by a single flap of skin and muscles, except that the covering here consists entirely of skin. Technic. — Having incised through skin and fascia, this integumentary flap is dissected up from the muscles throughout, including all overlying fascia, and is retracted above the sawdine (or disarticulation-line) — when the bone is sawed or disarticulated, and the flap dropped over the end of the limb — its terminal aspect being sutured to the transversely divided skin of the opposite side. Resulting Stump. — Very thinly covered, but as the skin so utilized is generally accustomed to pressure, the result is usually satisfactory. Indications. — Such localities as the knee-joint (disarticulation by a single anterior flap), or the elbow-joint (disarticulation Ijv a single postericr flap). Comment. — (i) As this method is generally used in a disarticulation, a capsulo-periosteal rather than a musculo-periosteal covering is provided. (2) Nutrition of a single flap of skin and muscle is more difficult to maintain than in the more ordinary methods — and the nutrition of a flap of skin alone is even harder. (3) Skin-flaps are more used now than formerly because, <)\ving to rarer suppuration, their vitality can be more counted upon. AMPUTATION BY EQUAL FLAPS OF SKIN AND MUSCLE. General Description. — Coverings for the stump are gotten from two opposite aspects of the limb in the form of two flaps composed of all the soft parts covering the limb — having equal bases and lengths — and the allowance of skin being sufficiently in excess to well cover the muscles. Technic. — The preliminaries being the same as in the ordinary circular am]jutation, two flaps are marked out, each having a width of base equal to the half-circumference at the saw-line and a length equal to three-fourths of the diameter of the limb at that same line (Fig. 250, A). With a large scal- pel, incise along the outlined flaps, passing through skin and connective tissue. When these integumentary flaps have retracted, proceed to form the remainder •of the flaps — cutting obliquely along the margin of the retracted skin, in such 270 AMPUTATIONS. a manner that the flaps will be bluntly (not thinh") beveled, directing the knife so that the beveling will be greatest (though not thin even here) at the tip, and thickest toward the base — and coming down upon the bone, or bones, a distance below the saw-line ecjual to a full diameter of the bone (or of the bigger bone) to allow for musculo-periosteal covering. At this level make a circular cut around the bone through the periosteum with a heavy knife — detach the musculo-periosteal covering of the bone upward to the saw-line — retract the soft part.s — divide the bone — suture the musculo-periosteal covering — quilt the muscles — and suture the skin. Resulting Stump. — .'\s a rule, e.xcellently covered by substantial tissues. The scar is termino-lateral (Fig. 251, B). Equal Mixed Flaps : — A. Fo Resulting suture-Hue. Indications. — In the continuity of limbs (between joints) where the bone or bones are equally covered with soft parts. Comment. — (1) The simplest form of making double flaps is by two vertical incisions down the opposite sides of what has been begun as a circular method. (2) One flap may be cut from without inward, and the other by transfixion. (3) In very muscular limbs it makes the meeting of skin over muscles easier if about 2.5 cm. (i inch) of skin and fascia are dissected up from the muscle, after marking out and dividing the skin and fascia, and then cutting the muscles to the bone in a beveling fashion. AMPUTATION BY EQUAL FLAPS OF SKIN. This operation is the same, in general contour and dimensions of the flaps, as the last — e.xcept that the covering here consists of skin only. AMPUTATION BV UNEQUAL FLAPS OF SKLN AND MUSCLES. 271 Technic. — Having incised through skin and fascia, upon the same lines as in the last form of amputation, the two equal llaps of integumentary tissues are dissected up to a level below the saw-line which will allow of providing a musculo-periosteal covering — at this level the muscles, after retracting the skin, are circularly divided down to the bone — this circular incision is con- tinued, on the same level (one-half diameter of the bone below the saw-line) around and through the periosteum — the periosteum is then retracted, with the overlying muscles, to the saw-hne — and the bone divided. The musculo- periosteal covering is then sutured over the bone — and the skin margins sutured together. Resulting Stump. — Thinly covered, no muscle being present — but is generally satisfactory in the localities where adopted. The scar is termino- lateral. Indications. — Where a satisfactory muscle covering is hard to secure — as in the lower third of the forearm and leg and in the lingers — the tendons predominating in these localities. Figs. 252 and 253. — Amputai ion AMPUTATION BY UNEQUAL FLAPS OF SKIN AND MUSCLES. General Description. — Coverings are furnished by two flaps taken from opposite aspects of the limb — each tlap having a base equal to one- half circumference of the limb at the saw-line — and one flap having a length greater than the other. One flap usually furnishes one-third or two-thirds of the covering, and the opposite flap two-thirds or one-third — the longer 272 AMPUTATIONS. flap generally coming from that aspect of the limb most thickly muscled. The flaps mav bear any relation to each other in relative length — but the two flaps combined furnish a covering equivalent to ij diameters of the limb at the saw-line. Technic. — This amputation is identical, except as to the length of the flaps, with the amputation by equal flaps of skin and muscle (Fig. 252, A). Resulting Stump. — Generally well covered. With scar either entirely lateral or partlv lateral and partly terminal, dependent upon the preponderance of one flap (i\er the other (Fig. 253 ,B). Indications. — Thigh and arm throughout, and upper parts of forearm and leg. AMPUTATION BY UNEQUAL FLAPS OF SKIN. General Description. — Coverings are of skin and fascia alone and are furnished by the two opposite aspects of the limb, in the form of two flaps having equal bases and unequal lengths. This amputation is identical throughout with the amputation by equal flaps of skin, e.xcept as to the length of the flaps. AMPUTATION BY UNEQUAL RECTANGULAR FLAPS OF SKIN AND MUSCLES. TEALE'S METHOD. General Description. — The general method of performing this operation is similar, in principle, to that for amputation by unequal flaps of skin and muscles — with the exception that the flaps are rectangular (instead of rounded) and of special dimensions Technic. — Having fixed upon the saw-line, two flaps are marked out, having their bases at that line and extending downward as described below. Find the circumference of the limb at the saw-line. The longer flap is to have its length and its breadth equal to a half-circumference at the saw-line. The shorter flap is to be one-fourth of the length of the longer, and its breadth equal to the remaining half-circumference at the saw-line. The longer flap should be of the same width all the way down. The shorter flap will have a width at its free end equal to very nearlv a half-circumference of the limb at the le\el where it terminates (as that level, in the case of the shorter flap, is so short a distance beneath the saw-line) (Fig. 254, A). Having marked out these flaps, which should be accurately measured, the vertical parts of the inci- sion should be made from above downward, connected at their lower ends by the transverse incision which marks the limit of the longer flap, and by another transverse incision across the opposite half-circumference of the limb, at the proper level, marking oft' the lower limit of the shorter flap. These incisions at first involve skin and fascia only. When retraction has occurred (making a diff'erence in the transverse incisions only), they are deepened throughor.t to the periosteum. The vertical limbs of the flaps are first cut to the peri- osteum — then the lower transverse limit of the longer flap, which is dissected up above the lower limit of the shorter flap — which in turn is cut transversely to the periosteum and dissected up. When a level below the saw-line is reached equal to a half-diameter of the bone at the saw-line, a circular incision is made through the periosteum and a musculo-periosteal covering raised. All the soft parts are now retracted above the saw-line and the bone divided. The musculo-periosteal covering is sutured. The longer flap is bent over ELLIPTICAL METHOD OF AMPUTATION. 273 the end of the bone — its end being sutured to the end of the shorter flap — the lateral aspects of the shorter flap are sutured to the lateral aspects of the longer — and the lateral aspects of the bent-over portion of the long flap are sutured to the contiguous lateral aspects of the unbent portion of the long flap. The muscles are quilted prior to suturing the skin. The part is well sujjpnrted by splint, with only light pressure over the bent longer flap. Resulting Stump. — An H-shaped cicatri.x is formed upon the aspect of the limb furnishing the shorter flap. The end of the bone is well covered when the long flap contains a preponderance of muscle — less well covered when containing a preponderance of tendons (Fig. 255, B). Figs. 254 and 255. — Amputation by Unequal Mixed Rectangular Flaps : — -A. Form and posiu< of incisions, and line of bone-section ; B. Resulting suture-line. Indications. — In the lower part of the leg (where the longer flap is taken from the anterior aspect) — and sometimes in the lower forearm (where the longer flap comes from the posterior aspect). ELLIPTICAL METHOD OF AHPUTATION. General Description. — This is not a distinct form of amputation. It may be considered a variety of the circular method (an oblique circular), or, equally, a variety of single-flap amputation — and may be held in an intermediate position. It is circular, as to skin incision; and flap, as to its manner of covering the stump and in the suturing. The skin incision is in the form of an ellipse, or a lozenge, the upper part of the elhpse being upon one aspect of the limb and the lower part upon the opposite — the lateral limbs of the figure crossing the lateral aspects of the limb to be amputated. 274 AMPl'TATIONS. The idea of the elHpse is brought out by imagining the outline projected upon a tlat surface. Technic. — Having fixed upon the saw-Hne (or Hne of disarticulation), a point is determined above this, on, say, the posterior aspect of the limb, which is just above the saw-line — this becomes the highest point of the ellipse. The point marking the lowest point of the ellipse is placed upon the opposite side of the limb, at a distance below the saw-line equal, appro.ximately, to I J diameters of the limb at the saw-line (as there is but this one source of covering). Between these two points the lateral limbs of the ellipse pass, crossing the lateral aspects of the limb to be operated obliquely, from above downward, and so planned as to give a well-rounded conve.x termination of the ellipse below to be brought up and fitted into a corresponding concavity above (Fig. 256, A). The incision first passes around the outline of the ellipse, through skin and fascia only. Around the lower three- fourths of the line of this retracted skin and fascia a second incision passes through the muscles to the bone. The soft parts (skin and muscles) forming the lower part of the ellipse (the part that is to remain attached to the limb which is to be retained) are now dissected up from the bone to a point sufficiently below the upper limit of the ellipse to allow a musculo- periosteal or capsulo-perios- teal covering to be raised, and then on up to just below the B upper limit of the ellipse (that is, to the saw-line or line of disarticulation). This large single mass of soft parts is well retracted — and the mus- .— Ampi-t^tio.n BY THE Elliptical , , r 1 .• 1 and posiiion of incision ; li. Re- cles on that aspect of the limb opposite to the one furnishing the muscles in the elliptical covering are circularly divided — and the limb sawed, or disarticulated, pre- serving the periosteum in the usual way. The lower convexity of the ellip- tical flap is now sutured into the upper concavity left by the part of the limb removed — the musculo-periosteal, or capsulo-periosteal, covering and the muscles being treated in the general manner by buried gut sutures — and the skin wound closed. Resulting Stump. — The ellipse is generally taken from a locality which affords a plentiful covering for the extremity, which is thus well provided for. The scar is lateral (Fig. 257, B). Indications. — Chiefly used for disarticulations — especially at the elbow and wrist, and in the supramalleolar amputation. Comment. — The muscle-portion of the ellipse may be cut also by trans- fixion, though, as usual, less satisfactorily. Figs. 256 and iHTHOD : — A, Fol ulting sulure-line. SELECTION OF AMPUTATION METHOD. 275 IRREGULAR METHODS OF AMPUTATION. This is a special feature of modern-day surgery. Formerly amputations were done upon hard and fast lines. Now there is a marked tendency to allow the method of amputation to be determined by the special features and need of the individual case — and, as a result, irregular amputations are more commonlv done, which, while accomplishing the general indica- tions, are not bound by any set rule, shape, or measurement. The practical surgeon, therefore, should, on common-sense ground, adapt his method of amputation to the case in point, rather than be bound by any fixed form of amputation. The greatest field for irregular forms of amputation is jn cases of injury and deformity, rather than in disease. SELECTION OF ARIPUTATION METHOD. Many considerations enter into the determination of the best method of amputation in a particular case — and the choice should be given to that method which promises to fulfil the greatest number of the following features; — Characteristics of Good Amputation Methods. — (1) Minimum sacri- fice of healthy tissue — (2) Best permanent bone-covering — (3) Small wound area — (4) Good blood-supply to stump — (5) Favorably placed cicatri.x — (6) Efficient drainage — (7) Simplicity of method — (8) \'essels and muscles cut transversely — (9) Possibihty of getting satisfactory musculo-periosteal covering — (10) Ease of e.xposing bone at saw-line — (11) Ease of bringing soft parts together over bone without tension — (12) .Adjustability of artificial limb — (13) Largest range of adaptability — (14) Shapeliness of resulting stump — (15) Rapidity of method. Comment. — Circumstances may determine the selection of an ampu- tation method known in advance not to be the best — for instance, owing to the increased mortality in approaching the trunk, a limb may be removed, in a case where the vitahty of the patient demands that every chance be given him, at a level which, while increasing his chances for fife, may not furnish the best covering. Again, in amputating about the hand, it may conserve the interest of the patient better to be satisfied with even a partial flap and allow the remainder to heal by granulation, rather than remove an additional h cm. (^ inch) of an important finger. Rapidity of method used to be the chief consideration, but is now the last in importance, e.xcept in special instances — other considerations taking precedence — the operation being done with dehberation and precision. Features of the Circular Method of Amputating. — (1) Minimum sacrifice of bone and soft jxarts of any method. — (2) Bone especially well covered in the infundibuliform variety. Conical stump sometimes follows retraction, especially in the cutT and modified varieties of the circular. — (3) Smallest wound area of any method. — (4) Tissues of stump well supplied with blood. — (5) Cicatri.x terminal. — (6) Efficient drainage when sutured antero-posteriorly. — (7) Most simple of any method. — (8) Main vessels and muscles cut transversely. — (9) Musculo-periosteal covering well provided. — (10) E.xposure of bone at saw-line not always easy. — (11) Xot always easy to bring soft parts together over bone. — (12) Terminal cicatrix favorable for hollow artificial limbs; unfavorable for solid limbs of lower extremity.— (13) Unfavorable for amputation following injury involving the aspects of 276 AMPUTATIONS. the limb to unequal heights. — {14) Somewhat greater tendency to become conical. — (15) Most rapid of any method. Features of the Flap Method of Amputating. — (i) Greater sacrifice of bone and soft tissues (especially in unequal flaps). — (2) Coverings of bone can be more largely regulated to suit demand. Conical stumps less apt to follow than after the cuff and modified forms of the circular. — (3) Greater wound area. — (4) In long flaps the blood-supply may not be so satisfactory. — (5) Terminal or termino-lateral cicatrix — can be planned as desired. — (6) Drainage as efficient as in the circular if the flaps be lateral. Not so efficient if the flaps be antero-posterior. — (7) Not so simple as the circular. — (8) Muscles divided obliquely; vessels also, and latter may be split up. — (9) Musculo-periosteal covering well provided. — (10) Bone easily exposed at the saw-line. — (11) Flaps easily brought together over bone. — (12) Terminal cicatrix favorable for any hollow artificial limb. Terminal portion of termino- lateral cicatrix pressed upon by solid lower limb, and lateral portion pressed upon by any hollow artificial limb. — (13) Favorable for amputations following injury involving the aspects of the limbs unequally. .Adaptable to any part of any limb. — (14) Stump apt to be more shapely than that of the circular. — (15) Less rapid than the circular. Circumstances Influencing Death-rate After Amputation. — The death-rate is greater; — (I) The nearer the am])utation is to the trunk — (2) In the lower than in the upper limbs — (3) For injury than for disease — (4) In men than in women — (5) Between the ages of five to fifteen than before or after. THE AMPUTATION STUMP. QUALITIES OF A GOOD STUMP. Firm in consistency — well covered — insensitive — of regular and svmmetrical contour. The death-rate and the quality of the stump determine the success of any form of amputation. The following features are characteristic of a good stump — and also indicate the changes which follow successful ampu- tation : — Skin. — Not adherent, except at cicatrix. Capable of withstanding (and, preferably, accustomed to withstand) pressure. Plentifully supplied with blood. Muscles. — The muscles of a stump are not retained as such — the muscle tissue disappears in greater part and is replaced by fibrous tissue. Ex- ceptionally some muscle tissue remains and continues to function. The mass of fibrous tissue which replaces it, however, serves a useful purpose in padding over the end of the bone. In brief, muscle tissue tends to de- crease — and fibrous tissue to increase. Muscles and tendons either become incorporated in the cicatrix, form new attachments to bone, or retract out of the wav. Bone. — The ends of the bones become rounded and the medullary canals closed by fibrous tissue. The end of the bone may either dwindle and atrophy, or the periosteum may, exceptionally, deposit an excess of bone. The shaft of the bone in an amputated limb also atrophies somewhat. Cartilage. — Following a disarticulation, the articular cartilage left atrophies and sometimes entirely disappears. Nerves. — .\lso atrophy to a greater or less extent. The ends generally become bulbous, but give no trouble unless they become adherent to bone or cicatrix. CONTRACTILITY OF THE TISSUES OF THE STUMP. 277 Vessels. — Share in the general atrophy, and dwindle to a size com- mensurate with the parts to be suppUed. Ligated trunks become obliterated to their nearest branch. Collateral circulation is established. CHARACTERISTICS OF A BAD STUMP. In contradistinction to the general qualities of a good stump, a bad stump may be tlaccid, scantily covered, sensitive, of irregular contour — and may be further characterized by the following conditions: — Skin. — Thin, scanty, tightly drawn, adherent, puckered — cold or purple from improper circulation — ulcerated from the same cause, or from trophic changes — involved with corns — and may become malignant. Muscles. — See the changes mentioned in the last eection. Connective Tissue. — Bursa> may form. Bone. — Osteitis, periosteitis, and necrosis may occur. Two s[)ecial forms of bad stump are met: — Painful Stump. — May be due to osteitis or periosteitis — but is generally due to compression of the nerve. The nerve may be directly pressed upon by new bone or fibrous tissue — may be stretched over the stump — or may be the seat of neuritis. The end of a painful nerve is generally bulbous — but not necessarily — for often normal-looking nerve-ends are sensitive, and bulbous ones non-sensitive. Conical Stump. — The end of the bone forms the apex of a cone which may be the result of one or more of the following causes — (1) Flaps cut too short — or bone too long. — (2) Sloughing or suppuration of the soft parts. — (3) Post-operative contraction of muscles. — (4) Growth of the bone from an active epiphysis in the young. Comment. — Unfavorable changes are less apt to occur in case of primary union than in the reverse. CONDITIONS INFLUENCING VITALITY OF STUMP. (I) Blood-supply — full or scant, impeded or unobstructed by position of stump-covering. — (2) Compression by bandage, dressing or splint. — (3) Tightness and unnatural position of flaps, as compared with easy and natural position. — (4) Full allowance of skin and non-separation of skin from muscle, as compared with the reverse. — (5) Long and loose tendons and aponeuroses. (6) Too rapid sawing of bone. — (7) Finally, site of amputation, manner of performing the operation, prior local condition, prior constitutional con- dition, and after-treatment — all influence the vitality of the stump. Comment. — The chief dangers to be avoided, are — over-tension in the skin and muscle covering — insufficient blood-supply — rough projections of bone and laceration of the parts — and inclusion of ner%'es in the cicatrization. CONTRACTILITY OF THE TISSUES OF THE STUMP. Skin. — The average contractility of the skin is equivalent to about one- third of its length. It is most contractile where thinnest — where the sub- cutaneous tissue is least — where its attachment to underlying parts is least — where it is least stretched by movement.s — and where the process of healing has been longest. It is least contractile where the opposite conditions e.xist. 27S AMPUTATIONS. Muscles. — The extremes of muscular contractility vary from a slight separation of divided parts up to a retraction of four-tifths of their length. Contractihty is primary, where it occurs at the time of the operation — and secondary, where it occurs subsequent to the operation. Muscles contract most — which are freest between origin and insertion — which have long fibers — and where the process of healing has been longest. The larger the muscle, the greater the amount left in the fla]j, and the younger and healthier the subject, the greater the contraction. Muscles contract least where the conditions are the reverse of those just mentioned. Skin, Fascia, and Muscles. — The average contractility of the mi.xed tissues of a flap, or covering, is generally equivalent to about one-third of the length of the flap, or co\-ering. Additional length, however, should be allowed, in calculating the length of coverings — (1) When the transverse section of the bone is large as compared with the transverse section of the soft parts — (2) When the amputation is considerably below the origin of the muscle involved — (3) When secondary retraction is expected. POSITION OF STUMP-CICATRICES. The cicatrix should be so placed as to be the least exposed to pressure after the healing of the wound. With Reference to Their Position. — Scars may be Terminal — at the end of the .stump; — Lateral — on one or more sides of the stump; — Tcrmino- lateral — occujjying the end and side of the stump. With Reference to Their Production. — The following methods of amputation produce the following kinds of scars; — Circular is followed by terminal .scar; — Ellijitical, by lateral scar, if the ellipse be oblique, and terminal if the ellipse be nearly horizontal; — Oval, by termino-lateral; — Racket, by termino-lateral; — Single flap, by lateral scar; — Double flap, by terminal scar, if the flaps be equal, and lateral if the flaps be unequal. Comment. — (1) Other things being equal, that method of amjjutation should be chosen which will bring the scar in the most favorable position for that particular case — and especiallv with reference to the subsequent functioning of the stump and its adaptability to an artificial limb. (2) In amputating in some .situations the muscles of one group being so much stronger than those of another, will often draw a scar, terminal at the time of opera- tion, much higher up upon one aspect than it will lie drawn on the opposite aspect. Calculations for such an occurrence have, therefore, to be made. FUNCTION OF AMPUTATION STUMPS. In the Upper Extremity. — The chief function of the stump in' the upper extremity is range of movement and power to wield an artificial limb, rather than to bear pressure and weight. As the chief pressure of an artificial limb comes upon the lateral aspects of the stump, the scar of the stump in the upper extremity is best when terminally placed. In the Lower Extremity. — The chief function of the stump in the lower extemity is to bear pressure and weight. As the chief pressure of a solid artificial limb comes upon the end of the stump, the scar of the stump in the lower extremity is best when laterally placed — in those cases in which a solid artificial limb is to be worn. .\s, however, most modern artificial SURGICAL ANATOMY OF THE FINGERS. 279 limbs for the lower extremit}-, for the better classes, are hollow, there is not now made the same ditTerence as formerlv. The Modern Type of Artificial Limb. — \A'hile the abo\e was particu- larly true of the older, cruder forms of artificial limbs (and is still true of the peg-leg), the modern forms of artificial limbs are nearly always made upon the basis of a light, hollow cone, and are so adjusted as to largely adapt themselves to the conditions found — and, generally speaking, most of the pressure is of the lateral aspects of the stump and living limb against the sides of the hollow cone of the artificial limb — so that pressure is exercised upon the lateral aspects of the living stump and limb rather than upon the end — and in the lower as well as in the upper extremity. Comment. — .-\ function of the stump of the upper extremity, especially about the hand, and more particularly of a woman, is to be as symmetrical and shapely as possible, in the case of partial sacrifice of that member. While in the case of a laborer it would certainly be better to sacrifice appearance to sti^ength and utility, one might be urged to sacrifice strength for appearance in the case of a woman of the non-workins; class. AMPUTATIONS AND DISARTICULATIONS OF THE UPPER EXTREMITY. SURGICAL ANATOMY OF THE FINGERS. Bones. — Third, second, and first phalanges of the fingers; — and second and first phalanges of the thumb. Articulations and Ligaments. — (a) Second Interphalangeal .\rticula- tions; anterior; two lateral; capsule. Posterior ligament not present — place supplied by united tendons of extensor communis digitorum and extensor indicis, for index; — extensor communis digitorum for middle and ring; — united tendons of extensor communis digitorum and extensor minimi digiti, for little finger, (b) First Interphalangeal Articulations; — anterior (glenoid); two lateral; capsule. Posterior ligament not present — place supplied by e.xtensor longus pollicis (extensor secundi internodii pollicis) for thumb; — united tendons of extensor communis digitorum and extensor indicis, for index; — extensor communis digitorum, for middle and ring; — united tendons of extensor communis digitorum and extensor minimi digiti, for little finger, (c) Metacarpo-phalangeal .Articulations; — anterior; two lateral; capsule. Posterior ligament — not present as distinct ligament — jilace supplied by scattered fibers from one lateral ligament to opposite lateral ligament; e.x- tensor brevis pollicis (extensor primi internodii pollicis) ; extensor longus pollicis (extensor secundi internodii pollicis), for thumb; — and the same ligaments for the other fingers as those for the first interphalangeal joints. Sesamoid Bones. — Two on palmar surface of metacarpo-phalangeal joint of thumb, dcxeloped in inner and outer heads of flexor brevis pollicis, which here replace the anterior ligament. One or two on palmar surface of metacarpo-])halangeal joint of index and little fingers. Rarely one on palmar surface of metacarpo-phalangeal of middle and ring fingers. Rarely one on j)almar surface of interphalangeal joint of thumb. Muscles and Tendons. — (A) Of Fingers in General; — (a) On palmar aspect; — flexor sublimis digitorum; flexor profundis digitorum. (b) On dorsal aspect of index; — united tendons of extensor communis digitorum and extensor indicis; first dorsal interosseous (abductor indicis"). On dorsal aspect of middle finger; — extensor communis digitorum; second dorsal 28o AMPUTATIONS. interosseous; third dorsal interosseous. On dorsal aspect of ring finger; — extensor communis digitorum; fourth dorsal interosseous; second palmar interosseous. On dorsal aspect of little linger; — united tendons of extensor communis digitorum and extensor minimi digiti; fourth lumbrical; third palmar interosseous, (c) On ulnar aspect of little finger;— abductor minimi digiti; fle.xor brevis minimi digiti. (B) Of Thumb; — (a) On palmar aspect; — tfexor longus pollicis. (b) On dorsal aspect; — extensor brevis pollicis (extensor primi internodii pollicis) ; extensor longus pollicis (extensor secundi internodii pollicis). (c) On radial aspect; — abductor pollicis; outer head of flexor brevis pollicis. (d) On ulnar aspect; — inner head of flexor brevis pollicis; adductor obliquus pollicis; adductor transversus pollicis. Sheaths (Thecae). — Processes of palmar fascia extending down fingers from palm of hand to bases of last phalanges, being attached to lateral margins of first phalanges, and forming sheaths for tiexor tendons. Synovial Membranes. — (a) Of index, middle, and ring fingers; — extend from base of last phalanges up to bifurcation of palmar fascia, namely, about opposite necks of metacarpals (corresponding, approximately, to middle crease on palm of hand, for index, and to lowest crease for middle and ring), (b) Of thumb and little finger; — extend from base of last phalanges to and into great synovial sac of hand. Nails. — Overlie the soft parts covering the distal two-thirds of the last phalanges on their dorsal aspect. Arteries. — (a) Palmar Supply; — Four palmar digital branches of super- ficial arch; radialis indicis of deep arch; princeps pollicis of deep arch, (b) Dorsal Supply; — Second and third dorsal interosseous branches of posterior radial carpal branch of radial; first dorsal interosseous (metacarpal) branch of radial; dorsalis indicis branch of radial; dorsalis pollicis branch of radial. Veins. — (a) Superficial; — digital (one on each side), (b) Deep; — venae comites. Lymphatics. — One Ivmphatic vessel on dorsal and one on palmar aspect of each side of each finger. Nerves. — (a) Median supplies — thumb, index, middle, and ring fingers, (b) Ulnar supplies — ring, little, and middle (sometimes), (c) Radial supplies — thumb, index, middle, and ring. SURFACE FORM AND LANDMARKS OF THE FINGERS. The proximal ends of the phalanges form the knuckles — and therefore the joint-line is beyond the knuckle. The interphalangeal joint-lines are found, with approximate accuracy, by flexing the distal phalanges at a right angle with the proximal phalanges (or metacarpals) — and then prolonging the mid-lateral axis of the proximal bone forward — this line will pass through the center of the joints. More accurately, the last interphalangeal joint is 2 mm. (-['.J inch), the first interphalangeal joint 4 mm. (^ inch), and the meta- carpo-phalangeal joint 8 mm. (J inch) beyond the prominence of the knuckle. The sesamoid bones can be felt in front of the metacarpo-phalangeal joint of the thumb. The palmar aspects of the fingers are crossed by three series of transverse folds; — the highest are single for the index and little fingers, double for the middle and ring — and are nearly 2 cm. (J inch) below the metacarpo-phalan- geal joints; — the middle are double for all the fingers — and are directly opposite the first interphalangeal joints; — the lowest are single for all the GENERAL CONSIDERATIONS IX FINGER AMPUTATIONS. 281 fingers — and are a little above the second interphalangeal joints. The thumb has two folds — the higher, single, crosses the metacarpo-phalangeal joint obliquely; — the lower, single, directly opposite the first interphalangeal joint. The free margin of the webs of the fingers is about 2 cm. (f inch) below the metacarpo-phalangeal joints. The lateral ligaments of the joints are nearer the palm than the dorsum. The sheaths of the fle.xor tendons extend from the metacarpo-phalangeal joints to the proximal ends of the third phalanges — are least distinct opposite the joints — gape when cut — and lead into the palm of the hand. The digital arteries bifurcate about 8 mm. (J inch) above the free margin of the webs of the fingers. The epiphyses form the heads of the four inner metacarpals, the base of the first, and the bases of all the phalanges — all joining the shaft about the twentieth year. The skin of the palm is thick, dense, and adherent — that of the dorsum, thin and looselv connected to the fascia. GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS OF THE FINGERS. Minimum sacrifice of tissue is the rule in all amputations about the fingers — especially in thumb, index, and little fingers — so that there may be left some length of digit, no matter how short, to approximate to other digits and objects grasped. The basal principle here is — (a) Save a stump, no matter how imperfect — (b) provided tendons remain connected to it, or can be sutured to it — (c) and sound skin can be found to cover it. Indeed, the last may be dispensed with, if there seem fair chance that granulation will cover over the part. Amputations here, especially in cases of injury, are often irregular operations, and amount to little more than trimming of mangled parts — as a bony stump of irregular form, provided flexion and extension exist, is better than a shorter stump of more symmetrical contour. Since the bones of the fingers are large, as compared with the surrounding soft parts, an ample allowance of covering should be made. In the interphalangeal region the joints are concave from side to side, with the concavity toward the finger-tips. In the metacarpo-phalangeal region the convexity is toward the tips Owing to the function of the fingers, cicatrices should be planned to fall out of the way of pressure — should not be terminal or palmar — and are best placed on the dorsum. The stump of a phalanx is often considerably in the way unless the flexor and extensor tendons can act upon it. Formerly all of a finger below the center of the middle phalanx (where the superficial flexor is attached) was sacrificed. Now, however, the flexor tendon is sutured into the mouth of the cut theca and periosteum, or even the flap, thereby securing control of the phalangeal stump. The fibrous sheaths of the flexor tendons gape open when cut across and their channels lead directly into the palm of the hand, and those of the thumb and little finger into the great synovial sac beneath the annular ligament of the wrist, furnishing a ready avenue for possible infection. They should, therefore, be closed bv two or three catgut sutures, passed from the palmar to the dorsal aspect of the sheath with a curved needle, whenever cut in the 282 AMPfTATIONS. course of an amputation about the fingers. But when cut, especially when the finger is extended, the flexor tendons draw up into the sheath out of sight, and if the sheaths were then sutured the action of the flexor tendons upon the phalangeal stump would be lost. Therefore, to give the flexor tendons a firm hold upon the part, the sutures should include flexor tendon, theca, and periosteum — passing, in order, from before backward, through anterior wall of theca, flexor tendon (if distal to center of middle phalanx), or tendons (if pro.ximal to center of middle phalanx), and posterior wall of theca, which is blended with the periosteum. Where the theca is imperfect, the tendons should be sutured to neighboring periosteum, glenoid ligament, adjacent fibrous tissue, or into the tissues of the flap. Thus the mouth of the sheath is closed by the tendon while anchoring the latter to the part. This sheath is absent over the terminal phalanx and over the distal inter- phalangeal joint — and is indistinct over the metacarpo-phalangeal joint. Where absent, the flexor tendons should be sutured into the neighboring structures, as just described. Where the periosteum is to be included in the suture, it should be stripped back before dividing the bone. If the base of the terminal phalanx be saved, the attachment of the deep flexor is preserved. If the upper third of the second phalanx be saved, the attachment of the superficial flexor is preserved. If the amputation be through the first interphalangeal joint, or proximal to it, both flexor tendons will be lost — unless they are sutured into the neighboring structures as just described (into theca, periosteum, or flaps). The best form of amputation for all parts below the metacarpo-phalangeal joint is one in which a palmar flap predominates — furnishing a covering of thick, sensitive skin accustomed to pressure — and a cicatrix on the dorsum. In disarticulations by the palmar flap method, a slight downward con- ve.xity given to the transverse dorsal incision gives a better apposition with the palmar flap than would a straight transverse incision over the dorsum of the joint. Disarticulation is best accomplished from the dorsum, after flexing the joint — cutting, in order, through the following structures — skin; fascia; extensor tendons (attached to the bases in the interphalangeal joints, and forming the posterior ligaments of the joints); dorsal portion of the capsule; the knife passing thence behind the base of the distal bone and cutting the lateral ligaments from within outward; anterior portion of capsule, from within; and anterior ligament, also from within. The glenoid ligament, the fibro-cartilaginous plate which is mainly attached to the base of the distal bone, should be left in the stump. A longitudinal cut made in the mid-lateral aspect of the finger will have the digital arteries on the palmar side. All flaps should be cut from without inward — none by transfixion. The heads of the metacarpals should be preserved, especially in those who require strength in their hands. Their removal weakens the hand. If left in, they and their soft overlying parts eventually atrophy to some extent and the gap is not so apparent. If removed, somewhat greater symmetry is acquired at the cost of strength. Musculo-periosteal coverings in these small amputations through the phalanges are often difficult to provide, but should be provided where possible — even a periosteo-capsular covering in disarticulating. In making all palmar incisions, the part should be extended — and flexed while making dorsal incisions. The fullest coverings will be thus secured. Guard against making flaps too narrow- and pointed — the heads of the bones to be covered are all large, following disarticulation. AMPLTATKJX THROUGH LAST PHALANX OK fIXGERS. 2S3 All incisions outlining the different amputations pass through only skin and fascia at first. All ligatures should be catgut — and the skin sutures either silk or silkworm- gut. In all amputations about the fingers the stump should be snugly dressed and bandaged, and an anterior splint should be included in the dressing. AMPUTATION THROUGH LAST PHALANX OF FINGERS. IN GENERAL. Best Form. — Palmar Flap. Comment. — The palmar tlap method furnishes the best form of covering — and, owing to the presence of the nail, is about the only available form of amputation in this locality. AMPUTATION THROUGH LAST PHALANX OF FINGERS BV P.VLM.AR FI.-\P. Description. — Single palmar flap of all tissues down to bone. Fig. 258.— Ampliations about the Finger :— A, Through first phalaii.x, by equal palmar and dorsal flaps; B, At first interphalaiigeal joint, by long palmar and short dorsal flaps; C. At second interphalangeal joint, by palmar flap. Position (for all Amputations about the Fingers). — Patient on back; upper extremity held out from body. or. better, supported on a small table; hand pronated and fingers flexed while dorsal incisions are made, and hand supinated and fingers extended during palmar incisions. Assistant stands in front of surgeon, between him and shoulder of patient — steadying the hand with both of his own and holding the adjacent fingers out of the way. Surgeon holds digit to be removed with thumb and forefinger of left hand — with back of thumb downward and his hand pronated during palmar incisions — and with his thumb upward and his hand supinated during dorsal incisions. Landmarks. — The space is so limited that the saw-line can only be placed between the matrix of nail and proximal end of second phalanx. Incision. — (i) Palmar incision — from saw-line downward along lateral aspect of phalanx, midway between dorsal and palmar surfaces, around the center of the pulp, and back to the saw-line on the opposite side. (2) Dorsal incision — connects upper ends of palmar incision, passing transversely over the dorsum with slight downward convexitv. (For principle, see Fig. 258, C, where disarticulation at the last interphalangeal joint is shown.) 284 AMPUTATIONS. Operation. — Having outlined these incisions, carry the palmar incision to the bone — dissect up all palmar tissues down to the bone — deepen the dorsal incision to the bone — retract the soft parts, in the entire circumference — and saw the phalanx with a light saw, while holding the tip of the phalanx with bone-holding forceps (as there is generally too little room for the fingers of the operator to grasp). Ligate the palmar digital artery on each side. Suture the deep flexor tendon to the periosteum or flap. Suture the palmar flap to the transverse dorsal line. DISARTICULATION AT SECOND INTERPHALANGEAL JOINT OF FINGERS. IN GENERAL. Best Method.— Palmar Flap. Other Methods. — Short Dorsal and Long Palmar Flaps. Comment. — Even where the double flap method is adojited, the covering must be almost entirely palmar, owing to the position of the nail. DISARTICULATION THROUGH SECOND INTERPHALANGEAL JOINT OF FINGERS BY I'.^I.MAR FL.AP Position. — .\s for amputation through last phalanx (page 283). Landmarks. — Second interphalangeal joint-line. Incisions. — (1) Palmar incision — begins opposite the joint-line, midway between dorsal and palmar surfaces — passes down lateral aspect for a distance equal to ij diameters of the finger at the disarticulation-line — crosses palmar aspect with bluntly rounded corners — and passes upward to the corresponding point on the opposite side of the finger. (2) Dorsal incision — connects upper end of palmar incision by a transverse incision made over dorsum of joint, with slight downward convexity (Fig. 258, C). Operation. — Having outlined these incisions through skin and fascia, carry the palmar incision to the bone on a line with the retracted skin — and dissect the soft parts up from the bone. Deepen the dorsal incision to the bone, along the line of retracted skin — open the joint from the dorsum and disarticulate from within outward. There is no theca here to close. Suture the deep flexor tendons into the neighboring tissues. Ligate the two digital arteries. Suture the palmar flap to the dorsal line. Comment. — The joint is sometimes first disarticulated by a transverse dorsal incision — and the palmar flap then cut from within outward — but with less satisfactory result. DISARTICULATION THROUGH SECOND INTERPHALANGEAL JOINT OF FINGERS r.V SHORT DOKSAL AND LONG PALM.\R I- LAPS. Position — Landmarks. — As in the last operation. Incisions. — (1) Palmar flap — little more than length of diameter of finger at disarticulation-line — begins at disarticulation-line, in mid-lateral aspect of finger — passes directly down the finger for the above distance — crosses the palm with bluntly rounded corners — and passes up the finger to AMPUTATION- THROUGH SECOND PHALANX OF FINGERS. 285 the corresponding site upon the opposite side. (2) Dorsal flap — one-third the length of the palmar — beginning and ending at the same points as the palmar — and crossing the dorsum with bluntly rounded corners at the above distance below the upper limit. (For principle, see Fig. 258, B.) Operation. — Carry these incisions to the bone on the lines of retracted skin, completing the palmar incision first — dissect the soft parts from the bone up to the joint-line — open the dorsal aspect of the joint and disarticulate — completing the operation as in the above method. AMPUTATION THROUGH SECOND PHALANX OF FINGERS. IN GENERAL. Best Methods. — Palmar Flap; Short Dorsal and Long Palmar Flaps. Other Methods. — Equal Dorsal and Palmar Flaps; Equal Lateral Flaps; Single External Flap (for index); Single Internal Flap (for little finger); Circular; Oblique Circular; Dorsal Flap. Comment. — Any single flap, unless taken from the palm, brings part of the scar into the palm. .\ dorsal flap gives a palmar scar. .^11 equal flap methods and circular methods give terminal scars. AMPUTATION THROUGH SECOND PHALANX OF FINGERS l',\ l>.\l,M.-\K I-L.\I'. Position. — .As for amputation through last phalanx (page 2S3). Landmarks. — Lines of proximal and distal joints. Incisions. — (i) Palmar incision — begins opposite saw-line in mid-lateral aspect of finger — passes vertically downward a distance equivalent to i^ diameters of the finger at the saw-line — crosses the palmar aspect with bluntly rounded corners — passes vertically upward in the mid-lateral aspect of the opposite side to a point corresponding with the one of beginning. (2) Dorsal incision — connects the upper limits of the limbs of the palmar incision, passing transversely across the dorsum with slight downward convexity. (For principle, see Fig. 258, C.) Operation. — The above incisions are now deepened to the bone, the palmar first and then the dorsal, on a line with the retracted skin. The soft parts are dissected otJ the bone back to the saw-line and are retracted while the bone is being sawed. Ligate the digital arteries. In amputating distally to the upper third of the second phalanx, the superficial flexor tendon will retain its attachment. The deep flexor tendon will, however, be severed and should be sutured into the mouth of the fibrous sheath (which ends at the middle of the second phalanx) and into neighboring periosteum and soft parts, if necessary — the closure of the sheath being accomplished in the process of anchoring the deep flexor tendon. The flap is then sutured in the usual wav. AMPUTATION THROUGH SECOND PHALANX OF FINGERS r.\ SHciRT DORS.AL AND LONG P.Al.M.AR FL.\PS. Position — Landmarks. — .^.s in the last operation. Incisions. — (i) Palmar Flap — (2) Dorsal Flap — both outlined exactly as in the disarticulation through the second interphalangeal joint by short 286 AMPUTATIONS. dorsal and long palmar flaps — with the necessary calculations for the change in position (page 284). (For principle, see Fig. 258, B.) Operation. — For the technic of the operation, see the disarticulation just mentioned. For the manner of dealing with the structures encountered, see the operation last described. DISARTICULATION AT FIRST INTERPHALANGEAL JOINT OF FINGERS. IN GENERAL. Best Methods. — Same as mentioned under amputation tiirou^h >econd phalanx (\ydis,c 2S5). Other Methods. — Same (page 285). Comment. — Same (page 285). DISARTICULATION AT FIRST INTERPHALANGEAL JOINT OF FINGERS K\ r.Al.MAR 1-L.\1'S. Position. — As in amputation through last phalanx (page 2S3). Landmarks. — First interphalangeal joint-line. Incisions. — .\s for disarticulation at second interphalangeal joint by palmar llap (page 284). (For principle, see Fig. 258, C.) Operation. — Same, in principle, as the disarticulation at the second joint of the fingers. Both flexor tendons are here severed below their inser- tions, and the use of the pro.ximal phalanx would be much interfered with unless these tendons were securely attached to the sheath, periosteum, or glenoid ligainent of the stump. DISARTICULATION AT FIRST INTERPHALANGEAL JOINT OF FINGERS r.V SHORT DORSAL AND LOMG PALMAR FLAPS. Position — Landmarks. — .\s in the last operation. Incision. — Same as in disarticulation at the second interphalangeal joint (page 2S5). (For principle, see Fig. 258, B.) Operation. — Same as in the operation just referred to (page 285). For treatment of the flexor tendons, see disarticulation at first interphalangeal joint by a palmar flap (page 286). AMPUTATION THROUGH FIRST PHALANX OF FINGERS . IN GENERAL. Best Methods.— Palmar Flap; Short Dorsal and Long Palmar Flaps. Other Methods. — Same as mentioned under amputation through second phalanx (page 2S5). To which list may be added the oval method. Comment. — Same as made under the o])eration just referred to (page 28s). AMPUTATION THROUGH FIRST PHALANX OF FINGERS P,V PALNLAR FLAP. Position. — .\s for amputation through last phalanx (page 283). Landmarks. — Lines of metacarpo-phalangeal and first interphalangeal. joints. DISARTICULATION AT METACARPOPHALANGEAL JOINT. 287 Incisions — Operation. — Same as for amputation through second phalanx (page 285). For reference to tiexor tendons, see under disarticulation at first interphalangeal joint by palmar flap (page 286). AMPUTATION THROUGH FIRST PHALANX OF FINGERS r.v sHOkr iiDRSAi- and palmar flaps. Position — Landmarks. — As in the above operation. Incision — Operation. — As for amputation through the second phalanx bv the same method (l)age 285). For reference to treatment of the flexor tendons and sheaths, see under disarticulation at first interphalangeal joint by palmar flap (page 286). DISARTICULATION OF FINGERS AT METACARPO-PHALANGEAL JOINTS, IN GENERAL. Best Methods. — Oval Method (for fingers in general and for thumb); Externo-])alniar Flap of Farabeuf (for index); Interno-palmar Flap of Fara- beuf (for little linger); Oblique Palmar Flap (for thumb). Other Methods. — Equal Lateral Flaps; Circular Incision, joined by vertical dorsal queue; Palmar Plap; Large External and Small Internal Flaps (for index); Large Internal and Small External Flaps (for little finger). Comment. — The first four are the best in the sites indicated and are superior to the others mentioned. The oblique palmar flap for the thumb gives the best covering where sufficient tissue e.xists. DISARTICULATION OF FINGERS, IN GENERAL, AT METACARPO- PHALANGEAL JOINT. BV 0\'AL MKIHOl). Description. — The queue is placed over the dorsum of the joint and the center of the oval passes across the palmar aspect at the web-line. Position. — As for amputation through the last phalanx (page 283). Landmarks. — Head of metacarpal; metacarpo-phalangeal joint-line; web of finger. Incision. — Begins just above head of metacarpal, on its dorsal aspect (in the position corresjjonding with its neck) — passes down the median dorsal aspect over the prominence of the knuckle, to just beyond the base of the first phalanx (which is about midway between the metacarpo- phalangeal joint-line and the free edge of the web) — at this point the hitherto median incision diverges into two symmetrical limbs — each sweeping across the dorso-lateral aspect of the finger to just below the junction of the finger with the web — and thence transversely across the palmar surface in the line of the crease, on a level with the free border of the web, coming to the opposite side just below the junction of the web with the finger. This rather extensive incision is best made with three strokes — from commencement to web of one side — from point of divergence of median line to web of opposite side — and across palmar surface connecting the two limbs (Fig. 259, H). Operation. — The above incision through skin and fascia is now deepened. The palmar portion is cut to the bone while the finger is forcibly extended. 288 AMPUTATIONS. The lateral portions are carried to the bone, cutting the lumbricales and \ k I Fig. 259. — Ampl'tations about the Fingers, Hand, and Wrist :— A, Through second phalanx of little finger, by single internal flap ; B, At first interphalangeal joint, by oval method ; C, Through second phalanx, by equal lateral flaps ; D. Through second phalanx of index, by single external flap; E. Through first i)halanx, by oblique circular; F. Through first phalanx, by ordinary circular ; G, At metacarpo-phalangeal joint of little finger, by Interno-palmar flap; H, At nietacarpo-phalangeal joint, by oval method ; 1, At metacarpo-phalangeal joint of index, by externo-palmar flap; J, Of little finger at carpo-metacarpal joint, by racket method ; K, Same of ring finger; L, Of middle finger and part of metacarpal, by racket method ; M, Of two inner fingers at carpo-metacarpal joints, by racket method ; N. Of thumb at carpo-metacarpal joint, by racket method ; O. Through metacarpo-phalan- geal joint of thumb, by oblique palmar flap; P. P. At wrist -jomt. by external flap. interossei. The soft parts are retracted to the joint-line. The extensor tendons are then cut and the joint thus entered from the dor.-um — the lateral METACARPO-PHALAXGEAI, DISARTICULATION OF TlIUMl!. 289 ligaments and glenoid ligament being cut from within and the disarticulation completed. The two digital arteries are tied and the synovial sheath closed. The edges of the sides of the oval are sutured in one vertical, antero-posterior line, in continuation with the queue of the incision. The splint applied should include the wrist-jarl of forearm, by modified circu- lar ; B. Through upper forearm, by equal aiUerioraud iiiistcrior flaps ; C. At elbow- joint, by long antero-iiiternal and short postero-external flaps. 310 AMPUTATIONS. and muscle. Therefore a point below the saw-line equal to three-fourth* of a diameter at the saw-Hne will mark the lowest limit from which the covering is to be pro\ided. Two small flaps are incised, each having a base equal to a half-circumference, and a length equal to half (the lower half) of the distance between the saw-line and the lowest hmit of the skin incision. These flaps will be bluntly rounded at their lower ends (Fig. 262, A). Operation. — Dissect up the integumentary flaps half-way to the saw- line — retract them, and, on a level with the retracted flaps, circularly divide the muscles to the bone. This circular incision also divides the periosteum and interosseous membrane. The muscles and periosteum are then retracted to the saw-line — and the bones divided, completing the section of the more movable radius first. Tie the radial, ulnar, anterior and posterior interosseous arteries. Stitch the musculo-]jeriosteal covering over the bones. Quilt the mus- cles or tendons of the anterior to those of the posterior aspect of the forearm if pos- sible. Suture the integumentary cover- ings in a straight line antero-posteriorlv. Comment. — The preponderance of tendinous over muscular tissues here makes the infundibular variety of the modified circular difficult or impossible. C AMPUTATION OF LOWER THIRD OF FOREARM BV CIRCIILAR METHOD (CUFF VARIETY). Description. — The cuff variety of the circular amputation is here done (see under Comment). A cuff of skin, circu- larly cut, is turned back — and the mus- cles circularly divided on a level with the reflected skin — the ends of the bones being covered by skin and fascia alone. Position. — As in the last operation. Landmarks. — Saw-line. Incision. — Circular cut, placed three- fourths of a diameter (at the saw line) below the line of bone-section — thus mak- ing a total covering of i^ diameters, as each side may be regarded as furnishing one-half of the covering. (For ])rinciple, see Fig. 263, A.) Operation. — This circular incision divides the skin and fascia, which are then dissected up, the forearm being vertical while the posterior dissection is done. This dissection and turning back of the flap is continued up to a distance below the saw-line which will leave space to provide a musculo- periosteal covering. Here, after well retracting the integumentary coverings, the muscles are divided circularly to the bone, — extending the hand while the fle.xors are cut and flexing it while the extensors are being severed. A circular cut is made through the periosteum, around each bone, on a level with the cut muscles — the interosseous membrane is divided transversely — Fig. 263. — Amputations about !'^)Ke- ARM AND Elbow:— A, TIhoukIi niidillcof forearm, by circular method ; B, At elbow- joint, by single external flap ; C, At elbow, by oblique circular method. AMPUTATION OF UI'PP:R TWO-THIRDS OF FOREARM. 311 and a musculo-periosteal covering is freed up to the saw-line, with a periosteal elevator, from each bone. All soft parts are now retracted and the bones sawed, completing the section of the more movable radius first. Tie the radial, ulnar, anterior and posterior interosseous arteries. Cut the tendons (which are here especially numerous) and the nerves short. Suture the musculo-periosteal covering over the bones — and stitch the skin and fascia in a vertical antero-posterior or lateral direction. Comment. — (i) Owing to the predominance of tendons in this locality, the infundibuliform variety of the circular method is impracticable. (2) The above operation is very similar to the modified circular method just described, which is generally considered better than the present form, in this locality. The cuff method, indeed, is not possible if the limb tapers very decidedly at the site involved. (3) A musculo-periosteal covering is specially indicated here, as being the best means of guarding against a fusion of the cut edges of the bones and consequent loss of pronation and supination. (4) As the large mass of tendons is difficult to cut squarely by a circular incision, a long, narrow knife mav be slipi)ed under them, and thev may then be cut directly upward from within — or they may be di\ided with strong, sharp scissors. AMPUTATION OF UPPER TWO-THIRDS OF FOREARM BV Egr.AI, .ANll.RIOR AND rOSTKRlOR KLAPS. Description. — The anterior and posterior aspects of the forearm furnish equal U-shaped flaps of skin and muscle — the anteriorly largely composed of supinator longus and fle.xors, — the posterior largely made up of e.xtensors. Position. — .\s in the modified circular method (page 309). Landmarks. — Saw-Une. Incisions. — .\n anterior and a posterior U-shaped flap are incised on the resijective aspects of the forearm, the base of each flap at the saw-line being equal to a half-circumference of the liml) at that line, and the length of each equal to three-fourths of the diameter — the hand being supinated in making the anterior fla]), and the forearm vertical in making the posterior flap (Fig. 262, B). Operation. — Having cut through skin and fascia in outlining the flaps, these incisions are now deepened upon the line of the retracted skin, beginning at the ulnar side of the anterior ilap, in case of the right arm (and on the radial side upon the opposite arm). The \ertical ulnar incision will involve the flexor carpi ulnaris and flexor profundus — the vertical radial incision will involve the two radial carpal extensors — both vertical incisions passing directly to the bones. The muscles on the anterior and posterior aspects of the forearm, at the lower rounded e.xtremities of the flaps, are cut from without inward in such a manner as to l)evel them slightly. The entire flaps are now raised from the bones up to a point sufficiently below the saw-line to furnish a musculo-periosteal covering — at which level the periosteum is circularly divided around the bones — the interosseous membrane cut trans- versely — and the musculo-periosteal covering freed to the saw-line. The soft parts are then retracted and the bones sawed. The radial, ulnar, anterior and posterior interosseous arteries are tied. The median, radial, and ulnar nerves should be cut short, or even dissected from the flay). The musculo- [leriosteal covering is sutured and the muscles quilted — and the integuments sutured in a lateral line 312 AMPUTATIONS. Comment. — These flaps may be less satisfactorily cut by transfixion — which method, also, the interosseous membrane is apt to be pierced. SURGICAL ANATOMY OF THE ELBOW-JOINT. Bones. — Humerus, radius, and ulna. Articulations and Ligaments. — (a) Of the Elbow- joint; — anterior, posterior, internal lateral and e.xternal lateral ligaments, and synovial mem- brane, (b) Of the Superior Radio-ulnar Joint; — orbicular ligament, and synovial membrane. Muscles in Neighborhood of Elbow. — (A) Muscles arising a greater or les.ser distance al>ove elbow and inserted below elbow: — (a) On anterior aspect; — biceps and brachialis anticus. (b) On posterior aspect; — triceps and subanconeus. (c) On radial aspect; — supinator longus and extensor carpi radialis longior. (B) Muscles arising from inner condyle of humerus and inserted into forearm and hand; — pronator radii teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor sublimis digitorum. (C) Muscles arising from outer condyle of humerus and inserted into forearm and hand; — extensor carpi radialis brevior, extensor communis digitorum, extensor minimi digiti, extensor carpi ulnaris, anconeus and supinator brevis. Muscles in Direct Relation with Elbow- joint. — .\nteriorly; brachialis anticus. Posteriorly; triceps and anconeus. Externally; supinator brevis and common tendon of origin of extensc^r muscles. Internally; common tendon of origin of flexor muscles. Arteries in Neighborhood of Elbow. — Brachial, with superior profunda, inferior profunda, and anastomotica magna branches. Radial, with radial recurrent branch. Ulnar, with anterior ulnar recurrent and posterior ulnar recurrent branches. Veins in Neighborhood of Elbow. — Superficial; — median, median basilic, median cephalic, deep median, radial, cephalic, anterior ulnar, poste- rior ulnar, and common ulnar. Deep; — Two venas comites accompanying each of abo\e arteries. Nerves in Neighborhood of Elbow. — Superficial; — musculocutaneous, internal cutaneous, lesser internal cutaneous, external cutaneous, and branches of musculospiral. Deep; — ulnar, median, radial and j)osterior interosseous branches of musculospiral. Bicipital Fascia. — .\ broad aponeurosis given off from inner side of tendon of biceps, opposite bend of elbow — and passing between the brachial artery and superficial veins and nerves of elbow oblicjuelv downward and inward to become continuous with the deep fascia .of forearm, fastening down the flexor muscles. Bursse in Neighborhood of Elbow. — Between olecranon and skin, and between olecranon and triceps. Epiphyses. — Portion of e].)iphysis forming radial condyle and trochlea is within the capsule of the joint — that forming the two condyles is without. The epiphyses for the trochlea and external condyle blend and join shaft about sixteenth or seventeenth vear — that for internal condvle, about eighteenth year. The upper epiphvsis of radius forms the head — is within the joint — and joins shaft about sixteenth or seventeenth year. The olecranon is chiefly formed by diaphysis — an epiphysis occurs in its summit from the tenth to twelfth year- — joins shaft about sixteenth or seventeenth year — anteriorly the epiphysis being intersynovial, and posteriorly subperiosteal. SURFACE FORM AND LANDMARKS OF THE ELBOW. 313 Movements of Elbow-joint. — (i) Flexion — by biceps, brachialis anticus, aided by muscles having origin from internal condyle of humerus and by supinator longus. (2) Extension — by triceps, anconeus, aided by extensors of wrist and by extensor communis digitorum and extensor minimi digiti. SURFACE FORM AND LANDMARKS OF THE ELBOW. Position of radio-humeral line, and hence the joint-line of the elbow, may be found by feeling for the depression between the head of the radius and capitellum of the humerus at the back of the elbow, marked by a dimple in the integument in the interval between the anconeus to the ulnar side, and the muscular mass of supinator longus and two carpal radial extensors to the radial side. The humero-radial articulation is horizontal — the humero-ulnar articu- lation sloijes slightly downward. The fold of the elbow, more prominent when the forearm is semi-flexed, is a little above the level of the joint, and forms the base of the triangular fossa below the elbow, whose sides are formed by the supinator longus and pronator radii teres. The inner condyle of the humerus is the more prominent and is a little more than 2.5 cm. (r inch) above the elbow-joint. The t>uter condyle is 2 cm. (J inch) above. When the forearm is fully extended, the inner condyle, tip of olecran(,n, and external condyle are all on the same transverse line (in extreme extension, the tip of the olecranon is slightly above) ; — when the forearm is flexed to a right angle, the tip of the olecranon is ilirectly below the condyles; — when the forearm is completely flexed, the tip of the olecranon is below and in front of the condyles. A line connecting the two condyles forms a right angle with the axis of the arm — and an angle with that of the forearm. The upper part of the olecranon is covered by the triceps — the lower part is subcutaneous, and separated from the skin Ijy a bursa. Three eminences are present upon the anterior aspect of the elbow region; — the biceps above and in the center — the supinator longus and common extensor group on the outer — and the pronator radii teres and commi n flexor group upon the inner side. The ulnar nerve and posterior ulnar recurrent artery lie in a deep groove between the olecranon and inner condvle of the humerus. The anterior integument of the elbow is thin and retractile — the posterior integument loose and but little retractile. GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATING AT THE ELBOW- JOINT. The stump after disarticulatijig at tiie elbow-joint is better for the adapta- tion of an artificial limb than after amputation through the arm. To find the elbow-joint — place the thumb just beneath the external condyle of the humerus and. grasping the wrist with the right hand, pronate and supinate the forearm — when the upper limit of the radial head will be found about 1.3 cm. (^ inch) below the external condyle. The joint is entered and disarticulated more easily from the outer side. 314 AMPUTATIONS. The muscles on the outer side of the elbow retract more powerfully than those upon the inner side, chietly owing to the presence of the supinator longus. The lower end of the humerus is so large that a liberal allowance of covering is necessary. And a more liberal covering has to be provided for the inner than for the outer condyle of the humerus — incisions, therefore, are longer on the inner aspect. The skin posteriorly is used to pressure — but the muscles here are not so available for padding as in front. Temporary drainage should be used after disarticulation. The stump should be elevated upon a splint. DISARTICULATIONS AT THE ELBOW, IN GENERAL. Best Methods. — Anterior Ellipse — best, where ample sound tissue e.xists; W'ell nourished and thick enough to cover bones well; cicatri.x well placed; but requires considerable tissue; skin-pouch over the olecranon is apt to be left. Posterior Ellipse — best where anterior tissue is unavailable; covering thin and uneven, though used to pressure. Long Antero-internal and Short Postero-external Flaps — cover disarticulated end of humerus well; especially indicated where both lateral aspects of forearm can furnish co\ering and neither anterior nor posterior can supply the large amounts of tis.sue neces- sary for the elli]itical methods. Other Methods. — Circular. Modified Circular, .interior Flap. Poste- rior Flap. Long Anterior and Short Posterior Flaps. Short .interior and Long Posterior Flaps. Single External Flap. Equal Lateral Flaps. Un- equal Lateral Flaps. Lateral Skin Flap. Racket Method. Of these methods, the circular requires the least sacrifice of parts, but the resulting covering is not so satisfactory. DISARTICULATION OF ELBOW- JOINT RV .VNTERKiR FI.I.IPSF — F.XRABEl'l- . Description. — The covering is, essentially, an anterior flap — the idea of the ellipse being gotten in viewing the outlined incision laterally. The lower anterior conve.xity of the covering is sutured into the upper posterior concavity. Position. — Given in the course of the operation. Landmarks. — Joint-line; prominence of olecranon; eminence of supinator longus on anterior aspect of forearm. Incision. — The highest point of the elli[)se is posterior, over the prominence of the olecranon. The lowest point of the ellipse is anterior, over the eminence of the supinator longus, ju.st above the middle of the forearm. Midway between the upper and lower rounded ends of the ellii)se the lateral borders of the ellipse pass along the mid-lateral aspects of the forearm (Fig. 264). Operation. — The surgeon stands on the left of either right or left elbow (which will place the patient's elbow on his right) — grasping his wrist with his left hand, and flexing the elbow, so rotates the limb as to make the entire elliptical incision without relaxing his hold of the wrist, or removing the knife, which passes from olecranon to olecranon. Taking the right limb, for instance, turn the slightly fle.xed elbow so as to present the radial aspect — DISARTICULATION OF ELBOW JOINT. 315 enter the knife at the apex of the olecranon — pass down the radial lateral aspect — across the lower end of the ellipse, on the anterior aspect of the forearm (with the forearm extended and supine) — then along the inner aspect (with elbow agani tfexed and the inner aspect of the forearm thereby made to present) and upward to the olecranon. The skin and fascia upon the proximal side of the lower end of this incision are now further retracted by hand. On the line of the retracted integuments the muscles are then cut obliquely from without inward and upward toward the joint, in such a manner as to bevel the anterior covering which is being raised — and, at the same time, raise as much of a capsulo-periosteal covering as possible. This anterior tfap is dissected and retracted upward to the joint-line. The anterior lateral and posterior ligaments of the joint are now cut in order. The triceps and any remaining posterior tissues are sev- ered. The radial, ulnar, interosseous, mus- cular branches, and, possibly, the posterior ulnar recurrent and terminations of the su- perior and inferior profunda are ligated. Quilt the muscles in the anterior flap to the fascia along the margins of the upper half of the ellipse. Suture the integumentary tis- sues of the convex lower end of the flap into those of the upper concavity. Temporary drainage is indicated. Comment. — After the integuments are incised, the muscles are sometimes, though less satisfactorily, cut by thrusting a long knife through the limb opposite the anterior aspect of the joint and cutting from within outward on a line with the retracted skin. DISARTICULATION OF ELBOW- JOINT I'.V IMJSTKRIOK l.LLIPSK. Description. — The covering is, practi- cally, a posterior flap — the idea of the ellipse being seen in a lateral view of the incision. Position. — Given in the course of the operation. Landmarks. — Joint-line; tip of olecranon. Incision. — The highest point of the ellipse is anterior, opposite the lower margin of the joint-line. The lowest part is posterior, between 8 and 10 cm. (3 and 4 inches) below the joint-Hne. Midwav between the upper and lower rounded ends of the ellipse, the lateral borders of the ellipse pass along the mid-iateral aspects of the forearm. With the elbow fle.xed to an angle of 13s degrees, the lateral parts of the incision will be parallel with the prolonged anterior aspect of the arm (Fig, 265). Operation. — The surgeon stands on the right of either elbow, grasping the [jatient's wrist with his left hand (the back of his hand uppermost and his thumb toward the patient's fingers), and manipulates the elbow so as to complete the incision at one sweep — beginning the incision at the anterior joint-line with the elbow flexed at the above angle — passing down the inner aspect (while that part is manipulated so as to render it prominent) — crossing Fig. 264. — DlSARTICULATlO-V AT El- Bow-joiNT : — By anterior ellipse. 3i6 AMPUTATIONS. the dorsal aspect (while the forearm is held vertical) — ascending the outer aspect (while that aspect is made prominent) — to the place of beginning. Upon the line of the retracted integuments, the deeper parts are now cut. Those along the posterior aspect of the ellipse are divided, together with the periosteum, and including the anconeus, and insertion of the triceps when reached, and are dissected up to just above the tip of the olecranon. The deeper parts along the anterior portion of the ellipse are then divided, corre- sponding with the joint-hne, and the capsule of the joint divided transversely, followed by division of the lateral ligaments and posterior portion of the capsule (unless a capsulo-periosteal covering can be raised). Tie the brachial, posterior interosseous, muscular branches and terminations of the superior and inferior profunda. Cut the ulnar nerve especially short. Quilt the muscles in the posterior flap to the fascia along the mar- gins of the upper half of the ellipse. Drain temporarily. Suture the integuments of the lower portion of the ellipse (the convexity) of the posterior flap, to the upper concavity of the incision. Comment. — Transfi.xion of the lower part of the posterior flap is even less advisable than transfixion in the anterior ellipse — as, in the former case, the bone is almost subcu- taneous. DISARTICULATION OF ELBOW- JOINT BY LONT, .\NTERO-INTERNAL .\XD SHORT POS- TERO-E.XTERNAL FI..APS. Description. — .\ method of vmequal lat- eral flaps of skin and muscles — the incisions themselves are lateral, the bulk of the mus- cles being antero-internal and postero-e.\- ternal. Fig. 265. — Disarticulation at Positlon. — The forearm is held in supi- .i.B(iw.—H\ postenor ellipse. nation during anterior incisions — and verti- cal during posterior incisions, or partly fle.xed. Landmarks. — Elbow joint-line; tip and base of olecranon. Incisions. — Antero-internal incision — begins at center of anterior aspect of the joint-hne — passes obliquely downward and inward over the forearm, in such a way as to meet the mid-lateral aspect of the forearm, on the ulnar side, at a distance of about 7.5 cm. (3 inches) below the joint-line — thence passes upward and backward along a corresponding line to the base of the olecranon. Postero-external incision — a shorter incision but very similar to the longer, passes between the same points, crossing the mid-lateral aspect of the forearm, on the radial side, about 2.5 cm. (i inch) below the joint- line (Fig. 262, C). Operation. — .\long the line of these retracted integuments the muscles are cut obliquely down to the bone — when they, and as much of the periosteum as possible, are dissected up to the joint-line in front, and to the tip of the olecranon behind. The elbow is then flexed — the triceps is divided at its SURGICAL ANATOMY OF THE ARM. 317 attachment to the olecranon — and disarticulation completed by dividing the posterior, lateral and anterior hgaments, in order. Tie the brachial, termina- tions of the superior and inferior profunda, and, possibly, some small muscular and articular branches. The large antero-internal flap folds over the articular end of the humerus— its muscles are to be quilted to those of the smaller flap — and the integuments of the two flaps sutured — placing the cicatri.x upon the e.xterno-terminal aspect of the joint. Fig. 266. — Disarticulation at Elbow : — By long anterior and short posterior flaps. Elbow :— By long posteri anterior flaps. SURGICAL ANATOMY OF THE ARM. Bones. — Humerus. Muscles of the Arm. — (A) .\nterior Humeral Region: — coracobrachiaiis, biceps, brachialis anticus. (B) Posterior Humeral Region: — triceps, sub- anconeus. (C) Muscles having their insertions in upper portion of humerus: — supraspinatus, infraspinatus, teres minor, subscapularis, pectoralis major, latissimus dorsi, deltoid, teres major. (D) Muscles having their origin from lower portion of humerus: — (a) From internal condvle and ridge: — pronator radii teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor sublimis digitorum — (b) From external condyle and ridge: — supinator longus, extensor carpi radialis longior, extensor carpi radialis brevior, ex- tensor communis digitorum, extensor minimi digiti, e.xtensor carpi ulnaris, anconeus, sujiinator brevis. Arteries of Humeral Region. — From Axillary: — acromial and humeral branches of acromial thoracic, subscapular, anterior circumflex, posterior ■circumflex, and axillary itself. From Brachial: — superior profunda, nutrient, 31^ AMPUTATIONS. inferior profunda, anastomotica magna, muscular, and brachial itbelf. P'rom Radial: — radial recurrent. From Ulnar: — anterior ulnar recurrent, posterior ulnar recurrent. Veins of Humeral Region. — Superiicial: — cephalic, basilic, Deep: — two vena- comites accompany each of above branches of main arteries, and also brachial artery, .\xillary vein is formed by two brachial vena' comites and basilic vein. Nerves of Humeral Region. — .\nteriorly: — musculocutaneous, metiian, internal cutaneous, ulnar, lesser internal cutaneous, intercosto-humeral. Posteriorly: — circumtle.x, musculospiral. SURFACE FORM AND LANDMARKS OF THE ARM. The humerus is almost entirely covered by muscles, being subcutaneous only at the internal and e.xternal condyles. The greater and lesser tuber- osities and the head may be defined. The greater tuberosity lies just below the antero-e.xternal aspect of the acromion. The lesser tuberosity lies to the inner side of and below the greater, the bicipital groove intervening. To feel the head of the bone, abduct the arm, when the head will project promi- nently into the axilla. The internal condyle and internal condyloid ridge, and e.xternal condyle and external condyloid ridge, can be felt just above the elbow-joint. The latter are more easily felt during semiflexion, as a depression between adjacent muscles. The greater tuberosity and external condyle are in the same straight line and face in the same direction. The head of the humerus and the internal condvle are also in the same straight line and likewise face in the same direc- tion. When the arm hangs bv the side, the bicipital groove looks directly for- ward. The rough prominence upon the outer aspect of the middle of the humerus, into which the deltoid is inserted, also marks the level of the insertion of the coracobrachialis and the origin of the brachialis anticus — and also the entrance of the nutrient artery into the bone, and the level at which the musculospiral nerve and superior profunda artery cross the back of the bone. The upper epiphysis is horizontal and placed just above the surgical neck, joining the shaft at the twentieth year. The coracobrachialis and biceps above, and the biceps below, form the prominent muscular mass of the front of the arm. The brachialis anticus is discernible at the lower part of the arm, on each side of the biceps. The triceps determines the form of the back of the arm. The inner head is least distinct. The outer head forms the large prominence just below the posterior border of the deltoid. The long head emerges from between the teres major and minor and descends along the back of the arm. The supinator longus and extensor carpi radialis longior form a prom- inence on the outer side of the lower portion of the arm. .^bove the middle of the arm, the biceps, deltoid, coracobrachialis, and long head of triceps are more or less free and capable of retraction. Below the middle of the arm, the biceps is the only free muscle. It is for this reason that the circular method of amjiutation is suitable only to the lower half of the arm. In women and in fat persons the contour of the arm is more rounded AMPLTATIOX OF THE ARM, IX GENERAL. 319 and more nearly of one size throughout. In the muscular, it is less regular and more flattened laterally. On the inner and outer sides of the biceps are found the inner and outer bicipital furrows — the cephalic vein occupying the latter — and the brachial artery and basihc vein the former. The superior profunda artery arises just below the (Outlet of the a.xilla — the inferior profunda opposite the center of the shaft — and the anastomotica magna about 5 cm. (2 inches) above the bend of the elbow. The skin is most retractile over the inner aspect of the arm. GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT THE ARM. The shortest stump of an arm, even an amputation at the surgical neck, is better than a shoulder-joint disarticulation — as such a stump will ordinarily be able to move an artificial limb. It is, therefore, desirable to retain as much of the humerus as possible, as leverage for the artificial limb. From the standpoint of the amputator, the arm may be divided into two natural regions — a lower third, more or less cylindrical, and where the muscles are largely attached to bone — and an upper two-thirds, more or less conical, flattened or irregular, and where the muscles are largely free and capable of retraction. Therefore a circular method of amputation is preferable for the lower third, and a flap method for the upper two-thirds. The surgical neck of the humerus marks the height at which a useful stump can be obtained, as the capsule extends down to its level internally. In amputating at the surgical neck, the bone is sawed between the tuber- osities, and insertions of the pectoralis major and teres major. The supra- spinatus, infraspinatus, teres minor, and subscapularis are left attached to the head of the humerus. The bone is sawed below the epiphyseal line. The synovial membrane of the joint (accompanying the biceps tendon) is apt to be opened on the inner aspect, where it is lowest. The bursa under the subscapularis tendon generally communicates with the joint and may be opened during the operation. As much of the attachment of the pectoralis major, teres major, and latissimus dorsi as possible is raised with the peri- osteum, so as to be included in the musculo-pericsteal covering of the end of the bone and in the quilting of the muscles, in order to retain the attach- ments of these muscles upon the stump and, therefore, their action upon the artificial limb. In an amputation through the upper two-thirds by an anterior flap twice as long as the posterior, the scar will eventually be terminal, owing to the much greater retraction of the anterior parts — the biceps contracting most of any muscle. A terminal cicatrix is sought in the stumps of the arm. The stump should be dressed upon a splint. For control of hemorrhage in amputating at the shoulder joint, see page 325. AMPUTATION OF THE ARM, IN GENERAL. Best Methods. — Modified Circular — best for the lower third. Long Anterior and Short Posterior Flaps — best for the upper two-thirds. Single External Flap — best at the surgical neck. Other Methods. — Simple Circular (infundibular form). Single Anterior 320 AMPUTATIONS. Flap (Malgaigne's method). Anterior Ellipse (practically an anterior flap). Posterior Ellipse (practically a posterior flap). Lateral Flaps (of skin and muscles). Rectangular Flap (Teale's method). Oval Method (at the surgi- cal neck) AMPUTATION THROUGH THE LOWER THIRD OF THE ARM i;v M(iini-n:n cikcri-AR mkthcjI). Description. — Two short skin-flaps are cut and turned back, and the muscles divided circularlv in the infundibular manner. Fig. 268.— Ampihttons THRornH Arm ani by modified circular ; B, Through upper p.Trt of At shoulder-joint, by external racket method (Lai deltoid, flap (Dupuytren's operation). MJOLiLDER : — A. Through lower part of arm. »y long anterior and short posterior flaps ; C, operation ) ; I), U. .^t shoulder, by external, or Position. — Patient supine, at edge of table; limb horizontally abducted over the edge of table during anterior incisions, and held vertically, with bent elbow, or drawn over the chest, in dorsal incisions. Surgeon on outer AMPUTATION OF THE m'PER TWO-THIRDS OF THE ARM. 321 side of right and inner side of left limbs. Assistants steady the limb above and below the site of am])utation. Landmarks. — Saw-line. Incision. — The lowest hmit of the skin incision is placed at a distance below the saw-line equal to three-fourths of the diameter of the limb at the saw-line (thus securing a covering of i^ diameters). Of this total dis- tance the small flaps will occupy, approximately, the lower one-third. These flaps are generally anterior and posterior (but may be lateral, or in any intermediate position, as the local conditions may demand). Their base is one-half the circumference of the limb — thev pass down the lateral aspects of the limb to nearly their lower limit, when they bluntly round transversely across the limb to a corresponding point on the opposite side. The anterior and posterior flaps are similar (Fig. 268, A). Operation. — These flaps of skin and fascia are freed up to their base and turned back as cuffs. Here the more superficial muscles are circularly divided, and retracted in turn. U]Jon the line of these retracted superficial muscles, the dee])er muscles are cut to the bone — at a level still beneath the saw-line. This last circular division also divides the periosteum around the entire bone. All the soft parts, including the periosteum, are now freed up to the saw-line and the bone divided. Tie the brachial, superior pro- funda, inferior profunda, muscular, and possibly the anastomotica magna, branches. See that the musculospiral nerve is cleanly divided, and excise any portion of it apt to be pressed upon in bending the flap over the end of bone. Suture the musculo-periosteal covering. Quilt the muscles. Suture the flaps in a lateral line. Comment. — (i) The modified circular method makes it easier to free the bone of soft parts up to the saw-line, and also furnishes a more sym- metrical terminal covering. If necessary, the skin-flaps may represent one- half of the distance between the saw-line and the lowest limit of the skin- incision. (2) The simple circular method (the infundibular form) may be done here in small limbs with flabby coverings — but would be difficult in large limbs with firm coverings. When the infundibular circular method is used, it should be an oblique circular, the circle dipping lower on the antero- internal aspect of the arm, where, owing to greater retraction, it will be sub- sequently drawn up to the level with the outer part. AMPUTATION OF THE UPPER TWO-THIRDS OF THE ARM i;V L<;iXG ANTERIOR ,\N'D SHORT rOSTi;RIOR 1-'I..\PS. Description. — Two U-shaped flaps of skin and muscle are raised, the posterior being one-half the length of the anterior. Position. —As in the last operation. Landmarks. — Saw-line. Incisions. — The liase of each flap equals one-half circumference at the saw-line. The length of the anterior flap is equivalent to one diameter at the saw-line. And the length of the posterior flap is one-half the diameter. Both are U -shaped flaps. Care is taken to place these flaps so that the brachial artery will not be apt to be split — the vessel should be in the posterior flap — and the points of junction of the two flaps on the inner and outer aspect of the arm should be so shifted toward the outer side as to make this certain. The arm is raised vertically while the posterior flap is being marked out and incised (Fig. 268, B). 322 AMPUTATIONS. Operation. — Having incised skin and fascia along the above lines, the muscles are divided along the retracted integumentary coverings — cutting to the bone along the vertical limbs of the flaps, and cutting obliquely inward and upward along the rounded transverse endings of the flaps, in a bluntly beveled fashion — coming down upon the bone sufficiently far below the saw- line to provide a periosteal covering, which, with the muscles, is freed up to the saw line — and the bone divided. Care is taken to divide the musculo- spiral nerve evenly and short — as well as the nerves in the anterior flap which bend over the end of the bone, partially excising them if necessary. Tie the brachial, superior profunda, and inferior profunda, and muscular branches. Quilt the muscles of the anterior to those of the posterior flap — the former chieflv covering the end of the bone. Suture the skin margins of the flaps. The limbs should be steadied by a splint which also includes the shoulder. AMPUTATION OF ARM AT SURGICAL NECK KV SINCLK E.\ lEKXAL 11..AP. Description. — A U-shaped flap, composed chiefly of deltoid, is raired from the outer aspect of the arm, while the parts on the inner aspect are divided transverselv, or with slight downward convexitv. on a level with the up])er limit of the Hmbs of the flap. Position. — As in the above operations — the limb being drawn well away lr( m tlie Imdy, which will give access to both outer and inner aspects. Landmarks. — Surgical neck of humerus (just below the tuberosities). Incisions. — Flap incision — the base of the flap, which is U-shaped, is placed about 2.5 cm. (i inch) below the saw-line through the surgical neck — its width being equal to half the circumference of the limb at the flap's upper limit — its length being that of the diameter at the saw-line. The anterior limb of the flap passes down the mid-anterior aspect of the arm, and the posterior limb down the mid-posterior aspect. Inner incision — crosses the inner aspect of the arm, with a slight downward convexity, connecting the upper limits of the vertical limbs of the flap (Fig. 269, B). Operation. — The above incisions pass, at first, through skin and fascia only. After the integuments have retracted, the external flap is cut from W'ithout inward, upon the line of the retracted tissues, beveling cbliquely upward and inward toward the upper limit of the flap. The bleeding vessels in this external wound are clamped as met. The inner incision is now deep- ened — and the axillary vessels tied as encountered and before being cut — and the nerves cut short. The tendon of the pectoralis major is preserved, the periosteum being divided below the bicipital groove and stripped up, including this tendon. Avoid opening the synovial sheath of the liiceps tendon, dividing it low down, together with the coracobrachialis. Detach the tendons of the latissimus dorsi and teres major as subperiosteally as possible. Retract the outer flap and the parts on the inner aspect of the arm up to the saw-hne — and divide the bone through the lowest part of the surgical neck possible. Avoid the circumflex nerve and the posterior circumflex artery. The brachial artery will have been tied in the course of operation — branches of the anterior and posterior circumflex and muscular branches which have not been previously tied are now taken up. Bring the outer flap across the end of the bone — quilt the muscles of the flap to those divided in the inner incision — and suture the integumentary portion of the flap trans- SURGICAL ANATOMY OF SHOULDER-JOINT. i^?, verselv to corresponding tissues of the inner wound. Dress the arm against a full jiiid in the axilla. Comment. — (i) The chief advantages of amputation through the surgical neck, over disarticulation at the shoulder, are, that the mortality is less; that a stump for an artificial limb is secured; and that there is not so much muscular atrophy. The chief disadvantages are, that the remaining epiph- Fig. 269. — A.MPUTAi lo.\s ABOUT Ar.m AND AT Shoi'ldhk : — \, Through lower part of arm, by equal lateral flaps; B, At shoulder-joint, by Furueaux Jordan's method; C, Through surgical neck of liumerus, by single external flap. ysis is apt to produce bone; and that the stump may be strongly abducted. (2) The outer flap may be less satisfactorily cut by transfi.xion. SURGICAL ANATOMY OF SHOULDER-JOINT. Bones. — Scapula; clavicle; humerus. Articulations and Ligaments. — (a) Acromio-clavicular Articulation: 324 AMPUTATIONS. superior acromio-clavicular, inferior acromio-clavicular ligaments; inter- articular fibro-cartilage; synovial membrane, (b) Coraco-clavicular Union: — trapezoid and conoid ligaments, (c) Shoulder-joint: — capsular, gleno- humeral bands of capsular, coraco-humeral, glenoid and transverse humeral ligaments, and synovial membrane. Muscles Reinforcing Shoulder-joint. — .\bove: — supraspinatus. Be- low: — long head of triccjis; an upward extension of pectoralis major. In- ternally: — subscapularis. E.xternally: — infrasjMnatus; teres minor. Within Joint: — long head of biceps. Surrounding Joint: — deltoid. Muscles in More or Less Direct Relation with Shoulder-joint. — (a) .Anterior Thoracic Region: — pectoralis major, pectoralis minor, subclavius. (b) Lateral Thoracic Region: — serratus magnus. (c) .\cromial Region: — deltoid, (d) Anterior Scapular Region : — subscapularis. (e) Posterior Scapu- lar Region: — supraspinatus, infraspinatus, teres minor, teres major, (f) Muscles Passing from Slioulder to .\rm .\nteriorly: — biceps, coracobrachialis. (g) JNIuscles Pas>ing from Shoulder to .\rm Posteriorly: — triceps. Movements of Shoulder-joint. — Forward: — pectoralis major, anterior fibers of deltoid, coracobrachialis, biceps (when elbow is flexed). Backward: — latissimus dorsi, teres major, posterior fibers of deltoid, triceps (when elbow is extended). Abduction: — deltoid, supraspinatus. Adduction: — subscapularis, pectoralis major, latissimus dorsi, teres major. Outward Rotation: — infraspinatus, teres minor. Inward Rotation: — subscapularis, latissimus dorsi, teres major, ])ectoralis major. Bursae in Neighborhood of Joint. — Beneath tendon of subscapularis — communicating with joint by opening on anterior side of capsule. Beneath tendon of infraspinatus (sometimes present) — communicating with joint by opening on posterior aspect of capsule. Between under surface of deltoid and outer surface of capsule — not communicating with joint. Biceps tendon passes through the joint and is surrounded by tubular sheath continuous with synovial membrane. Arteries in Neighborhood of Shoulder-joint. — Suprascapular, trans- versalis colli, superior thoracic, acromial thoracic, long thoracic, alar thoracic, subscapular, anterior circumtlex. posterior circumflex. Veins in Neighborhood of Shoulder-joint. — Two suprascapular, two transversaHs colli, superior thoracic, acromial thoracic, long thoracic, alar thoracic, subscapular, anterior circumflex, posterior circumflex, cephalic Nerves in Neighborhood of Shoulder-joint. — .\cromial branch of cervical plexus, posterior thoracic, suprascajnilar, external anterior thoracic, internal anterior thoracic, upper subscapular, lower subscapular, middle subscapular, circumflex. — and following passing through axilla to arm and forearm; musculocutaneous, internal cutaneous, lesser internal cutaneous, median, ulnar, musculospiral. SURFACE FORM AND LANDMARKS OF SHOULDER- JOINT. To find the direction and position of the shoulder-joint — having fully abducted the arm, draw a slightly curved hne from the middle of the coraco- acromial ligament, with convexity inward, to the innermost part of the head of the humerus felt in the axilla. The coracoid process is not actually within the infraclavicular fossa, but lies near the pectoro-deltoid groove, covered by the anterior fibers of the deltoid, and a little below the clavicle. SURGICAL CONSIDERATIONS IN SHOULDER DISARTICULATIONS. 325 The center of the coraco-acromial Kgament lies over the superior aspect of the shoulder-joint. The greater tuberosity of the humerus is feU externally — the lesser ante- riorly- To the former are attached the supraspinatus, infraspinatus, and teres minor, in order, from above downward. To the lesser — the subscapularis. With the arm by the side and the hand supine, the bicipital groove looks directly forward — the head of the humerus lying entirely to the outer side of the vertical line from the coracoid process. The head of the humerus faces, practicallv, in the direction of the inner condyle — and the greater tuberosity in the direction of the outer condyle. The upper epiphysis of the humerus unites with the bone about the twentieth year — the inner part of the cartilage is within the capsule of the joint — the outer, anterior and posterior parts are subperiosteal. The surgical neck lies between the bases of the tuberosities and the inser- tions of the latissimus dorsi, teres major, and pectoralis major. The deltoid gives the rounded outline to the shoulder — and its insertion is marked bv a depression on the outer aspect of the middle of the arm. The groove between the pectoralis major and deltoid contains the cephalic vein and the humeral branch of the acromio-thoracic artery. The acromio-thoracic artery emerges from the upper border of the pec- toralis minor in the course of the brachial artery, where a line from near the junction of the third rib and its cartilage to the coracoid process crosses that vessel. The posterior circumflex artery and circumflex nerve cross the surgical neck of the humerus transversely about 1.3 cm. (5 inch) above the center of the vertical axis of the deltoid. The skin over the deltoid is thick, adherent, and little retractile — that over the pectoralis major is fine and retractile. The dorsalis scapuke artery crosses the axillary border of the scapula opposite the center of the vertical axis of the deltoid. GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATING AT SHOULDER-JOINT. Methods of Hemorrhage-control during operations near the Shoulder- joint : — (a) Wyeth's Shoulder Transfixion Pins, with tubular rubber Tourni- quet placed above them; — The anterior pin enters the middle of the anterior axillary fold, slightly to the inner side of the center of the fold — and emerges 2.5 cm. (i inch) within the tip of the acromion process. The posterior pin enters the posterior axillarv fold, at a point corresponding with the entrance of the anterior pin — and similarly emerges posteriorly 2.5 cm. (i inch) within the tip of the acromial ])rocess. Care is necessary to avoid striking the spine of the scapula with the posterior pin. Rubber tubing of 1.3 cm. (^ inch) diameter is wound several times around the axilla, above the pins, and tied (Fig. 209, right shoulder), (b) Preliminary exposure and double ligation of the axillary artery, with division between the two ligatures (as in Larrey's operation, page 329). (c) Digital compression of the main artery in the flap by an assistant, who grasps the part just prior to division of the artery (as in Spence's operation, page 327). (d) By Tourniquet and Pad; — A firm pad is placed in the axilla — over this are placed se\eral turns of rubber tubing passing around the axilla — the ends are then carried in a single figure-of-eight fashion over the clavicle of the same side, and thence across 326 AMPUTATIONS. the chest and are tied beneath the opposite axilla. Two strijjs of sterile gauze run beneath the tubing anteriorly and posteriorly (or placed in posi- tion prior to applying the tubing) will enable the tubing to be further and more securely drawn inward and thus make less the chances of slipping when the head of the humerus is removed (Fig. 209, left shoulder), (e) Compression (digital or instrumental) of subclavian artery against the first rib, either with or without preliminary incision over the third part of the artery, through the superficial tissues, (f) Securing of the main vessels at the lower end of the incision, as met in the course of the operation — an ordinary tourniquet having been first apphed — (as in the Fourneau.x Jordan method). Comparison of methods of hemorrhage-control : — The control of hemor- rhage in disarticulating at the shoulder-joint, or in amputating very near the shoulder articulation, is the most serious consideration connected with these operations. Wyeth's method, where the pins do not interfere with the operation as planned, may be regarded as the best means against hemorrhage. Preliminarv exposure and ligation of the artery — and compression of the artery in the flap — may be regarded as the next best methods. The axillary vessels should be as cleanly cut as possible — and so approached as to be secured before being cut, where the method of preliminary ligation is adopted. The branches of the brachial plexus are to be divided high up. The acromial process should always be preserved — as it furnishes a support for the artificial limb. A capsulo-periosteally covered stump should be sought — as furnishing the best support for an artificial limb — therefore one should endeavor to detach the insertions of the pectoralis major, latissimus dorsi, teres major, subscapularis, supraspinatus, infraspinatus, and teres minor along with the periosteum and capsule, in so far as this is possible. A vertical wound, in closing the site of operation, affords the best drainage. Sometimes drainage is made through a secondary opening. Temporary drainage is always indicated — owing to the extensive synovial surfaces. The stump should be dressed so as to compress dead spaces — and steadied against the thorax as a .'iplint by the surrounding bandaging. DISARTICULATION AT SHOULDER- JOINT, IN GENERAL. Best Methods. — Anterior Racket Method (Spence's oi)eration). Ex- ternal Racket Method (Larrey's operation). External or Deltoid Flap (Dupuytrcn's operation). Other Methods. — .Anterior and Posterior Flajjs. Circular. Elliptical. Lateral Flaps. Fourneaux Jordan's Method. Comparison of Methods. — The racket methods are the best. The features of the anterior racket method are: — excision of the shoulder-joint may be done, instead of an amputation, through the vertical portion of the incision, which may be alone made at first, until it be found whether ampu- tation be necessary; there is the smallest division of muscle; the posterior circumflex artery and circumflex nerve are not cut; the main vessels are easily controlled. The features of the external racket method are: — the vertical portion of the incision also allows of an excision, the incision at first being exploratory, through which an excision of the joint may be made, or the operation mav be converted into an amputation; there is considerable DISARTICULATION AT SHOILDER-JOIXT. 327 division of muscle and the joint is more deeply placed than in the anterior racket; the posterior circumtlex artery and circumflex nerve are apt to be cut. The disadvantages of the external or deltoid flap, which may be regarded as probably the third best form of disarticulation, are, that the circumflex nerve and posterior circumflex artery are cut — and that preliminary exam- ination of the joint is impossible. DISARTICULATION AT SHOULDER- JOINT BY ANTERIOR RACKET METHOD — SPEN'CKS OrERATiON. Description. — The queue of the incision is placed over the anterior aspect of the upper end of the humerus — the diverging limbs of the racket, or oval, encircling the inner and outer aspects of the arm and meeting behind. Position. — Patient near edge of table; shoulders elevated; head to oppo- site side; limb partly abducted. Surgeon on outer side of both shoulders, or may .stand on inner side of left. First assistant stands between shoulder and patient's head, controls hemorrhage and retracts flaps. Second assistant stands near elbow and manipulates limb. Landmarks. — Coracoid process; pectoro-deltoid groove. Incision. — .\bduct the arm and rotate the head of the humerus outward. Begin ihe incision just to the outer side of the coracoid process — pass down through the clavicular fibers of the deltoid and pectoralis major, until the humeral attachment of the pectoralis major is reached, which is divided. From this point, the outer limb of the racket curves gently outward through the lowest part of the deltoid to the posterior border of the a.xilla. From the point of division of the humeral attachment of the pectoralis major, the inner liml; of the racket curves downward across the inner aspect of the arm — until it coincides with the opposite limb of the racket (Fig. 270, B). Operation. — (i) The vertical portion of the incision is carried directly to the bone. The outer limb of the racket at first passes through skin and fascia, and is then deepened to the bone and through the periosteum, along the line of the incised integuments. The inner limb of the racket merely passes through skin and fascia, and especial care is taken that it goes no deeper at this stage. (2) Returning to the outer lip of the wound, the anterior liber of the deltoid will be found divided, and this lip of the wound is now freed from the bone and joint, as nearly subperiosteally as possible, thereby securing the retention of some of the attachments of the pectoralis major, latissimus dorsi, and teres major to the fibrous tissue — the freeing being accomplished by means of the thumb, periosteal elevator and knife, and continuing up to the great tuberosity — carefully avoiding (by hugging the bone) injury to the circumflex nerve and posterior circumflex artery, which are raised from the bone in this outer flap. (3) The inner Hp is similarlv, though less extensively, freed up to the lesser tuberosity, carefully guarding the axillary vessels. (4) By manipulating the limb from the elbow, fle.xed at a right angle, the head of the bone and its tuberosities are made to present themselves in the wound. By rotating inward, the great tuberosity presents, and the supraspinatus, infraspinatus, and teres minor are severed very close to the bone. By rotating outward, the lesser tuberosity presents, and the .subscapularis is severed. (5) The long head of the biceps is next cut, and the capsule opened by dividing it transversely against the head of the bone. The capsule being cut and the muscles attached to the tuberosities severed, the head of the bone is now disarticulated and thrust upward above the 328 AMPUTATIONS. glenoid ca\'itv, by abducting and rotating the head of the humerus outward — the connection of the hmb being maintained by the still unsevered tissues upon the inner aspect. (6) The surgeon grasps the disarticulated head with Fig. 270.— Amputations through Arm and at Shoulder :— A, Through lower arm, by oblique circular method ; B. At shoulder, by anterior racket method (Spence's operation) ; C, Of upper limb, together with scapula and part of clavicle, by anteroinferior (pectoro-axillary) and postero-superior (cervico-scapular) flaps (Berger's operation). the left hand and draws it outward from the trunk. As he does so, the first assistant, standing behind the shoulder, places the palm of the fingers of both hands against the a.xillary aspect of the still uncut inner tissues, and his thumbs, one from each side, between the neck of the bone and the tissues DISARTICULATION AT SHOULDKR-JOIXT. 329 of the inner side, compressing the axillary vessels between the thumbs in the wound and the outspread fingers in the axilla — until he feels all circulation controlled. The surgeon now passes a long knife between the neck of the bone and the thumb-nails of his assistant, and, by a steady, sawing move- ment, cuts his way from within downward and outward, aiming to come out on a line with the retracted integuments along the original incision, along the inner limb of the racket. As the knife cuts its way out, the fingers of the assistant follow the blade closely, with the artery under his grasp. Just prior to the final passage of the knife, the tissues are tightly grasped and steadily held, until the knife emerges — when he presents to the surgeon the cut margin of the inner flap, with the vessels in easy evidence. (7) Tie the brachial artery at once, and the two brachial venas comites and the basilic vein. In the vertical and external limb of the racket, in incising and deepen- ing the wound, branches of the acromial thoracic, the anterior circumflex, and muscular branches are at first clamped and subsequently tied. (8) The posterior circumflex nerve should not be injured. The nerves which are severed are cut short. (9) The margins of the capsulo-periosteal wound, where any appreciable periosteum has been saved, are sutured. The muscles are quilted by deep and superficial tiers of buried catgut (chromic) sutures. Temporary drainage is provided. The integumentary edges of the wound are sutured in one vertical line. The stump should be snuglv compressed against the thorax by the bandage. Comment. — (i) This operation is an illustration of the control of hemor- rhage by digital compression in the flap. (2) By saving as much of the attachment of the pectoralis major, latissimus dorsi and teres major, in the subperiosteal freeing of the humerus, connections in the stump are formed by these tendons and considerable range of movement is therebv added to an artificial limb. (3) The axillary vessels have been exposed where the inner limb of the racket crosses their course and ligated prior to disarticula- tion. (4) Where the deltoid tissues are very thick, this flap mav be ad- vantageously thinned a little by making the incision of the outer limb of the racket in a bevehng manner. (5) The more nearly the operation- is done subperiosteally, where no contraindication to the preservation of the peri- osteum e.xists, the greater the safety to the important tissues, especially the circumflex nerve and posterior circumflex arterv. DISARTICULATION AT SHOULDER- JOINT BY EXTKRN.AI. KACkKT M K P ilnl) — I.ARRFA'S OPER.\TION. Description. — The queue of the incision is placed over the external aspect of the upper end of the humerus — from the center of this incision (which may first have been made for exploration of the joint alone) the two limbs of the racket diverge — encircling the anterior and posterior aspects of the arm and meeting on the inner side. Position. — As in Spence's operation (page 327). Landmarks. — Prominence of acromion. Incisions.— (I) Vertical incision — (arm being sHghtly abducted) begins immediately below the anterior aspect of the prominence of the acrcmion and passes thence vertically down the external aspect of the arm for 10 cm. (4 inches). (2) Oval incision — from the center of the vertical incision the two limbs of the oval, or racket, begin and pass obliquely downward over 330 AMPUTATIONS. the anterior and posterior aspects of the limb, meeting upon its inner border on a level with the lowest part of the vertical incision (Fig. 268, C). Operation. — (1) The vertical incision passes at once through the deltoid directly to the bone and into the joint. The operation, which may have been begun as an e.xploratory one, may end with an investigation of the joint — or may proceed to an e.xcision of the joint structures — or may end as an amputation. If the latter, the oval, or racket, incision, as above described, is added to the vertical incision. (2) The hmbs of the racket are at first incised through skin and fascia only, and may be made at one stroke, or, better, by two. (3) The anterior limb of the racket is now deepened, while the arm is rotated outward — the incision passing through the anterior portion of the deltoid — the tendon of the pectoralis major is severed as near the bone as possible — the coracobrachialis and biceps are divided — and, ne.xt to these, the axillary vessels are encountered, carefully exposed and doubly ligated, beyond the posterior circumflex branch. This flap is then freed up to the joint. For the same reasons mentioned under the last operation, the freeing of these flaps should be done as subperiosteally as possible. (4) The posterior limb of the racket is similarly deepened, the arm being rotated inward — the incision passing through the posterior portion of the deltoid — and meeting the anterior limb upon the inner side of the arm. This flap is then also freed up to the joint as subperiosteally as possible. (5) Dis- articulation is accompUshed (after severing close to the bone in the above freeing of the anterior and posterior flaps, the attachments of the supra- spinatus, infraspinatus, and teres minor to the great tuberosity, and the subscapularis to the lesser) by cutting the capsule and the long head of the biceps against the head of the bone transversely. The head of the bone is now disarticulated and thrust upward. (6) To sever the remaining soft parts, the surgeon grasps the disarticulated head of the humerus with his left hand and draws it outward — then inserts a long knife between the neck of the bone and the remaining undivided parts, and, by a sawing movement, cuts his way downward and outward between the severed axillar\- vessels and the bone, coming out on a line with the retracted inner limb of the racket incision (just as in the disarticulation by the anterior racket). (7) Besides the above-named vessels, the anterior and posterior circumflex are both apt to be divided, as well as some muscular branches. The circumflex nerve is likely to be severed. All nerves are cut short. (8) The capsule is to be trimmed, if hanging in tags. Temporary drainage is used. The capsulo- periosteal, or capsulo-muscular covering is sutured — the muscles quilted deeply and superficially — and the skin sutured in a vertical line. Comment. — This operation is an illustration of the control of hemor- rhage bv the ligation of the main vessels in the line of incision, prior to dis- articulation. DISARTICULATION AT SHOULDER- JOINT Bv K\Ti:kN.\i. TLAXTAR FI.ArS. Description. — The covering is gotten equally from the dorsal and plantar surfaces and the scar is terminal. Position. — Patient supine; foot over edge of table. Surgeon grasps toes with left hand, with thumb on dorsum and fingers on plantar surface for dorsal incisions — and thumb on plantar and fingers on dorsum for plantar incisions — manipulating the foot as indicated. After the incisions are made, an assistant takes the toes and the surgeon manipulates the flaps. The surgeon stands for the dorsal and sits for the plantar incisions. Incisions. — (Supposing the left foot to be operated upon) — the dorsal incision (with foot extended and toes fle.xed) begins at the mid-lateral aspect of the metatarso-phalangeal joint of the great toe — passes vertically down the inner margin of the foot to the middle of the first phalanx — thence rounds broadly on to the dorsum of the foot and follows the line of the web, dipping in between the toes as they are separated, until the little toe is reached, when the incision again rounds broadly into the outer aspect of the foot and passes vertically up in the mid-lateral aspect to the metatarso-phalangeal joint. The plantar incision (with foot flexed and toes extended) passes transversely across the plantar surface of the foot, connecting the distal ends of the vertical limljs of the dorsal incision — beginning at a point where the vertical limb begins to round onto the dorsum, the plantar incision rounds ontcj the plantar METATARSnPHALAXGEAL DISARTICLLATIUN EX MASSE. 343 surface at the middle of the first phalanx of the great toe, and thence follows the line of the web and creases of the toes, dipping in between the toes as they are separated, until the little toe is reached, when the incision rounds into the outer aspect and joins the dorsal incision at a point where the outer vertical limb began to round onto the dorsum (Fig. 272, A, A). Operation. — The dorsal incision is deepened to the extensor tendons Fig. 272. — Disarticulations about the Foot: — A. A. Of all the t joints, by equal short dorsal and plantar flaps ; B, B. Of all the toes a short dorsal and long plantar flaps (Lisfranc's operation ) . es at metatarso-phalangeal tarso-metalarsal joints, by and freed half-way back to the joint-line, when the extensor tendons are cut transversely, each toe being previously forcibly flexed in turn. The flap of entire soft parts is then dissected back to the metatarsophalangeal joint-line. The plantar incision is now deepened to the flexor tendons and freed half-way back to the joint-line, when the flexor tendons are cut transversely, each toe being previouslv forcibly extended in turn. The flap of entire soft parts is then dissected back to the metatarsophalangeal joint-line. Both flaps are well retracted to the general joint-line — the toes are fle.xed and the joints are opened from the dorsum and the lateral ligaments cut from within out- ward. The toes are then extended and the plantar ligaments are cut from the plantar surface, preserving the glenoid ligaments. The disarticulation 544 AMPUTATIONS. of each toe is thus completed in turn. The tlexor sheaths are closed. Two plantar and two dorsal digital arteries for each toe are cut — the latter may not require ligature. The dorsal and plantar flaps are sutured in one lateral, terminal Hne. Comment. — It is difficult to get covering for the large head of the first metatarsal — special care is, therelore, given to procuring this covering by keeping well in the mid-lateral aspect of the inner surface of the great toe until quite to, or beyond, the middle of the first phalanx, before rounding into the dorsal and plantar surfaces. SURGICAL ANATOMY OF THE FOOT. Bones. — Five metatarsals; seven tarsals (astragalus; os calcis; scaphoid; internal cuneiform; middle cuneiform; external cuneiform; cuboid). Articulations and Ligaments. — (A) Metatarsophalangeal Articula- tions: — See Surgical Anatiimy of Toes, page 333. (B) Articulation of Meta- tarsals with each other: — iJorsal, plantar, transverse metatarsal, interosseous ligaments, and synovial membrane. (C) Articulations of Metatarsals with Tarsals: — dorsal, plantar, and interosseous ligaments, and synovial mem- brane. (D) Articulation of E.xternal Cuneiform and Cuboid : — dorsal, ]ilantar, and interosseous ligaments, and synovial membrane. (E) Articu- lations of Internal, Middle, External Cuneiform bones with each other: — dorsal, plantar, and interosseous ligaments, and synovial membrane. (F) .Articulation of Scaphoid and Cuboid: — dorsal, plantar, and interosseous ligaments, and svnovial membrane. (G) Articulation of Scaphoid and three Cuneiform Bones: — dorsal and plantar hgaments, and synovial mem- brane. (H) .\rticulation of Astragalus and Scaphoid: — Superior astragalo- scaphoid ligament, and synovial membrane. (I) Articulation of Os Calcis and Scaphoid: — superior (or external) and inferior (or internal) calcaneo- scaphoid ligaments, and synovial membrane. (J) Articulation of Os Calcis and Cuboid: — (a) Dorsal — superior and internal (interosseous) ligaments; (b) Palmar — long calcaneo-cuboid (long plantar) and short calcaneo-cuboid (short plantar) ligaments. And synovial membrane. (K) Articulation of Os Calcis and Astragalus: — external, internal, and posterior calcaneo-astraga- loid, and interosseous ligaments, and synovial membrane. (L) Articulation of Tarsus with Bones of Leg: — See Surgical .Anatomy of the Ankle, page 358. Anterior Annular Ligament. — Consists oi two portions; — (a) ^'ertical (Superior) Portion: — Binds down extensor tendons to tibia and fibula. Con- tinuous with fascia of leg above, and extending from anterior border of tibia to anterior border of subcutaneous surface of fibula. Contains synovial sheath for tendon of tibialis anticus. Following structures pass under it — extensor proprius hallucis, extensor longus digitorum, peroneus tertius, anterior tibial vessels and nerve, (b) Horizontal (Inferior, or Y-shaped) Portion: — Binds down extensor tendons to tarsus. Is connected with vertical portion. .Attached, externally, to superior surface of os calcis, — anteriorly, to depression for interosseous ligament. It passes upward and inward in a superficial band (which runs in front of the peroneus tertius, extensor longus digitorum, and part of origin of extensor brevis digitorum), and a deep band (which runs behind these muscles). Having formed this loop containing the above muscles, surrounded by synovial membrane, these two bands unite and redivide into two limbs. The Up])er Limb passes upward and inward to the internal mallenlus — containing tibialis anticus muscle and its SL'RGICAI. AXATOMV OF THE FOOT. 345 synovial sheath in its structure, but passing over extensor proprius hallucis and anterior tibial vessels and nerve. The Lower Limb passes downward and inward to the scaphoid and internal cuneiform — running over extensor proprius pollicis, tibialis anticus, and anterior tibial vessels and nerve. Internal Annular Ligament. — Extends from inner malleolus above, to internal border of us cakis below, converting the grooves of this region into four canals, each lined by separated synovial membrane. The canals transmit, from within outward — tibialis posticus — flexor longus digitorum — posterior tibial vessels and nerve — flexor longus hallucis. It is continuous, above, with deep fascia of leg, and, below, with plantar fascia and origin of abductor hallucis. External Annular Ligament. — Extends from extremity of external malleolus to outer surface of os calcis. Binds down and transmits tendons of peroneus longus and brevis beneath the outer ankle, in one synovial sheath. Plantar Fascia. — (a) Central Portion: — Arises from internal tubercle of OS calcis, posterior to origin of fle.xor brevis digitorum — divides, near heads of metatarsals, into processes for each of five toes — which again sub- divide, opposite metatarsophalangeal joints, into superficial and deep por- tions. The superficial part is inserted into the transverse sulcus between sole and toes. The deep part redivides into two slips — which blend with fle.xor tendons and sheaths and transverse metatarsal ligament. Two vertical intermuscular septa are sent up by central portion — separating middle from external and from internal plantar groups of muscles, (b) Outer Lateral Portion: — From os calcis to base of fifth metatarsal — covering inferior surface of abductor minimi digiti — and continuous with central and dorsal fascia, (c) Inner Lateral Portion: — From internal annular ligament — covering abductor hallucis — and continuous with central and dorsal fascia. Muscles. — (a) Dorsal Region: — Extensor brevis digitorum; and muscles from leg (page 362). (b) Plantar Region: — First Layer — abductor hallucis, flexor brevis digitorum, abductor minimi digiti; — Second Layer — flexor ac- cessorius, four lumbricales; — Third Layer — flexor bre\'is hallucis, abductor obliciuus hallucis, abductor transversus hallucis, flexor brevis minimi digiti; — Fourth Layer — four dorsal interossei, three plantar interossei. And muscles from leg (page 362). Synovial Membranes of Tarsal and Metatarsal Joints. — Synovial membranes exist f! masse. Short Dorsal and Long Plantar Flaps, with sawing otT the end of the internal cuneiform (Hey's Operation) — for the toes en masse. Other Methods. — Liternal Flap — for great toe. External Flap — for little toe. Equal Plantar and Dorsal Flaps — for the toes en masse. Long Plantar Flap — for the toes en masse. DISARTICULATION OF TOE WITH ITS ENTIRE METATARSAL IIV R.ACKHT METHOIl. Description. — The coverings are gotten from the lateral and plantar aspects, and the cicatrix is vertical and dorso-terminal Position. — As in the metatarsal amputation, page 348. Landmarks. — Tarso-metatarsal joint; interdigital web. Incision. — Begins just above the tarso-metatarsal joint, in the mid- dorsal aspect — passes vertically down in the median line to the head of the metatarsal — thence the two limbs of the o\al diverge — the outer limb running downward across the outer aspect of the toe to the web — the inner limlD across the inner aspect to the web — the two meeting in the digito-plantar crease (which about corresponds to the center of the first phalanx) (Fig. 271. .!)■ . Operation. — Deepen the vertical incision, dividing the extensor tendons as high up as encountered, while the toe is flexed. Deepen the oval incision to the bone, upon the lateral and ]jlantar aspects, extending the toe while severing the flexor tendons transverseh'. Free the soft parts along the dorsum and lateral surfaces, with a periosteal elevator, hugging the bone closely. Forcibly extend the toe and its metatarsal and free the plantar surface as far as possible. Sever, from the dorsum, the ligaments binding the metatarsal to the tarsus and to the adjacent metatarsals, while the tee is being manipu- lated and the ligaments are put upon the stretch — thus completing the dis- articulation. Divide the flexor tendons high up and close the sheaths. Two dorsal and two plantar digital arteries are cut and are to be tied. Suture the wound in one vertical line. Comment. — (i) By hugging the hone verv closelv and guarding the point of the knife while disarticulating, minimum damage is done to the tissues of the sole of the foot. (2) Disarticulation of the second toe from the tarsus and adjacent metatarsals is somewhat difficult (see Lisfranc's o]ieration). DISARTICULATION OF GREAT TOE WITH ITS ENTIRE METATARSAL V.y K.\rKET METHOIl. Description - Landmarks. — .As in the last operation. Incision. — Begins just above the tarsometatarsal joint, at its dorso- internal aspect — passes vertically downward along the outer margin of the extensor tendon to just beyond the center of the metatarsal — thence the two limbs of the oval diverge — the outer hmb passing across the dorso-external aspect of the toe to the web — the inner limb passing across the dorso-internal aspect to the plantar surface at a point opposite the web — the two limbs meeting in the digito-plantar crease. If needed for purpose of exposing the joint more readily, an additional transverse incision may be added to the upper end of the vertical incision, running as far as thought necessary directly inward parallel to the tarso-metatarsal joint (Fig. 274, B). Operation. — Deepen the vertical incision, exposing and dividing the TARSOMETATARSAL DISARTICULATION OF GREAT TOE. 351 tendons of the extensor proprius and brevis hallucis near the tarso-metatarsal joint. Deepen the limbs of the oval, cutting to the bone along the lateral and plantar surfaces. Free, up to the tarso-metatarsal joint, the soft parts from the external, internal, and plantar surfaces of the metatarsal and phalanx by closely hugging the bones with periosteal elevator, rotating the toe as indicated. The sesamoid bones are left behind, and the structures about the metatarso-phalangeal joint are removed as nearly subcapsulo-periosteally as possible, in order to retain the attachment of the severed tendons there inserted. Open the tarso-metatarsal joint from the dorsum, completing the disarticulation by severing the remaining ligaments while under tension Fig. 274. — Ampi'tations about the Toes and Foot — Inner view :— A, At interphalangeal joint of great toe, by plantar flap ; B. Of great toe and its metatarsal, at tarso-metatarsal joint, by racket method, with transverse incision added to upper end ; C. Inner aspect of plantar and dorsal incisions in Synie's disarticulation of foot at ankle, by heel-flap ; C. Line of tibial and fibular section ; D. Inner aspect of plantar and dorsal incisions, in PirogofT's disarticulation at ankle, by heel-flap : D', Line of section of bones of leg, in same ; D". Line of section of os calcis. in satne ; E. Inner aspect of plantar and dorsal incisions in subastragaloid disarticulation of foot, by heel-flap. during the manipulation of the toe. Divide the tendons of the peroneus longus and tibialis anticus. Cut the flexor tendons short and close their sheaths. The following arteries are divided — two dorsal digital, two plantar digital, and termination of internal plantar. Guard against wounding the communicating branch of the dorsalis pedis in the first interosseous space. The suture line will be vertical and fall over the dorso-e.xternal aspect of the toe, out of the wav of pressure. Comment. — When the upper transverse incision is added, the vertical incision generally begins just below the tarso-metatarsal joint and the trans- verse incision is then parallel with the tarso-metatarsal joint. When the vertical incision alone is used, it begins over the internal cuneiform. 352 AMPUTATIONS. DISARTICULATION OF LITTLE TOE WITH ITS ENTIRE METATARSAL BV RACKET METHOD. Description — Landmarks. — As in the last operation. Incision. — Begins just above the tarso-metatarsal joint at its dorso- external aspect — passes vertically downward along the outer margin of the extensor tendon to just beyond the center of the metatarsal — thence the two limbs of the oval diverge — the inner limb passing across the dorso-internal aspect of the toe to the web — the outer limb passing across the dorso-external aspect of the plantar surface at a point opposite the web — the two limbs Fig. 275.— Amputations ABOUT THE Toes and Foot— Outer view :— A, Through first interph; langeal joint of little toe, by oblique circular method ; B. Of little method, with added curved incision at upper end ; C, Outer aspect of pi tion of foot at ankle, by a heel-flap ; 1", liiu- nf sectio pect of plantar and dorsal incision-,, m Pum-mIT's disai md fibula in same ; D", Linem ^, , 1 1 ,.s calcis. ,bv oblique elliptical incision; i:'. Ill d plantar incisions in Subastragaloid U metatarsal. b\' hrough tibia and fibula, in disarticulation at ankle ; D', Line ilcis, in same ; E, Supramalleolar fibular section in same ; F. Outer tion of foot by heel-flap. meeting in the digito-plantar groove. If needed for purpose of more readily exposing the joint, an additional transverse, or oblique, incision may be added to the upper end of the vertical incision, by prolonging the latter a short way directly outward parallel with the tarso-metatarsal joint (Fig. 275, B). ' Operation. — The steps of the operation are practically the same as m the corresponding operation upon the great toe (page 350). The metatarsal is disarticulated from the cuboid and from the fourth metatarsal. Two dorsal and two plantar digital arteries are cut. TARSOMETATARSAL DISARTICULATION OF THE TOES. 353 DISARTICULATION OF TWO OR THREE CONTIGUOUS TOES WITH THEIR ENTIRE METATARSALS PA' OVAL OR RACKET METHOD. Description. — Same, in principle, as the operation for the removal of a single toe and its metatarsal (page 350). Where two contiguous toes are removed, the vertical portion of the incision is placed between the two toes, beginning just above the saw-line and diverging to include both toes — meeting on the plantar surface of the web between them. Where three contiguous toes are removed, the vertical portion of the incision is placed over the middle metatarsal, beginning at the saw-line, or just above, and diverging to include all three toes, meeting at the center of the plantar surface of the middle "toe, in the digito-plantar crease (Fig. 271, I). DISARTICULATION OF ALL THE TOES AT TARSO-METATARSAL JOINTS BY SHORT DORSAL AND LONG PL,\N r.\R FL.AFS— LISFRAXCS OPERATION. Description. — Disarticulation of the anterior portion of the foot at the tarso-metatarsal Une — the stump being formed of plantar and dorsal tissues. Position. — .\s for the metatarsal amputation (page 348). Landmarks. — Tarso-metatarsal joint-line; heads of metatarsals. Incision. — (Supposing the foot of the right side to be operated upon) — (1) Dorsal Flap — The surgeon's left hand grasps the foot with his thumb on the base of the fifth metatarsal and forefinger on the base of the first, his palm to the sole — the foot being extended. The incision begins just behind the base of the fifth metatarsal, nearer the plantar than dorsal surface — passes straight down the outer aspect of the foot for 2.5 cm. (i inch) — thence rounds onto the dorsum and crosses the foot wdth slight downward convexity, parallel with and about 1.3 cm. (h inch) below the tarso-metatarsal joints, reaching the inner border of the foot 1.3 cm. (i inch) below the tarso- metatarsal joint — thence rounds into the inner aspect of the foot and passes straight upward and ends 2 cm. (| inch) above the cuneiform -metatarsal articulation, somewhat nearer the plantar than the dorsal aspect. (2) Plantar Flap — the surgeon holds the toes between the fingers on the dorsum and thumb on the plantar surfaces — the foot being fie.xed. The incision is con- tinuous with the horizontal portion of the dorsal incision, passing down the outer lateral aspect of the foot along the plantar edge of the fifth metatarsal to just below its middle — then graduallv rounds into the sole and sweeps obliijuely across the plantar surface in such a way as to cross the fifth meta- tarsal just above its neck, the fourth metatarsal at its neck, the third and second opposite their heads, and then the first metatarsal at the metatarso- phalangeal joint — thence rounds into the inner mid-lateral aspect of the foot and passes straight up its border, along the plantar edge of the first meta- tarsal, to become continuous with the vertical portion of the dorsal incision (Fig. 272, B. li). Operation. — I)ee|ien the dorsal line to the extensor tendons and free back the superficial tissues for about 6 mm. (^ inch) — and then divide all the soft parts down to the bones, while the foot is fully extended on the leg and the toes flexed on the foot — and free the flap to the joint-line, hugging the bone to save the interosseous vessels and portions of interosseous muscles. 23 354 AMPUTATIONS. Deepen the plantar incision to the flexor tendons and free back the Ifap of superficial tissues to the hollow behind the heads of the metatarsals — and then divide all the soft parts down to the bones, while the foot is fully flexed on the leg and the toes extended on the foot — and free the flap to the tarso- metatarsal joint line. Both flaps contain all the soft parts to the bones. Disarticulation is now accomplished from the dorsum. Retract the flaps — extend the fool — and begin the disarticulation by entering the knife behind the prominent base of the fifth metatarsal, at the outer side of the foot — and then, passing obhquely forward and inward, cut the peroneus brevis and tertius tendons and disarticulate the fifth, fourth, and third metatarsals. Then turn to the inner side of the foot, and sever the ligaments of the first tarso-metatarsal joint, and divide the expansion of the tibialis anticus. There remains the freeing of the second metatarsal, which is somewhat difficult, unless undertaken in a definite manner. Hold the knife like a dagger, with the cutting-edge toward the ankle, the blade pointing forward at an angle with the dorsum of the foot — enter the point deeply between the bases of first and second metatarsals, where they begin to bind — elevate the handle until ])erpendicular to the dorsum, cutting, at the same time, forward — and thus the ligaments binding the base of the second metatarsal to the base of the first metatarsal and internal cuneiform are severed (the mana?uvre being called the "coup de maitre"). Repeat this manoeuvre between the bases of the second and third metatarsals. Complete the disarticulation of the second metatarsal by .severing, from the dorsum, the ligaments between the middle cuneiform and base of the metatarsal. Divide any connecting bands upon the plantar aspect of the joints. The peroneus longus tendon now alone holds the metatarsal — put this upon the stretch, dividing it high up. The following arteries are to be tied — in the dorsal flap; four dorsal interosseous, communicating branch of dorsalis pedis; — in plantar flap; five plantar digital branches of external plantar (and possibly the external plantar itself) and the termination of the internal jjlantar. Suture any open sheaths. Quilt the muscles. Suture the plantar and dorsal flaps in one transverse line. Support the stump upon a splint. Comment. — (i) The ]jlantar flap may be cut first. (2) The dorsal flap mav be made and disarticulation accomplished, and then the plantar flap cut from within outward — which is not so satisfactory as the above. (3) Freer aOowance should be made to cover the thicker inner than the thinner outer side of the foot — which is the reason for cutting the inner aspect of the flap longer. (4) Guard against making the dorsal flap too short and too scant on the dorsal aspects — and also against making either flap too pointed. (5) Guard against mistaking the scapho-cuneiform joint for the metatarso- cuneiform joint. (6) Guard the plantar tissues while disarticulating the second metatarsal. (7) The dorsal flap should include most of the tissues upon the outer and inner aspect of the foot. (8) This method makes an excellent and useful stump. DISARTICULATION OF ALL THE TOES AT THE TARSO-METATARSAL JOINTS. WITH SAWING OFF OF END OF INTERNAL CUNEIFORM. t;v short diiks.\l .wd lonc ri..A.\i.\R i-L.\rs— mcv s oper.ation. Description. — This operation is similar to Lisfranc's as to incisions, freeing of flaps, ligation of vessels and suturing of wound — difl'ering only in one respect — namelv, after disarticulating the four outer metatarsals, MEDIC i-TAKSAI, DISAK'I'ICL'I.A TION OF FOOT. 355 the protrudiiiL; end of the innermost cuneiform is sawed ofT on a line with the others, and removed together with the first metatarsal still articulated. DISARTICULATION OF ANTERIOR PART OF FOOT AT MEDIO-TARSAL JOINT, IN GENERAL. Best Methods.— Short Dorsal and Long Plantar Flaps — Chopart's Operation. Other Methods. — Modified Oval ('rrii)ier's Operation) — medio-tarsal disarticulation, with liorizontal sawing of os calcis. DISARTICULATION OF ANTERIOR PART OF FOOT AT MEDIO-TARSAL JOINT BV SHORT DORSAL AND LONt^ PLANTAR FLAPS — CHOPART'S OPERATION. Description. — Disarticulation of anterior portion of foot at astragalo- scaphoid and calcaneo-cuboid joints, by means of a short dorsal and long plantar flap — the operation being somewhat similar to Lisfranc's tarso- metatarsal disarticalation. Position. — As for Lisfranc's operation. Landmarks. — .-\stragalo-scaphoid ]o'ml (just behind the tuberosity of the scaphoid); calcaneo-cuboid joint (midway between the e.xternal malleolus and tubercle of fifth metatarsal); tarso-metatarsal joint-line; middle of meta- tarsus. Incisions. — (Right foot) — Plantar incision — begins on outer aspect of foot, little nearer plantar than dorsal surface, and at a point opposite the calcaneo-cuboid joint (see Landmarks) — passes straight down the outer side of foot to near middle of lifth metatarsal — thence rounds inward and crosses sole of foot, opposite the middle of the metatarsals, to the inner side of the foot — rounds into the inner border of the foot and passes straight up that border, little nearer the plantar than dorsal surface, to a point opposite the astragalo-scaphoid joint (see Landmarks). Dorsal incision — begins by curving from the outer Umb of the jilantar incision, just posterior to the fifth tarso-metatarsal joint — and ends by curving into the inner limb of the plantar incision just posterior to the first tarso-metatarsal joint — crossing the dorsum opposite the bases of the metatarsals (Fig. 273, B, B). Operation. — Deepen the plantar incision, the foot flexed on the leg and the toes e.xtendeti on the foot, to the flexor tendons. Free the skin and fascia a short distance — divide all soft [larts to the bones — and dissect up the flap of the entire soft parts to the tarsometatarsal joint. Deepen the dorsal incision, the foot extended on the leg and the toes flexed on the foot, to the extensor tendons. Free the skin and fascia a short distance — divide all the soft parts to the bones — and dissect up the flap of the entire soft tissues to the tarsometatarsal joint. Disarticulate from the dorsum while the foot is forcibly extended — rotating the forepart of the foot outward while .>;evering the ligaments of the astragalo-scaphoid joint, and inward while dividing those of the calcaneo-cuboid articulation. The tendons of the tibialis anticus and posticus, and peroneus tertius, brevis, and longus, are cut among the deeper structures. Quilt the muscular and tendinous tissues of the two flaps, especially suturing the extensor tendons and tibialis andcus of the dorsal flap, to the tissues of the plantar flap — in order to counteract the 3 $6 AMPUTATIONS. tendency of the tendo Achillis to permanently extend the foot. In the dorsal flap, the dorsalis pedis and its tarsal and metatarsal branches are cut — and in the plantar flap, the terminations of e.Nternal and internal plantar arteries, and plantar digital branches. Comment. — (i) Considerable tendency exists for displacement of the bones of the stump subsequent to healing — either the posterior portion of the OS calcis being drawn up by the tendo .\chillis, thus throwing the head of the OS calcis downward to be pressed upon in walking — or the stump is turned into the varus position and the patient walks upon the outer border of the OS calcis. (2) The proportionate lengths of the flaps and the manner of their making may be varied, as described in Lisfranc's operation. The total covering required is about i| diameters at the saw-line. DISARTICULATION OF FOOT AT ASTRAGALO-SCAPHOID AND AS- TRAGALO-CALCANEAL ARTICULATIONS- SUBASTRAGALOID DISARTICULATION— IN GENERAL. Best Methods. — Large Interno-plantar Flap (Farabeuf). Heel-flap. Other Methods. — Oval, or Racket INIethod (Maurice Perrin). Oval Method (Wrneuil). Comparison. — The interno-plantar flap furnishes the best bloo(l-sup])ly — the cicatrix is well placed and the stump is broad. But the method requires considerable healthy, available tissue — the operation is somewhat difficult to perform — and the flap is somewhat unwieldy. The heel-flap method is a simpler operation and requires minimum tissue — but gives a narrower stump. DISARTICULATION OF FOOT AT ASTRAGALO-SCAPHOID AND AS- TRAGALO-CALCANEAL JOINTS- SUBASTRAGALOID DIS- ARTICULATION BV I„-\RGF, INTERNO-PLANTAR FLAP — FAR APJ'.ri'. Description. — A modified oval method. The structures below the astragalus are removed — the stump being covered by a large flap gotten from the sole and inner border of the foot — the scar being horizontal and upon the outer and anterior aspects of the foot. Position. — As in the preceding operations, in general — the surgeon so manijnflating the foot with his left hand as to turn it from side to side in following the complicated incision. Landmarks. — Tendo .^chillis; external malleolus; base of fifth meta- tarsal; ioint between scaphoid and cuneiforms; joint-line between scaphoid and internal and middle cuneiforms; tendon of extensor longus hallucis, cuneo-metatarsal joint of big toe; external tuberosity of os calcis. Incision. — Begins at outer margin of insertion of tendo Achillis — curves upward to a point 2.5 cm. (i inch) below the external malleolus — passes horizontally forward at this level, parallel with the border of the foot, until a point is reached on a hne connecting the base of the fifth metatarsal with the joints between the scaphoid and cuneiform bones — thence curves sharply across the dorsum, just anterior to the joint-line between the scaphoid with the internal and middle cuneiforms, until the tendon of the extensor longus hallucis is reached — thence curves slightly forward to cross the inner border of the SUBASTRAGALOID DISARTICULATION OF FOOT. 337 foot in the line of the cuneo-metatarsal joint of great toe — thence sweeps across the center of the sole — and, curving into the outer border of the foot, follows that border to the external tuberosity of the os calcis — thence upward to end at the insertion of the tendo Achillis, at the point of beginning (Fig. 276). Operation. — The above incision is now everywhere deepened to the bone along the line of retracted skin and fascia, using a stout knife and cutting with force as the parts are put upon the stretch — cutting all tendons cleanly — and opening no joints. Now fle.x the leg upon the thigh, turn the knee inward, and press the inner side of the leg on the table, so that the outer side of the leg presents and the foot is beyond the edge and kept upon the stretch. Dissect up, cleanly from the bones, the outer dorsal portion of the flap, until the head of the astragalus is exposed in front and the tendo .\chillis Fig. 276. — SUBASTRAGAI-C (Farahei-f);— A, Outline of aspect. DiSARTTCfLATION OF FoOT BY LARGE INTK ision upon outer aspect of foot ; B, C)utline of behind — divide the tendo Achillis — enter the astragalo-scaphoid joint on its dorsal aspect — keep the knife in the interarticular line and cut backward between the astragalus and os calcis, passing beneath the tip of the external malleolus to the already cut tendo Achillis, severing all ligaments and everting the OS calcis as the ligaments are cut — until the under surface of the astragalus is free. The foot is further twisted into extreme varus, and the inner and under surfaces of the os calcis are bared, working from the inner toward the under and outer surfaces of the os calcis, by cutting with short strokes of a strong knife, and closely hugging the bone to avoid damaging important structures on the inner aspect, especially the vessels which supply the flap. By the time the externo-plantar border of the os calcis is reached, the dorsum of the foot will be looking downward. Free the skin from the posterior surface of the os calcis carefully so as not to score the integumentary parts. Sever any emaining connections. Cut the anterior and posterior tibial 358 AMPUTATIONS. nerves high up. The following arteries are encountered, in the direction of the incision, and will recjuire ligation — posterior peroneal, anterior peroneal, dorsalis pedis, internal plantar and external plantar. Provide temporary drainage, by puncturing the heel portion of the flap. Quilt the muscles and tendons. Suture the flap in an external and anterior horizontal line. Dress the stump upon a posterior splint. DISARTICULATION OF FOOT AT ASTRAGALO-SCAPHOID AND AS- TRAGALO-CALCANEAL JOINTS— SUBASTRAGALOID DIS- ARTICULATION F.v }n:Ki, FL.\r. Description. — The structures removed are the same as in the above operation. In the present instance the coverings are furnished from the heel and sole tissues. The steps of the operation are very similar to those of Syme's disarticulation of the foot at the ankle-joint. Position. — See Svme's operation (page 360). Landmarks. — External and internal malleoli. Incisions. — Plantar incision — begins 1.3 cm. (J inch) below the tip of the external malleolus — passes directly across the sole of the foot — and ends 2.5 cm. (i inch) below the posterior border of the internal malleolus. Dorsal incision — is U-shaped, connecting the upper ends of the plantar incision — curving across the dorsum on a level with the astragalo-scaphoid joint (Fig. 274, E, and Fig. 275, F). Operation. — For the general steps of the operation, see Syme's dis- articulation at the ankle-joint (page 360), which is similar in general prin- ciple, though different in detail. Deepen the incisions to the bones — dissect the heel-flap backward and the dorsal flap upward — open the astragalo- scaphoid joint from the dorsum and cut backward, disarticulating the astraga- lus from the os calcis. The extreme head of the astragalus may be sawed off". The operation is concluded as in Syme's — the same vessels being also ligated. Other Amputations About the Foot. — (i) Anterior Intertarsal Dis- articulation (Jaeger's Operation) — consists of a disarticulation between the three cuneiforms posteriorly, and the scaphoid anteriorly — the cuboid being sawed across in a line with the disarticulation. This would occupy a position between Lisfranc's tarso-metatarsal disarticulation and Chopart's medio- tarsal disarticulation. (2) Amputation Through the Posterior Tarsus — if soft parts cannot be gotten to cover Chopart's stump, the articular surfaces of the astragalus and os calcis are sawed off. (3) Subastragaloid Osteoplastic Amputation (Hancock's Operation) — the tuberosity of the os calcis is sawed off and applied to the lower surface of the astragalus, from which the articular cartilage has been removed. SURGICAL ANATOMY OF ANKLE-JOINT. Bones. — Tiljia; fibula; astragalus. Articulations and Ligaments. — Anterior tibio-tarsal, posterior tibio- tarsal, external lateral (consisting of anterior astragalo-fibular, posterior astragalo-fibular, and middle calcaneo-fibular fasciculi), internal lateral (or deltoid) ligaments, and synovial membrane. SL'RCaCAL COXSIDERATIOXS IN AXKLE DISARTICULATIONS. 359 Muscles. — See under Foot (page 345) and Leg (page 362). Movements of Ankle-joint. — Extension — by gastrocnemius, soleus, plantaris, tibialis ])osticus, peroneus longus, peroneus brevis, flexor longus digitorum, flexor longus hallucis. Flexion — by tibialis anticus, peroneus ter- tius, extensor longus digitorum, extensor proprius hallucis. Adduction — tibialis anticus, tibialis posticus, .\bduction — Peroneus longus, peroneus brevis. Arteries. — Following branches of anterior tibial — internal and external malleolar and dorsalis pedis. Following branches of posterior tibial — internal calcaneal branch of posterior tibial: — and foOowing branches of peroneal branch of posterior tilaial; anterior peroneal, posterior peroneal, and external calcaneal. Veins. — Superficial — internal saphenous and tributaries; external saphen- ous and tributaries. Deep — Two venae comites accompany each artery. Nerves. — From lumbar plexus — internal saphenous from anterior crural. From sacral plexus — following from great sciatic — external saphenous (from communicans poplitei and communicans peronei) ; plantar cutaneous, articu- lar, internal plantar and external plantar (from posterior tibial) ; articular, muscular and external (or tarsal) (from anterior tibial); and internal and external branches of musculocutaneous. Annular Ligaments. — See under Foot (page 344). SURFACE FORM AND LANDMARKS OF ANKLE-JOINT. Tlie general feature of the ankle-joint is that of the prominentlv rounded superior surface of the astragalus received into the dome of the tibia, and bounded laterally by the descending malleoli. The line of the joint is transverse — crossing the front of the leg about 1.3 cm. (i inch) above the tip of the internal malleolus. The external malleolus extends from 1.3 to 2 cm. (^ to | inch) lower than the internal — and is placed upon a plane about 1.3 cm. (h inch) posterior to the internal malleolus. The external malleolus is opposite the center of the joint — the internal is in front of the center of the joint. The tip of the external malleolus is nearer the posterior border of the fibula, and the tip of the internal malleolus nearer the anterior border of the tibia. Chief structures about the ankle-joint — .\nteriorly — (from within outward) tibialis anticus, extensor proprius hallucis, anterior tibial artery, anterior tibial nerve, extensor longus digitorum, peroneus tertius. Posteriorly — tendo .■\chillis. Internally — (from before backward) tibialis posticus, flexor longus digitorum, companion vein, posterior tibial artery, companion vein, posterior tibial nerve, flexor longus hallucis. Externally — (from before backward) peroneus brevis, peroneus longus, external calcaneal and termination of peroneal artery. The lower epiphysis of the tibia includes the articular surface and internal malleolus, and unites about the eighteenth year. The lower epiphysis of the fibula includes the articular surface and outer malleolus, and unites about the twentv-first vear. GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATIONS AT ANKLE-JOINT. Great care should be taken of the blood-supply to the heel tissues forming the stump — the chief vessels being the external calcaneal of the posterior 360 AMTUTATIONS. peroneal, externally; and the internal calcaneal of the external plantar, internally. In section of the lower ends of the tibia and fibula most of the anterior and posterior tibio-fibular and interosseous ligaments are saved. A posterior splint is used in the dressing following disarticulation. DISARTICULATION OF FOOT AT ANKLE-JOINT, WITH REMOVAL OF MALLEOLI AND ARTICULAR SURFACE OF TIBIA, IN GENERAL. Best Method. — Heel-flap — Syme's operation. Other Methods. — Modified Oval Method — Roux's operation. Large Interno-plaiitar Flap — Faralieuf's ojieration. Internal Lateral Flap. Modi- fied External Racket. Dorsal Flap. DISARTICULATION OF FOOT AT ANKLE-JOINT. WITH REMOVAL OF MALLEOLI AND ARTICULAR SURFACE OF TIBIA, BY HKEI. FLAP — SVMi:S OPKKATIOX. Description. — .\s described in the title. Position. — Patient supine; foot elevated and over edge of table. As- sistant steadies leg with one hand and holds foot at right angle to leg by grasping toes with other hand. Surgeon sits for jilantar and stands for dorsal incisions. Landmarks. — Outline of ankle-joint; malleoli. Incisions. — Plantar incision — begins at tip of external malleolus, on the right side (the surgeon's left palm resting on the instep, with forefinger and thumb upon the malleoli) — passes vertically down the outer side of the foot, across the sole and vertically up the inner side of the foot to a point 1.3 cm. (^ inch) below the tip of the internal malleolus. This incision passes exactly at a right angle to the long axis of the foot, in a straight line between these two points — if inclined forward, the flap is very difficult to dissect from the OS calcis — if inclined backward, it is easier to separate but apt to form a scant)' covering, with imperfect vascular supply. If the inner limb cf the vertical incision passes up to the posterior border of the inner malleolus, the posterior tibial arterv is more in danger of being divided before its bifurca- tion and the main branch of the flap, the internal calcaneal of the external plantar, lost. The above incision is made in two cuts, each from a malleolus to the center of the sole. Dorsal incision — (surgeon's left palm to sole, with thumb and first finger grasping the margins of the foot and extending it) — connects the upper ends of the plantar incision by an incision sweeping straight across the front of the ankle. The dorsal and plantar incisions are approximately at a right angle to each other (Fig. 274, C, C, and Fig. 275, C, C). Operation. — The plantar incision, made with a strong knife, passes directly and cleanly to the bone. The large heel-flap is freed from the os calcis as far as its tulaerosities, partly by the use of the left thumb, partly by a stout knife cutting close to the bone. It is possible, Init difficult and unadvisable, to entirely dissect and retract the heel-flap from the tuberosities and posterior surface of the os calcis, from the plantar wound. With the PIROGOFF'S OPERATION. 361 foot fully extended the dorsal incision is now made directly to the bone, cutting the tendons and ligaments cleanly. This incision cuts directly through the anterior hgament of the ankle-joint and opens the articulation. The disarticulation is continued by cutting the lateral ligaments from within outward, and completed by similarly cutting the posterior ligament. The tendo Achillis is now cut. The foot is then drawn downward and forward and the posterior and lateral surfaces of the os calcis dissected free of the heel covering by working from behind downward and forward with short, close strokes of the knife while the parts are under tension. The malleoli are now closely cleared of their soft parts, hugging the bones and guarding the flaps. The soft jjarts are well retracted — and the tibia and fibula are sawed transversely at about 6 mm. (J inch) aljoxe the inferior border of the tibia (which will remove the articular surface of the dome) — the malleoli being steadied by forceps during the sawing. Ligate the anterior tibial, external and internal plantar, and probably the external and internal malleolar of the anterior tibial, the anterior peroneal, internal malleolar of posterior tibial, and internal and external saphenous veins. Cut all nerves short, especially those of the heel flap, which is bent over the ends of the sawed bones. Suture the heel flap to the dorsal incision — using tension-sutures in addition to coaptation-sutures, if there be much strain upon the suture-line. Institute drainage through a counter-opening in the heel-flap, if indicated. So dress the part, with a posterior splint included, as to draw the heel-flap forward and upward. Comment. — ( 1) This is probably the best form of disarticulation about the ankle and usually furnishes a very satisfactory result. (2) It is advisable to free the os calcis subperiosteally, if possible — and also to leave the posterior epiphysis, in the young, in the flap. DISARTICULATION OF FOOT AT ANKLE-JOINT. WITH REMOVAL OF MALLEOLI, ARTICULAR SURFACE OF TIBIA. AND ANTERIOR PART OF OS CALCIS.-IN GENERAL. Best Method. — Heel-flap — Pirogoff's operation. Other Methods. — Racket Method (Pasquier-LeFort) — racket from inner side, with horizontal division of calcaneum. \\"atson"s modification of Piro- goff's Heel-flap Method — sawing calcaneum from plantar surface immediately after plantar incision. Sedilot's modification of Pirogoff's operation — middle (internal) oval method, with oblique sawing of calcaneum. Others have sawed the os calcis in angular and curved directions. DISARTICULATION OF FOOT AT ANKLE-JOINT, '^^TITH REMOVAL OF MALLEOLI, ARTICULAR SURFACE OF TIBIA, AND ANTERIOR PART OF OS CALCIS, P.V HEKL-FL.Vr— I'lKOGOFl- S nl'KK.^TU.lN. Description. — .An intra-calcaneal osteoplastic amputation of the foot. The ojjeration is very similar to Syme's, except that the anterior and major portion of the os calcis is sawed off and the remaining posterior portion, which is left in the heel-flap, is adjusted to the transversely sawed tibia and fibula. Position — Landmarks. — .\s in Syme's operation (page 360). 362 AMPUTATIONS. Incisions. — Plantar incision (right foot) — begins just anterior to the tip of the external malleolus — passes vertically down the outer side of the foot, across the sole, and vertically up the inner side of the foot to a point 1.3 cm. (^ inch) below and a short distance anterior to the tip of the internal malleolus (which points are a little anterior to those of Syme's operation). Dorsal incision — is somewhat more convex; that is, passes further down on the dorsum of the foot than does Svme's (Fig. 274, D, D', 1)", and Fig. 27s, D, D', D"). Operation. — These incisions are made and deepened in the same manner as in Syme's operation. The heel-flap is not freed back from the plantar surface of the os calcis quite to its tuberosities. The disarticulation is accom- plished as in Syme's. The foot is placed in extreme extension and the upper surface of the os calcis exposed, but the tendo Achillis not cut. The whole of the OS calcis having been freed except its posterior third, the saw is applied (with the foot in extension) to the upper surface of the os calcis, 1.3 to 2 cm. (i to J inch) behind the astragalus, and made to saw its way oblicquely down- w-ard and forward (or more nearly vertically, in the extended position of the foot) in a line about parallel with the now distorted heel incision — all the soft parts being carefully retracted the while, especially the inner arteries. The lower ends of the tibia and fibula are then freed as in Svme's and are sawed off in the same manner, except that, after entering the anterior surface of the bone about 6 mm. (} inch) above the inferior border of the tibia, the section is so made that the saw emerges posteriorly about 1.3 cm. (i inch) higher than on the anterior surface (to be parallel with the section of the calcaneum). Ligate the same vessels as encountered in Syme's operation. Cut the nerves short and the loose tendons. Approximate the sawed cal- caneum to the sawed tibia — and suture the plantar flap to the dorsal incision. Comment. — (1) If the sawed ends of the bone do not lie in good apposi- tion, a thin slice of bone may be further removed with the saw where indicated — or the surfaces of bone may be nailed or pegged together. But when the proper calculations are made the surfaces can generally be held in contact by the suturing together of the fibrous tissues surrounding the sawed ends, with buried chromic gut. (2) The stump thus gained is a little longer than in Syme's operation — the flap is better nourished, is firmer, contains bone and tendo Achillis, and the movement is greater. But the bone is apt to necrose, or become displaced, or may not unite. The operation is more suitable to traumatic cases. An artificial limb is harder to fit. The method is, altogether, not superior to Syme's. SURGICAL ANATOMY OF LEG. Bones. — Tibia; fibula. Articulations and Ligaments. — (a) Superior Tibiofibular .\rticula- tion — anterior and posterior superior tibio-fibular ligaments, and svno\ial meml)rane. (b) Middle Tiljio-fibular Articulation — interosseous membrane. (c) Inferior Tibio-fibular Articulation — anterior and posterior inferior tibio- fibular and transverse ligaments, inferior interosseous membrane, and svnovial membrane. Muscles. — (a) Anterior Tibiofibular Region: — tibialis anticus; extensor ])roprius hallucis; extensor longus digitorum; peroneus tertius. (b) Posterior Til)io-fil)ular Regi<.n: — (i) Superficial Muscles; — gastrocnemius, soleus, plantaris. (2) Deep Muscles: — pophteus, flexor longus hallucis, flexor SURFACE FORM AND LANDMARKS OF LEG. 363 longus digitorum, tibialis posticus, (c) Outer, or Fibular, Region : — peroneus longus, peroneus brevis. Arteries. — Following branches of popliteal — inferior muscular, inferior external articular, inferior internal articular. Anterior tibial and following branches — posterior recurrent tibial, superior libular, anterior recurrent tibial, muscular, internal malleolar, external malleolar. Posterior tibial and following branches: — peroneal (with its muscular, nutrient, anterior peroneal, and communicating branches), muscular, nutrient, and communi- cating branches. Veins. — Superficial — internal saphenous and tributaries — external saphe- nous and tributaries. Deep — Two vena? comites for each artery. Nerves. — (a) From lumbar ple.xus — (i) From anterior crural; posterior branch of internal cutaneous; long saphenous branch and its branches. . (b) From sacral plexus — (1) From great sciatic — anterior popliteal and muscular branches; communicans poplitei. Posterior tibial and muscular branches. External popliteal (or peroneal) and cutaneous branches. Anterior tibial and muscular branches. Musculocutaneous and muscular and cutaneous branches. SURFACE FORM AND LANDMARKS OF LEG. Following parts of the tibia are palpable — external tuberosity (more prominent); internal tuberosity (broader); tubercle; anterior border, or crest (for upper two-thirds); internal border; internal surface (from tuberosity to malleolus) ; internal malleolus. Following parts of fibula are palpable — head ; lower part of external surface of shaft (between peroneus tertius, and peronei longus and brevis); external malleolus. The filnila is on a plane considerably posterior to the tibia. No muscular libers are attached to the lower third of the tibia. The sharp crest of the tibia has become rounded in its lower third. The interosseous space is widest at the center of the leg, decreasing in width toward both ends. The tibialis anticus forms a muscular prominence running down the leg external to the tibia. The extensor longus digitorum, a smaller prominence, fills the rest of the interval between the fibula and the tibialis anticus muscle — a groove intervening between these two muscles above, and the extensor proprius hallucis coming to the front between them below . Externally, the peroneus longus, brevis, and tertius form a muscular prominence. The internal aspect of the leg is formed — anteriorly, by the subcutaneous tibia — posteriorly, by the projecting border of the soleus and tendon of the tibialis posticus. The fleshy mass of the calf is formed by the gastrocnemius and soleus, tapering to the tendo .\chillis — and beneath them the popliteus, flexor longus hallucis, flexor longus digitorum, and tibialis posticus. A groove exists between either malleolus and the extended tendo Achillis. The interosseous membrane separates the anterior from the jxisterior tibio-fibular muscles. Tendons predominate over muscles in the lower third of the leg. The gastrocnemius and soleus have joined by the time the lower third of the leg is reached. The greatest girth of the leg is at about the junction of the upper and 364 AMPUTATIONS. middle thirds — tapering gradually above to the knee-joint — and rapidly decreasing in size below toward the ankle. The popliteal artery bifurcates about 5 cm. (2 inches) below the knee- joint — on a level with the lower part of the tubercle of the tibia. In ampu- tating 2.5 cm. (i inch) below the head of the fibula, one main artery, the popliteal, is cut — at 5 cm. (2 inches), two main arteries, the anterior and posterior tibials — and at 7.5 cm. (3 inches), three main arteries, the anterior and posterior tibials and the peroneal (Holden). GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT THE LEG. In the lower and middle thirds of the leg, the Ijulk of tlie muscles are posterior — hence a posterior flap forms the best covering. In the upper third of the leg the bulk of the muscles are postero-e.xternal — hence a flap chiefly e.xternal furnishes the best covering. In all amputations through the upper third of the leg, it is well to cut the fibula at a higher level than the tibia, as it is apt to be drawn out of posi- tion and be e.xposed to pressure. The "place of election," especially referred to in older writings, was understood to be a hand's-breadth (or an average of 9 cm., or 3^ inches) below the knee-joint. The termination of the stump, in amputations about the leg, does not directly meet pressure (except in the peg-leg) — the pressure being borne by the lateral aspects of the hollow modern limb — so that a terminal scar (except where a peg-leg is contemplated) is not objectionable. It is especially necessary, in amputating in the lower extremity, to dissect out all nerves which may be pressed upon — especially in the flap forms of operation. In sawing the bones of the leg, the prominent border (shin) of the tibia should be beveled, as described in the General Principles (page 252). The stump should be dressed upon a splint — and be kept out from under the bedclothes. AMPUTATIONS ABOUT THE LEG, IN GENERAL. Best Methods. — Oblique Elliptical (Guyon's Supramalleolar .\mpu- tation) — for the supramalleolar region. Large .-Vnterior and Small Posterior Flaps (Farabeuf) — for lower third, between supramalleolar region and lower limit of middle third. Large Posterior and Short Anterior Flaps (Hey's Operation) — for middle third. Large External Flap (Faralieuf) — for upper third. Bilateral Hooded Flap (Stephen Smith's Operation) — for "place of election," or up])er part of upper third. Other Methods. — Modified Circular — for supramalleolar region. Obli(|ue Elliptical (Duval) — for lower third. Rectangular Flaps (Teale) — for lower third. Large Posterior and Small Anterior Flaps (Henry Lee) — for middle third. Circular Method. Ecjual Lateral Flaps. Large Posterior Flap. Large .'\nterior Flap. Long Anterior and Short Posterior Flaps. Oblique Circular, forming an anterior flap — for upper and lower thirds. Oblique Circular, forming an antero-external flap — for middle thirds. Oblique Circular — forming a dorsal flap — for supramalleolar region. Long anterior AMPUTATION THKOL'GH LOWER THIRD OF LEG. 365 Curved Flap. Long Anterior Rectangular Flap. Large Anterior Semilunar and Small Posterior Semilunar Flaps. AMPUTATION OF LEG THROUGH SUPRAMALLEOLAR REGION l;V 111:1, lc._>L'K ELLIPTICAL INXISION' — GUVOXS SrPR.ANLALLF,OL.AR OPER.\TK)N'. Description. — An operation somewhat resembling Syme's — the tibia and fibula being divided below the medullary canal, and the ends of the bones covered by a heel-flap of skin and muscles. Position. — In operating upon the leg, in general, the limb projects over the edge of the table — the patient being supine — the surgeon standing to the outer side of the right, and inner side of the left — the assistant steadving the part to come away. In the present operation, the surgeon grasps the foot in his left hand and manipulates it so as to readily e.xpose the line of incision. On the right, the foot is turned inward and the incision begins at the outer side of the heel — crosses the outer aspect of the foot, which is then turned upon its outer side, and the incision carried to the heel along the inner aspect. On the left, the incision may begin in front, with the foot upon its inner side. Landmarks. — .\nkle-joint; malleoli; greatest prominence of the heel. Incision. — Begins, say, on the anterior aspect of the ankle, opposite the center of the ankle-joint — curves obliquely downward and backward over the lateral aspects of the foot, just skirting the inner malleolus, and passing slightly in front of the external malleolus — ending over the summit of the curve of the heel. The incision may be made from the instep to the heel, or vice versa (Fig. 275, E, E'). Operation. — The above incision is made through skin and fascia, and is then everywhere deepened to the bone — except that the ankle-joint is not opened, and the peronei tendons behind the external malleolus are not cut, until the soft parts have been cleared above the ankle-joint. The soft tissues are now carefully freed up about 5 cm. (2 inches) above the tips of the malleoli, providing a musculo-])eriosteal covering — using great care to preserve the vessels on the inner aspect — the surgeon standing for the anterior clearing, and sitting (or elevating the limb) for the posterior clearing. The tendo Achillis is divided. The peronei tendons are cut at about the level of the ankle. The ankle-joint is not opened. The anterior tibial, posterior tibial, termination of the peroneal, and anterior peroneal vessels are ligated. The nerves and tendons are cut especially short. It is probably better to dissect out the posterior tibial nerve. The heel-flap is then sutured to the upper transverse incision, and the stump dressed as in Syme's operation. AMPUTATION THROUGH LOWER THIRD OF LEG BV L.ARCE POSTERIOR -AND SM.\LL ANTERIOR f L.\PS - FAR.M'.FrP. Description. — The operation is usually known as a large posterior flap method, the anterior flap supplying so small a part of the covering. Both flaps are of skin and muscle. The posterior flap, which forms the bulk of the covering, is derived really more from the posterointernal aspect, and the anterior or smaller flap, which is about one-fourth the length of the larger, from the antero-external aspect. 366 AMPUTATIONS. Position. — See Guyon's operation (page 365) — and under Incision, below. Landmarks. — Saw-line. Incisions. — Posterior flap — begins (on the right side) with the leg turned to present the inner side, at the saw-hne, on the inner side of the leg — and passes vertically down in front of the inner border of the tibia for a distance Fig. 277.— Amputations about the Leg : — A. Through lower third of leg. by large posterior and small anterior flap; B, Through middle third, by long posterior and short anterior (Hey's opera- tion); C, Through upper third, by bilateral hooded flaps (Stepheii Smith's operation). equal to about ij diameters of the limb at the saw-line — then rounds across the posterior aspect of the leg. The outer limb of the incision begins, with the leg turned to present the outer side, at the saw-line, on the outer side of the leg — and passes vertically down just behind the fibula, for a distance equal to about ij diameters of the leg at the saw-line — then rounds across the posterior aspect of the leg to meet the inner incision. The anterior flap is made bv a transverse incision, slightlv conve.x downward, passing between the two vertical incisions, at a distance below their upper ends equal to about one-fourth of the length of the posterior flap (Fig. 277, A). AMPUTATION THROUGH MIDDLK THIRD OF LEG. 367 Operation. — These incisions having been made through siiin and fascia, the tendo Achillis is divided on a Une with the retracted skin and the leg is turned to present its inner side — and the upper part of the inner incision is deejjened for a length of about 5 cm. (2 inches), by freeing the muscles from the tibia. The leg is now turned to present the outer side and the upper end of the outer incision is similarly deepened for a distance of about 5 cm. (2 inches), by freeing the muscles from the fibula. The leg is fle.xed during these incisions. Through these two opposite openings, the left thumb and index are thrust, meeting in the center, and thus the soft parts are picked up and drawn from the bones, the limb still being tfexed. A long knife is passed through this opening and made to cut its way out on a line with the retracted skin, bluntly beveling the flap. The anterior incision is now deepened to the bones on a hne with the retracted skin. The soft parts are then freed back to the saw-line — the interosseous membrane being divided transversely, and the periosteum having been circularly divided a distance below the saw-line sufficient to furnish a covering of one diameter of each bone at the saw-line. The soft parts are retracted and the bones are sawed — beveling the prominent anterior border of the tibia as described at page 252. Ligate the anterior tibial, posterior tibial, peroneal arteries, and internal and ex- ternal saphenous veins. Suture the periosteo-muscular coverings over the ends of the bones. Quilting of the muscles is particularly indicated, as the heavy posterior muscles are apt to sag backward. Dissect out the posterior tibial nerve. Dress the stump on a posterior splint. AMPUTATION THROUGH MIDDLE THIRD OF LEG BY LONG POSTERIOR .AND SHORT .VN'TERIOR KL.XPS — IIV HEVS OPERATION. Description. — The covering is by skin and muscle flaps, furnished almost entirely from the posterior aspect of the leg. The method is fre- quently termed simply a long posterior flap operation — and differs liut little from the preceding operation. Position. — As in Guyon's operation (page 365) — and as given under Incision, Ijelow. Landmarks. — Saw-line. Incisions. — The posterior flap is U-shaped — its breadth is equal to half the circumference of the limb at the saw-line, and its length is equivalent to one diameter of the limb at that line. It begins 2.5 cm. (i inch) below the saw-line (instead of at that line). The inner limb passes vertically down the leg just behinii level with adductor tubercle ; B. Gritti-Stokes's supracoiidyloid amputation ol thigh ; with dotted lines. B' and B". show- ing division of lemur above level of adductor tubercle, and splitting of patella ; C, Through lower part of thigh, by long anterior and short posterior flaps. the pophteal, muscular, articular, anastomotica magna. The patella is gras])ed firmly by lion-jaw forceps, and held in such a way as to present its articular surface horizontally. .\ section of the bone is made in such a manner as to remove the articular surface of the patella. This is best accom- plished with a narrow, thin saw. It may also be done with a broad chisel, and, less satisfactorily, with cutting pliers. The cut surface of the patella is then appro.ximated to the sawed end of the femur. It may be held in place by inserting two or three ivory or steel pegs through previously drilled holes in the patella — or by wire or chromic gut suturing through drill-holes 382 AMPUTATIONS. near the margins of patella and femur — or by closely suturing fibrous parts about the patella to the fibrous or periosteal parts about the lower end of the femur. The anterior and posterior flaps are then sutured togetlier. Firm pressure is used against the stump, in the dressing, to aid in steadying the patella against the femur. Comment. — The scar is drawn up posteriorly out of the wavof pressure. This operation is comparable with Pirogoff's osteoplastic amputation of the leg. AMPUTATION THROUGH LOWER THIRD OF THIGH IIV CIHLHJI I", nKClLAK MHTllch Description. — Owing to greater retraction u]ion the posterior and inner aspects of the thigh, and in order, therefore, that the incision may eventually occupy the same height around the entire circumference of the limb, the circular incision is placed obliquely — so that it is lowest where the muscular retraction is greatest, namely, at the postero-internal aspect of the thigh. Position. — .\s in the transcondyloid operation. Landmarks. —Saw-line. Incision. — The highest part of the circular incision is antero-e.xternal and is a little more than half the diameter of the limb (at the saw-line) below the bone-section. The lowest part of the circular incision is postero-internal and is little less than one diameter of the limb (at the saw-line) below the bone-section — the two calculations of covering thus providing ij diameters of covering in the aggregate. Such an incision is hard to follow unless pre- viously marked (Fig. 281, A). Operation. — The above incision through skin and fascia is made with two strokes of a long knife — the limb being conveniently rotated during the manceuvre, as described under the '' Circular Method of .Aimputation," page 234. The skin and fascia are then obliquely retracted a short way, parallel with the original incision — and the more superficial muscles circularly divided. These are further retracted and the deeper muscles circularly divided to and including the periosteum, to the bone — cutting each time parallel with the skin incision. The skin, muscles, and periosteum are freed up to just above the saw-line, and retracted — as in the ordinary infundibular form of circular amputation — and the bone sawed. The femoral, anastomotica magna, descending branches of the external circumflex, perforating and muscular branches will be cut and require ligature. The muscles are quilted in two tiers. The skin is sutured so as to make an antero-posterior scar. Comment. — (i) This may be called an elliptical method, as well as an oblique circular. It is not appropriate except at the lower third of the thigh — where it is excellent. (2) Where great difficulty is experienced in freeing back the soft parts, the circular operation may be modified by adding one or two short lateral vertical incisions, thus forming two antero-posterior in- tegumentary flaps — and dividing the muscles circularly after retracting the skin. This, however, constitutes the modified form of circular am])utation. AMPUTATION THROUGH LOWER. MIDDLE, OR UPPER THIRD OF THIGH r.\- LOX(-, AXTRKIOK AXD SHORT POSTERIOR I'l.ATS. Description. — Two U-shaped flaps of skin and muscle are raised, ante- FLAP AMPUTATIONS OF THIGH. 383 riorly and posteriorly — the latter being one-fourth the length of the anterior and a little narrower at the base. Position — Landmarks. — .As in the above operation. Incisions. — .\nterior flap — is equal, in length, to i^ diameters of the Kig. 281. — Amputation lethod : B, Disarticulation at hip-joint, by anterior racket. ■ part of tliigh, by oblique thigh at the saw-line, and. in width, a little more than ^ circumference. It begins (on right side) (with thigh rotated outward) opposite the saw-line, at about the middle of its inner aspect, or a fraction behind — passes vertically down the inner side of thigh — rounds broadly across the anterior surface, 384 AMPUTATIONS. at a distance below the saw-line equal to li diameters, and into the outer aspect — and passes vertically upward (the thigh now rotated inward) to a corresponding point on the opposite side. Posterior flap — begins and ends at the upper limits of the anterior flap — rounding across the posterior surface at a distance below the saw-line equal to a half-diameter — the surgeon's hand passing beneath the thigh. In the above calculations, extra length is allowed, because of the e.xtra retraction (Fig. 280, C). Operation. — The tissues outlined in the anterior flap are now jiicked up by the surgeon's left hand, and, along the line of the retracted flap, the muscles are divided obliquely from without inward and upward — so beveling the flap that its extremity will consist of skin and fascia alone. The muscle tissue will begin to enter into the formation of the flap just above the extremity, and increases in thickness to the bone — into contact with which it will come at about one-half to three-fourths the diameter of the femur below the saw-line, at which level the whole thickness of the muscle will be represented. The thigh is then elevated and the posterior flap similarly cut, being obliquely beveled from without inward and from below upward, leaving skin and fascia at the lower end of the flap and full thickness of the muscles at the upper end, where the bone is reached the same distance below the saw-line as in the anterior flap. At the level at which the bone has been reached in the upward cutting of the flaps, a circular sweep of the knife around the femur frees the periosteum. The soft parts, including the periosteum, are then freed upward to just above the saw-line (which is everywhere easily accomplished except at the linea aspera posteriorly) and the bone sawed. If the flaps have been made above the middle of the thigh, the femoral, pro- funda, descending branches of the external circumflex, and muscular branches will be cut in the anterior flap — and branches of the perforating arteries in the posterior flap. If the flaps have been made below the middle of the thigh, the descending branches of the external circumflex and muscular branches will be cut in the anterior flap — and the femoral, anastomotica magna, and branches of the perforating in the posterior flap. Suture the musculo-periosteal covering over the end of the bone. Quilt the heavy muscles of the flaps in at least two tiers, with buried chromic gut sutures. The anterior flap will drop over the end of the I one and be sutured to the posterior flap. The flaps are well supported by the pressure of the dressing, in which a posterior splint has been included — and the limb placed upon an inclined plane. Comment. — The flaps may be cut by transfixion, after outlining through skin and fascia — but less satisfactorily. AMPUTATION THROUGH LOWER. MIDDLE. OR UPPER THIRD OF THIGH BV EQIIAL ANTERIOR AND POSTERIOR FLAPS. Description. — Same in all essential respects, except as to difference in length nf flaps, as amputation by long anterior and short posterior flaps. Position — Landmarks. — .^s in the last operation. Incisions. — Anterior flap — is, in length, three-fourths the diameter of the limb at the saw-line. Posterior flap — is, in length, one diameter of the limb — its greater retraction eventually reducing its length to that of the FLAP AMPUTATIONS OF THIGH. 385 anterior flap. The width of both is equivalent to half the circumference of the limb at the saw-line (Fig. 282, A). Operation. — As in the preceding. The vessels severed are also the same. Comment. — (1) The method by equal flaps is indicated only where the Fig. 282.— Amputations about Thigh and at Hip-joint: equal anterior and posterior flaps ; B, Disarticulation at hip-joint hip-joint, by long anterior and short posterior flaps. -A, Through middle anterior tissues are limited. (2) Less sacrifice of length of limb is involved. (3) These flaps are frequently cut by transfixion, without even outlining through the integumentary tissues in advance — but such technic is not ad- visable. 25 386 AMPUTATIONS. AMPUTATION OF THIGH JUST BELOW THE TROCHANTERS BY EXTERNAL 0\A1, METHOD, Description. — Similar in principle to disarticulation of the hip-joint by the external racket method (page 392) — except that the vertical incision begins lower, and the bone is divided below the lesser trochanter. Position. — As in disarticulation of the hip-joint by the external racket method (page 392). Landmarks. — Great trochanter; lesser trochanter. Incision. — With the limb adducted, rotated in and slightly flexed, the vertical portion of the incision begins over the prominence of the great tro- chanter, in the mid-outer aspect of the limb — passes vertically down the outer side of the thigh for about 10 cm. (4 inches) — thence the limbs of the oval diverge to pass over the anterior and posterior aspects of the thigh and meet in the center of its inner side, at a point about 5 cm. (2 inches) lower than the lower end of the vertical incision. Thus an inverted Y is formed upon the outer side of the thigh. Operation. — The skin and fascia are dissected up along the oval portion of the incision for about 5 cm. (2 inches). The vertical incision is then deepened to the bone. Through the vertical incision the shaft is freed as extensively as possible. The muscles are now circularly divided on a line with the retracted skin and fascia. The soft parts are entirely freed from the bone up to the saw-line — providing a musculo-periosteal covering when near that line. The soft tissues are retracted and the femur sawed. Ligate the femoral artery and vein, profunda artery and vein, internal circumflex, descending (and possibly transverse) branch of external circumflex, comes nervi ischiadic!, and many muscular branches. Suture the musculo-periosteal flap. Quilt the muscles with two tiers of gut sutures, along both vertical and oval portions of incision. Suture skin in a horizontal line, forming externo-terminal scar. Include splint in dressing and place on an inclined plane. SURGICAL ANATOMY OF HIP- JOINT. Bones. — Os innominatum; femur. Articulations and Ligaments. — Capsular (with following au.xiliary bands — pectineo-capsular, ilio-trochanteric, and ischio-capsular) ; iliofemoral (also an auxiliarv portion of capsular ligament); ligamentum teres; cotyloid; transverse; and svno\ial membrane. Synovial Membrane of Hip-joint. — Beginning at border of carti- laginous surface of head of femur — covers neck of femur within joint — is reflected to inner surface of capsular ligament — covers both surfaces of cotyloid ligament and fat at bottom of acetabulum — and is prolonged around ligamentum teres to head of femur. Muscles of Region of Hip-joint. — Mentioned in connection with the Thigh (page 37^1). Muscles in Relation with Hip-joint. — Anteriorly: — psoas and iliacus. Posteriorly: — pyriformis; gemellus superior; obturator internus; gemellus in- ferior; obturator externus; quadratus femoris. Superiorly: — straight and reflected tendons of rectus; and gluteus minimus. Internally: — obturator externus and pectineus. Bursae in Relation with Hip-joint. — Between great trochanter and SURFACE FORM AND LANDMARKS OF HIP-JOINT. 387 gluteus maximus. Between vastus externus and gluteus maximus. Between front of joint, and ]3soas and iliacus (often communicating with joint). Movements of Hip-joint. — Flexion: — by psoas, iliacus, rectus, sar- tciriu>, |)ci tineus, adductor longus, adductor brevis, anterior fibers of gluteus medius, and minimus. Extension: — by gluteus maximus, biceps, semi- tendinosus, semimembranosus, gracilis. Adduction: — by adductor magnus, longus and brevis, pectineus, gracilis. Abduction: — by gluteus maximus, medius and minimus. Inward Rotation: — anterior fibers of gluteus medius, gluteus minimus, and tensor vagina; femoris. Outward Rotation: — posterior filjers of gluteus medius, pyriformis, obturator externus, obturator internus, gemellus superior and inferior, quadratus femoris, psoas, iliacus, gluteus maximus, adductor magnus, longus and brevis, pectineus, sartorius. Arteries of Region of Hip-joint. — (a) From Internal Iliac — obturator; internal pudic; sciatic; iliodumbar; lateral sacral; gluteal, (b) From External Iliac — deep circumflex iliac, (c) From Femoral — see Arteries of Thigii, page 376. Veins of Region of Hip-joint. — Superficial: — tributaries of internal sa[)henous. Deej): — accompany corresponding arteries. See \'eins of Thigh, page 376. Nerves of Region of Hip- joint. — (a) From Dorsal Nerves: — lateral cutaneous branch of last dorsal, (b) From Posterior Divisions of Lumbar Nerves: — cutaneous nerves from external branches of three upper posterior divisions, (c) From Lumbar Ple.xus: — ilio-hypogastric, ilio-inguinal, genito- crural, external cutaneous, anterior crural, obturator, accessory obturator, (d) From Posterior Divisions of the Five Sacral and First Coccygeal Nerves: — external branches, (e) From the Sacral Plexus: — muscular, superior gluteal, inferior gluteal, perforating cutaneous, pudic, small sciatic, great sciatic. SURFACE FORM AND LANDMARKS OF HIP-JOINT AND VICINITY. Spine of the os jjuijis is ])alpable, and is nearlv on a level with the upper border of the great trochanter — and the upper border of the great trochanter is on a level with the center of the hip-joint. Top of the great trochanter is about 2 cm. (| inch) below the level of the head of the femur. Great trochanter is from 7.5 to 10 cm. (3 to 4 inches) below the iliac crest, and a little in front of its center. Head of the femur lies just below Poupart's ligament — and just external to its center. Nelaton's line runs from the anterior superior iliac spine to the most prominent part of the tuberosity of the ischium. It runs through the center of the acetabulum and indicates the level of the hip-joint. Bryant's line — (with patient flat on back) — first line is dropped vertically to the table, from the anterior sujierior iliac spine; — second line passes, in a straight direction, in a line with the long axis of the thigh, from the top of the great trochanter to meet first line; — third line runs from the anterior superior iliac spine to the top of the great trochanter. On the damaged or diseased side, the second line will be shortened. .■\nterior superior iliac spine and the crest of the ilium are palpable. Posterior superior iliac spine is marked by a depression on each side of, and on a level with, the spinous process of the second sacral vertebra — and is just behind the center of the sacro-iliac articulation. 388 AMPUTATIONS. The anterior inferior iliac spine is al)i>ut j tni. (f inch) above the upper border of the acetabuhim. Line from the posterior superior iUac spine to the outer part of the tuber- osity of the ischium will cross the posterior inferior iliac spine nearly 5 cm. (2 inches) below the posterior superior iliac spine — and the ischial spine about 10 cm. (4 inches) below the posterior superior iliac spine. Tuberosities of the ischia are palpable on either side of the anus, beneath the lower border of the glutei maximi, especially when the hip is flexed. They are covered, in standing, by the lower margin of the glutei maximi — and, when sitting, by the dense skin and fascia alone. Third sacral spine is on a level with the lowest limit of the spinal mem- branes and the cerebrospinal fluid, and is o])posite the upper border o{ the great sacro-sciatic notch. First piece of the sacrum is on a level with the spine of the ischium. Apex of the coccyx is just behind the last piece of the rectum. Gluteus maximus forms the rounded outline of the buttock — its lower border being more oblique and higher than the fold of the buttock. A line from the side of the coccyx to the lower border of the great trochanter corre- sponds with the lower border of the gluteus maximus. Fold of the buttock is caused by the creasing of the skin in fiexion and extension, and does not correspond with the lower margin of the gluteus maximus but is lower and less oblique. The antero-internal margin of the acetabulum is about 5 cm. (2 inches) external to the pubic spine. Edge of the great sacro-sciatic ligament can be felt by pressing deeply under the lower edge of the gluteus maximus. Femoral artery is separated from the capsule of the hip-joint by the psoas magnus, upon which it rests. For the landmarks of the gluteal, sciatic, and pudic arteries, see under the Ligations of those arteries (pages Sg, 86, and 88). Ossification in the head of the femur begins at the enfl of the first year, uniting with the shaft at the eighteenth year; — that in the great trochanter begins in the fourth year, and that in the lesser trochanter at the thirteenth to fourteenth year, uniting, in both cases, about the eighteenth year. The epiphyseal line of the head of the femur is entirely within the capsular ligament. GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATION AT THE HIP- JOINT. The question of control of hemorrhage is the most serious problem in hip-joint disarticulations. The methods of hemorrhage-control are the following; — Wyeth's mattress- needles and tourniquet; elastic tourniquet; preliminary ligation of femoral; Senn's method; ligation of femoral during amputation; digital compression of the femoral, or of the external iliac, above the amputation-site; digital compression of the femoral in the flap, as cut; stout needle beneath the femoral vessels, with rubber tubing wound in figure-of-eight fashion over it (Tren- delenburg's method). The first three of the above methods are the best. Such methods as pressure of the abdominal aorta, either extra- or intra- abdominally, or through the rectum, are now not usually resorted to. Only some form of circularly surrounding tourniquet controls hemorrhage GENERAL COXSIDERATIOxXS IX HIP-JOINT DISARTICULATION, 389 from branches of the internal iUac, as well as from the femoral. When hemorrhage is once controlled, any form of disarticulation may be adopted. Manner of applying Wyeth's mattress-needles and tourniquet: — Two steel needles from 3 to 5 mm. (j-,!- to f*,. inch) in diameter and 25.5 cm. (10 inches) in length are inserted and capped with corks (to prevent their points from injuring operator and assistants). The outer needle enters the tissues of the outer aspect of the thigh 6 mm. (| inch) below and just to the inner side of the anterior superior iliac spine — traverses the superficial muscles and fascia upon the outer side of the hip, and emerges on a level with, and about 7.5 cm. (3 inches) external to, the entrance. The inner needle enters the tissues of the inner aspect of the thigh internal to the saphenous opening, and about 1.3 cm. (^ inch) below the crotch — traverses the adductors — and emerges 2.5 cm. (i inch) below the tuberosity of the ischium. White rubber tubing, about 7 mm. (J inch) in diameter, is wound tightly four or five times around the thigh above the fixation-needles, and clamped. This rubber band com])resses the common femoral against the rim of the pelvis, anteriorly — and the gluteal, sciatic, and internal pudic against the margin of the great sacro-sciatic notch, posteriorly (Fig. 209, left hip). Manner of applying the ordinary rubber tourniquet (Jordan Lloyd's method) — First elevate the limb to a vertical position, and hold thus for a few minutes, further aiding the emptying of blood from the limb bv down- ward massage. A strip of sterilized roller bandage is laid down the outer, and one down the inner aspect of the tliigh. A sterilized pad is placed over the external iliac artery. Rubber tubing, about 1.8 m. (6 feet) long, is passed around the thigh in several tight turns, over the pad and pieces of roller bandage. The center of these turns is placed between the tuberosity of the ischium and the anus (of the operated side) — the tubing being brought up so as to pass over the center of the iliac crest. The two ends of the tubing are finally grasped firmly in either hand and tightly drawn upward and forward and made to cross each other above the center of the iliac crest. \i the point of crossing, an assistant, with the back of the hand (the right hand for the left side, and vice versa) to the patient's body, grasps and holds the crossed rubber band. Or the two ends may be carried around the trunk, brought back again, and make a second similar traversing as the first spica — the two ends being then tied, or clamped, above the center of the iliac crest (of the same or opposite side). The two roller bandages forming the two loops are now drawn upward to hold the tourniquet in place and lift it further from the field of operation — one coming up from in front of the anterior superior iliac spine, and the other from opposite the ischial tuberositv. The anterior part of the tourniquet, running above and parallel with Poupart's ligament, compresses the external iliac under the pad — the posterior part, running across the great sacro-sciatic notch, compresses the gluteal, sciatic, and internal pudic (Fig. 209, right hip). Manner of preliminary ligation of femoral: — see under Ligations, page 97, and Figs. 209 ^left thigh) and 38. Manner of applying Senn's method of hemorrhage-control in disarticula- tion at the hip-joint — A straight inciiion of about 20 cm. (8 inches) is made over the central aspect of the great trochanter, in the long axis of the limb, and ctjmmencing about 7.5 cm. (3 inches) above the superior border of the great trochanter. As soon as the femur has been exposed and the head of the bone disarticulated, a pair of hemostatic forceps is introduced closed behind the femur, and on a level which would correspond with that of the trochanter minor when in normal position (that is, prior to disarticulation) — 390 AMPUTATIONS. and is pushed inward and downward below the ramus of the ischium and just posterior to the adductor muscles — until felt through the skin on the inner aspect of the thigh, when an incision is made over its tip and the instru- ment pressed on through. By opening the blades, the tunnel through the soft parts is enlarged — and the forceps are then made to seize a piece of rubber tubing at its center and draw the doubled portion backward through the wound at the outer aspect of the thigh, leaving the free ends protruding through the inner opening. The portion of the tube grasped by forceps is then cut in two. The hmb is now held elevated a few moments, during which the return of blood to the trunk is further aided by downward massage. The anterior half of the tube is then carried firm.ly around the anterior portion of the soft ])arls and tied or clamped — and the posterior around the posterior portion, and similarly tied or clamped — thus controlling all circulation prox- imal to the tubing — the tubing being prevented from slipping bv the tun- neUng of the soft parts. The operation is then completed. Where the disarticulation has been done by a method allowing of free exposure of the femur in advance of disarticulation, the shaft can be largely freed subperiosteallv — with the result that a sufficient growth of bone usuallv occurs to enable the stump to be freely moved in all directions. Temporary drainage is indicated — and should be provided through an o[)ening made posteriorly, if no dependent opening exist as a result of the operation. Sutures are left in an extra length of time — and the flaps are subsequentlv temporarily supported by strapping. The stump should be rather firmly bandaged and supported upon a pillow. DISARTICULATION AT HIP-JOINT, IN GENERAL. Best Methods.— \\"veth's Method. External Racket Method. Anterior Racket Mcth,..!. Other Methods. — Furneaux Jordan's Method (external vertical incision, with circular division of muscles). Long Anterior and Short Posterior Flaps. Equal Anterior and Posterior Flaps. Equal Lateral Flaps. Antero-internal and Posteroexternal Flaps. Modified Circular Method. Single Internal Flap. Esmarch's Method (circular division of muscles and bone, with dissection out of the bone through an external vertical incision). DISARTICULATION AT HIP- JOINT UV WVETH S METHOD. Description. — Having controlled hemorrhage by means of rubber-tubing wounfi around the thigh at its junction with the pelvis, above two large pins introduced in a special manner, a circular incision is made around the thigh, followed bv a vertical external incision, and disarticulation at the hip-joint accomplished: Position. — Patient supine, drawn to foot of table until the sacrum rests upon the corner, with hip projecting beyond, and kept from slipping from table by being steadily held. Surgeon generally stands upon the outer side of both thighs, although it is more convenient to be upon the inner side of the left limb. An assistant hold- and manipulates the limb projecting over the DISARTICULATION AT HIP-JOINT. 391 table. Another assistant steadies the pelvis and guards the method of hemor- rhage-control. Control of Hemorrhage. — Special pins are introduced in the manner described under General Surgical Considerations (page 389). Previous to Fig. 2S3.— Amputations through Thigh and at Hip-joint : — A, Through lower part of thigh, by modified circular; B, Disaniculatioii at hip-joint, by Wyeth's method. the application of the pins, the limjj should be constricted by an Esmarch rubber bandage, from the toes to the hip-joint — unless contraindicated. Landmarks. — Great trochanter; points for the passage of the pins (page 389)- Incisions. — .A circular incision is made around the thigh about 1^.3 cm. 392 AMPUTATIONS. (6 inches) below the center of the anterior aspect of the rubber tourniquet. The vertical incision passes vertically down the external aspect of the thigh, directly over the great trochanter — passing in a straight line from the tourni- quet to the circular incision (Fig. 283, B). Operation. — The circular incision passes through skin and fascia alone. These are dissected up to the level of the lesser trochanter — that is. for about 5 cm. (2 inches). At this level the muscles are circularly dixided to the bone, on a line with the retracted skin and fascia. The vertical incision is now made from the tourniquet down to the circular division, passing directly over the great trochanter. The larger vessels are at once tied — the femoral and profunda arteries and veins, and any other prominent vessel. Through the vertical incision, which has extended, at one sweeji, directly through skin, fascia, muscles, and periosteum to the bone, the soft parts are all cleared, as subperiosteally as possible, from the shaft and tuberosities of the femur. Retract the soft parts and divide the capsular ligament transversely over its outer aspect. Manipulate the limb as a lever, nicking the cotyloid ligament to let in air — cut the ligamentum teres — and disarticulate by thrusting the head of the femur upward and outward. If not already severed, divide the posterior aspect of the capsule, and any retaining structures — and remove the hmb. If the enucleation be difficult, which is rarely the case in this extensive exposure, the margin of the acetabulum can be chipped away with a chisel sufficiently to let in air — or, if all the vessels be ligatured, the tourniquet may be removed carefully and slowly and the disarticula- tion completed. The remaining vessels in the posterior aspect of the wound are now ligated — these are chiefly the branches of the sciatic, obturator, ex- ternal and internal circumflex, and perforating. Having trimmed away all tags of tissue, the heavy muscles are to be quilted together with especial care, bv means of two or three tiers of chromic gut sutures. Drainage is to be established — the margins of the wound united in one continuous termino-external suture-line — firm compression made in dressing the wound — and the stump supported upon a pillow. Comment. — This method probably represents the safest, simplest, and best manner of disarticulating at the hi])-joint. DISARTICULATION AT HIP- JOINT BY EXTERN.-\L RACKET METHOD. Description. — The queue of the incision is placed over the external aspect of the joint — the limbs of the incision encircling the anterior, internal, and posterior aspects of the thigh. Hemorrhage is controlled by an ordinary rubber tourniquet. Position. — Patient is sufficiently turned to the opposite side to expose the area, and is drawn to the end of the table so that the ])elvis rests upon the edge of the table and the hips project beyond — the limb is adducted, rotated inward, and slightly flexed. Surgeon and assistants stand as in the last operation. Control of Hemorrhage. — For the description of the application of the rubber tourniquet, see (lencral Surgical Considerations, page 389. .'\lso see Hemorrhagc-ci>ntri)l. under the last operation, for reference to the Fsmarch bandage. Landmarks. — Great trochanter. DISARTICLLATIOX AT HIP-J(lI.\T. 393 Incision. — The queue begins about 5 cm. (2 inches) above the upper border of the great trochanter — passes vertically down the limb, along the posterior border of the great trochanter, for about 17 cm. (7 inches) — the two limbs of the racket here diverge to encircle anteriorly and posteriorly, meeting upon the center of the inner aspect of the thigh, about 5 cm. (2 inches) lower down than the termination of the vertical portion of the incision — forming an inverted Y on the outer aspect of the thigh. The limb is rotated as the incision is made (Fig. 282, B). Operation. — These incisions pass, at first, through skin and fascia only. The skin and fascia of the oval portion of the incision are then dissected up for about 5 cm. (2 inches). The vertical portion of the incision is now deep- ened to the bone — with the limb in the original position. The anterior, superior, and posterior borders of the great trochanter are cleared of muscles in the order named — as subperiosteally as circumstances allow. The shaft of the femur is cleared, as far as possible, to the e.xtent of the vertical incision. .Adduct the limb strongly and divide the superior and posterior parts of the capsule transversely — lie.x the limb and divide the anterior part of the capsule — rotate outward and cut the round ligament — and then disarticulate. Having ascertained that the tourniquet is compressing the parts well, after the dis- articulation of the head of the femur, the muscles are circularly divided on a level with the retracted skin and fascia of the oval incision. The important vessels are at once ligated — consisting t>f the femoral and profunda arteries and veins, the internal circumlle.x (and possibly the transverse branch of the external circumflex), comes nervi ischiadic!, and muscular branches. The muscles are quilted in two or three tiers, with buried chromic gut sutures, along both the vertical and oval portions of the wound. The suture-line of the skin margins will be termino-external, in one straight line. Comment. — The approach to the bone is through a region less vascular than by the anterior racket method. The hip-joint can be preliminarily examined, in case disarticulation prove unnecessary. Disarticulation can be effected before severing the vessels. The subperiosteal method can be more easily carried out than by an anterior approach. The branches of the internal pudic are comparatively little involved — there is a low transverse division of the muscles — and good drainage is secured. The method is probably better than disarticulation by the anterior racket method. DISARTICULATION AT HIP- JOINT KV .WTEKIOK RACKET METHOD. Description. — The queue of the racket, or oval, is placed anteriorly — the linil)s of the oval encircUng the external, internal, and posterior surfaces. Xo tournicjuet is used. The femoral is ligated during operation, and the remaining vessels as encountered. Control of Hemorrhage. — Utilizing the queue of the incision, the common femoral artery and vein are exposed and ligated — during the progress of the operation. Otlier vessels are secured as exposed. Position. — Patient supine — otherwise as in the external racket method (page .^92). Landmarks. — Center of Poupart's ligament; course of femoral artery. Incision. — The queue begins at the center of Poupart's ligament — passes down along the femoral artery for about 7.5 cm. (3 inches) — thence curves inward anrl crosses the inner aspect of the thigh about 10 cm. {4 inches) 394 AMPUTATIONS. below the genito-crural fold — continues across the posterior aspect of the thigh — crosses the outer side of the limb a short distance below the base of the great trochanter — and thence ascends upward and inward obliquely across the anterior aspect to join the vertical incision about 5 cm. (2 inches) below its commencement at Poupart's ligament (Fig. 281, B). Operation. — This incision passes well through skin and fascia only, which are allowed to fully retract — and is made with several sweeps of the knife, while the limb is manipulated as indicated. Through the vertical portion of the racket incision, tne common femoral artery and vein are early exposed and each ligated in two places and severed between the ligatures. The skin and fascia are fully freed around the entire incision, without any special dissection. The muscles on the outer side (sartorius, rectus, tensor vagina; femoris) are divided and the external circumflex artery doubly ligated and severed. Passing backward, rotate the thigh inward and cut the insertion of the gluteus maximus. Passing forward, rotate the thigh outward and cut the psoas — and retract the parts and doubly ligate and divide the internal circumflex artery. Divide the muscles of the internal flap on a level with the retracted skin (pectineus, gracilis, and adductors), ligating the muscular branches. Adduct and rotate the thigh inward — severing the muscles attached to the great trochanter. Abduct and rotate the thigh outward — cut the capsule transversely — disarticulate — sever the round ligament — and the obturator externus tendon, if still undivided. The head of the bone is now drawn forward and outward — a long knife is carried behind the bone, passing downward and backward and divi(jng the remaining parts at the posterior aspect, on a level with the retracted skin (hamstrings, parts of the adductors and sciatic nerve) — ligating the perforating and muscular branches. The muscles are quilted in two or three tiers — after having severed all tags of tissue and instituted drainage. The margins of skin are sutured in a single vertical line. The stump is dressed as in the preceding operations. Comment. — While possessing many good points in common with the method bv external racket incision, the anterior racket method possesses the further advantage that the hip-joint is more easily and directly reached, and disarticulation more readily accomplished. No special form of tourniquet control is necessarv. There is, however, not so good an opportunity aff'orded for a preliminary examination of the hip-joint, with possible excision sub- stituted for amputation. The operation is longer, owing to the slower hemor- rhage-control. OSTEOPLASTIC AMPUTATIONS. Description. — .\n osteoplastic operation, in general, consists in the approximation of fresh sections of bone to each other, for the purpose of bringing about union between their opposed surfaces. In an osteoplastic amputation, some portion of a distal bone is raised in the form of an osseo- periosteal flap, adherent to its neight)orirg soft jiarts, and apphed to the sawed aspect of the proximal bone. In performing osteoplastic amputations a special saw should be provided — a bow-saw with a scroll-blade of strong, narrow, thin metal, which can be turned in any direction while in the act of making bone-sections, such as the Helferich pattern of saw. (A saw for osteoplastic work is now on trial which is, practically, a Gigli saw held in a bow-handle.) The freshened surfaces of bone are variously held in contact — the edges of the surrounding periosteum may l;e sutured together — the OSTEOPLASTIC AMI'UTATIONS. 395 bone-surfaces may be wired, pegged, or nailed — or the bone aspects may be Figs. 284 and 285.— Bier's Osteoplastic Amputation of the Leg:— A, Showing mannt raising anosseo-periosteal flap from tibia ; B, Showing bone-flap brought over sawed ends of tibia fibula, and its periosteal margins sutured to the margins of periosteum around tibia and fibula, osseo-periosteal flap is here shown separated from its soft parts, to which it should be adhe (Modified from Bier.) held in apposition (especially where there is no strong counter-pull) simple suturing of the surrounding soft parts together. )v the Figs. 286 and 2S7.— Sabanejeff's Osteoplastic Ampctatio.n through 1 ing bone-sections through femur, and in raising an osseo-periosteal flap in apposition of bony parts after amputation. (Modified from Sabanejeff.) i :— A. Show- B, Showing Objects of the Osteoplastic Method of Amputation. — (1) Closure and protection of the medullary canal; — (2) Securing of a solid end of bone to meet pressure— brought about by the rounding otT of the section of bone 396 AMPUTATIONS. whose surface becomes united with the end of the main bone; — (3) Avoidance of adhesions between sawed bone and soft coverings — and, by retaininc; the mobility of these parts, thereby lessening the chance of neuralgia and ulcera- tion in the stump. Application of the Osteoplastic Method of Amputation. — Up to the present time, the chief sites at which this method of amputation has been used have been in the lower e.xtremity — that is, where pressure-bearing stumps are sought. The following are examples of the osteoplastic method of amputation; — Pirogoff's osteoplastic amputation of the foot (page 361) — Lister's modification of Garden's transcondyloid amputation of the thigh (page 37q) — Gritti-Stokes's supra condyloid amputation of the thigh (page 380) — Sabanejeff's amputation of the thigh (Figs. 286 and 287) — Bier's amputation of the leg (Figs. 284 and 285). CHAPTER Xlll. EXCISIONS. GENERAL CONSIDERATIONS. Definitions. — Excision signifies a cutting-out. By Excision of Joints, is meant the removal of the articular ends (including cartilage and synovial membrane) of the bones entering into the formation of the joint, with a minimum injury to the neighboring parts. The articular extremities of the proximal and distal bones are removed, except in the cases of the shoulder- and hip-joints, where the articular ends of the humerus and femur, respec- tively, are alone removed, the articular cavities of the scapula and os in- nominatum being gouged or scraped. In Excision of Bones, the removal of a bone is signified, with minimum injury to neighboring structures. In the Total Excision of a bone, the entire bone is removed, including its articular ends. In the Partial Excision of a bone, a part, only, of the bone is removed. By Resection, is meant the removal of the entire thickness of a bone (thus, a joint is said to be excised b_v the resection of the ends of its constituent bones) — but the terms excision and resection are generally used synonymously. Osteoplastic Resection signifies the temporary removal of a bone, or part of a bone, covered bv its soft parts still attached, for the purpose of exposing more deeply seated structures — the cutaneo-muscular-osseous flap being re- placed later. Object of Excisions. — By the o]jeration of Excision, in the case of the extremities, limbs are often now saved in a state of usefulness which formerly were entirely lost by amputation — thus marking one of the greatest advances of modern conservative surgerv. General Features of Excisions. — (i) Total removal of all diseased tissue. (2) Preservation of a useful limb. The excessive removal of bone, or faulty repair of a wound, or improper after-treatment may result in a tlail limb. A movable joint is to be expected everywhere, except in the case of the knee, where ankylosis is sought. (3) The removal of bare bone, free of its periosteum — with minimum disturbance to surrounding soft parts and neighboring parts of bone. (4) Division of bones in such a manner, and at such an angle and height, as to place them in a position favorable to the formation of a new joint — or favorable to ankylosis in the most desirable position. The operation is rarely undertaken in the very young or in the very old. Indications for Excision. — Joint disease (generally tuberculosis); dis- ease of shaft or articular ends of bones; extensi\e injury to bone or joint; unreduced dislocation; ankylosis; deformity; compound dislocation or frac- ture; fracture-dislocation; ununited fracture. Preparation. — Locally, the part should be prepared as for any extensive operation — the part should be shaved, and should come upon the table in an aseptic dressing. Constitutionally, the patient should be gotten into a condition to stand a long operation — and, subsequently, to meet the demands of a prolonged convalescence. Previous to the operation, an apparatus 397 398 EXCISlOiXS. should be provided suitable for the double purpose of retaining the part immovable, and, when desired, of enabling passive movement to be accom- plished. In no other class of o])erations does the final result so largeh' depend upon the mechanical contrivance in which the part is to be subsequently held and passively exercised. Instruments. — Scalpels, light and heavy; bistouries, sharp and blunt; e.xcision-knives (strong instruments, with good grasping handles and stout blades); scissors, straight and curved, sharp and blunt; saws, large and small, solid-bladed and open-bladed, broad and narrow, especially saws with ad- justable and revolvable blades, chain and Gigli saws, key-hole saw, Adam's pattern, Hey's pattern; forceps, dissecting, toothed, and artery-clamp; bone- holding forceps, of various sizes and curves; periosteal elevators, an especially large variety of straight, curved and angular, light and heavy; rugines and raspatories; retractors, angular and curved, toothed and smooth; spatuhe, metal or ivorv; directors, ordinary grooved and saw-directors; probes; chisels, narrow and broad, straight and curved; osteotomes, various; bone-gouges and curettes, of various shapes and sizes; drills; flushing-gouge; pins, pegs, and needles; wire; suture and ligature material of silk, gut, chromic gut, silkworm-gut, and wire; needles; needle-holders; Esmarch rubber bandage and tourniquet. Varieties of Excision. — A joint or a bone may be excised by either the subperiosteal or the open method. EXCISION BY THE SUBPERIOSTEAL METHOD. Description. — In this method it is sought to ])re>er\e the entire periosteum — from the site at which it is first reached in the operation — on upward or downward to the opposite limit of the wound. In the case of excising a joint, no periosteum covers the articular ends of the bones — the periosteum liecoming merged into the fibrous tissue of the cayisular ligament — and here a periosteo-capsular covering is separated continuously. The advantages of the subperiosteal method are: — (a) Production of new bone from the preserved periosteum; (b) Preservation of the capsule of the joint, with the ligaments attached to it — and hence a stronger and more useful joint; (c) Preservation of the attachment of tendons to neighboring periosteum — and hence additional strength and movement; (d) Less hemorrhage, and less damage to surrounding tissues, as, when the bone is once reached, the opera- tion is henceforth conducted in a comparatively safe area, between bone and periosteum (or between bone and periosteo-capsular covering); (e) The neighboring intermuscular planes (except to reach the bone) are not opened up — the operation-site being circumscribed by the periosteal or capsulo- periosteal sheath raised. The disadvantages of the subperiosteal method are the following: — (a) Possibility of retaining diseased periosteum; (b) Difficultv of the operation, and the likelihood of detaching the periosteum in shrecls; (c) Time necessary for its performance. To summarize — the subperiosteal method is excellent in theory, but is often difficult, and some- times contraindicated. in practice. The subperiosteal method should be adopted whenever possible — and carried out as far as possible — where the periosteum is healthv. Always aim for the subperiosteal method, where the periosteum is healthy and there be no contraindication — and, if only partly successful, less damage will have been done to the neighboring tissues, and the result vvill be more satisfactory, than if the open method had been EXCISION BV THE SUBPERIOSTEAL METHOD. 399 undertaken from the start. As a result of a successful subperiosteal e.xcision, bone is reproduced, refilling the periosteal cavity to a greater or lesser extent, and assuming a form largely determined by the limiting periosteum — being poured out, so to speak, into a mould of periosteum or capsulo-periosteum. Sometimes no new bone forms — sometimes an excess. Some reabsorption of the new bone occurs. Exceptionally, reproduction of shafts and joint surfaces of bones is remarkable — and the functioning almost normal. As to the peculiarities of the periosteum, — in the young, it is thick and easilv detachable (and also more valuable) ; — in the old (and in cadavera) it is thinner and more adherent; — in chronic inflammation, it is easily detachable (but often less valuable here). Preparation. — Given under General Considerations. Position. — Patient's limb is placed in such a position as to be -most accessible to the surgeon, and, at the same time, most relax the overlying parts. Surgeon stands in the same general relation to the limb as in ampu- tating — to the outer side of right and inner side of left limbs. Assistant so stands as to steady the part or retract the lips of the wound. Special positions will be mentioned under special operations. Landmarks. — Will be mentioned under each operation. Preliminary Control of Hemorrhage. — While the same need for the control of hemorrhage does not e.xist as in the case of amputations, as no important vessels are ordinarily cut, yet, to avoid what hemorrhage would otherwise occur, and for the sake of having a clean, dry field, it is best to apply a rubber constrictor above the site of operation. If its apphcation be preceded by elevation and proximal massage of the limb, less regurgitant bleeding will occur. Though oozing may be greater after the removal of an Esmarch than might be the case had it not been used, yet the advantages more than conterbalance the disadvantages. The constrictor should always be removed before suturing the wound, that all vessels which still bleed may be taken up. Incision. — An incision should be chosen which is simple — which passes to the joint or bone, by the most direct and safest route — which will do the minimum injury to the neighboring structures on its way to the site — which will fall in with the intermuscular planes — and, if possible, with the cleavage line of the skin. The incision should be fully long enough to admit of easy mani]julation in the depth of the wound, upon which the subperiosteal method so largely depends. Generally a single straight cut is used. The incision usually passes at first through only skin and fascia — but, in some cases, passes directly to bone. Operation. — (i) If the primary incision have passed only through skin and fascia, an intermuscular plane is now sought, and, by lateral retraction of the lips of the wound and the underlying muscles, the bone is reached — with the least possible damage to the soft parts and without any further cutting, but simply by separation of fascial planes. In other instances, the way may be partly opened up by separation and retraction, and partly by cutting muscular tissue and less important vessels and nerves. In still other cases, the original incision passes directly to the joint or bone. In any event, the final incision passes down through the periosteum of the lower end of the proximal bone — through the capsule of the joint — and through the perios- teum of the upper end of the distal bone — all in one continuous sweep of a stout excision knife. (2) Having once gotten within the periosteum and capsule, the knife is laid aside and this capsulo-periosteal covering of the joint and articular ends of the bones — cr the periosteum alone where cnly 400 EXCISIONS. the interarticular portion of the bone is involved — is separated by means of periosteal elevators, which work constantly toward the bone, hugging it always. Where the tendons and muscles are inserted into the periosteum, these are levered off the bone by means of periosteal elevators and rugines — retaining their attachments continuous with the periosteum. In other words, in an ideal case, the osseous tissue is decorticated, or shelled out of its capsulo- periosteal sheath, leuving the periosteum and capsule intact and continuous, as well as the ligaments of the joint and the tendons in the neighborhood. (3) As soon as the articular ends have been sufficiently freed and bared in their capsulo-periosteal sheath, disarticulation is accomplished and the ends of the bones, in turn or together, are protruded through the incision, or in- cisions, and are excised just above their articular cartilages — the soft parts being protected during the sawing. (4) The sawed ends of the bones are now drawn back within their capsulo-periosteal covering. The tourniquet is then loosened and the vessels not tied during the steps of the operation which bleed are now tied. The edges of the capsulo-periosteal sheath are sutured together with catgut. But where muscles have been cut along the original incision, these are quilted with catgut. Even where no muscle- fibers are laid bare, but only the rounded borders uncut, it is well to quilt together such separated muscles, as the fascia covering them unites and fills the dead spaces and hastens repair of the wound as a whole. Temporary drainage is indicated in the larger e.xcisions. The suturing of the skin should be done with silk or silkworm-gut — which is usuallv removed about the tenth day. Application of Retentive Apparatus, and After-treatment. — The future u>cfulncss of the limb clepends almost more ujion the after-treatment than upon the manner of ojieration. There is hardly any set of operations in which the ultimate outcome is more dependent upon the care and manage- ment subsequent to operation. The usefulness of the limb also largely depends upon non-suppuration, or but limited and brief suppuration. While temporary drainage is at first indicated, the dressings should be dry and infrequent. In applying the first dressing, the limb may be immobilized upon almost any splint — often the permanent position, or method of treatment, cannot be adopted immediately. Or the limb, on the other hand, may be put up in its permanent and special splint from the first. This latter course is preferable when possible. In still another class of cases, as in operating for deformity, it may take some time to bring the limb into its permanent position. The kind of splint or retentive apparatus adopted is extremely important. It should be selected to do the special work in hand — and be very precisely applied. Its features are, — (a) that it should firmly grasp the limb above and below the excised joint — and (b) that it should be hinged, the hinge corresponding with the joint, so that from time to time the angle of the joint can he changed, while still retaining the relative relations of the ends of the bones. If mobiUty is to be expected, the ends of the bones should not be put up in direct contact — the amount of separation varying with circumstances — the separation being less in adults, and where much perios- teum has been saved, than in the reverse conditions. If ankylosis be desired, the ends of the bones should be put up in close contact in the position desired — and should be kept rigidly in contact until union is solid. .-Xs to passive movement, there is no fixed time at which it should begin. It should com- mence just as soon as acute inflammation and sensitiveness subside (generally in from one to three weeks). General good health, massage, and electricity all aid the favorable course of the traumatism and the final functioning. EXCISION BV THE OPEN xMETHOD. 401 What has been said of a[)paratus and after-treatment in connection with the subperiosteal method of excision, also apphes equally to the open method. Comment. — (1) No vessels of importance are ordinarily injured in the operations of excision — but, if injured, should be lijjated. (2) AH synovial membrane, and even extra-articular tissue, must be removed if diseased. (3) Where muscles or tendons must be divided, their oblique division is preferable. In any event, they should be sutured with gut. (4) Extensive gouging, or curettage, is a legitimate substitute for t3-pical excision, where the latter is impracticable — as where an epiphyseal cartilage might be de- stroyed. (5) Where ankylosis is sought, the synovial membrane should be thoroughly dissected away. (6) Retention of the periosteum gi\es firmness to the cicatrix, even where the amount of bone deposited is little or none — lessens the shortening of the limb — and helps retain the proper relational attachment of the muscles. A periosteo-capsular covering favors the repro- duction of a joint with articular cartilages, and gives support to ligaments. (7) Tendons often have to be removed with knife, cutting close to the bone — or may be chiseled away with a thin shell of bone. (8) The removal of tissue must not, ordinarily, be stopped short of the removal of the entire diseased structures. (9) The destruction of the epiphyses in young children should be avoided. (10) When the saw-section does not remove all of the involved bone, it is better to remove the balance with a gouge than to saw another section. (11) The gap of an excised bone may be filled bv bone- grafting. (12) Tlie periosteum is easily removable in chronic osteitis anf! svnovitis — and hard to remove in acute periosteitis. EXCISION BY THE OPEN METHOD. Description. — Xo attempt is here made to preserve the periosteum. The loniiiiuous attachment, therefore, of periosteum and capsule is sacrificed — though the capsule is preserved. The tendons are peeled from their attach- ment to the periosteum — and some of the ligaments of the joints are sacrificed. The open method is more rapid, but more damage is done to the neighboring structures, and less satisfactory functioning of the joint is apt to follow. The chief indication for adopting the open method is found in those cases where, from disease, or other cause, the preservation of the periosteum is contraindicated. For further comparison, see under Description of the Subperiosteal Method, page 398. A reckless and careless sacrifice of capsule, tendons, and ligaments in the open method is distinctly unjustifiable. In undertaking the ojien method, even in disease, the operation should Yte carried out with the underlying idea of a "modified subperiosteal method as far as consistent." Preparation Position— Landmarks. — .\s in the subperiosteal method. Preliminary Control of Hemorrhage. — The use of a constrictor is here indicated even iiiore than in the sub])eriosteal method — as hemorrhage will, usually, be greater, from the greater damage to the involved parts. Incision. — The line of incision for the open method is generallv the same as that for the subperiosteal method. Sometimes, however, the sub- periosteal excision of a joint is done through one incision — and the open excision through another. Whether the position of the line of incision be the same or not, the manner of making it and of reaching the level of the bone, or joint, are the same. Operation. — I'p to tlie point of reaching the le\el of the joint, or bone, 26 there is no difference between the open and subperiosteal methods of excision. Once the bone is reached in the open method, however, no attempt is made to preserve the periosteum — although the soft parts are disturbed as little as possible. The periosteum is not cut through over the bones above and below the joint. The muscles and tendons are detached — not cut, but peeled — from the bones as closely as possible. While some of the ligaments of the joint are saved, some are unavoidably lost. This separation is accom- plished by rugines, raspatories, and by stout e.xcision knives, rather than by periosteal elevators. The capsule of the joint is cut into as soon as the articular region is sufficiently exposed and cleared. The bones are then disarticulated and their ends protruded and sawed off, during which the soft parts are well protected. The ends of the bones are now drawn back into their musculo-capsular (rather than periosteo-capsular) sheath — the con- strictor rela.xed — the vessels ligated — the cut or separated muscles quilted — and the limb put up and subsequently treated as in the subperiosteal method. Application of Retentive Apparatus, and After-treatment — Com- ment. — As in Excision by the Suljpcriosteal Method (page 400). EXCISIONS ABOUT THE FINGERS. Surgical Anatomy — Surface Form and Landmarks. — See under .\m- putations of the Fingers, ])ages 279 and 280. General Surgical Considerations. — (1) Typical excisions about the Fig. 28S.— Excisions about the Fingers :— A, Excision of terminal phalanx, by U-shaped pal- mar incision ; B, Excision of second phalanx of index, by dorso-external incision ; C, Excision of first inlerphalanyeal joint, by two lateral incisions. fingers are unusual. Incomplete excisions for dead bone are more common. (2) Excision of the terminal phalanx is better than disarticulation at the last interphalangeal joint. (3) Excision of the interphalangeal joints is very satisfactory. (4) Excision of the metacarpo-phalangeal joints often leaves a useless joint — except in the case of the thumb. It should not be done in the young, as it destroys the epiphyses of the metacarpal and phalanx. It is satisfactory in the case of the thumb, especially if the phalangeal ejjiphysis be left (there is no lower metacarpal epiphysis). (5) In excisions of the phalanges and metacarpals, the subperiosteal method is particularly indicated, although its execution is not very satisfactory. (6) Partial excision of the phalanges and metacarpals is more satisfactorv than total excision. (7) About the only phalanges one usually attempts to excise are the last of all the fingers, the second of the index, and the first of the thumb. Methods of Excision about the Fingers. — (a) For Terminal Phalanx EXCISION OF TERMINAL PHALANGES OF FINGERS. 403 of Finger or Thumb: — Best Method; U-shaped Palmar Incision, (b) For Second Interphahmgeal Joint: — Best Methods; Two Lateral Incisions (for fingers in general) ; Dorso-e.xternal Incision (for index) ; Dorso-internal Inci- sion (for little finger) ; — Other Methods; Dorsolateral Incision; Single Lateral Incision, (c) For Second Phalanx: — Dorso-lateral Incision (for fingers in general — if done at all); U-shaped Palmar Incision (for thumb) ; Dorso- external Incision (for index); Dorso-internal Incision (for little finger — if done at all); — Other Methods; Two Lateral Incisions, (d) For First Inter- phahmgeal Joints: — Two Lateral Incisions (for fingers in general); Dorso- external Incision (for index and thumb); Dorso-internal Incision (for little finger); — Other Methods; Single Lateral Incision, (e) For First Phalanx: — Dorso-lateral Incision (for fingers in general — if done at all) ; Dorso-internal Incision (for thumb — and for index, if done in the latter case at all) ; Dorso- internal (for little finger — if done at all); — Other Method; Two Lateral Incisions. EXCISION OF TERMINAL PHALANGES OF FINGERS V.y rSHAI'HD PALMAR INCISION'. Position. — As for Amputations about the Fingers (page 283). Landmarks. — Terminal interphalangeal joint. Incision. — U-shaped incision — beginning opposite the terminal inter- phalangeal joint-line, with the two limbs about three-fourths of the width of the finger apart, and with the convexity extending downward nearly to the nail-tip (Fig. 288, A). Operation. — The incision passes directly to the bone — the soft parts are dissected up in the form of a palmar flap — and the terminal phalanx grasped with forceps, disarticulated, and enucleated. The palmar flap is then sutured back into position and the digit dressed upon a palmar splint. Comment. — Is is better to make a partial excision, if possible, leaving the base of the phalanx — which insures the retention of the epiphysis and the attachment of the flexor jirofundus digitorum. If a total excision be done, suture the flexor tendon into the stump and close the beginning of the flexor sheath, if demonstrable. EXCISION OF SECOND INTERPHALANGEAL JOINTS OF FINGERS l;\- TWO LATERAL INCISIONS. Position. — .\s for Amputations about the fingers (page 283). Landmarks. — Second Interphalangeal joint-line. Incisions. — Two straight incisions in the mid-lateral aspects of the fingers, with their center over the joint-line (Fig. 289 A. A'). Operation. — The incisions pass directly through skin, fascia, lateral ligaments, periosteum, and capsule into joint. By hugging the bones and working between them and the soft parts with a sharp, fully curved small periosteal elevator, the bones are everywhere freed. The articular ends are then disarticulated — thrust out of the wounds — cut off with saw — and the sawed ends drawn back. The musculo-periosteal-capsular sheath is then closed on either side with buried gut sutures. The skin wounds are sutured and the parts dressed on a palmar splint. 404 Fig. 289.— Excisions about the Hand and Wrist :— A. A'. Excision of second interphalangi joint by two lateral incisions ; B, Of second interphalangeal joint of index, bv dorso-external iiicisio C, Of second interphalangeal joint of little finger, by dorsn-innrti:il inrision ; D, fll -.k .m.l i.h.il.iiix finger, by dorso-lateral incision ; E, E', Of first interphal;ui^..,l ],,i,ii,l.> i«,,1,iim,i1 iii> isi, first phalanx of thumb, by dorso-external incision ; G, ( 11 tu. 1 u ,u p" l.ll.ll.^ll^l ,il imhh l,^ ,1, ,1 s,. I.iiera (dorso-external) incision ,■ H, Of metacarpo-phalangeal inimtn at first superficial. The dorsal cutaneous branch of the ulnar nerve is avoided, if possible. The incision is carried down along the inner border of the ex- tensor carpi ulnaris — upon the ulna, cuneiform, unciform, and fifth meta- car|)al — going through the posterior annular ligament, capsule, and jjeri- osteum of the ulna, carpal and metacarpal bones. (3) Decortication is begun upon the radial side. The perio.steum and ligaments are stripped ui) from the dorsal surface of the carpal bones as far as can be done through the radial incision. .\11 the tendons are raised with their periosteum bodily from their grooves, with their sheaths unopened. The same steps are re- ])eated through the ulnar incision — hugging the bones closely and elevating off all the overlying tissues, working entirely between these tissues and the bones. (4) Removal of the carpal bones. .As each carpal bone is outlined and partially sejiarated, it is seized from the dorsum of the hand with strong hone-forceps, and, while being twisted from side to side, its lateral attach- ments are severed as close to the bone as jjossible, and its palmar attachments as subperiosteally as jiossible, and removed. The most convenient order in 4IO EXCISIONS. which to remove the carpal bones is, scaphoid, semilunar, cuneiform, os magnum, trapezoid, and body of unciform. .\11 are thus freed and removed — e.xcept that the pisiform (which is deeply seated and has the attachments of the flexor carpi ulnaris and abductor minimi digiti) is left; — and the unci- form process of the unciform bone (which is also deeply seated and has the attachments of the fle.xor brevis minimi digiti, flexor ossis metacarpi minimi digiti, and anterior annular ligament) should be cut through with bone-pliers and left — and the trapezium (which is rarely diseased and which enters into the important metacarpo-trapezial joint of the thumb, and has the attach- ments of the abductor polhcis, flexor ossis metacarpi pollicis, flexor brevis pollicis, and anterior annular ligament) should also be left. If any of these be diseased, however, they should be removed. (5) The lower ends of the radius and ulna are now freed of periosteum, by following them around from the upper part of the vertical incisions. The soft parts are all then retracted and the ends of the bones protruded through the wound and removed just above the articular cartilages — or, if but little diseased, may be simply gouged without being extensively freed. (6) The articular ends of the metacarpals should be gouged, if not much involved — or, if extensively diseased, removed, by being protruded into the wound and a thin slice of bone taken off with a narrow saw. (7) Temporary drainage is used — the wound sutured and dressed — and a special spHnt applied. Comment. — (i) The subperiosteal method is difficult, but if carefully carried out, no tendons are cut. In the open method the tendons of the extensores carpi radialis longior et brevior are cut — and tendons of the flexor carpi radialis, flexor carpi ulnaris, and extensor carpi ulnaris are in danger of being cut. (3) The ends of the radius and ulna may be first disarticulated and sawed, and then the carpal bones removed, if such a course seem more convenient. (3) The radial arter}- and the palmar structures are to be specially guarded. EXCISION OF THE WRIST-IOINT BV SINGLE DORSO-RADI.AL I.NXISION — BOECKKL-LANC.ENBECK OPERATION. Description. — Same as for the last operation, as to the bones removed — but dil'ferent in incision of approach. Position. — .^s in preceding operation. Landmarks. — See Incision. Incision. — Straight incision, between the extensor communis digitorum and extensor indicis, on the inner side, and extensor longus pollicis (extensor secundi internodii pollicis) on the outer side, running close to the outer border of the former — extending from the ulnar border of the dorsal surface of the lower third (or half) of the second metacarpal up over the radius for about 5 cm. (2 inches) above the joint-line (Fig. 289, O, O')- Operation. — The incision is made carefully, and branches of the radial ner\e to tiie middle finger avoided, if possible. The incision is now deepened toward the second metacarpal, trapezoid, scaphoid, capsule, posterior annular ligament, and radius. In this deeper incision, however, the tendons of the extensor indicis and extensor communis digitorum are retracted when exposed — and the tendons of the extensor radialis longior and extensor radialis brevior are not cut. These latter tendons are isolated and are then freed down to their attachment into the bases of the second and third metacarpals respec- tively. If the trapezium is to be left, together with the pisiform and unciform TOTAL EXCISION OF THE ULNA. process of the unciform, it is possible, though difficuh, to complete the exci- sion without se\'ering these tendons. Otherwise, however, and where the tissues are much infiltrated and bound down especially, these two tendons are detached subperiosteally at their insertion. If not divided, these tendons are shifted from side to side in the subsequent manipulations. If divided, they are sutured back as nearly in their normal ]jo.sitions as ])ossible, at the end of the operation. The remaining ste[)s of the operation — decortication — freeing and excising of the ends of the radius and ulna — removal of the carpal bones — freeing and excising, or gouging, of the ends of the metacarpals — together with the closure of the wound — are all carried out through this single opening, aided by good lateral retraction, just as in Ollier's opera- tion by the double dorsal incisions. Comment. — The chief objections to the operation are the difficulty of dealing with the bones to be excised without division of the extensores carpi radiahs longior et bre- vior — and damage done to the extensor muscles of the hand, dorsiflexion some- times being seriously impaired subsequently. EXCISION OF THE ULNA, IN GENERAL Surgical Anatomy — Surface Form and Landmarks. — Given under .\m[)u- tations about the Forearm, pages 307 and 308. General Surgical Considerations. — The entire ulna, or any portion of its di- aphysis, may he removed. After-treatment. — A long supporting splint for the forearm, with passive move- ment at the elbow and wrist. Results. — Satisfactory results have fol- lowed the subperiosteal method. TOTAL EXaSION OF ULNA r,V LONG POSTERIOR I.N'CISIOX. Fig. 290. — Excisions abolt the L.o.s'G Bones of the Upper E.xtre.m- ITY : — A, Excision of ulna, by long pos- terior incision ; B. E.xcisioii of radius, by long externo-dorsal incision; C. Ex- cision of part of diaphysis of humerus, by external vertical incision. Position. — Patient's forearm is pro- nated and outstretched upon a small table. Landmarks. — Ulna; elbow- and wrist- joints. Incision. — In the long axis of the ulna, and placed so as to fall upon its posterior border in the interval between the anconeus and flexor carpi ulnaris above, and Ijetween the fle.xor carpi ulnaris and extensor carpi ulnaris below (Fig. 290, A). Operation. — Having incised the skin and fascia, the above intermuscular spaces are recognized and followed to the bone — after having sought the dorsal branch of the ulnar nerve beneath the flexor carpi ulnaris, about 5 412 EXCISIONS. cm. (2 inches) above the wrist-joint, and henceforth guarded it. The perios- teum is incised to the bone througliout along the line of incision. The center of bone is then freed of periosteum entirely around its circumference, using a well-curved periosteal elevator. A chain or Gigli saw is now carried between bone and periosteum and the former divided at its center. Each end of the bone is then seized with bone-forceps and, while manipulated, is further freed of periosteum up to and into the capsules of the elbow- and wrist-joints — thus raising a periosteo-capsular covering. Both articular ends are dis- articulated — the periosteo-capsular sheath sutured with buried gut stitches — the muscles quilted — the skin-wound closed, e.xcept for temporary drainage of the elbow and wrist articulations — and the limb put up upon a long splint. Comment. — If it be possible to leave one or both articular ends of the bone, it is desirable. EXCISION OF THE RADIUS. IN GENERAL. Surgical Anatomy — Surface Form and Landmarks— General Sur- gical Considerations — After-treatment — Results. — .\s in the case of the Ulna, page 411. TOTAL EXCISION OF RADIUS BY LONG EXTERNO-DORSAL IiNXISION. Position. — Patient's forearm lies outstretched and upon its ulnar border, resting on a small table. Landmarks. — Radius; elbow- and wrist-joints. Incision. — In long axis of radius, and placed so as to fall upon its ex- terno-dorsal aspect, in the groove between the supinator longus and extensor carpi radialis longior (Fig. 290, B). Operation. — Having incised the skin and fascia, this intermuscular space is identified and followed to the bone — after having sought the radial nerve beneath the supinator longus and henceforth guarded it. The periosteum is incised to the bone throughout. The insertion of the pronator radii teres is raised from the bone with the periosteum and turned forward. The supinator brevis is bisected vertically, the anterior half being displaced forward with the radial nerve, the posterior half backward with the posterior inter- osseous nerve. The bone is now' freed of its periosteum entirely around its circumference at its center, using a fully curved periosteal elevator. A chain or Gigli saw is passed between bone and periosteum and the former divided. Each end of the bone is then seized with bone-forceps — and the operation completed as in the corresponding operation upon the ulna (page 411). Comment. — Same as for the Ulna (page 412). EXCISION OF ELBOW-JOINT. Surgical Anatomy— Surface Form and Landmarks.— Given under Disarticulation at the Elbow, i)ages 312 and 313. General Surgical Considerations. — (1) Excision of the elbow joint consists in the removal of the lower end of the humerus and the upper ends of the radius and ulna. (2) It is difficult, if not impossible, to save the peri- osteo-capsular sheath intact. (3) Partial excisions may be done— of the articular ends of either humerus, radius, or ulna. (4) The brachialis anticus EXCISION OF ELBOW.JOINT. 413 is inserted into the ulna beyond the coronoid process, — and the triceps into the sides as well as the tip of the olecranon, and thence into the deep fascia of both sides of the forearm, especially on the inner side. Therefore as little of these parts is to be sacrificed as possible. The preservation of the bands of fibers continued from the triceps to the fascia of the forearm is important in excising the elbow, as the power to extend the limb is thereby preserved in part. For the relation of the triceps and brachial anticus to the move- ments of the forearm, see Movements of the Elbow-joint, page 313. (5) The ulnar and posterior interosseous nerves are to be especially guarded in these operations. After-treatment. — .A special jointed splint is indicated that will hold the forearm and arm at any angle to each other, with the power to change the angle without removing the splint. The limb is at first put up at an angle of-135 degrees, with the forearm midway between pronation and supination, the ends of the bones being about 1.3 cm. (J inch) apart, and the fingers free. Where ankylosis is feared (as in children and after the subperiosteal method), or where much bone has been removed, the limb may be put up at a right angle from the start. Results. — Satisfactory, as a rule, .\nkylosis is likely to follow if the sawed ends are kept in contact — and a flail limb, if kept too far apart. There is generally a tendency to the posterior displacement of the bones of the forearm. Best Methods. — Posterior Median Incision (Langenbeck). Posterior Bayonet-siiaped Incision, with or without an additional Ulnar Incision (Oilier). Tlie Radioulnar Articulation may be excised by a Posterior \'ertical Incision. Other Methods. — Dorso-radial .\ngular Incision (Kocher). Lateral Radial and Ulnar Incisions (Hueter). H-shaped Incision (Moreau). Pos- terior Angular Incision (Nelaton). EXCISION OF ELBOW- JOINT BY POSTERIOR MKDl.^N IN'CISION — I.AN'GEN'BECKS OPERATION. Position. — Patient supine, near edge of table. Assistant on side of table opposite to surgeon, holding the operated limb by the wrist and forearm, with patient's forearm across his (the patient's) chest, so that the arm is vertical and the forearm horizontal (nearly at a right angle to the arm) — thus throwing the flexed elbow prominently out toward the surgeon, with the ulna and olecranon uppermost. Surgeon stands to outer side of elbow, on the invoked side, and cuts from the forearm toward the arm. Landmarks. — Lower end of humerus; elbow-joint; upper ends of radius and ulna. Incision. — About 10 cm. (4 inches) in length, in the long axis of the limb, passing directly over the center of the humerus, olecranon fossa, olec- ranon process, and posterior crest of ulna — half of the incision being above the tip of the olecranon and half below (Fig. 291, A). Operation. — (1) This incision is made at once directly through soft parts, j)eriosteum, and capsule to the bone — and, in the above position, will pass from above downward, from the forearm over the olecranon and onto the arm — bisecting the triceps tendon, incising the capsule and passing through the muscular portion of the triceps onto the humerus. (2) The incision is at once deepened to the bone throughout — efficient retraction of 414 EXCISIONS. the lips of the wound being very important for the ease of the subsequent steps. The periosteal elevator, of various curves, and the rugine, should closely hug the many irregularities about the joint-structure — raising up the periosteum and the periosteo-capsular sheath with the attachments of the ligaments undisturbed. The surgeon's left thumb aids in the separation, while the knife is used as sparingly as possible — the object being to peel the bones bare of all soft parts, including periosteum. (3) The inner aspect of the wound is first freed. The inner half of the triceps tendon is freed from the olecranon — especial care being observed and the bone being very closely hugged in freeing the groove between the olecranon and internal condyle, that the ulnar nerve may not be wounded. The internal lateral liga- ment is freed from the humerus and ulna, and, with it, the common origin of the fle-xor muscles, together with the perios- teum. (4) The outer aspect of the wound is next freed. The outer half of the tri- ceps tendon is separated from the olecra- non, with especial care that its expansion into the deep fascia of the forearm be not severed. The anconeus, the continua- tion of the outer portion of the triceps, is similarly separated. The external lat- eral ligament, and, with it, the common origin of the extensor muscles, are sepa- rated from the external condyle, together with the periosteum. The supinator brevis is freed from the external condyle and ulna and turned forward, especially guarding the interosseous nerve between its superficial and deep portions. (5) The bones are now everywhere free ex- cept upon their anterior surfaces. The articular end of the humerus is generally first removed. The patient's hand, of the involved side, is placed prone upon the table near his head, and firmly held there, while steadying the forearm in an upright position — while an assistant steadies the arm midway between a ver- tical and horizontal. By firmly drawing the soft parts downward (toward the shoulder) the assistant protrudes the lower end of the humerus upward. Its anterior surface is now sufficiently cleared — and, while the articular end is steadied with lion-jaw forceps, and the soft parts retracted with spatula; or retractors, the bone is sawed at a right angle to its axis and generally on a level just below the tips of the condyles, or at whatever height may be in- dicated. (6) The articular ends of the radius and ulna are now removed. By drawing down (toward the wrist) the soft parts from the radius and ulna, while held in the above almost vertical position, their articular ends are made to protrude, and are freed as far as necessary on their anterior surfaces, care being taken that the attachment of the brachialis anticus is not entirelv freed from the coronoid process. The olecranon is seized and Fig. 291. — Excisions about Elbow: — A, Excision of elbow-joint, by posterior median incision (Langenbeck's operation); B, B', E.\cision of elbow-joint, by radial and ulnar lateral incisions ; C, E.\cision of superior radio-ulnai' articulation, by pos- terior vertical incision. EXCISION OF ELBOW-JOINT. 415 steadied with forceps, tlie soft parts well retracted, and the articular end of the olecranon sawed off horizontally to its base, the section including a thin slice from the articular end of the radius. (7) The wound in the periosteo- capsule is sutured with buried gut stitches. The muscles are quilted, also by buried gut sutures. The wound is closed, with temporary drainage pro- vided — and dressed upon a special splint previously provided. (See After- treatment, page 413-) Comment. — (•) Avoid injury to the ulnar and posterior interosseous nerves. (2) Do not completely detach the insertions of the brachialis anticus and triceps from all their neighboring attachments, as such attachments preserved greatly aid fle.xion and extension. (3) The biceps in.sertion is also to be strictly guarded, but is not so much in danger as the others men- tioned. (4) Freer access may be given to the articulation by an earlier division of the olec- ranon. (5) Partial e.xcision of the articular end of the ulna may be readily done through the posterior median incision. EXCISION OF ELBOW- JOINT BY POSTERIOR B.AVO.XET-SH.^rED INCISION. WITH OR WITHOUT AN" ADDITICJN.AL SHORT \ ERTICAI. LLNAR INCISION — OLLIER'S OPERATION. Description. — The operation can usually be completed through the bayonet-shaped in- cision alone. Where insufficient access is thereby given, a short vertical ulnar incision may be added. Position — Landmarks. — As in the above operation. Incisions. — (1) Bayonet-shaped incision — the upper part of the incision is vertical, practically parallel with the a.xis of the hu- merus, placed in the groove between the tri- ceps and supinator longus, and e.xtends from about 5 cm. (2^ inches) above the joint-line to the tip of the outer condyle, — the middle portion is oblique, placed between the outer head of the triceps and anconeus, and ex- tends from the tip of the outer cond\le obliquely downward and inward to the base of the olecranon, — the lower portion is again vertical, placed over the posterior border of the olecranon and extends from the base of the olec- ranon down the forearm for about 4 to 5 cm. (li to 2 inches). (2) Ulnar incision (when used) — is a vertical incision of about 5 cm. (2 inches) and is placed over the lateral aspect of the internal condyle. It is resorted to in order to secure more workinir-room. especiallv in cases of disease (Fig. 292, A and B). Operation. — (1) The above incision is at first only superficial. The intermuscular planes above indicated are identified and in these planes the incision is carried to the bones, through the periosteum and periosteo-capsulai sheath. (2) Through this wound, by means of rugine and periosteal elevator, are detached, subperiosteally, the triceps insertion, external lateral ligament, Fig. 292. — Excisions about El- bow : — A. Excision of elbow-joint, by bayonet-shaped incision (Ollier's operation); B, LMnar incision, added to bayonet-shaped incision, if needed. 4i6 Exrisioxs. common origin of extensor muscles and insertion of brachialis anticus, and the olecranon and border of the sigmoid cavity are decorticated and the head of the radius exposed. (3) Through the same wound — or through the addi- tional ulnar incision, if necessary — the internal lateral ligament and common origin of flexor tendons are freed, and the internal condyle decorticated, special care being taken of the ulnar ner\'e in the grooxe between the olecranon and internal condyle. (4) Disarticulation is now accomplished. The articular ends of ulna and radius are thrust outward, freed to the desired extent, if not already so (being careful to preserve the greater part of the attachment of the brachialis anticus), steadied with forceps and sawed hori- zontally through at the base of the olecranon, including a slice of the radius. The articular end of the humerus is similarly treated. (5) The periosteo- capsular sheath is sutured — the muscles quilted — temporary drainage estalj- lishefl — the wound closed — and the part dressed upon a special splint. Comment. — (i) The disadvantages of this method are, that the external expansion of the triceps tendon is cut; the anconeus atrophies (for the nerve to it comes from that branch of the musculospiral which supplies the outer head of the triceps and is cut in the oblique portion of the incision) ; and the ulnar nerve is less easily kept from harm. (2) Partial excision (of the articular ends of humerus, ulna, or radius) may be done through part of Ollier's incision. EXaSION OF SUPERIOR RADIO-ULNAR ARTICULATION BV POSTERIOR VF.RTIC.M- IN(IS10N\ Description. — An o|)eration sometimes done for unreduced dislocation of the head of the radius. Position. — As in excision of the elbow-joint by the ])osterior median incision. Landmarks. — Elbow and radio-ulnar articulations. Incision. — X'ertical, about 5 cm. (2 inches) in length, with its center over the radioulnar articulation, and placed behind and over the posterior part of the su])inator longus (Fig. 291, C). Operation. — Incision passes through skin and fascia. The supinator longus is recognized and is either slightly displaced, the incision passing along its posterior border — or the incision passes directly through its posterior fibers and upon the supinator brevis. This latter muscle is then carefully divided over the head of the radius, preferably in the direction of its fibers (guarding the posterior interosseous nerve between its two layers, and also the musculospiral nerve and the biceps tendon). The orbicular ligament is now severed — the parts well retracted — the head exposed and removed with a Gigli or other saw. The musculo-periosteo-capsular structures are sutured with buried gut stitches — the muscles quilted — the wound closed — and the elbow dressed upon a special splint. EXCISION OF HUMERUS. Surgical Anatomy -Surface Form and Landmarks. — Given under Amputations about the .\rm, jiagcs 317 and 318. General Surgical Considerations. — The entire humerus has been ex- cised subperiosteally, followeil by a u.seful arm. Generally, however, only portions of the shaft are excised. The operation for its entire removal will EXCISION' OF HUMERUS. 417 be described — any portion of the incision being available for the remo\al of special portions of the bone. The result of the operation, even of a portion of the bone, is often a flail and useless limb. EXCISION OF HUMERUS BV LONG EXTERNAL INCISION. Position. — Patient is turned partly u])on his side and the arm so placed as to expose its external aspect. Landmarks. — Pectoro-deltoid groove; external bicipital sulcus. Incision. — So placed as to lie between the deltoid and pectoralis major above — and along the external bicipital sulcus below (Fig. 290, C, where incision for partial excision is given). Operation. — The incision is carried through skin and superficial fascia, and is then carefully deepened between the soft parts, through the periosteum, to the bone throughout. The deltoid fascia is incised and the groove between the deltoid and ]iectoralis major opened up by retraction — the bicipital fascia incised — and the humerus reached along the outer border of the coraco- brachialis and brachialis anticus. Avoid, by retraction, the acromial thoracic and cephalic vessels in the pectoro-deltoid groove — the circumflex vessels and nerve at the surgical neck — the musculospiral ner\e and superior pro- funda artery to the outer side of the middle of the shaft — and the musculo- cutaneous nerve between the biceps and brachialis anticus in the lower third of the arm. The bone is freed subperiosteally, the insertions of the tendons being raised with the periosteum. The entire circumference of the bone is freed at its center. A chain or Gigli saw is then passed between periosteum and center of humerus and the bone divided — after which either end is grasped by bone-forceps and cleared toward either articulation. The articular ends are disarticulated in a manner similar to the disarticulation in the e.xcision of a joint — except that the ends of the bones are approached from the shaft. The long musculo-periosteal sheath of the diaphysis, and the musculo- periosteo-capsular sheaths of the articular ends, are united with buried gut sutures — the muscles quilted — temporary drainage established at the joint- ends — and the wound closed. The limb is dressed in a long rigid splint, which includes both shoulder and elbow. (See end of preceding page.) EXCISION OF SHOULDER- JOINT. Surgical Anatomy — Surface Form and Landmarks. — Gi\en under Disarticulation at the Shoulder-joint, pages 32;^ and 324. General Surgical Considerations. — Excision of the shoulder-joint con- sists in the removal of the articular end of the humerus, with gouging, only, of the glenoid fossa — no ]jarl of the scapula being removed with a saw. The subperiosteal method is especially desirable, the best results attained having followed this method. After-treatment. — The sawed end of the humerus is held in contact with the glenoid fossa, the arm being bound to the side, an axillary pad inter- vening, and the weight of the extremity being supported by a sling. The axillary pad is important in keeping the head of the bone from being drawn under the coracoid process, which is more likely when the external rotators have been cut and the pectoralis major and latissimus dorsi act unopposedly. 27 4i8 EXCISIONS. Passive movements should begin as soon as acute inflammation subsides — abduction being the last movement, as it displaces the head inward. Results. — All movements are to be expected, except abduction beyond a right angle. Weights may also be lifted. Best Methods. — Anterior Oblique Incision (Baudens, Hucter, and Oilier). Other Methods. — Anterior Vertical Incision (Langenbeck). Posterior \ertical Incision. Deltoid Flap. Anterior Curved Incision. Posterior Cur\ed Incision. Comparison of Methods. — The anterior olilique methocl in\ol\cs the minimum damage to tlie deltoid muscle, the chief muscle of the shoulder- joint. Fig. 295. — Excisions about thk Shouldkk : B, Excision of slioulder-joint, by aiitei ic axial i of slioulder-joiut, by anterior sioii; C, Excision of clavicle EXCISION OF SHOULDER-JOINT BY ANTERIOR OBLIQUE INCISION. Position. — Patient supine, near edge of table, shoulders raised, arm slightly abducted. Surgeon to outer side of both shoulders. .Assistant supports limb. Landmarks. — Coracoid process; pectoro-deltoid groove; shoulder-joint. Incision. — iiegins just to outer side of tip of coracoid process and passes obliquelv downward and outward along the anterior border of the deltoid for 9 to 10 cm. (3^ to 4 inches) (Fig. 293, A). EXCISION OF CLAVICLE. 419 Operation. — (i) This incision passes, at first througli skin and fascia, from the coraco-acromial arch to its lower end. The pectoro-dehoid groove is then demonstrated. The cephahc vein and pectoral muscle are drawn inward — the deltoid outward. The biceps tendon is identified, its sheath opened, and the contained tendtni drawn inward. The incision is continued in the original line through the capsule into the joint just to the outer side of this tendon, and through the periosteum onto the humerus. (2) The outer lip of the wound is now cleared. The periosteum, capsule, muscular and tendinous insertions are separated by rugine and periosteal elevator as one continuous layer. An assistant depressing the elbow and rotating the humerus inward, brings the greater tuberosity into the wound, and the insertions of the supraspinatus, infraspinatus, and teres minor are cleared. (3) The inner lip of the wound is similarly cleared. By depressing the elbow- 'and rotating the humerus outward, the lesser tuberosity is brought into the wound. The biceps tendon is now drawn out and the insertion of the subscapularis is separated. (4) The head of the humerus is then disarticulated by depressing the elbow and thrusting the head forward through the retracted wound, while the biceps tendon is drawn inward. The neck of the bone is now cleared posteriorly, hugging the bone carefully to avoid damage to the circumflex vessels and nerve. After disarticulation, the head of the humerus is steadied by lion-jaw forceps and sawed, the section passing from without and slightly downward and inward, the surgeon so standing, on both sides, as to grasp the limb with his left hand distally to the saw-cut, while the soft parts are well retracted by an assistant. Following the section, the margins of the sawed bone may be rounded slightly. The humerus is sawed between the attach- ments of the pectoralis major, latissimus dorsi and teres major below, and the muscles of the tuberosities above — the section being as high as possible, (5) The glenoid cavity is gouged thoroughly with a sharp spoon, and the capsule of the joint is scraped, if indicated. (6) Temporary drainage is; provided through a posterior opening. The head of the bone is drawn intf* place — the periosteo-capsular wound is sutured with buried gut stitches — the muscles cjuilted — and the wound closed. Comment. — (i) The capsule should not be cut transversely, if avoidable. (2) .All the muscles, tendons, and ligaments should be raised attached to the periosteo-capsular covering. (3) The head of the bone may t)e, less advis- ably, divided in situ by means of a chain or Gigli saw. EXCISION OF CLAVICLE. Surgical Anatomy. — .Anteriorly; — su])raclavicular nerves and \ein con- necting cephalic and external jugular veins cross the antero-superior surface of the clavicle. Interiorly; — axillary vessels and brachial plexus rest upon the first rib, under the clavicle, the subclavius muscle and dense fascia inter- vening. Posteriorly; — omohyoid, scalenus anticus, scalenus medius, scalenus posticus, sternohyoid, and sternothyroid muscles; subclavian, suprascapular, and internal mammary arteries; innominate, subclavian, and external jugular veins; brachial plexus, phrenic and posterior thoracic nerves; pleura, apex of lung, an posterior MiliLil incision B B Vertebral incision in total L\(_isijn of scapula b> \ertebraland spinal incisions ; C L Spinal incision in total excision of scapula by \ertebral ind spinil incisions D V shaped incision, for excision of superior angle ot scapula F V shaped ' excision of inferior angle of scapula. 422 EXCISIONS. spinatus, infraspinatus, and subscapularis) — and also the scajtular head of the biceps at the upper jjart of the glenoid fossa, and the scapular head of the triceps at the lower part of the glenoid fossa. (8) Divide the remaining muscles connecting the a.xillarv border of the scapula to the arm, the teres major and minor, cutting these muscles from in front — seizing and tying the subscapular artery pro.ximal to the origin of the dorsalis scapula?. (9) The deeper muscles, the supraspinatus, infraspinatus, and subscapularis, are re- moved with the bone — e.xcept that their tendons of insertion into the humerus are left. Drop the flaps into place and suture their margins. Temporar\- drainage should be used, as oozing is apt to be marked. -Excisin : — A, Excision of sin riiui spinous process o ulder-joint, by deltoid scapula. Comment. — If necessary, the subcla\ian may be compressed through an incision. The chief vessels, however, may be ligated in advance of incisions for the flaps, that is, before the beginning of the operation proper — but can generalh- be taken up during the o])eralion, before actually cutting them. Partial Excisions of the Scapula. — The acromion process max- be excised through an incision placed centrally over its prominent contour (Fig. 295, B). The angles of the bone may be removed by V-shaped incisions (Fig. 294, D and E). The body of the scapula is excised through practically the same incisions as are used for the total excision. EXCISIONS OF BONES AND JOINTS ABOUT THE TOES. Surgical Anatomy Surface Form and Landmarks. — Given unde Am])utations about the Toes, pages 333 and 334. EXCISION OF FIRST IxXTERPIIALANGEAL JOINT OF TOE. 423 General Surgical Considerations. — Tlie same general principles apply in excisions about the toes as in excisions aJjout the fingers. The details of the various excisions about the toes will, therefore, not be separately given. Besides, excision of the parts of the toes is quite rare — am- putations generally being done in- stead. This applies to all the toes except the great toe — with reference to which it may be understood that most of the following o])erations apply. EXCISION OF TERMINAL PHA- LANX OF TOES. Best Method. — U Shaped Plantar Incision. Description. — As for the termi- nal phalanx of finger, page 40.:;. EXCISION OF SECOND INTER- PHALANGEAL JOINT OF TOES. Best Method.- Two Itorso-lat era! Incision-.. Description. — .\s for the second interphalangeal joint of the fingers (page 403) — except that the inci sions are here more dorsal than lat eral. (Fig. 296, A, A'.) EXCISION OF SECOND PHA- LANGES OF TOES. Best Methods. — Two Dorso- lateral Incisions — for toes in general. U-shaped Palmar Incision — for great toe. Description. — As for the sec- ond phalanx of the fingers (page ,■05) — or of the thumb (])age 40^). (Fig. 296, B, B'.) Fig. 296. — Excisions abol't the Foot :— A, A'. Excision of second phalangeal joint by iwo dor- sal incisions ; B. E', Excision of second phalanx, hy two dorsal incisions; C, C, Excision of first phalangeal joint, by two dorsal incisions; D. Exci- sion of fust phalangeal joint of great toe by dorso- inteinal incision ; E. E'. Excision of metatarso- phalangeal joint bv two dorso-lateral incisions ; F. ZXCISION OF FIRST INTERPHA- kxcisio,, of mel.-,la,sal. by dorsal incision: G, Ex- LANGEAL JOINT OF TOE. ^'}^'"'" "' '"f ala.sal by dorsal i.^isioi. with addi- tional angular incision; H. H'. Osteoplastic rescc- BeSt Method.— Two 1 )orso-lat- ''O" "' amerior tarsus and tarso-inetalarsus, by in- 1 T • • r ^ ■ I ternal and external dorso-lateral incisions. eral Incisions — for toes in general. Dorso-internal Incision — for great toe. Description. — As for the first interphalangeal joint of the fingers (page 406) — or of the thumb (also page 406). (Fig. 296, C, C.) EXCISIONS. EXCISION OF FIRST PHALANX OF TOE. Best Methods. — Dorso-internal Incision — for great toe. Two Dorso- lateral Incisions — for toes in general, if done at all. Description. — As for the first phalanx of the fingers in general, if done at all (page 406^ — or for the thumb (also page 406). EXCISIONS OF BONES AND JOINTS ABOUT THE FOOT. Surgical Anatomy — Surface Form and Landmarks. — Given under Amiaitations and Disarticulations about the Foot (pages 344 to 347). General Surgical Considerations. — (ij The general features of ex- cisions of the metatarsals are the same as of excisions of the metacarpals. (2) Individual metatarsal bones are not frequentlv excised. That of the great toe is the one most often excised. (3) The sesamoid bones are left in situ, as in the hand. (4) The chief tarsal bones systematically excised are the os calcis and astragalus. Other portions of the tarsus are excised as indicated. And other tarsal bones are wholly or partially excised in such operations as those for the deformities about the foot. EXaSION OF METATARSO-PHALANGEAL JOINTS. Best Methods. — Two Dorsolateral Incisions — for the toes in general. Dorso internal Incision — for the great toe. Description. — .\s for the metacarpo-phalangeal joint of the fingers, in general (page 406) — or of the thumb. (Fig. 296, E, E'.) EXCISION OF THE METATARSAL BONES. Best Methods. — Dorsal Incision — for toes in general. Dorso-internal Incision — for great toe. Other Methods. — Interno-plantar Flap — for great toe. Description. — .\s for the metacar|)al bones by dorsal incision (page 407) — or of the metacarpal of the thumb by dorso-external incision (page 408) (Fig. 296). EXCISION OF ASTRAGALUS BY KXTERNAL CUKX'El) l.\CISU)N'. Position. — Patient supine, foot resting on inner side. Surgeon on side of oi)erati(>n. .Assistant steadies foot and leg. Landmarks. — Fibula; astragalus; base of fifth metatarsal. Incision. — Begins about 7.5 cm. (3 inches) above ankle, at anterior border of fibula — pas.ses vertically downward external to peroneus tertius and musculocutaneous nerve — and curves thence forward over outer surface of astragalus to base of fifth metatarsal (Fig. 297, A). Operation. — Having incised skin and fascia, retract the peroneus tertius inward and extensor brevis digitorum outward. In the interval thus left, incise the capsule of the ankle-joint and open the medio-tarsal joint. Free the neck of the astragalus and the lower ends of the tibia and fibula. Divide EXCISION' OF ASTRAGALUS. 425 the calcaneo-astragaloid ligament and anterior and posterior bands of the external lateral ligament. Run along the outline of the astragalus at its junction with the os calcis and scaphoid with a stout knife. Invert the foot forcibly and, while in this semidislocated ])Osition, free the inner surface of the astragalus, using special care near the posterior tibial vessels and nerve. The astragalus is now grasped with bone-forceps and removed — severing anv further binding ligaments which may hold it, while under tension. The leg then drops down upon the upper surface of the os calcis. The soft parts are brought together with dee]) and superficial sutures — the deep sutures being of chromic gut and including as much fibrous tissue as possible. Temporary drainage is used — and the foot is put up at a right angle to the leg. Comment. — E.xcision of the astragalus by the external curved incision is preferable where the unyielding condition of the tissues does not require two lateral mcisions, as in the following operation. EXCISION OF ASTRAGALUS BY EXTERN'.AL ANGULAK AyiU INTER.VAL CURVED INCISION. Description. — The bone is most easily removed from the outer aspect — the bone being approached between the tendons of the tibialis amicus and tibialis posticus, on the inner side — and, on the outer side, between the tendons of the peroneus tertius and peroneus brevis. The operation is done by the open method. Position. — Patient supine, foot extending over edge of table and turned to face inward and upward for inner incision and outward and upward for outer incision. The surgeon stands facing the foot. The assistant steadies leg and ti es. Landmarks. — Inner and outer malleoli; articular border of tibia; as- tragalo-scai)hoid joint; astragalo-calcaneal joint. Incisions. — (1) External Angular Incision; — The \'ertical portion begins just above the level of the articular border of the tibia, on its antero-external aspect, and passes downward between the tendons of the peroneus tertius and peroneus brevis, parallel with and just behind the former tendon, for about 6 cm. (2^ inches), and ends over the cuboid bone; — the Horizontal portion, shorter, is at a right angle to the vertical portion, beginning about its center and passing backward and slightly downward, ending just below the tip of the external malleolus. (2) Internal Curved Incision; — begins just above the level of the articular surface of the tibia, on its antero-internal aspect, and passes down immediately in front of the anterior margin of the tibia to slightly below the tip of the internal malleolus, whence it curves backward and ends just below the center of the internal malleolus. (Fig. 297, B, and Fig. 298, C.) Operation. — (i) These incisions first pass through skin and fascia only. (2) The outer incision is then deepened first, and the two rectangular flaps turned back and the antero-external aspect of the astragalus exposed between the tendons of the peroneus tertius and peroneus brevis. Forciblv extend and invert the foot, retracting the tendons, and divide the ligaments between the astragalus, on the one hand, and the fibula, os calcis, scaphoid, and tibia, on the other — as far as can be accomplished from the outer wound. (3) The inner incision is now deepened and the curved flap turned back and the antero-internal aspect of the astragalus exposed between the tendons of the tibialis anticus and posticus. Forcibly extend and evert the foot, re- 426 EXCISIONS. tractinj; the tendons out of the way, and complete the division of the Hgaments binding the astragalus to the tibia, os calcis, and scaphoid — as far as can be Fig. 297. — Exclslo.Ns ABOLT THF. FooT : — A, E.xcision of astragalu E.vtenial angular incisior.. in excision of astragalus by external angular a C, Excision of OS calcis, by horizontal curved and vertical incisions. Fig. 298.— Excisions ARorr rnK Foot ;— .\, Kxi isi,,r, .,1 lurtiiiiial plialaiix by U-shaped palmar incision; B, Excision of metatarsal of great toe, by (hirsr)-internal incisioTi, with or without one or more additional incisions at one or both ends; C, Internal curved incision, in excision of astragalus by external angular and internal curved incisions ; D, Internal angular incision, in excision of ankle- jtiint b\- external curved and internal angular inci-^iotH further accomph'shed from the inner wound, (4) The foot Ijeing again firmly e.xtendcd and inverted, the astragalus is seized with lion-jaw forceps EXCISKIN OF ANKLE-JOINT. 427 and strongl)' \vhii)|)ed out throuffh the outer wound — any remaining connec- tions being severed while on the stretch. (5) Suture the flaps into place — in.stitute temporary drainage — and jjut u]) the foot at a right angle to the leg. Prior to suturing the skin-flaps, it is well to apply several buried chromic gut sutures wherever loose portions of fibrous tissue may be brought into contact to strengthen the parts. Comment. — (1) This e.xcision may be made through simply the vertical y)ortions of these two incisions — by retracting the lips of the wounds and thus reaching the l)ones. (2) Movement of the ankle-joint is not expected. Other Methods of Excision. — External .\ngular Incision. Transverse Incision. Internal and External \'ertical Incisions. EXCISION OF OS CALCIS BV HfJRIZOXT.XL CUR\'EU ANU \-ERTICAL INCISIONS. Description. — The bone is removed from the posteroexternal aspect. The operation should be done as subperiosteally as possible. Position. — Patient lies on sound side with foot supporterl on inner side and free. Surgeon faces foot. Assistant steadies leg. Landmarks. — Base of fifth metatarsal; position of jjosterior tibial vessels; tendo Arhillis; calcaneo-cuboid joint. Incisions. — Horizontal Incision — begins at base of fifth metatarsal — passes horizontally backward, well above the margin of the .sole, around the convexity of the heel to its inner side, to a point about 3.2 cm. (ij inches) internal to the median line of the heel — stopping well posterior to the posterior tibial vessels and nerve. Vertical Incision — begins about 5 cm. (2 inches) above the horizontal incision, on the outer side of the foot — and passes ver- tically downw-ard just anterior to the tendo Achillis, and between it and the tendons of the peroneus longus and brevis, and meets the horizontal incision at a right angle. (Fig. 297, C.) Operation. — (i) These incisions are now deepened and the two small flaps made by them are turned forward and u]jward, and backward and upward, respectively. (2) The os calcis is exposed behind the peronei tendons and the periosteum incised in the lines of the incisions. By means of a rugine everything is raised from the bone as subperiosteally as possible — on its outer, under, posterior, inner, and upper surfaces, in order. The tendo Achillis is severed and the soft parts and tendons are well retracted during this decortication. (3) The head of the bone is grasped with lion-jaw forceps and is drawn outward — the remaining connections being severed while on the stretch. (4) The flaps are dropped into place and sutured — temporary drainage being established. The foot is put up at a right angle, upon an anterior splint (so as not to exert any undue pressure upon the wound). EXCISION OF ANKLE-JOINT. Surgical Anatomy -Surface Form and Landmarks. — (liven under Disarticulation at the .\nkle. pages 358 and 35Q. General Surgical Considerations. — The operation is not frequently performed. .'Vnkylosis results in the majority of cases. The mcdio-tarsal joint, however, generally takes on considerable compensatory action. Some 428 EXCISIONS. shorteniiii,' results. Sometimes the entire astragalus is removed at the same time. After-treatment. — The foot is kept at a right angle to the leg in a fi.xed splint — and in the same straight line with the leg. Although ankylosis is sought by some surgeons, movement is aimed at by the majority — and passive movements are begun earlv. EXaSION OF ANKLE-JOINT BY TRANSVERSELY CUR\HU K.XTKRNAI. INCISION — l.Al'ENSTEIN'S OPERATION. Description. — The joint is expo.sed through a single e.xternal incision, and the articular surfaces of the bones brought into the field by disarticula- tion accomplished by forcible temporary inversion of the foot. Position. — Patient midway between supine and lateral positions; foot resting upon inner side. Surgeon stands behind heel to make incision, and faces font til Kimplete operation. Assistant steadies leg. Landmarks. — .\nkle and astragalo-scaphoid joints ; peroneus tertius tendon; external malleolus; tendons of peroneus longus, brevis. and Achillis. Incision. — Begins on dorsum of foot, midway between ankle-joint and astragalo-scaphoid articulation, and over peroneus tertius tendon — passes nearly horizontally backward below and beyond the outer malleolus — and thence upward between the tendo .\chillis, on the one hand, and the tendons of the peroneus longus and brevis, until from 5 to 7.5 cm. (2 to 3 inches) above the joint (Fig. 299, A). Operation. — (1) The skin and fascia are at first carefully divided. The musculocutaneous nerve is identified and drawn inward. The peroneus ter- tius tendon and e.xtensor tendons are also displaced inward. The external saphenous vein and nerve are not disturbed posteriorly. (2) The incision is deepened between the retracted extensor tendons and fibula down to the as- tragalus, dividing the capsule cf the ankle-joint back to the external malleolus. The three bands of the external lateral ligament are separated from the outer malleolus. The sheath of the peroneus longus and brevis is carefully incised upward posteriorly to the fibula so that it may be subsequently sutured (the .sheaths being separate below the tip of the external malleolus and common above the tip). The tendons are then removed from their sheath and re- tracted backward. By dividing the peroneal sheath high up the leg and freeing of the tendons, sufficient room may often be gotten for disarticulation without severing the tendons — otherwise these tendons must be cut and subsequently sutured with catgut. (3) The periosteum is now divided over the fibula, and it, together with the peroneal sheath, are separated posteriorly, with as much as possible of the periosteum, from the posterior surface of the fibula and tibia. (4) The periosteum is similarly separated from the anterior part of the fibula and anterior surface of the tibia, carrying with it the attachment of the anterior portion of the capsule. The foot is thus freed from its attachments to the outer aspect of the fibula and to the anterior and posterior aspects of the tibia. (5) Forcibly bend the foot inward until disarticulation is so completely accomplished that the inner aspect of the foot rests against the leg and the sole looks upward (toward the crotch), turning upon the internal lateral ligament as a hinge — the ligament being preserved, if possible. .^11 the joint surfaces are thus brought well to view — and no tendons are severed, except as mentioned above. (6) As much of the bones is now removed as indicated. It is especially sought to avoid EXCISION OF ANKLE-JOINT. 429 sawing off more than the articular surface of the astragalus — and the gouging of the articular surfaces of the tibia and fibula, leaving the malleoli to prevent lateral displacement of the foot. If necessary, however, as much may be removed of the osseous tissues as in the following o])eration. (7) If the peroneal tendons have been severed, these are now sutured with chromic gut — replaced in their sheath — and the sheath, in any event (whether the tendons have been divided or not), is repaired by chromic gut suturing. Temporary drainage is used — the wound closed — and the foot put up at a right angle. EXaSION OF ANKLE-JOINT BV KXTERN.AL d'RX'KD AND INTERNAL AKCULAR INCISIONS. Position. — Patient rests midway between side and back, so as to bring Fig. 299.— Excisions abc lUT THE Foot:— A, Excis lion of ank le-joinl by ti nal incision ; B. External cur ved incision, in excision t» 1 .u.kli-joii :it b\ extern angular incisions. ed and internal inner aspect of foot uppermost during the inner incision, and vice versa; with foot supported. Surgeon faces foot. Assistant steadies limb. Landmarks. — The lower part of tibia and inner malleolus; lower part of fibula and outer malleolus; tibio-astragaloid joint. Incisions. — (i) External Incision — (with foot resting on inner aspect) — about 7.5 cm. (3 inches) in length — extends down the antero-lateral aspect of fibula to just below the tip of the outer malleolus — thence curves backward around the external malleolus and passes upward along the posterior border of the fibula for about 2.5 cm. (i inch) (Fig. 299, B). (2) Internal Incision — (with foot resting upon outer aspect) — about 7.5 cm. (3 inches) in length — extends down inner aspect of tibia to tip of internal malleolus. .\ second incision may then be added — either a transverse incision meeting the first almost at a right angle, and extending about 1.3 cm. (A inch) on either side (Fig. 298, D) — or a curved incision passing forward. Operation. — (1) The outer incision passes down through skin, fascia, and periosteum as far as it lies over the fibula — that portion below the external 430 i:\cisioxs. malleolus at first passes through skin and fascia alone. The j)eriosteum is now turned forward and backward over the fibula — the external lateral ligament and capsule are split in line with the vertical incision and turned backward and forward with the periosteum. The peroneus longus and brevis tendons are retracted backward. The anterior surface of the fibula, and as much as possible of the anterior surface of the tibia and astragalus, are freed subperiosteally through the outer wound, as well as the posterior surface of the fibula, and as much as possible of the posterior surface of the tibia. (2) The lower end of the fibula is now divided with a chain or Gigli saw, or with a chisel, about 2.5 cm. (i inch) above its tip — and is grasped by bone-forceps and removed, aided by a touch of the rugine where necessary. (3) The internal incision is made through skin, fascia, and periosteum to bone, where it lies over the tibia — and through skin and fascia; below the tip of the malleolus. The periosteum is similarly freed forward and back- ward, with the overlying and connected ligaments — freeing, through the inner wound, the outer and remaining portions of the anterior and posterior sur- faces of the tibia, and the anterior surface of the astragalus. The internal lateral ligament and capsule are similarly divided vertically and turned for- ward and backward as part of the periosteo-capsular covering. (4) The anterior and posterior tibial tendons are well retracted while working through the inner incision — and if a low-er cross-cut be added to the inner vertical incision, care is taken that it does not e.xtend far enough anteriorly or pos- teriorly to injure the.se tendons. (5) The lower end of the tibia is now either divided in silii with a chain-saw, or protruded through the inner wound, grasped with forceps, and sawed just above its articular surface. (6) The upper portion of the astragalus is then sawed ofif with a thin, narrow saw, through the outer wound — or entirely disarticulated and removed, as indi- cated. (7) The inner and outer wounds are sutured — temporary drainage established — and the foot dressed at a right angle to the leg. EXCISION OF TIBIA. Surgical Anatomy — Surface Form and Landmarks. — Given under .\m|)ulations about the I^eg. General Surgical Considerations. — Where a subperiosteal e.xcision is (lone, a very useful limb often results, e\en after the entire removal of the bone. The articular ends should be left if possible. Any portion of the tibia may be removed through the corresponding part of the following in- cision. TOTAL EXCISION OF TIBIA KV INTI:R\.\I. \EKTIC.\L INCISION'. Position. — Patient supine; leg turned outward. Surgeon to outer side of right limli, cutting downward, and vice versa on left. Landmarks. — Inner aspect of tibia, which is practically e\erywherc subcutaneous. Incision. — Passes just in front of the inner Ijorder of the entire length (if the tibia, from the knee-joint to the ankle-joint (Fig. 300, A). Operation. — The incision passes directly through periosteum to bone — running behind the tendons of the sartorius, gracilis, and semitendinosus above — and the internal sajjhenous nerve being recognized and retracted KXnSIOX OF IIDLI.A. 431 # below. Once beneath the periosteum, the sliaft of the bone is entirely freed sul>periosteally by means of a \vell-cur\ed perios- teal elexator. The periosteum, together with all the muscles and tendons attached, is freed to near the articular ends. A chain or Gigli saw is then passed between the bone and periosteum and the bone divided at its center. Each end of the tibia is grasped in turn, with strong bone-forceps, and drawn outward — during which manlane just mentioned is identified in the upper portion of the wound and followed to the bone. The transverse terminal branch of the external circumflex artery is encountered above, passing beneath the vastus externus muscle — and the superior external articular artery below, winding around the bone. The incision is carried directly through perios- teum to bone. The [XTiosteum is then freed, together with attached muscles and tendons, from the entire circumference of the femur, by means of fully curved rugine and periosteal elevators, especially along the inner and outer lips of the linea aspera. Having freed the center of the shaft, pass a chain or Gigli saw between bone and periosteum — divide the bone — grasp either end with bone-forceps and draw outward — and further free the bone while thus held, as far upward and downward as indicated. Then again pass the chain saw subperiosteally at either end and divide. If feasible, the femur may be freed over the entire length and circumference of the part to be re- moved, and then a chain saw passed at the upper and lower limits and the bone thus divided but twice. Suture periosteal sheath — quilt the muscles with buried sutures — close the wound — and put the limb up in a rigid, straight splint (v. .After-treatment, page 434). EXaSION OF HIP- JOINT. Surgical Anatomy— Surface Form and Landmarks. — Given under Disarticulation of Hij)-]oint, pages 386 and 387. General Surgical Considerations. — (1) Excision of the hip-joint con- sists in the removal of the upper end of the femur and scraping of the acetabu- lum. (2) No tourniquet is necessary — the slight hemorrhage encountered is from small vessels which are controlled as divided. (3) .According to some, the section of the bone should, as a rule, be made below the great trochanter, for even where less of the bone is involved, retention of the great trochanter is apt to be followed by harmful pressure. .According to other surgeons, as little of the bone should be removed as possible, together with the minimum disturbance of the muscles of the trochanters. After-treatment. — The limb is kept at absolute rest — in full extension — with the sawed end of the femur slightly separated from the acetabular cavity. Results. — .A movable and useful joint generally follows. .Ankylosis or a flail limb is exceptional. Some atrophy generally occurs — and there is always some shortening. 4.^6 EXCISIONS. Best Methods. — .\nterior Strai!i;ht Incision (Barker). External Straight Incisiun ( [.aiiuenbeck). Posterior .Angukir Incision (Kocher). Other Methods. — Curved Retro-trochanteric Incision. Comparison of Methods. — I-'ach method has its own special indication. The method In- external incision is, on the whole, probably the best. The anterior incision does least harm to neighboring structures, dividing no muscles (which the e.xternal and ])osterior incisions do). The posterior incision gives the freest access to the joint and the best drainage. ior U-shaped incision. EXCISION OF HIP-JOINT BY EXTERN.AL STRAIGHT INCISION — L.\NGENBECK'S OPER.ATION. Position. — Patient on sound side; thigh flexed at an angle of 45 degrees and rotated inward. Surgeon to outer side of hip. Assistant, grasping knee and foot, rotates and manipulates the limb as indicated. Landmarks. — Great trochanter. Incision. — Begins over the ilium, about 7.5 cm. (.^ inches) above the upper border of the great trochanter (which is about opposite the upper margin of the great sacrosciatic notch) — passes downward for 11.5 to 12.5 cm. (4^ to 5 inches) in the long axis of the limb, lying just behind the center of the outer surface of the great trochanter, and ends just below the base EXCISION- OF HIP-IOINT. 437 of the great trochanter. (In the above position of the limb, the direction of the incision will be represented by a straight line from the posterior superior iliac spine, passing down the center of the long axis of the limb.) (Fig. 303.) Operation. — (1) This incision passes, at first, through skin and fascia — then through the gluteus maximus, dividing it, approximatel\', in the line of its fibers. (2) The gap between the gluteus medius in front, and pyriformis behind, is sought and widened to the joint by retraction — and the capsule of the joint and periosteum of the great trochanter are divided to the bone in the line of the original incision. If necessary, the capsule of the joint is further divided transversely. By means of curved rugine and periosteal elevator, the anterior and posterior cap- sulo-periosteal flaps are raised, subperiosteally, if possible — or by the open method. (3) The cotyloid ligament is cut by thrusting a stout knife between the head of the bone and the cotyloid ligament and cut ting the ligament toward the rim of the acetabulum, and air thus allowed to enter and separate the ar- ticular surfaces. In those cases where difficulty is ex- perienced in admitting air to the joint cavity, a small portion of the rim of the acetabulum, with its coty- loid cartilage, may be chis- eled away over about 1.3 cm. (h inch) of the circum- ference. (4) The muscles attached to the outer and posterior surfaces of the great trochanter are now raised subperiosteally, or severed, while an assistant, grasping the knee and foot, rotates the thigh inward, — and those attached to the anterior surface and lesser trochanter while the thigh is rotated outward. (S) The ligamentum teres is now divided and the head of the bone dislocated backward and out- ward by depressing the limb (if the thigh partly rests over the end of the table as a fulcrum) and rotating outward. (6) The soft parts are further cleared from the upper end of the femur and retracted. While steadied with bone-holding forceps, the head of the femur is sawed below the great tro- chanter, with slight obliquity, from above downward, and from without inward. (7) The acetabular cavity is scraped or cleared with a gouge. All synovial recesses are curetted. (8) Temporary drainage is instituted — the capsule sutured — the muscles quilted — the wound sutured — and the limb put up in extension (see .\fter-treatment, page 435). Fig- 303— KxcisioN- HiP-joiNT:— By external straight aiigeTibeck's operation). 438 EXCISIONS. Comment. — (i) Only minor hemorrhage occurs, seldom necessitating ligature. (2) The strength of the capsule is increased if its transverse division be avoided. (3) Some surgeons remove as httle of the head of the femur as possible, sawing through the neck — but it is generally better to saw below the great trochanter, as this mass of bone, if left, is apt to be drawn up and constantly press the cicatri.x. (4) Considerable division of muscle is made. EXaSION OF HIP- JOINT BV ANTERIOR STR.\IGHT INCISION — B.XRKER'S OPER.ATION. Position. — Patient supine; limb extended. Surgeon on side of operation. Assistant steadies limb. Landmarks. — Anterior superior iliac spine; groove between tensor vagi- na? femoris and glutei on outer sifle, and sartorius and rectus on inner side. Incision. — Begins on front of thigh, about 1.3 cm. (5 inch) below the anterior superior iliac spine — passing downward and slightly inward for 7.5 to 10 cm. (3 to 4 inches), in groove formed, on inner side, by sartorius and rectus, and, on outer side, by ten- sor vagina; femoris and glutei (I-ig. 304). Operation. — (i) This incision passes through skin and fascia, at first. The external cutaneous ner\e is avoided, being retracted outward, if in the way. The above intermuscular groove is rec- ognized and the muscles forming it retracted inward and outward. (2) The terminal branch of the truns\erse division of the external circumflex artery is encountered and geneiallv requires ligation. The parts are further drawn aside and the joint reached without any division of muscles whatever, or of any vessels or nerves of im- portance. (3) An incision is now made over the anterior aspect of the joint, in line with the original incision, passing through the capsule into the joint and on to the head of the femur. (4) The cotyloid ligament is in- cised to admit air into the joint and enable the head of the femur to be drawn down lower. The neck of the bone is exposed and divided /;; silu with a nar- row saw, or with a chain or Gigli saw — the soft jiarts being as much retracted as possible. The severed head is then seized with strong bone-forceps and removed, the ligamentum teres having been cut. (5) The acetabular cavity and recesses of svnovial membrane are curetted with Barker's flushing-gouge Fig. 304. — Excision of Hip-join straight incision. EXCISION OF HIP-JOIXT. 439 — and the operation completed as in the excision by external incision. Tem- porary drainage is used and is best accomplished through a counter-opening made posteriorly. Comment. — Disarticulation may be accomplished as in the external incision and the head excised outside of the wound. EXCISION OF HIP-JOINT BV POSTERIOR ANGULAR INCISION' — KOCHERS OPERATION. Position. — Patient on sound side; hip prominent; knee semiflexed and rotated inward. Surgeon stands behind hip. -Assistant steadies the part. Landmarks. — Great trochanter; direction of fibers of gluteus maximus. Incision. — Begins at base of exter- nal aspect of great trochanter — passes thence upward and forward to its an- terior superior angle — and then runs obliquely upward and inward in the line of the fibers of the gluteus maxi- mus (Fig. ,^05). Operation. — (i) The incision passes through skin and fascia, at first. Di- vide the aponeurosis of the gluteus maximus over the external aspect of the great trochanter — and ligate the cut branches of the external circumflex ar- tery. (2) Divide the fibers of the mus- cular portion of the gluteus maximus in the upper part of the wound, and ligate the cut branches of the gluteal artery. (3) Dissect through the intermuscular fat and fascia and expose the inter\al between the gluteus medius and mini mus above and pyriformis below — drawing the two fcjrmer upward and the latter downward. Thus the pos- terior part of the capsule and acetabu- lum are approached and exposed. (4) Divide the capsule along the su])erior border of the p}Tiformis. Rotate the thigh outward and subperiosteally sep- arate the gluteus medius from the outer surface and the gluteus minimus from the anterior l)order of the great trochanter, raising a thin layer of bone, with rugine or chisel, if necessary. Then subperiosteally detach the pyriformis, obturator internus, and gemelli from the inner aspect of the great trochanter, and the obturator externus from the digital fossa. (5) Rotate the thigh inward and free the inner and posterior aspects of the great trochanter. The head, neck, and great trochanter are thus cleared. Some branches of the internal circumtlex ma)' require ligation near the capsule of the joint, and branches of the external circumflex near the base of the great trochanter. (6) Cut the internal cotyloid ligament to admit air — divide the ligamentum teres from behind, on the head of the Fig. 305. — Excision of Hip-joint :— By pos- terior angular 440 EXCISION'S. femur while the Hmb is adducted, flexed, and rotated inward. The head is now dislocated through the wound by outward rotation, and removed. (7) The periosteo-muscular wound is sutured with buried chromic gut stitches — the muscles quilted — temporary drainage established — the wound closed — and the limb jiut uj) u]Jon a splint in e.xtension. Comment. — The above o|)eration is really a development of Langenbeck's external incision, but admits of freer access to the joint and gives better drainage. EXCISIONS ABOUT THE SUPERIOR MAXILLA. Articulations of Superior Maxilla. — With frontal; ethmoid; nasal; lachrymal; malar; inferior turbinated; palate; vomer; and its fellow. Muscles Attached to Superior Maxilla. — Orbicularis palpebrarum; inferior oljlinue; levator labii supcrioris aheque nasi; levator labii superioris; levator anguli oris; comijressor nasi; depressor ahe nasi; dilator naris poste- rior; masseter; buccinator; internal ])terygi}id; orbicularis oris. Arteries in Neighborhood of Superior Maxilla. — Facial and its follow- ing branches: — superior coronary, arteria septi nasi, lateralis nasi, angular, muscular (masseter and buccinator). From temporal: — transverse facial. From internal maxillary: — anterior dental, alveolar or posterior dental, descending or- posterior palatine, ]jterygopalatine, sphenopalatine, infra- orbital. From ophthalmic: — inferior pal])ebral. Veins in Neighborhood of Superior Maxilla. — (i) Superficial: — Facial, with its following tributaries, — angular, superior and inferior lateral nasal, inferior palpebral, infraorbital, anterior internal maxillary (deep facial, between buccinator and masseter muscles), superior coronary, transverse facial, and muscular branches (masseter and buccinator). (2) Deep: — veins corresponding to branches of internal maxillary artery, forming the pter\\goid plexus (situated on the inner surface of the internal pterygoid and partly around the external pterygoid) — ending, anteriorly, in the anterior internal maxillary (or deep facial), joining the facial vein — and ending, posteriorly, in the internal maxillary vein, which unites with the common temp.iral vein to form the fem]iorom:ixillary \ein Chief Nerves in Neighborhood of Superior Maxilla. — (i) From facial: — malar; supraorbital branches of temporofacial division; and buccal branch of cervicofacial division. (2) From superior maxillary division of fifth nerve: — malar; posterior superior, middle sujjerior, and anterior superior dental; paliieliral; nasal; labial. (3) From sphenopalatine ganglion— anterior (large) palatine; middle (e-xternal) palatine; posterior (small) jalatine; superior nasal branches; nasopalatine; upper ])osterior nasal. Other Structures in Neighborhood of Superior Maxilla.— Eye; nasal duct; antrum of Highmore. Surface Form and Landmarks of Superior Maxilla.— The superior maxilla forms the largest part of the face— the outer wall and larger part of floor of nose— the larger part of roof and i)art of outer wall of mouth— and part of floor of orbit. General Surgical Considerations in Operations upon Superior Maxilla. — See under Description and Comment, in Excision of the upper jaw, pages 441 and 443. EXCISIUX (IF SUI'KRKJR MAXILLA. EXCISION OF SUPERIOR MAXILLA BY MEDIAN INCISII )N — 1- KKCLSSU.NS ( il'HRA IIOX. Description. — Ordinarily refers to removal of superior maxilla of one side, as herein described — more rarely, to the removal of both superior maxilhc. The entire bone is removed — except the upper part of the nasal process. In addition to the removal of the entire bone, the following additional bones are removed, in whole ur in ])art: — lower jtart of malar; part or whole of palate bone; whole inferior turbinated. Preliminary Steps to Excision. — Preliminary tracheotomy is often per formed, with plugging of the larvnx, or the use of a tampon-cannula. Pre- liminary exposure of the external carotid, with temporary ligation of the vessel during the operation, is also often performed. Both of these steps are indicated in difficult cases where especial trouble is antici I)aterl. Position. — Patient supine; head and shoulders well elevated; face turned to sound side; region shaved; posterior nares [slugged (for earlier part of operation) . Surgeon to right side, in either case, .\ssistant oppo site surgeon. Landmarks. — (ieneral contour and boundaries of superior maxilla. Incisions. — Median Incision — begins about i.,^ cm. (-J inch) below the inner canthus — passes down in the naso-facial groove — curves around convexitv of ala nasi — passes along margin of nostril, in naso-labial groove, to mid-line of lip — and thence downward through the center of the upper lip. Hori- zontal Incision — passes from the beginning of the median incision along the lower border of the orbit, to end over the malar bone beyond the outer canthus (Figs. 306, .\, and 307, A, B, C). Operation. — (1) The above incision pas.ses everywhere to the bone. While incising from the inner canthus to the septum nasi, and from the inner canthus to the malar, the facial artery is compressed over the inferior maxilla. Just before dividing the upper lip, the lip is compressed on either side of the median line, between thumb and finger, and, when severed, the superior coronary arteries are tied while still compressed. In this median incision are cut the following arteries and corresponding veins — angular, lateralis nasi, superior coronary, arteria septi nasi, and branches of the infraorbital. In the horizontal incision, branches of the infraorbital and transverse facial are cut. (2) Dissect up the flap included in the above incisions — clearing the surface of the superior maxilla as completely as possible, though not subperiosteally. The infraorbital artery is divided during this stage. (3) 06.— Skin Inci.sio.\sin Exci.sions ab li-L.-E: — A, E.xcision of superior tna.x II incision ( Fergusson's operation); of inferior maxilla. 442 EXCISIONS. Detach the nasal cartilages from the bone. Divide the nasal process of the superior maxilla with a tine saw, from the junction of the nasal process with the lower border of the nasal bone, to the margin of the orbit just below the canal for the nasal duct. (4) Raise the periosteum from the floor of the orbit, including the origin of the inferior oblique, and retract them upward, carefully protecting the eye-structures. With a fine, narrow chisel, chisel oljlicjuely across the orbital plate, from the end of the saw-cut dividing the nasal process, to the anterior end of the sphenoma.xillary fissure. (5) The orbital and external surfaces of the malar bone are now cleared, the former subperiosteally, preparatory to sawing. A chain or Gigli saw is then guided into position through the sphenomaxillary fissure and zygomatic fossa, upon a curved carrier, or aneurism- needle, closely hugging the bone — and the malar bone divided ob- liquely through its middle, from the anterior end of the sphenomaxil- lary fissure downward and out- ward to the center of its lower free border. (6) Extract the cen- tral incisor tooth of the involved side. Divide the muco-periosteal covering of the hard palate in the median line along the intermax- illary and interpalatal sutures, from the alveolar process to the posterior nasal spine. Similarly divide the muco-periosteal cover- ing of the floor of the nose, with a long knife, cutting as near the septum as possible, from the pos- terior nasal spine to the anterior nasal spine. Make a transverse incision across the roof of the mouth, at the junction of the hard and soft palates, and separate the latter from the former. Pass a long, narrow saw in through the nose, seeing that its tip passes through the interval between the separated hard and soft palates (not injuring the latter), and divide the horizontal plate of the palate and palatal and alveolar portions of the superior maxillary bone as nearly in the central line as the septum nasi will allow. The descending palatine and nasopalatine arteries are cut here and bleed freely. (7) Grasp the superior maxilla with large bone-forceps, catching the orbital and ah'eolar aspects of the bone, and gently wrench it from side to side to determine the position and extent of the remaining connections which still hold it in place. The two remaining bony connections are, part of the orbital plate, and the union between the pterygoid processes and superior maxilla. These are generally severed with cutting forceps. The former is more accessible. The latter, after depressing the inferior maxilla, and freeing the outer and posterior surfaces of the superior maxilla, is sejiarated by means of angular bone-cutting forceps introduced within the mouth and passed up Pig- 307- — Bone Sections in Excisions about THE Maxillae ; — A. R, C. Lines of bone-division in excision of right snperior maxilla, by Fergusson's method; D, Line of division of inferior maxilla, in excision of left inferior maxilla. EXCISIONS ABOUT THE INFERIOR MAXILLA. 443 behind the maxillary tuberosity — being sure that the soft palate has been entirely separated and held out of the way. Or, after dejjre.-^sing the inferior maxilla, a chisel may bt used between the superior maxilla and pterygoid process. The superior maxilla is thus drawn away in the hold of the large forceps, after all bony connections have been divided. The posterior dental, pterygopalatine, and infraorbital arteries are here severed. (8) All bleeding vessels are now secured, and remaining hemorrhage controlled by temporary gauze packing. The wound is sutured throughout — and with especial care through the upper lip, to avoid distigurement. Drainage is established through the mouth. Feeding is done by a tube for a time. An artificial palate is generally worn after the operation. Comment. — (i) No attempt is made to remove the superior maxilla subperiosteally in the above operation. (2) Preservation of branches of the facial nerve is important. (3) While the above method of freeing the bone from its final attachments is to l)e preferred, yet if difficulty be experienced in severing the pterygomaxillary connections by cutting forceps, the superior maxilla may be separated from the pterygoid processes by a quick downward wrench, tearing it away from its bony attachments. (4) The upper jaw may also be excised bv the methods of Velpeau, Langenlieck, Liston, Gensoul, Nelaton, Boeckel, Oilier, and others. Partial Excisions of the Superior Maxilla. — The following parts of the upper jaw may he done through special incisions, — (a) Alveolar and palate ]irocesses. — (b) ()rbital and nasal ]3ortions, — (c) All the superior maxilla below the infraorl)ital foramen. — (d) All the su]ierior maxilla except the orbital plate. EXCISIONS ABOUT THE INFERIOR MAXILLA. Ligaments of Temporomaxillary Articulation. — External lateral; internal lateral; stylomaxillary; capsular; interarticular fibrocartilage. Two synovial membranes. Muscles Attached to Inferior Maxilla. — To Outer Aspect; — lexator labii inferioris; orbicularis oris; depressor labii inferioris; depressor anguli oris; platysma myoides; buccinator; masseter. To Inner Aspect; — Genio- hyoglossus; geniohyoid; mylohyoid; digastric; su])erior constrictor of pharynx; temporal; internal pter\'giiid; external ])ter\'goid. Arteries in Neighborhood of Inferior Maxilla. — Facial and following branches; — submaxillary, submental, muscular (]}terygoid, masseter, buc- cinator), inferior labial, inferior coronary. Internal maxillarv and following branches: — tympanitic, middle meningeal, inferior dental, ])terygoid, masse- teric, buccal. From temporal: — transverse facial. (The internal carotid lies considerably to the inner side of the lower jaw.) Veins in Neighborhood of Inferior Maxilla. — Superficial; — facial, with its following tributaries; transverse facial, inferior coronarv, inferior labial, submental, submaxillarv, muscular (|)ter\g(iid, masseter, buccinator). Superficial and Deei); — external jugular and its tributaries; common tem- poral, internal maxillary, communicating branch from the facial to external jugular. Deep; — veins corresponding to the above branches of the internal maxillary artery. (The internal jugular vein lies considerably to the inner side of the lower jaw.) Chief Nerves in Neighborhood of Inferior Maxilla. — From facial; — buccal, supramaxillary and inframaxillary branches of cervicofacial division. From inferior maxillarv division of fifth nerve; — internal ptervgoid. masse- 444 EXCISIONS. teric, temporal, buccal, external pterygoid, auriculotemporal, lingual, inferior dental. (The glossopharyngeal and hypoglossal are considerably to the inner side of the inferior maxilla.) Other Structures in Neighborhood of Inferior Maxilla. — Part)tid gland; submaxillary gland; sublingual gland. Surface Form and Landmarks of Inferior Maxillary Region. — (i) Steno's duct of the parotid gland crosses the ascending ramus of the inferior maxilla horizontally, about 2 cm. (J inch) below and parallel with the zygo- matic arch — the transverse facial artery lying above and the facial nerve below it. (2) The facial nerve crosses the parotid gland forward and slightly downward, from the junction of the anterior border of the mastoid process and the ear. (3) The facial artery crosses the inferior maxilla at the anterior border of the masseter muscle — the facial vein lying just behind. EXCISION OF TEMPOROMAXILLARY ARTICULATION r.\ .Wi.i lAk ixcisiu.N. Description. — Consists in removal of condyle of inferior maxilla. The iiiterarlicular fibro-cartilage of the joint and the glenoid cavity are, ordinarily, not di-^turlied. Position. — Patient's head and shoulders elevated; faced turned to opjjo- site side. Surgeon on side of operation. Assistant opposite. Landmarks. — Ascending ramus and condyle of inferior maxilla. Incision. — \ertical portion — begins at lower border of zygoma and passes vertically downward anterior to the temporal artery (which is about 2 cm., f inch, in front of the tragus), ending just above the transverse facial artery (which is from 1.3 to 2 cm., 5 to | inch, l)elow the zygoma). Horizontal portion — passes forward along the lower Imrder of the zygoma for about 4 cm. (i^ inches). (Fig. 308.) Operation. — Incise through skin and fascia and turn the triangular flap thus raised downward and forvvard. Be on the lookout for the transverse facial artery, Steno's duct, and facial nerx'e, all crossing parallel with the zygoma from behind forward, and in the above order from above downward. Retract the lower border of the wound downward to avoid these — and the vertical border backward, with the anterior margin of the parotid gland. Incise whatever portion of the masseter fibers are encountered along the lower border of the zygoma — and along the ascending ramus, if any extend into the field. Incise the capsule of the joint vertically and expose the condyle. Clear the circumference of the neck of the condyle, as near the condyle itself as possible, closely hugging the bone — leaving some of the lower fibers of the external pterygoid, if feasible. Conduct a Gigh saw around the neck of the bone and divide it just below the condyle. This is better than dividing it 1)V chisel or pliers. Seize the condyle with bone-forceps and divide any remaining connections, while putting traction upon the end of the bone — preserving the capsule as intact as possible. Suture the capsule with buried gut. If the masseter have been extensively removed from the zygoma, suture it back to the periosteum. Establish temporary drainage. Close the angular wound — and dress the jaw closed. Comment. — (i) Both temporomaxillary articulations may require simul- taneous excision. (2) The joint ma\' be less satisfactorily excised from \\ ilhin the mouth. EXCISION OK IM-ERIOK MAXILLA. 445 EXCISION OF INFERIOR MAXILLA BY SINGLE IXCISInX AMlXi; IXI-i:kIOR AM) POSTKRIOR BORDERS. Description. — Ordinarily refers to the removal of the inferior maxilla of one side. Both sides may be removed. The bone is removed subperiosteally, when the preservation of the periosteum is not contraindicated. Position. — Patient supine; head and shoulders elevated; head to opposite side; face shaved. Surgeon on side of operation. Assistant stands opposite. Landmarks. — General contour of bone, especially its inferior and poste- rior borders. Incision. — Begins in the midline of the chin, just below the free portion of the lip — passes down the front of the chin well around its prominent border Fig. 308. — E.KCISION OF Th x.xiLLARV Articulation : — By angulai — thence follows the lower border of the inferior maxilla, passing a little nearer the posterior than the anterior aspect of the border (in order to hide the scar) to the angle — thence upward along the posterior border of the ascending ramus — ending about opposite the center of the ascending ramus (about opposite the lobule of the ear). (Fig. 306, B, and 307. D.) Operation. — (i) This incision is everywhere carried through skin, fascia, plat_\'sma, and periosteum to bone — excejJt over the facial arterv, where the skin alone is incised. The facial artery is then regularly exposed, doublv ligated and cut between the ligatures. (2) All the structures (see Surgical .Anatomy, page 443) covering the outer surface of the inferior maxilla are now raised subperiosteally, working from the free border of the bone toward the alveolar margin, and from the symphysis toward the angle and upward along the ascending ramus. The mental vessels and nerve are divided at the mental foramen. The strong attachment of the masseter muscle is difficult to free from the margin of the angle, except with a sharp rugine, after having 446 EXCISIONS. cut through the periofteum to the bone. The bone is closely hugged every- where. The clearing is continued as high up the ascending ramus as can be reached with the bone hi silii. (3) The structures along the inner aspect of the horizontal ramus of the jaw are now similarly separated subperiosteally, in the same order as upon the outer surface, as far as they can be reached. Guard against injuring the submaxillary and sublingual glands. (4) The mucous membrane is then divided along the alveolar margin, on the outer and inner sides — all the muscles having been freed from both aspects of the bone. The lower lateral incisor tooth is extracted and a chain or Gigli saw- conducted around the bone at the site of the empty socket. As much of the attachments of the digastric, geniohyoid, and geniohyoglossus of the involved side as possible are saved (for their future action). (5) Seizing the anterior end of the severed jaw, and drawing it outward, the remaining structures are detached from the inner aspect — internal pterygoid muscle, inferior dental arterv and nerve at the inferior dental foramen, superior con- strictor of the pharynx, internal lateral ligament, stylomaxillary ligament. If not already divided, the mylohyoid and posterior part of the mucous mem- brane of the mouth are now separated. (6) Firmly depress the antericr portion of the inferior maxilla, thereby bringing the coronoid process further forward and downward — and then cut from it the temporal muscle with blunt curved scissors, following the anterior border of the coronoid process upward. (7) Still further depress the inferior maxilla, until the coronoid process is more accessible. This is especially necessary, as the original in- cision ceases about the center of the posterior border of the ascending ramus, in order to avoid the danger of cutting the important structures near the upper half of the posterior border of the ascending ramus (parotid gland, facial nerve, transverse facial and internal maxillary arteries, Steno's duct, and temporomaxillary vein) — hence the coronoid process is thus approached from before rather than from behind. The inferior ma.xilla should be de- pressed only, and not rotated outward — in doing the latter, the internal maxillary artery is apt to he hooked around the inner portion of the condyloid process and dragged out into the wound, and even ruptured. (8) Following the upper inner aspect of the condyloid process, free the insertion of the external ptervgoid with elevator, or cut with blunt curved scissors. Divide the capsule and disarticulate the head of the bone forward. If not already divided, sever the internal lateral, stylomaxillary, and pterygomaxillary ligaments, and any binding bands of fascia, or fibers of the external pterygoid muscle. (9) The wound is temporarily drained through the posterior portion of the incision. The skin wound is carefidlv sutured to avoid scar. Comment. — (1) Excision, where large growths complicate, may require a prehminary ligation of the e.xternal carotid — and a preliminary tracheotomy, with tamponing of the laryn.x — as well as division of the entire thickness of the lower lip. (2) If the median portion of the inferior maxilla, and therefore the genial tubercles, be removed, the tongue must be stitched forward to keep it from falling backward. (3) The coronoid and condyloid processes may require to be first divided with forceps or chisel, and then withdrawn. (4) Only healthy periosteum is to be saved — otherwise an open operation is indicated. (5) .\ny portion of the alveolar process, or of the body, may be removed. (6) Both inferior maxilla may be simultaneously removed, by a repetition of the above iirocedure. (7) Feeding through a tube is, at first indicated after the operation. EXCISION OF ENTIRE RIB AND COSTAL CARTILAGE. 447 EXCISION OF RIBS. Surgical Anatomy — Surface Form and Landmarks. — Given under tlie Thcjrax, [lauts 57D and 578. General Surgical Considerations. — (i) The following extents of rib may be removed; — (a) An entire rib, from and including its chondroslernal articulation, to and including its costovertebral articulation; — (b) Part of a rib (the rib proper), from and including the chondrocostal, to and including the costovertebral articulation; — (c) Part of a rib, from and including the chondrocostal, up to the costotransverse articulation; — (d) .\ny limited por- tion of a rib; — (e) Two or more adjacent ribs, in whole or in yjart. (2) Unless contraindicated, the portion of rib covered by periosteum should be removed subperiosteally (that is, the rib pro]5er). Best Methods of Excision. — By parallel incision over center of rib — for one riVi, or [lart of a rib. Parallel incision midway between ribs — for two adjacent ribs. EXaSION OF ENTIRE RIB AND COSTAL CARTILAGE BV P.AR.VLLEL IN'CISKlX (.l\ER CENTER (IE RIB, Position. — Patient near edge of table, in such a position as to render site of operation accessible, and resting upon pad so as to render the part prominent. Surgeon on side of operation, or behind, if patient be upon side. Assistant stands opposite. Landmarks. — Upper and lower border of rib; chondrostemal articula- tion; costovertebral articulation. Incision. — The long parallel incision begins over the center of the chondro- stemal articulation — passes directly over center of costal cartilage and rib — endina over costovertebral articulation. The posterior end of this incision will be over the center of the vertebral ends of the ribs, in the case of the lower ribs — but will run along their upper border, just above the transverse pro- cesses of the vertebrre, in the case of the upper ribs. Operation. — Incise directly through skin, fascia, overlying muscle, and periosteum, down to bone. Over the costal cartilages there is no periosteum, as such. The treatment of the overlying muscles will be modified by the part of the chest involved — where unimportant, they are cut through — where important and capable of retraction after being cut, they are divided in their cleavage line as far as this is possible — otherwise their fibers must be cut. Important vessels, and especiallv important nerves, coursing downward from the axillary region, are to be avoided, if possible. The rib is freed subperiosteally — and with especial care along the groove upon the lower, inner aspect, where the intercostal vessels and nerve run — using fully curved periosteal elevator and rugine. Guard the pleura behind the posterior surfaces of the ribs — intrathoracic fascia alone here intervening. Having freed the center of the rib around its entire circumference, a chain or Gigli saw is carried between bone and periosteum and the rib divided. First one and then the other cut end of the rib is seized with bone-forceps and drawn outward — and, while held in this position, is freed toward either end and disarticulated. The musculo-periosteal sheath is sutured with gut — and the wound closed. Comment. — For excision of two or more consecutive ribs, in whole or in part, see Estlaender's and Schede's operations, pages 604 and 607. 448 EXCISION OF COCCYX K\ I'OSTHKIUR MFiDIAN INCISION. Description. — Separation of coccyx at sacrococcygeal articulation and remo\ al from its bed of soft parts. Position. — Patient on side at edge of table; thigh fle.xed; buttocks sepa- rated. Laxidmarks. — Tijj and outline of coccyx, and position of sacrococcygeal articulation. If necessary, this articulation may be determined by means of a gloved finger introduced within the rectum and the coccyx palpated between this finger within and the thumb without. Incision. — Begins in middle line, just above sacrococcygeal articulation — passes verticall}' downward — and ends just below the tip of the coccyx Operation. — Incise through skin and fascia to the bone. Separate the gluteus maximus from the posterior surface — the coccygeus from the anterior surface — the sphincter ani from its tip in front and the levator ani from its tip behind — and the sacrococcygeal ligaments from its upper aspect — hugging the bone closely and putting the parts upon the stretch after freeing the tip — thus completing the disarticulation. Sometimes the bone may be more easily removed by freeing its posterior aspect and lateral borders — then dis- articulating and levering out its upper end — and, while this is being drawn backward, its anterior surface is freed from above downward. The incised muscles are sutured together deeply with buried gut — and the superficial wound closed. OSTEOPLASTIC RESECTIONS OF BONES AND JOINTS. Description. — .\n osteoplastic operation, in general, consists in the ap- proximation of fresh sections of bone to each other, for the purpose of bringing about union between their oppo'sed aspects. The surfaces brought thus into contact may have been originally in contact, as the margin of an oval of bone turned back from the skull and afterward dropped into its old place, — or some new bony contact may be brought about, as when, after total excision of the tarsus, the sawed ends of the metatarsals are approximated to the sawed ends of the tibia and fibula. Osteoplastic Resection of a Bone consists in the resection, or cutting through, of a bone in such a way as to leave its soft coverings attached, and, in addition, a hinge-like connection of soft parts connecting it with the neighboring bone from which cut — and in then turning, that is, breaking, back the portion of bone, with its soft cover- ings adherent and soft hinge intact, in some convenient direction, thus ad- mitting of free access to the underlying structures sought in the special opera- tion — and of subsequently, upon completion of the object sought, turning the bone-flap, or bone part, with its connected soft parts, back into its original place — union of the bony surfaces being e.xpected and a reproduction of the slaliis ante quo — as in the osteoplastic exposure of the brain, or the osteo- plastic exposure of the elbow-joint by temporary resection of the olecranon. Osteoplastic Resection of a Joint is an operation in which, after the ordinary excision of the joint, the sawed bony surfaces immediately beyond the joint are brought into contact for jiermanent union — and, therefore, implies that no motion is to be expected in that region. The excision of the knee joint, or of any other joint, where ankylosis is expected, or results, whether ex- pected or not, is, consecjuently, not, properly speaking, a simple excision, but an osteoplastic excision or resection. OSTEOPLASTIC RESECTIONS ABOUT FOOT. 449 General Surgical Considerations. — (i) The osteoplastic resection of a bone, as to the manner of its performance, is done, in all practical respects, in the same way as an excision of a bone — except that the soft parts are not cleared from the surface of the bone entering into the osteoplastic flajj, and that the hinge-like connection of soft ]jarts between the bone-flap and the main bone, or bony surroundings, is disturbed as little as possible. (2) The osteoplastic resection of a joint is performed, as far as the excision itself is concerned, in precisely the same manner as an ordinary excision of a joint — except that after the removal, or excision of the joint surfaces, the cut surfaces of the bones beyond are brought into permanent contact— and solid bony union sought. OSTEOPLASTIC RESECTION OF ANTERIOR TARSUS AND TARSO- METATARSUS nV IN'TKKN.AL AND KXTERNAL i)( IRSOI.ATERAI, INCISIONS. Description. — Consists in the removal of the tarso-metatarsal joints; the entire tarsal bones distal to the astragalo-scaphoid and calcaneo-cuboid, or medio-tarsal, joint (namely, the scaphoid, cuboid, internal, middle and ex- ternal cuneiform); and the articular surfaces of the astragalus and ob calcis; followed by the approximation of the sawed proximal and distal bones. The operation is resorted to in disease, especially tubercle, of the anterior tarsal joints. Where the disease is limited to the bases of the metatarsals, a tarso- metatarsal excision is done — the bases of the metatarsals and adjacent articular surfaces of the cuboid, internal, middle and external cuneiforms are alone removed. Where the disease is more general, in addition to the tarso-meta- tarsal excision, the anterior tarsus (scaphoid, cuboid, and three cuneiforms) is also excised. And where the disease is still more extensive, the articular surfaces of the posterior tarsus (astragalus and os calcis) are additionally remoN'ed Position. — Patient supine, with foot over edge of table and so manipulated as to bring the site of operation into prominence during the various steps. Surgeon faces foot. .Assistant steadies and manipulates foot and leg. Landmarks. — First metatarsal, internal cuneiform, scaphoid, and head of astragalus, on inner aspect of foot, — and fifth metatarsal, cuboid, head of OS calcis, and external malleolus, on outer aspect. Incisions. — Internal Incision — from the posterior third of the dorsal aspect of the first metatarsal backward over the internal cuneiform and scaphoid to just above the dorsolateral aspect of the head of the astragalus. External Incision — from the posterior third of the dorsolateral aspect of the fifth metatarsal (external to the extensor tendons) backward over the cuboid to the dorso-lateral asjject of the os calcis, between the calcaneo-cuboid articulation and external malleolus. (Fig. 296, H, H'.) Operation. — (1) The internal incision first passes through skin and fascia. Then working upward and toward the middle line of the dorsum, the attachment of the tibialis anticus is separated from the first metatarsal and the internal cuneiform — and the dorsal aspect of the first metatarsal, internal cuneiform, scaphoid, and part of astragalus are bared, as far toward the middle of the dorsum as possible. Then working downward and toward the middle line of the sole, the attachment of the posterior tibial to the tuber- osity of the scaphoid and internal cuneiform is separated — and the plantar surfaces of the first metatarsal, internal cuneiform, scaphoid, and part of astragalus are cleared, as far toward the center of the sole as possible. (2) 29 45° OSTEOPLASTIC RESECTIONS. The external incision also, at first, involves skin and fascia. First working toward the dorsum, the tendon of the peroneus tertius is then separated from its attachment to the base of the fifth metatarsal — and the dorsal aspect of the outer metatarsals, cuboid, and part of os calcis, and as far toward the center of the dorsum as possible, are cleared. Then working toward the sole, from the outer aspect, the attachment of the peroneus brevis is separated from the base of the fifth metatarsal and the tendon of the peroneus longus is fietached from the groove under the cuboid and drawn backward — and the under surface of the other metatarsals, cuboid, and part of os calcis are cleared as far toward the center of the sole as possible. (3) The cuboid, three cuneiforms, and scaphoid are removed by being grasped by bone-forceps and dissected out from the lateral wounds. The articular surfaces of the metatarsals below, and astragalus and os calcis above, are then sawed or gouged. (4) The sawed ends of the metatarsals are approximated to the sawed ends of the astragalus and os calcis — the dorsal and plantar redundancy of tissue being eventually taken up. (5) Temporary drainage is established — the two lateral wounds sutured — and the foot put up upon a splint, at a right angle to the leg. Buried chromic gut sutures between the deeper fibrous margins of the wound should be placed wherever indicated. Comment. — The anterior tarsus alone may be removed, ijy limiting the incision accordingly. OSTEOPLASTIC RESECTION OF MID-TARSUS ¥.\ I;.\T1:RXAL TRA\S\F.RSK ri'R\'EI) INCISlnX. Description. — Removal of anterior part of astragalus and os calcis, and Fig. 309. — OsTHorLAsTlc RESECTIONS ABoi'T THK FooT :— A. Osteoplastic resection of mid-tarsus by e.\teriial transverse curved incision; B, B'. Osteoplastic resection of posterior tarsus b\' external curved incision: B, C, Incision in osteoplastic resection of foot by externo-lateral curved incision (modification of Wladimiroff-Mikulicz operation). the posterior jiart of the scaphoid and cuboid — followed by the approximation of the sawed distal and pro.ximal bones. Position. — .-Xs in the al)ove operation. OSTEOPLASTIC RESECTION OF POSTERIOR TARSUS. 451 Landmarks. — Medio-tarsal joint line (astragalo-scaphoid and calcaneo- culjoid articulations); external malleolus. Incision. — Begins over dorsal aspect of astragalo-scaphoid joint — curves obliquely downward and outward over upper part of calcaneo-cuboid joint, and passes thence backward to a point on a line with and about 1.3 cm. (5 inch) below the external malleolus (Fig. 309, A). Operation. — (1) Incise skin and fascia. The musculocutaneous nerve is encountered and retracted at the upper angle of the wound, and the external saphenous nerve and vein at the lower. The tendons of the peroneus tertius and extensor longus digitorum appear at the upper part of the wound and are retracted. The tendons of the peroneus longus and brevis appear at the lower part of the wound — their sheaths are slit and the tendons retracted. (2) The medio-tarsal region is approached in the interval thus made. The capsule is incised over the head of the astragalus — the astragalo-scaphoid joint opened — and the capsule separated from the articular ends of both bones. (3) Retract downward the upper border of the extensor brevis digitorum and o[)en the calcaneo-cuboid joint, and free the capsule from the articular ends of both bones. (4) Sever the greater process of the os calcis and neck of astragalus with chisel and remove with bone-forceps, cutting the binding ligaments under traction. With chisel or gouge, remove as much of the cuboid as indicated — and the whole or as much as necessary of the scaphoid. (5) The sawed scaphoid and cuboid are approximated to the sawed astragalus and OS calcis. The slit sheaths are sutured over the peronei tendons — the deep jjarts brought together with buried chromic gut sutures — the wound sutured — and the foot put up at a right angle to the leg, with the leg flexed. No drainage is established unless articular surfaces are left. OSTEOPLASTIC RESECTION OF POSTERIOR TARSUS BY E.XTERNAL CURVED INCISloX. Description. — Removal of astragalus and anterior half of os calcis; together with the articular surfaces of the tibia and fibula, and of the scaphoid and cuboid; after which, the anterior sawed surface of the posterior half of the OS calcis is approximated to the sawed surfaces of the tarsal bones (scaphoid and cuboid) ; and the upper sawed surface of the posterior half of the os calcis is approximated to the sawed tibia and fibula. Position. — Patient supine, with foot resting upon its inner side. .Surgeon stands upon the outer side — and an assistant steadies the leg and foot. Landmarks. — Tendo .\chillis; external malleolus; base of fifth meta- tarsal. Incision. — Begins upon external border of tendo ,\chillis, about 7.5 cm. (3 inches) above the ankle-joint — passes down behind the tendons of the pero- neus longus and brevis and external malleolus — thence forward, nearer the sole than the external malleolus, to the base of the fifth metatarsal (Fig. 30C), BB'). Operation. — (i) Incise skin and fascia. Slit sheaths of peroneus longus and brevis and retract the tendons forward. Separating the margins of the wound as far as possible, open the capsule of the ankle-joint and, working beneath this with rugine and periosteal elevator, free the surfaces of the astragalus and os calcis, and their articulations with the scaphoid and cuboid, as far as possible in all directions, and working as subperiosteally as possible. The origin of the extensor brevis digitorum is separated from the antero- 452 OSTEOPLASTIC RESECTIONS. external aspect of the os calcis. The articular line of the astragalus is freed as fully as possible. (3) The foot is then forcibly inverted and, while in this position, the astragalus is strongly prized and drawn out by bone-forceps, the binding ligaments being cut under tension. The peronei and tibial tendons are carefully preserved. (3) The calcaneo-cuboid articular surfaces are then separated. The lower ends of the tibia and fibula are projected into the wound (by complete inversion of the foot) and sawed off just above the articular lines, leaving enough of the external malleolus for the peronei tendons to hook behind, if possible. The anterior half of the os calcis is then removed by vertical section with saw or chisel. The posterior half of the os calcis is now depressed forward, so as to render its upper surface accessible, and a horizontal slice of bone is removed from its upper surface, but not involving the tendo Achillis. The posterior articular surfaces of the scaphoid and cuboid are thrust into the wound (by twisting the anterior portion of the foot inward) and a vertical section made just posterior to their articular surfaces. (4) The vertical section of the posterior half of the os calcis and vertical sec- tions of the scaphoid and cuboid are now approximated — and the horizontal sections of the tibia and fibula are dropped down upon and approximated to the horizontal section of the upper aspect of the posterior part of the os calcis. (5) Repair the incised sheaths of the ])eroneus tendons by suturing them over the tendons with buried gut. The wound is sutured and the foot jjut up at a right angle to the leg. Comment. — (i) The tendons of the peroneus longus, brevis, and tertius, and of the tibialis anticus and posticus, and their attachments, are especially preserved intact. (2) The excision of the calcaneo-astragaloid joint alone may be done through this incision. OSTEOPLASTIC RESECTION OF FOOT BY TRANSVERSE IIPPER AND IX)\VER AND OBLlglE LATERAL LNCISIONS — WLADIMIRCTFE-MIKIILICZ OPERATION. Description. — Removal of soft parts of heel, together with astragalus and OS calcis, and approximation of sawed tibia and fibula to sawed scaphoid and cuboid. A foot in the permanent position of extreme talipes equinus results, the patent walking upon the balls and phalanges of the toes. Position. — Patient sujiine, with knee fle.xed to enable inner or outer side of foot to be turned uppermost at end of table. Surgeon's position will vary with the varied steps of the operation. Landmarks. — Tuberosity of scaphoid; base of fifth metatarsal; external and internal malleoli; ankle-joint. Incisions. — Transverse Plantar Incision — from tuberosity of scaphoid across sole of foot to a point slightly behind the base of the fifth metatarsal. Internal and E.xternal Oblique Incisions — pass from the upper extremities of the plantar incisions obliquely upward and backward over the inner and outer aspects of the foot to the bases of the internal and external malleoli. Posterior Horizontal Incision — passes transversely backward around the posterior aspect of the leg, connecting the upper extremities of the inner and outer oblique incisions. (Fig. 310, C, C, C", D, and E.) Operation. — (1) The above incisions are everywhere carried to the bone — the plantar vessels and posterior tibial nerve being divided in the transverse plantar incision. (2) Flex the foot forcibly — divide the tendo Achillis and the posterior ligaments — opening the articulation from behind. Further flex the foot on the leg and complete the disarticulation of the ankle-joint. OSTEOPLASTIC RESECTION OF FOOT. 453 (3) By means of rugine and periosteal elevator, and approaching from the lateral incisions, detach the soft parts from the dorsum of the foot as sub- periosteally as possible, thus guarding the anterior tibial vessels and extensor tendons. (4) Disarticulate anteriorly at the astragalo scaphoid and calcaneo- cuboid joints, and remove the astragalus and os calcis with the adherent soft coverings. (5) Divide the tibia and fibula horizontally just above the articular surfaces. Divide the scaphoid and cuboid vertically at about the center of each bone. Appro.ximate the sawed surfaces of the tibia and fibula above, to the scaphoid and cuboid below, in the vertical or extreme talipes equinus position — holding them in place by kangaroo tendon, silver wire, or pegs. (6) Having tied all vessels, appro.ximate and suture the cut ends of the j)osterior tibial nerve. Establish temporarv drainage. Suture the trans- verse plantar incision and the lower half of the oblique lateral incision, to Fig. 310.— Excisions abiht tvek Foot :— A, Excision of first plialanx of great toe, by dorso- interiial incision ; B, Excision of metatarso-phalangeal joint of great toe by dorso-internal incision; C, C, C". Skin incisions in WladimirofT-Milculicz's osteoplastic resection of foot ; D, Bone-section of scaphoid and cuboid, in same; E, Bone-section of tibia and fibula, in same. the upper half of the ol)lique lateral incision and posterior liorizontal incision. The limb is then ])ut uj) in a plaster cast. Comment. — (1) The redundancy of tissue is soon taken up. (2) The limb is generally permanently a little lengthened, and a special boot is always to be worn. (3) Nourishment of the part occurs through the dorsalis pedis artery and its anastomoses with the plantar. (4) The section of bone below may be made through the three cuneiforms and cuboid. TOTAL EXCISION OF TARSUS OR OSTEOPLASTIC RESECTION OF FOOT BY K.\TEKXO-L..\TKR.M, CfKNKI) 1 NCISION — MOUIFIC.VTION OF \VL.\1.1IM1R1)FF- MIKL'I.ICZ OPERATION. Description. — Removal of all the tarsal bones, and sawing otT of distal articular surfaces of tibia and fibula and proximal articular surfaces of meta- 454 OSTEOPLASTIC RESECTIONS. tarsals — with approximation of sawed tibia and fibula to sawed metatarsals — the foot being brought into a vertical line with the leg. This is a modification of the Wladimiroff-jNIikulicz osteoplastic resection of the foot, and is prefer- able to that operation where the soft tissues of the heel do not have to be sacrificed. The patient walks on the balls of the toes and the phalanges. Position — Landmarks. — As for osteoplastic resection of posterior tarsus, page 451. Incision. — .\s for osteoplastic resection of j)osterior tarsus — e.xcept that ihe incision extends to near the end of the fifth metatarsal (Fig. 309, BC). Operation. — The exposure and freeing of the surfaces of the tarsal bones, lower end of the tibia and fibula, and bases of the metatarsals are accomplished in the same manner as described in freeing the bones involved in osteoplastic resection of the posterior tarsus, except that the clearing is more extensive. The origins and insertions of all the muscles and tendons into the bones to be removed are to be separated as encountered. All vessels and nerves are carefully guarded by working close to the bones. The tendons of the peroneus longus and brevis are freed from their sheath and drawn forward. The tendo Achillis is subperiosteallv separated from the os calcis. The long dorsal, plantar, external and internal tendons are .separated — and the short muscles as well. The tarsal bones are to be removed one by one while the foot is forcibly inverted, access being gained to the region, if neces- sary, by chiseling off the external malleolus. The articular ends of the tibia and fibula and of the metatarsals are exposed by thrusting them through the external wound and are sawed otT. Their sawed surfaces are then placed in contact in a vertical line — the fibrous tissues brought together with chromic sutures, where indicated — the superficial wound closed — and the limb put up in a splint, or plaster, in such a manner as to retain this position. OSTEOPLASTIC RESECTION OF SUPERIOR MAXILLA B\ VI;RTIC.\L .\N|) IIORIZdXTAI. INCISKIXS Description. — Having made the same incisions, preceded by the same preliminaries, as in the ordinary excision of the upper jaw by Fergusson's method (page 441), and carried them everywhere to the bone — the soft parts are carefully guarded, and are nowhere freed from the bones, except in so far as necessary to reach the bones in making the original incisions. The bones are now divided just as in that operation, everywhere along the line of skin incision — except that no division of the bone is made from the anterior end of the sphenomaxillary fissure through the malar — this portion of bone being preserved for the "hinge." When all other connections have been divided, the bone, with its soft parts adherent, is broken outward and back- ward through the above indicated undivided portion as a hinge — by putting pressure from without over the region where the bone is to be broken back, and then prizing it outward and backward in that direction, .^t the end of the operati(m, the flap of bone and soft parts is turned back into place — and, if necessary, the bone wired. Comment. — It is better to previously divirle the frontal process of the malar, making a limited incision for that purpose, prior to turning back the bone — thus avoiding the uncertainty of the line of breakage and possible harm that might result to neighboring structures through the rougher manoeuvre. OSTEOPLASTIC RESECTION OF SUPERIOR MAXILLA. 455 CHONDROPLASTIC RESECTION OF NASAL CARTILAGES TO i;\i'i>si-: XDSi-; anu antekiur nasupharvnx bv .nasal route, bv traxs- \ERBE I.NXISION — ROUGE'S OPERATIOX. Description. — The cartilaginous portion of the nose is temporarily separated from the bony nares and turned upward. Position. — Patient supine, with head elevated and thrown back. Landmarks. — Line of reflection of mucous membrane of upper lip. Incision and Operation. — .\n assistant stands behind the head and draws the upper lip well upward, holding it opposite the angles of the mouth. The surgeon, standing in front, with scissors curved on the flat, cuts the mucous membrane in the line of its reflection from the superior ma.xilla, from one bicuspid tooth to the opposite one, hugging the bone throughout. .Simi- larly separate the cartilaginous septum from the anterior nasal spine, and alar cartilages from the lateral borders of the ma.xilla. Having retracted the cheeks well, the anterior nares is now turned upward and backward toward the forehead. .\t the end of the operation, the nose is dropped back into place and the cut edges of the mucous membrane sutured, if sufficient free margin exist — but suturing is not necessary. Comment. — This operation gives imperfect access to the nasopharynx — but satisfactory access to the nose. The cheeks must be sufficiently separated from the underlving bones to enable the nose to be turned back. OSTEOPLASTIC RESECTION OF SUPERIOR MAXILLA TO KXPdSK XASOl'HARVN.X BV PALATINE ROUTE, BV TR.\N'S\ERSE AND MEDIAN INCISIONS — ANNAXDALE'S OPERATIOX. Description. — Aiter having exposed the bony anterior nares as in Rouge's operation, the alveolar and palatal processes of the superior maxilla are divided in the median line, and the septum nasi also diWded. The two halves of the superior maxilla can then be separated from 1.3 to 2.5 cm. (h to 1 inch). Position. — Patient su]jine, head elevated and thrown back. Surgeon fares patient. Landmarks. — .\nterior and posterior nasal spines; .septum nasi; two central incisors. Incisions. — Transverse Incision — through mucous membrane of upper li|) (this portion of the operation being similar to Rouge's). ^ledian Incision — follows the base of the septum nasi, as near to the middle line as possible, and extending along the floor of the nose from the margin of the posterior bony nares to the anterior bony nares, and along the alveolar process of the superior maxilla between the two central incisors, possibly extracting one. Operation. — Exj)ose the bony anterior nares as in Rouge's operation fpage 455). Divide the septum nasi just above the maxillary attachment, from before backward, with a fVne narrow saw, or with cutting pliers. Having gagged the mouth open, separate the soft from the hard palate by a short transverse incision crossing the median line. If necessary, the soft palate may be divided. Drill holes in the alveolar process for future wiring. Bv means of a fine, narrow saw, introduced through the nose, divide the entire length of liard palate and alveolar process of superior maxilla, in the median line. The two halves of the superior maxillx are now prized apart and the 456 OSTEOPLASTIC RESECTIONS. nasopharynx reached with instruments. Upon the completion of the opera- tion, the alveolar process is wired and the soft palate sutured back to the soft tissues of the hard palate (and together, if divided). The nose-flap of Rouge's operation is dropped back into place and the mucous lips of the wound closed. Comment. — The room thus furnished is not great. The above operation may be considered the first step of an osteoplastic resection of the entire superior ma.\illa. OSTEOPLASTIC RESECTION OF SUPERIOR MAXILLA TO EXroSK XASorHARYXX BY MAXILLARY ROUTK, BY TWO SEMILUNAR INCISIONS— LANGENKECK'S OPERATION. Description. — .\ tongue-shaped flap, having its base over the nose and its apex over the malar bone is turned forward and inward upon the nasal bone and nasal process of superior maxilla as a hinge. Position. — Patient supine; head elevated and turned to opposite side. Surgeon on side of operation. Landmarks. — Naso-frontal suture; ala nasi; malo-zygomatic arch. Incisions. — Upper Incision — begins at root of nose and passes down- ward and outward just below the lower border of the orbit, ending a short distance posterior to the center of the malar. Lower Incision — begins at ala nasi and passes ujnvard and outward across the cheek, joining the outer end of the upper incision. These united incisions may extend further out- ward as a single incision along the zygoma, if necessary. Operation. — (i) Incise everywhere through skin, fascia, and muscles, and through i)eriosteuni to bone. Separate the periosteum for only a wide enough interval along the hues of incision for a saw to travel — except along the floor of the orbit, where it is stripped to the anterior end of the spheno- maxillary fissure. The masseter is detached from the malar where exposed. The soft parts are not otherwise raised from the bone. (2) Depress the inferior maxilla and pass a sharp periosteal elevator, or pointed director, below the inferior border of the zygoma, opposite its junction with the malar, and thrust it horizontally through the pterygomaxillary fissure to the outer wall of the nasal cavity, which is recognized by a finger in the mouth. Upon this guide, introduce a fine key-hole saw and divide the zygomatic arch upward — continuing the section so as to enter the sphenomaxillary fissure, cutting the posterior wall of the superior maxilla and following the floor of the orbit nearly to the lachr3-mal bone. If possible, however, it is better to make the saw section follow the line of the upper semilunar incision, thus avoiding the orbital plate. (3) The saw is again passed into the pterygo- maxillary fissure and made to cut forward and downward, passing through the walls of the antrum and into the anterior nasal cavity near its floor — following, approximately, the line of the inferior semilunar incision. (4) Pass the periosteal elevator into the pterygomaxillary fissure and prize the severed portion of the superior ma.xilla upward and inward — bending it over the nasal bone and nasal process of the superior maxilla (which fracture in the act) as a hinge. (5) .At the end of the operation, turn the displaced bone, with its soft coverings attached, back into place — and suture the wound. Comment. — Next to the osteoplastic resection of the entire bone, the above operation gives freer access to the nasopharynx than does any of the other partial osteoplastic resections mentioned. OSTEOPLASTIC RESECTION OF INFERIOR MAXILLA. 457 OSTEOPLASTIC RESECTION OF INFERIOR MAXILLA TO EXPOSE STRUCTURES IN FRONT OF FAUCES THROUGH DIVIDED SYMPHYSIS I!Y MEDIAN INCISION. Description. — The inferior ma.xilla is divided at the symphysis menti and either side drawn outward — followed by returning the halves into position and wiring Position. — As for e.xcision of inferior ma.xilla (page 445). Landmarks. — Symphysis menti. Hyoid bone. Incision. — Median incision, in line of symphysis menti, extending from the upper alveolar margin to the center of the upper border of the hyoid bone. Operation. — The central incisor of the lower jaw is drawn. The incision is then carried through skin, fascia, muscles, and periosteum to bone, over the inferior ma.xilla, — and through skin and fascia alone, between the inferior maxilla and hyoid. Having freed the anterior surface of the jaw in the middle line, the posterior surface is similarly freed over a narrow area, passing between the digastric, mylohyoid, geniohyoid, and geniohyoglossus, with as little damage as possible to them. Two holes are drilled on either side of the central line for future wiring. .\ Gigli saw is then conducted through — the bone is divided — and the two lateral halves of the inferior maxilla are drawn aside for the necessary manipulation that the special operation may necessitate. At the end of the operation the two halves of the bone are wired — and the wound closed. Comment. — Where exposure posterior to the fauces (pharynx) is desired, the lower jaw should be divided in front of the ascending ramus. PART II. THE OPERATIONS OF SPECIAL SURGERY. CHAPTER I. OPERATIONS UPON THE HEAD. I. THE CRANIO-CEREBRAL REGION. SURGICAL ANATOMY OF SCALP, SKULL, AND BRAIN. Muscles in Relation with Outer Surface of Skull. — Anteriorly; frontal portidti (if nci ipitofrcintalis; corrugator supercilii; orbicularis pal- pebrarum. Posteriorly; occijntal portion of occipitofrontalis; trapezius; sternomastoid ; complexus; splenius capitis; rectus capitis posticus minor and major; obliquus capitis superior; trachelomastoid; digastric; rectus capitis lateralis. Laterally; aponeurosis of occipitofrontalis; temporal; attrahens aurem; attolens aurem; retrahens aurem; external pterygoid. Superiorly; aponeurosis of occipitofrontalis. Arteries of Scalp. — Anteriorly; frontal and supraorbital branches of ophthalmic. Posteriorly ; occipital and posterior auricular branches of external carotid. Laterally; superficial temporal branch of external carotid, with its anterior and posterior branches; posterior auricular branch of ex- ternal carotid. Veins of Scalp. — Anteriorly; frontal, emptying into angular vein; supraorbital, empt\ing into frontal and ojjhthalmic veins. Posteriorly; occipital, emptying into deep cervical vein; posterior auricular, emptying into temporomaxillary vein. Laterally; anterior, middle, and posterior tem|_)oral veins; forming common temjwral, which empties into temporo- maxillary vein; [losterior auricular, em])tying into external jugular. Nerves of Scalp. — Anteriorly; supraorbital branch of ophthalmic. Posteriorly; occipitalis major, from cervical plexus. Laterally; temporal branches of facial; auriculotemporal branch of inferior maxillary; occipitalis minor, from cervical ]jlexus; auricularis magnus, from cervical plexus. Parts of Brain. — Medulla oblongata; pons varolii; cerebellum; crura cerebri (mid-l)rain) ; cerebrum. The onlv parts of the brain at [)resent accessible to o|)eration are the cerebrum and cerebellum. Chief Fissures upon Surface of Cerebrum. — Great Longitudinal Fissure; extending antero-posteriorly in the median line and separating the hemis|iheres of the cerebrum. Sylvian fissure ; most important of the in- com|)lete fissures of the brain. Forms boundary between frontal and tcm- poro-sphenoidal lobes. Contains middle cerebral artery. Begins at anterior perforated space, upon base of brain, and, running outward, divides into an anterior limb (passing forward into inferior frontal convolution), an ascending 459 46o OPERATIONS UPON THE HEAD. limb (passing upwarri also into inferior frontal convolution), and a horizontal or posterior limb (representing the continuation of sylvian fissure, passing backward and upward). Rolandic fissure; second most important incom- plete fissure of brain. Forms boundary between frontal and parietal lobes. E.xtends from great longitudinal fissure, at a pc.int about 55 per cent, of the distance from the nasion to the inion, to or nearly to horizontal limb of fissure of Sylvius. Parieto-occipital fissure ; forms boundary between ])arietal and occipital lobes. Begins about half-way between rolandic fissure and posterior e-xtremity of brain — its outer portion e.xtending downward and forward upon external aspect of brain for about one inch — its inner portion extending upon internal aspect of hemisphere. These four fissures just mentioned divide the surface of the cerebrum into the five following lobes. Chief Lobes of Cerebrum. — Frontal lobe; forms forepart of hemi- sphere — rests upon orljital plate of frontal bone — presents three surfaces. Boundaries; Posteriorly, rolandic fissure, — Inferiorly, orbital plate of frontal bone and horizontal limb of sylvian fissure, — Internally, calloso-marginal fissure. Frontal (supero-external) surface, ' presents precentral, superior frontal, and inferior frontal sulci, — and ascending frontal, superior frontal, middle frontal, and inferior frontal convolutions. Orbital (inferior) surface, presents triradiate (or orbital) and olfactory sulci, — and internal orbital, anterior orbital, and posterior orbital convolutions. Mesial (internal) sur- face, is given below. Parietal lobe; that portion of convexity of brain lying between frontal and occipital and above temporal lobes. Boundaries; Anteriorly, rolandic fissure, — Posteriorly, external parieto-occipital fissure and a line continuing its course, — Inferiorly, horizontal limb of sylvian fissure and a line connecting this fissure with inferior end of superior occipital sulcus, — Internally, it is continued into the mesial .surface of the hemisphere. Sulcus; intraparietal (consisting of .su]»erior and inferior vertical and horizontal parts). Convolutions; ascending parietal; superior parietal; supramarginal and angular gyrus. Occipital lobe ; posterior extremity of hemisphere — rests upon tentorium — continuous with parietal lobe above and temporal lobe below. Boundaries; .Anteriorly; external parieto-occi])ital fissure and a line continuing its course, — Posteriorly; superior fossa of occipital bone, — Inferiorly; tentorium, — Internally; it is continued into the mesial surface of hemisphere. Sulci: superior, mir angle of ])arietal, mastoid process of temporal and jugular process of occipital, to end in posterior compartment of jugular fossa. From the internal occipital protuberance the lateral sinus forms a slight curve, with upward convexity, to back of ear. on level with upper border of meatus auditorius externus, constituting the transverse portion of the lateral sinus, — and thence passes in a curved line, convexity forward, over prominence of mastoid process to its apex, as far as a point 5 mm. (y\ inch) below lower border of external auditory meatus, thus forming the sigmoid portion of the lateral sinus. The Transverse portion of the Longitudinal Sinus lies above a straight line drawn from the external occipital protuberance to the center of the external auditory canal — its highest portion (which is opposite the posterior inferior angle of the parietal, at masto-parietal suture) lying from 15 to 25 mm. (f to i inch), generally averaging from 15 to 20 mm. (I to if inch), above this line, and somewhat external to its center. The Sigmoid portion of the Longitudinal Sinus generally lies from 10 to 12 mm.. or j'g- to ^ inch (extremes 2 to 12 mm., or nearly J to ^ inch), from the poste- rior wall of meatus auditorius externus (corresponding, ayjproximately, to posterior reflection of skin from pinna of ear to head). Distance of sinus from surface of mastoid process varies from i to 15 mm., or from nearly yV to I inch (average distance being about 7 mm., or f inch). Width of .sig- moid portion of sinus (which is larger than transverse portion) is from 5 to 15 mm. (I to I inch). Right lateral sinus is generally larger, more forward, and more superficial than left. Junction of transverse and sigmoid portions lies directly below anterior part of parieto-mastoid suture. Inferior longi- tudinal sinus ; situated in free margin of falx cerebri. Straight sinus ; extends along line of junction of falx cerebri and tentorium. Occipital sinus; contained within attached border of falx cerebelli. (2) Sinuses at base of skull; — circular, transverse, caverrous, superior ])etrosal, inferior petrosal. Chief Veins of Cerebrum. — Cortical (Hemispheral or Superficial), consisting of .superior and inferior cortical veins, which empty chiefly into the more superficial venous sinuses of the dura mater; — Central (Ganghonic or Deep), collect into two venae Galeni, which unite to form the vena magna Galeni, which empties into the straight sinus; — Basilar, which enters vein of Galen. Chief Veins of Cerebellum. — Superior and Inferior veins. CHIEF CRANIAL LANDMARKS. 463 CHIEF CRANIAL LANDMARKS. Nasion: mid-point of nasofrontal suturt-; most important anterior median landmark. Glabella: jioint in median line between superciliary arches; unrelial)le, may be an elevation or a depression. Bregma (anterior fontanelle) : point where coronal, sagittal, and frontal sutures meet; just in front of center of line between the two auditory meatuses. Coronal Suture: on line from bregma to middle of zygomatic arch, running 2.5 to 3.8 cm. (i to li inches) anterior to rolandic fissure. Obelion: point on sagittal suture on a Hne running between the two parietal foramina. Lambda (posterior fontanelle): junction of lambdoid and sagittal sutures; 8 to 10 cm. (Sys to 4 inches) behind superior rolandic point (a point 55 per cent, of distance from nasion to inion, on median line), or 6 to 7 cm. (2| to 2f inches) above e.xternal occipital protuberance. Lambdoid (or parieto-occipital) Suture: sometimes an elevation of superior border of occipital bone marks this suture, which is roughly represented by a line from the external occipital protuberance to the lower part of the tip of the mastoid process. Inion (or e.xternal occipital protuberance): most important jiosterior median landmark. Superior Occipital Curved Lines (nuchal line) : running from the e.xternal occipital protuberance outward toward mastoid process, marking the posterior junction of the head and neck. E.xternal Occipital Crest: from external occipital protuberance to center of posterior border of foramen magnum; sometimes palpable. Nuchal Furrow: depression in median vertical line between posterior muscles of neck, having in its center, above, the external occipital protuberance; its u])i)cr end corresponding with inner ends of superior curvefl occipital lines. Orbit: margin everywhere palpable. Supraori)ital .\rch: palpable throughout. Internal .\ngular process: inner end of supraorbital arch. External Angular Process: outer end of supraorbital arch. Superciliary Ridge: first prominence above supraorbital arch. Frontal Eminence: second prominence above supraorbital arch. Superior Temporal Ridge: especially marked at forepart of lateral aspect, leading downward and forward to external angular process; gives attachment to temporal fascia. Superior Stephanion: where coronal suture crosses superior temporal ridge. Inferior Temporal Ridge: indicates upper boundary and attachment of temporal muscle, the contraction of which muscle will aid in determining site of rirlge. Inferior Stephanion: where coronal suture crosses inferior temporal ridge. Pterion: point in zygomatic fossa, from 3.8 to 5 cm. (ij to 2 inches) behind external angular process and same distance above zygoma, where parietal, temporal, frontal, and sphenoid bones meet. Sylvian Point: where svlvian fissure reaches the convexitv of the hemi- sphere, at a point from 2.9 to 3.2 cm. (i| to ij inches) directly behind external angular process. 464 OPERATIONS UPON THE HEAD. Parietal Eminence: most prominent postero-lateral eminence. Malar Bone: palpable throughout. Retro-orbital Tubercle; apophysis upon posterior border of upper part of frontal process of malar bone, a short distance below malo-frontal suture; the most important anterior lateral landmark. Zygomatic .'Vrch: palpable throughout; its upper border may be taken as I practically horizontal measurement, in the upright position of the body. .\uricular Point: center of external auditory meatus; most reliable middle lateral landmark. Preauricular Point: point on Reid's base-line (v. i.) in depression between tragus of the ear and condyle of inferior ma.xilla. Supra-auricular Point: point yertically abo\e auricular point, at root of zygomatic process. Squamous Suture: summit of which is 4.4 cm. (if inches) aboye zygoma. Mastoid Process of Temporal: palpable throughout. Asterion : point behind ear where parietal, temporal, and occipital bones and lambdoicl and squamous sutures meet; about 1.8 cm. (j inch) behind and 1.2 cm. (^ inch) aboye upper part of posterior border of mastoid process. Note : — For other landmarks of the cranio-cerebral region, see the methods of Chipault (page 472), Reid (page 476), and Chiene (page 478) for local- izing the brain areas, and also the data under the following di\ision of the subject. CRANIO-CEREBRAL TOPOGRAPHY. Description. — Relation of areas and structures of brain to the cranial bones. While discrepancies are found in the statements of the highest authorities in this department of surgical \york, and differences actually exist in different heads, the following may be considered the most generally accepted data, for the ayerage head. Extent of Cerebral Hemispheres. — (1) Superior or mesial border; extends from mid -point of nasofrontal suture to a jioint ayeraging i cm.. or yV inch (extremes, 5 to 15 mm., or ^ to | inch), aboye the external occipital protuberance, and 5 mm. (| inch) to its left and 15 mm. (f inch) to its right (representing the width of the superior longitudinal sinus and attachment of the dural walls). It is separated from the opposite hemisphere by the superior longitudinal sinus above, which deviates slightly to right, and by falx cerebri below. (2) Inferior or lateral border; (a) Frontal Portion; — begins in median line, opposite floor of nasofrontal grooye — arches upward and out- ward 8 mm. (I inch) above center of supraorbital margin of frontal bone — crosses temporal crest just above external angular process — thence descends slightly to a point in temporal fossa about 30 mm., or i^ inches (extremes, 29 to 32 mm., or ij-^ to Iy\ inches), directly behind external angular process, where it coincides with margin of temporal lobe at a point where the sylvian fissure reaches the convexity of the hemisphere (the sylvian point) — the frontal lobe in front and above and the temporal lobe behind and below forming a receding angle here. (More roughly outhned, the frontal portion lies just above the eyebrow in front, and just above the upper margin of the zygoma laterally.) (b) Temporo-occipital Portion; — continuing the line of lower margin of frontal portion from the sylvian point, at receding angle formed bv sylvian fissure, it curves slightly downward and forward from the lower margin of frontal lobe to a point 20 mm. (f| inch) above the zygoma, and 15 mm. (f inch) behind external angular process (which marks the CRANK )-C1-:REBRAL TOPOGRAPHY. 465 anterior pole of the temporal lobe) — thence passes backward on level with upper border of posterior half of zygomatic arch — thence still backward at an average distance of 6 mm., or ^ inch (extremes, 3 to g mm., or i to f inch), above the roof of meatus auditorius e.xternus — continuing horizontally backward it crosses the supramastoid crest — and runs thence to a point 5 to 15 mm. (I to I inch) above the e.xternal occipital protuberance, 5 mm. (J inch) external to the protuberance on the left, and 18 mm. (J inch) external to it on the right. (More roughly outlined, the temporo-occipital portion co- incides with the upper margin of the zygoma laterally, and the superior curved line of the occi])ital posteriorly.) Extent of Cerebellum. — Occupies inferior cerebellar fossae and is in contact with cranial wall, extending upward to lower margin of transverse portion of lateral sinus above, and forward to posterior margin of sigmoid portion of lateral sinus in front. Great Longitudinal Fissure. — Straight median line from mid-point of nasofrontal suture to center of external occipital protuberance — with a slight tendency to the left, especially posteriorly. Great Transverse Fissure. — (Between cerebrum and cerebellum.) Represented, ap])roximately, by a line between external occipital protuberance and center of external auditory meatus. Sylvian Fissure. — The parts of the sylvian fissure may be traced out by measurement, or by means of the sutures of the skull, (a) Location of parts of Sylvian Fissure by Measurement; Sylvian Point — found by carrying straight line from posterior margin of fronto-malar junction directly horizon- tally backward for 3.1 to 3.5 cm., or i^ to if inches (average, 3.3 cm., or ij\ inches), thence vertically upward for 6 to 12 mm., or J to ^ inch (average 9 mm., or f inch), the termination of which latter line marks the sylvian point, where the anterior branches of the sylvian fissure are given off. Sylvian Line — found by carrying a straight line from the sylvian point backward and upward to a point from 1.2 to 1.8 cm. (^ to f inch) below the most prominent part of the parietal eminence. Horizontal or Posterior Limb of Sylvian Fissure — that portion just mentioned (from sylvian point to lower part of parietal eminence) having a length of 7.5 to 10 cm. (3 to 4 inches). Ascending Limb of Sylvian Fissure — a line 3 cm. (iy\- inches) long, drawn upward and forward from the sylvian point, at right angle to sylvian line. Anterior Limb of Sylvian Fissure — a line 2 cm. (|f inch) long, drav^n horizontally forward from the sylvian point, (b) Location of Parts of Sylvian Fissure by means of Sutures of Skull; Point of Division of Sylvian Fissure — in the pterion, under or verv near the spheno-parietal suture, near its posterior end. Horizontal or Posterior Limb of Sylvian Fissure — runs from the point of division backward and slightly upward, following the squamous suture at first, and then crossing the temporal portion of the parietal bone to the inferior temporal line, and thence ascending beneath the parietal eminence. Ascending Limb of Sylvian Fissure — runs from the point of division obliquely upward and forward, crossing the lower end of the coronal suture, .'interior Limb of Sylvian Fissure — runs from point of division forward in the direction of the spheno-parietal suture. The horizontal limb of the sylvian fissure is more oblique, and further above the squamous suture, up to the third or fourth year than subsequently. Rolandic Fissure. — The parts of the Rolandic Fissure may also be traced (lut by measurement, or by means of the sutures and bony landmarks, in the exposed skull; (a) Location of position and direction of Ri.landic Fissure by Measurement; Superior Rolandic Point — variously estimated at 3<^ 466 OPERATIONS UPON THE HEAD. from 55 to 57 per cent, (average being between 55 and 56 per cent., probably about 55.7 per cent.) of distance from mid-point of naso-frontal suture to external occipital protuberance. Quain, upon another basis, gives the point at I cm. (y% inch) behind the center of the naso-inial line, and Poirier as 2 cm. (yf inch) behind that center. Where the inion is indistinct, the superior ro- landic point may be considered as 18 cm., or j^-^ inches, in large (and 17 cm., or6Y^ inches, in small) heads posterior to the nasion, in the median line. Direc- tion of Rolandic Line — forms an angle generally averaging about 70 degrees (extremes 64 degrees to 75 degrees) with the median line. (Formerly the angle was generallv considered 67^ degrees. Different writers have gi\en the wide variations covered in the above extremes.) The rolandic hne coincides with the rolandic fissure more accurately in its upper part — the inferior genu of the rolandic fissure projecting slightly in front of the rolandic line below its cen- ter, corresponding to a point 5 to 15 mm. (| to | inch) above the lower tem- poral line. Inferior Rolandic Point — lies on the rolandic line generally i cm. (y'^ inch) above the sylvian line (v. s.). Length of Rolandic Fissure — gen- erally from 8.5 to 9.5 cm. (3^ to 3I inches). (b) Location of Rolandic Fis- sure by Bony Landmarks; lies entirely under the parietal bone, the superior rolandic point being from 4 to 5 cm. (if^ to 2 inches) and the inferior rolandic point about 3 cm. (lyif inches) posterior to the coronal suture. The rolandic fissure is somewhat further forward and more obliquely placed in children under nine years. Parieto-occipital Fissure. — .\ line about 2 cm. (jf inch) long running transversely outward, at right angle to naso-inial line, from a point averaging about 6 mm., or ^ inch (extremes, from lambda itself to a point 15 mm., or f inch), in front of lambda. Where the lambda is not distinct, its position lies from 6 to 7 cm. (2f to 2f inches) above the external occipital [irotuberance, or 8 to 10 cm. (3J to 4 inches) behind the superior rolandic point. The above line represents the external portion of the fissure, the internal portion lying upon the mesial aspect of the hemisphere. (If the horizontal limb of the sylvian fissure be continued backward to the median line, its last 2 cm. — j-f inch — would represent, approximately, the external portion of the parieto-occipito fissure.) In children this fissure lies somewhat further forward. Precentral Fissure. — Runs downward and forward about 15 mm. (f inch) anterior to and nearly parallel with the rolandic fissure. Its upper portion hes from 2 to 3 cm. (-^f to jj\ inches) behind the upper part, and its lower portion from i to 2 cm. (f to -j-f inch) behind the lower part of the coronal suture. Its lower end terminates about i cm. (| inch) above the sylvian fissure. Postcentral Fissure. — Runs downward and forward about 15 mm. (f inch) ])ostcrior to and nearly parallel with the rolandic fissure. Superior Frontal Fissure. — Line running forward, approximately parallel with the naso-inial line, from the precentral fissure, just internal to mid-distance between temporal crest and median line, to the supraorbital notch. Inferior Frontal Fissure. — Line running forward and slightly down- ward from the precentral fissure to just above the superior stephanion (inter- section of superior temporal ridge and coronal suture), and thence forward, nearly coinciding with the anterior portion of the temporal ridge. Intraparietal Fissure. — The ascending portion runs upward for about 1.8 cm. (f inch) nearlv parallel with and about 1.5 cm. (f inch) posterior to the rolandic fissure. The longitudinal portion runs thence backward and CRANIO-CKREBRAL TOPOGRAPHY. 467 slightly inward just above the parietal eminence, being about 4.5 cm. (iff inches) from the median line anteriorly, and about 3.5 cm. (if inches) poste- riorly, at a point opposite the lambda. Superior Temporo-sphenoidal (Parallel) Fissure. — General direction of this fissure is represented bv a straight line passing from the retro-orbital tubercle to the lambda, which line coincides more accurately with the tem- poral ])art of the fissure. This fissure lies beneath the superior part of the squamous portion of the temporal, and posterior part of temporal portion of parietal, and thence turns upward across the temporal lines and passes under the u])per division of the parietal bone. Placed somewhat higher in children. Ascending Frontal Convolution. — Lies beneath the anterior third of the parietal Ihhil-, Superior Frontal Convolution. — Its base lies under the anterior third of the parietal, and its main part corresponds to somewhat less than the inner half of the frontal region of the frontal bone. Middle Frontal Convolution. — Its base lies under the anterior third of the parietal; its main ])art corresponds to somewhat more than the outer half of tlie frciiital region nf the frontal bone, and its anterior portion lies under the frontal eminence. Inferior Frontal Convolution. — Its base lies under the anterior third of the parietal; the ape.x of its triangular part lies under the anterior inferior angle of the parietal; and its orbital part lies beneath the temporal division of the frontal and superoir end of great wing of sphenoid Island of Reil. — Pole of the triangular island of Reil rorresponds with the sylvian point. Posterior Angle corresponds with a point on the sylvian line 3.5 cm. (if inches) behind the sylvian point. Superior Boundary is indicated by an evenly curved line, with upward convexity, extending from the posterior angle to the upper extremity of the ascending limb of the sylvian fissure, and thence forward in the same curve 1.5 cm. (f inch) beyond a vertical line passing upward from the sylvian point. Postero-inferior Boun- dary extends from the posterior angle downward and forward to a point on the superior temporo-sphenoidal line directly below the sylvian point. Parietal Lobe. — Lies beneath the parietal bone, the parietal eminence overlying some |)art of the supramarginal convolution. Ascending Parietal Convolution. — Lies between the rolandic fissure and the ascending portion of the intraparietal fissure. Angular Gyrus. — .\t the intersection of Reid's posterior perpendicular line (v. i.) and the direct continuation of the svlvian line. Temporal Lobe. — Lies chiefly beneath the squamous part of the temporal and the posterior and inferior fourth of the parietal — its anterior end lying under the great wing of the sphenoid — its posterior part (inferior temporal convolution) Iving beneath the occipital lobe. Occipital Lobe. — Lies in the cerebral portion of the occipital bone, and sometimes slightly beneath the adjoining parietal. Basal Ganglia. — Consist of the following; nucleus caudatus and nu- cleus lenticularis. forming the corpus striatum; claustra; amygdaloid nuclei. The o[jtic thalami lie near the corpora striata, but belong to the thalamen- cephalon or interbrain. The above gangha, except the amygdaloid nucleus, lie subjacent to the island of Reil — they extend slightly beyond the limits of the island — and are circumscribed by the curved line limiting the main part of the lateral ventricle (v. i.). The following important white fasciculi are closely related to the corpora striata; inner capsule; outer capsule; anterior commissure; ta;nia semicircularis. 468 OPERATIONS UPON THE HEAD. Lateral Ventricle. — Commencing at the anterior extremity of the Ante- rior Horn, I cm. (f inch) in front of the most anterior point of the outHne of the island of Reil (v. s,), pass backward along the Body of the Lateral Ventricle in a curve following parallel with and i cm. (f inch) above the superior boundary of the island of Reil, to a point 2 cm. (|f inch) behind its posterior limit — thence the Descending Horn curves forward and downward to terminate i cm. (| inch) below the level of the superior temporo-sphenoidal (parallel) fissure and slightly anterior to a hne from the lower rolandic point to the preauricular point — while the Posterior Horn passes backward from this curve, a variable distance, toward the back part of the hemisphere, which is somewhat higher than the occipital pole. Another method of locating the lateral ventricle is to take a point 3.1 cm. (i^ inches) above and the same distance behind the external auditory meatus (Keen). Ordinarily the lateral ventricle lies at a distance of 5.7 to 6.3 cm. (2j to 2J inches) from the surface. Naso-lambdoidai Line. — Begins at naso-frontal groove — passes directly backward 6 mm. (| inch) above the external auditory meatus to end i cm. (I inch) above the lambda (or, if that is net recognizable, about 7 cm., or 2J inches, above the external occipital protuberance). It pasfes through the lower part of Broca's (inferior frontal) convolution — runs along the pcsterior hmb of the sylvian fissure for 4 to 6 cm. (if^ to 2| inches) — touches the lower part of the supramarginal convolution — passes through the base of the angular gyrus — and ends in the parietooccipital fissure. Superior Longitudinal Sinus. — Is represented by two straight lines, both beginning tugcther from the mid-point of the naso-frontal suture (foramen caecum) and sKghtly diverging as they pass pcsteriorly, one going to a point opposite the external occipital protuberance and 5 mm. (y-g inch) to its left, the other to a corresponding point 15 mm. (| inch) to the right of the external occipital protuberance. This divergence represents the attachment of the laminae of the falx cerebri forming the sinus, which increases in width poste- riorly. Lateral Sinuses. — Transverse Portion forms a slight curve, with upward convexity, from external occipital protuberance to back of ear, on level with upper border of external auditory meatus. The highest part of the sinus (opposite masto-parietal suture) lies from 1.5 to 2.5 cm. (f to i inch) above a straight line drawn from the external occipital protuberance to the center of the external auditory meatus and a little external to its center. Sigmoid Portion passes from back of ear, on level with upper border of external auditory mea- tus, in a sigmoidally curved direction (convexit)' forward) over the prominence of the mastoid process to its apex, h'ing generally from 10 to 12 mm., or -^-^ to i inch (extremes, 2 to 12 mm., or nearly J to § inch), behind the posterior wall of the external auditory meatus, and extending downward about 5 mm. (■jj^ inch) below the lower border of the external auditory meatus. Eistance of sigmoid portion from outer surface of mastoid process is about 7 mm., or f inch (extremes, i to 15 mm., or j\ to | inch). Width of sigmoid portion is about 10 mm., cr | inch (extremes, 5 to 15 mm., or -^^ to f inch). (For other data concerning the Lateral Sinuses, see Surgical Anatomy of Brain [page 462], and Relations of Mastoid Antrum, [page 502].) Middle Meningeal Artery and Its Branches. — For course and rela- tions, see under Surgical Anatomy of the Brain (page 461 ), and under the Surgical Anatomy in connection with the ligation of those vessels (pages 47-4Q). Facial Nerve. — Descends in fallopian canal through the mastoid pro- cess, lying between the sigmoid portion of the lateral sinus and the external LOCALIZATION OF BRAIN AREAS. 469 auditory meatus (very near the latter). For fuller description of its relations, see under Surgical Anat(im\- of the Mastoid region (pages 502 and 503J. LOCALIZATION OF BRAIN AREAS. Description. — The determination of the situation of those areas of the Brain which are concerned with certain functions. These centers do not Fig. 311.— LocALlZATlo.M OF Brain Arhas :— Outer aspect of riglit sitie. (Mtjdificd from Gray, Dalton necessarily coincide with fi.xed convolutions — are not limited in extent by hard and fast lines — often overlap each other — and their jiosition and dimen- sions are not, in all cases, invariably fi.xed, nor absolutely ascertained. Each functional center most probably has a wider general representation over the adjacent areas and a more limited special representation, whereby a small area may be removed without total paralysis of that part of the limb specially represented by that area. The following summary may be taken as repre- senting the present state of knowledge of the best authorities. Sensori-motor Area. — The area of common sensation and motion. 47° OPERATIONS UPON THE HEAD. Corresponds with the cortical surface of the anterior and posterior central convolutions, which lie along both sides of the rolandic fissure. Extends, from above downward, from the longitudinal fissure to the sylvian fissure. From before backward, these areas, while chiefly occupying the ascending frontal and ascending parietal convolutions, also occupy convolutions in front of and behind these two chief convolutions. In the right-handed this area is larger upon the left hemispheie. If this area along the rolandic fissure, from the longitudinal fissure to the sylvian fissure, he divided into three appro.ximatelv equal parts, the functional centers will be distributed as follows; (i) Lower Third of Sensori- motor Area; — (a) In Upper and Forward Part; eyebrows; cheeks; upper face muscles: — (b) In Lower and I'orward Part; lower face muscles; tongue; larynx: — (c) In Hinder Part; mouth; pharynx; ])latysma; (2) Middle Third of Sensori-motor Area: — (a) In Upjier and Forward Part; shoulder; arm: — (b) In Middle Part; elbow: — (c) In Hinder and Lower Part; forearm; hand; fingers: — (3) Upper Third of Sensori-motor Area (including the union in the paracentral lobe upon the median aspect of the LOCALIZATION OF DRAIN AREAS. 471 hemisphere): — (a) In Forward Part; trunk; hips; thigh: — (b) In Middle Part; knee: — (c) In Back Part; leg; foot; toes. (Figs. 311 and 312.) In the posterior part of the second frontal convolutions are the centers for the movements of the eyes and head. The sensori-motor area is repre- sented upon the median aspect of the brain in the following order, from before backward; — head; arm; trunk; leg. (Fig. 313.) Speech Areas. — (In the left hemisphere in the right-handed, and in the right hemis[)here in the left-handed.) (1) Motor Speech Area (speech memories and power of talking) — in the posterior part of the third frontal convolution. (2) Auditory Speech Area (memories of word-sounds) — in first and second temporal convolutions. (3) \'isual Speech Area (memories of printed words) — in lower parietal region. (4) Power of Writing Language Fig- 3'3— LoCALI Arkas : — Median aspect. Ualloii and Ecker. l (writing memories) — proljably in the posterior part of the second frontal convolution, or in the lower parietal convolution. Area of Sight Sensation. — In the occipital lobe; lying in the corte.x of the calcarine fissure and cuneal lobe, upon the median aspect — and upon the conve.xity of the occipital convolutions, upon the outer aspect. Area of Sound Sensations. — In first and second temporo-sphenoidal conx'olutions. Area of Smell- and Taste-sensations. — Upon the under and inner surface of the li}) of the tem])oro-s])henoidal lobe, resting upon the sphe- noidal bone. Area of Higher Psychical Centers. — Outer and median aspects of the frontal l..bes. Cortex of Basal Surface of Cerebral Hemispheres. — No assignable functions. 472 OPERATIONS UPON THE HEAD. Crura Cerebri — Pons — Medulla. — Emlsrace the centers of various cranial nerve-nuclei — antl transmit motor and sensory tracts to the spinal cord. Basal Ganglia. — Function unknown — disease of these ganglia only made known li\' also involving the internal capsule. Cerebellum. — Regulates the equilibrium of the body. CHIPAULT'S METHOD OF CRANIO-CEREBRAL LOCALIZATION. Description. — This method of cranio-cerchral localization is based upon the relations of the parts of the brain to the skull, as determined by the percentage measurements of the skull made in the metric system. It is, therefore, ecjually applicable to skulls of different sizes, shapes, and ages. Following Fixed Bony Landmarks of Measurement are taken: — Nasion — mid-point of naso-frontal suture (avoid confusing this with the glabella). Inion — external occi]iital protuberance. Retro-orbital Tubercle — the apophysis upon the posterior border of the upper part of the frontal process of the malar bone, a short distance below the fronto-malar suture. The most prominent part of this apophysis forms the lower limit of the three primary lines of Chipault's method (avoid confusing this with the e.xternal angular process of the frontal bone). (Fig. 314.) Following Percentage Points are Marked upon the Median Naso- inial Line (a line extending in the median line cf tlie head, fnm nasion to inion) — which percentage points are to become the median or upper limits of lines to be subsequently drawn: — Precentral Point is marked at 45 per cent, of the distance from nasion to inion. Rolanthc Point is marked at 55 per cent, of the distance from nasion to inion. Sylvian Point is marked at 70 per cent, of the distance from nasion to inion. Lambdoidal, or Superior Temporo-sphenoidal Point, is marked at 80 per cent, cf the distance from nasion to inion. Lateral Sinus Point is marked at 95 per cent, of the distance from nasion to inion. (Fig. 315.) (Illustration — suppose distance from nasion to inion to be 30 centimeters — then jYtt '^^ that distance, or the Precentral point, will be 13.5 cm. from the nasion; — ^\, or the Rolandic point, 16.5 cm.; — yW' or the Sylvian point, 21 cm.; — j-'y^, or the Superior Temporo-sphenoidal point, 24 cm.; — -jS^-j, or the Lateral Sinus point, 28.5 cm. If measured in inches, and the naso- inial line measured 12 inches, ^-5% of 12 inches, or the Precentral joint, would lie 5.4 inches from the nasion, etc.) Three Primary Lines are Drawn. — Sylvian Line — from retro-orbital tubercle to sylvian point (70 per cent.) — its anterior portion marking the sylvian fissure. Superior Tcmporo-sjihenoidal Line — from retro-orbital tubercle to lambdoidal or superior temporo-sphenoidal point (80 per cent.) — its anterior part marking the superior temporo-sphenoidal fissure. Lateral Sinus Line — from retro-orbital tubercle to lateral sinus point (95 per cent.) — its anterior part crossing the lower portion of the temporal lobe — its poste- rior portion marking the upper part of the transverse portion of the lateral sinus, the tentorium cerebelli, and the great transverse fissure of the brain. (Fig. 316) These three primary lines are now marked off into tenths of their lengths. (For instance, if the svlvian line measures 21 cm., this line is divided ofi into ten parts of 2.1 cm. each.) CHIPAULT'S METHOD OF CRANIO-CEREBRAL LOCALIZATIOxV. 473 Two Secondary Lines are Drawn. — Precentral Line — from junction of second and third tenths of sylvian line, to precentral [joint (45 per cent.) — commencing at the bifurcation of the sylvian fissure, it at first follows the ascending limb of the sylvian fissure, and then corresponds in its two upper thirds to the precentral fissure. Rolandic Line — from junction of third and H5% F'ig- 314- — Chipaitlt's Mrthod of Cranio-cerebral Localization — Scalp Vitw : - A. Nasi< B. Inioii : C. Retro-orbital tubercle ; 45;^, or Precentral point ; ss-r. or Rolandic point ; 7054, or Sylv point; .Sff?, or Superior temporo-sphenoidal point; 95^, or Lateral sinus point; D. Sylvian line; Superior temporo-sphenoidal line; F. Lateral sinus line; G. Precentral line; H. Rolandic line Junction of second and third tenths of sylvian line ; J, Junction of third and fourth tenths of sylv line. fourth tenths of sylvian line, to rolandic point (55 per cent.) — beginning at lower e.xtremity of rolandic fissure and following its entire length. These two secondary lines are now divided and marked off into tenths. Tluis, with the tenths marked on the three primarv lines, sufficient data are furnished for all practical purposes of localization. Other Points and Lines. — Inferior Frontal Fissure — begins at junction of third and fourth tenths of precentral line Anterior Branch of Middle 474 OPERATION'S UPON' THE HEAD. Meningeal Artery — crosses the second tenths of the three primary lines. Lateral X'entricle — lies directly opposite the junction of the third and fourth tenths of the superior temporo-sphenoidal line. This point strikes the Body of the lateral ventricle at its posterior part. Hartley has determined that the ca\ity of the ventricle is reached at a distance from the surface of the brain equal to one-third of the transverse diameter of the brain itself opposite Fig. 3i,s. — Chipault's Mhthod of Cranmo-cerebral Localization — Skull View : — A, Nasic B, Inion ; C, Retro-orbital tubercle ; 45^. or Precentral point ; 55^, or Rolandic point ; 70;^, or Sylv point; 8ofi, or Superior temporo-sphenoidal point; 95^, or Lateral sinus point; D. Sylvian line; Superior temporo-sphenoidal line ; F, Lateral sinus line; G. Precentral line; H, Rolandic line; Junction of second and third tenths of sylvian line; J, Junction of third and fourth tenths of sylv line; K. Lateral sinus. this point. (For example, take the full diameter of the skull and scalp with calipers, say 15 cm. — take thickness of skull and scalp of the side opened, say I cm. — double this for the opposite side — take result of this doubling, sav 2 cm., from the total transverse diameter, which will give the diameter of the Ijrain alone, say 13 cm. — take one-third of this, say 4.3 cm. — and enter the brain to that depth upon a direct horizontal line.) To puncture the Descending Horn oi the lateral ventricle. Hartley passes through the CHIPAULT'S METHOD OF CRANIOCEREBRAL LOCALIZATION. 475 middle temporo-sphenoidal convolution in a line directly above the external auditory meatus. To puncture the Posterior Horn of the lateral ventricle, he passes through the middle temporo-sphenoidal convolution in a line with the posterior border of the mastoid process. Summary. — Having determined the position of the chief fissures of the Fig. 316.— CHIPAULT'S Method OF Cranio-cerebral Localization— Brain View :— A, Nasion ; B, Inion ; C, Retroorbilal tubercle ; 45";, or Preceiitral point ; ss";. or Rolandic point ; 7])crations. Landmarks. — IJetermined by bony landmarks of skull, or calculated by some method of cranio-cerebral localization, according to special operation. 31 482 OPERATIONS LT'OX THE HEAD. Control of Hemorrhage. — Ordinarily the hemorrhage is controlled by clamping the arierics in the margin of wound as cut. Excess of bleeding can be temjiorarily controlled, until arteries are clamped, by digital com- pression of temporal, occipital, or posterior auricular vessels against the skull. Where much bleeding is anticipated, the arteries may be compressed against the skull by circular constriction, as explained under General Surgical Considerations in Cranio-cerebral 0])erations (page 479). See also under Comtiient at end of this operation, and under Operations for Intracranial Hemorrhage (page 489). Incision. — An incision is made outlining an oval or U-shaped tlap, with its convexitv toward the crown of the head and its pedicle toward the base, its sides corresponding with the general direction of the vessels and nerves, thus providing for free ingress of arteries into the flap, \\here possible, so place the flap as to avoid the main arteries. Size of flap should be consider- ably greater (at least 1.2 cm., or h inch, all around) than the disc of bone to be removed, so that the cicatrix of the soft parts should not overlie the margin of the bone-opening. The center of the soft flap should about corre- spond with the center of bone-disc to be removed. (The oval-flap incision is distinctly superior to the crucial or ether form of incision.) Operation. — (1) The original incision passes directly through skin, fascia, muscle (or aponeurosis), and periosteum to the bone throughout. Clamp arteries as cut, followed by ligation of main vessels with gut and removal of clamp forceps, so as to avoid encumbering the site of ojeration with instruments. (2) The periosteum, together with the overlying parts adherent to it, is then detached from the bone, en nwsse, with [periosteal elevator (its adherence being firmest along the suture lines), and the entire flap turned down — and either held out of the way by a metallic nr thread retractor, or stitched to the neighboring soft parts. (3) When all bleeding has been controlled, apply trephine to desired site, with its pin slightly pro- jecting, withdrawing pin as soon as teeth of instrument have cut a groove in the bone.' By repeated right to left pronations and supinations of wrist, continue the half circular movements of the trephine until the section is made through the bone, to but not into the dura. The progress of the trephine is best determined at intervals by withdrawing the instruir.ent and ascer- taining the depth of the groove by the tip of the flat end of the ordinary probe, which readily detects the yielding dura. Additional pressure should be made u])on that aspect of the incision which is thickest or is least cut, while the trephine is tilted away from the part completely divided. If the teeth of the trephine become blocked with bone-dust, remove such dust with trephine- brush or gauze. Pressure upon the instrument should decrease as the brain is a])proached. At first, greater resistance in going through the outer table of the skull is offered — then less resistance as tne instrument passes through the diploe, and the bone-dust of the diploetic region is usually more blood- stained — then finally greater resistance is experienced again in passing through the inner talile. When section of bone has been almost or quite completed, the button of bone may generally lie lifted out by means of an elevator or in the grasp of special curved, thin-b'aded trephine-forceps. (4) If more space be required than afforded by the removal of the button, it may be gotten by biting out pieces of Ijone from the circumference of the opening by means of suitablv curved rongeur forceps — or bv making an additional contiguous trephine-opening of the same or smaller size, followed by biting out of the intervening liridge-work of bone. (5) The dura mater is now exposed, and should be opened by marking out, on a very small scale, a flap very similar OSTEOPLASTIC RESECTION OF SKULL. 483 to the scalp-flap — its pedicle should be placed so as to best preserve its blood- supply (without reference to coinciding with the pedicle of the scalp-tlap) — its convexity should lie in the opposite direction and be evervwhere suffi- ciently far from the edge of the bone (at least 6 mm., or ^ inch) to enable the cut margins of dura to be sutured at the end of the operation. If arteries of fair size cross the dura, they should be ligated, v.-here possible, prior to incising the dura, by passing a small, fully curved needle, armed with f.ne gut, beneath them, including the dura, .\rteries should be tied along the line which will form the convexity of the flap, rather than where they enter its pedicle. If not possible to tie them in ailvance, they should be caught as soon as cut and tied or twisted. The dura should be carefullv incised with a light touch of the point of a iine, sharp knife, or cut with fine curved scissors, aided by grasping the small dural flap with delicate forceps as soon as a margin of it is free, and taking care not to wound the surface of the brain or the vessels coursing over it. (6) The special object of the operation, whatever it may be, is now carried out. (7) Having accomplished the par- ticular object of the operation, the dural flap is dropped into place and sutured with two or three, or more, fine gut sutures, by means of a small, fullv curved needle held by needle-forceps, while the dura is steadied by fine forceps. (8) The opening in the bone may now be treated in one of several wavs: (a) Left without replacement of any bone-tissue, which is especially done in the making of small trephine-openings; — (b) The button of bone may be replaced intact upon the dura, and the soft flap of periosteum and other tissues brought over the button — a method which may be pursued in dealing with buttons of larger size; — (c) The button may be divided into parts by fragmentation and sprinkled o\er the dura, where they form the nucleus of new bone growth; — (d) .\ celluloid, metallic, or gutta-percha jjlate may be placed in the opening. In trephinings of small diameter the button is not generally replaced. In large openings some surgeons do, and some do not, replace the button, whole or fragmented, or some artificial covering. \Miere the button, either intact or fragmented, is used, it is dropped into warm normal salt solution as soon as removed. (9) The flap of scalp tissues is now brought back into its original position — the edges of the periosteum are sutured with catgut — and the edges of the overlying soft parts are sutured interruptedly with silkworm-gut, silk, or catgut, passing through all the soft tissues down to the periosteum. (10) No drainage is ordinarily used unless specially indicated — and, if indicated, a few strands of catgut, horsehair, silk, or gauze suffice. A full dressing is apphed. Comment. — Bleeding from the diploe may be stopped by compressing a small part of the bone upon the vessel with bone-forceps, or by plugging with catgut or surgeon's wax Bleeding from the dura may be checked by fine catgut ligature. For bleeding from venous sinuses, see Ligation of Longitudinal and Lateral Sinuses (page 490). It is probably always best to open the dura in all cases of trephining. OSTEOPLASTIC RESECTION OF SKULL. Description. — Temporary partial displacement of a section of the skull, together with its overlying soft parts unseparated — accomplished by ]jartly bending, partly breaking backward, the base of the bony section from the dura, upon a hinge, as it w-ere, of the soft parts, without complete severance 484 OPERATIONS UPON THE HEAD. of the vascular supply — followed by the replacement of the flap of bony and soft parts into apposition. (See Fig. 320.) (The replacement of a trephined button of bone is, strictly, an instance of osteoplastic resection with temporary complete displacement of the excised piece of bone.) Indications. -For exploration; tumors; intracranial abscess; intracranial j.-ig. 320.— Osteoplastic Rkskction of the Skull :— A, Cutaiieo-musculo-osseous flap lempo- rarilv turned back; the componenl parts adherent, and with scalp vessels cut along the margin; B, B, B, B, Four trephine-openings made preceding the sawingof the bone ; C, Line alongwhich the bone was cracked back ; D, Incised dura, with divided vessels ligated ; E, Dural flap turned back ; sutures through margins of incised dura and dural flap ; G, Periosteum retracted from lint cut ; H, Margin of skull left by temporary removal of osteoplastic flap ; I, Surface of brain. , Gut- hemorrhage; exposure of Gasserian ganglion; wounds. In general, where the freest access to brain is required. Preparation and Position. — See under General Surgical Considerations in Craniocerebral Ojierations (page 478). Landmarks. — Same as for trephining (q. v.). Control of Hemorrhage from Scalp.— Hemorrhages ordinarily con- trolled as in trephining (q. v.). Where extensive hemorrhage is anticipated OSTEOl'LASriC RESECTION OF SKULL. 485 the vessels may be controlled by circular constriction, as explained under General Surgical Considerations in Cranio-cerebral Operations. Form of Cranial Opening. — (1) The best and general form is that of a horseshoe, with its liroader convexity upward and its more contracted base downward (Fig. 320) — or an i-'-shaped flap, the horizontal cuts at base (which mav or may not be made) serving as liberating incisions. (2) A square, or a rectangular piece longer than broad, may be used — though the process of bending backward is always aided if the base be somewhat narrower than the free portion. (3) A second horseshoe, or square of bone, mav be turned l)ack, if the original flap do not furnish sufficient room — the second being cither turned back in an opposite direction from the first but in the same line, or from one side of the original opening. Incision of Scalp. — The form of scalp incision will be regulated by the previously determined form of bone section. Having decided this, the in- cision througii the soft parts should conform, in general outline, with the bone section to be made, but should extend at least 1.2 cm. (^ inch) beyond the line of bone section so that the cicatrix of soft parts will not fall directly over the line of bony union or repair. The incision should be so placed, where possible, as to give free ingress of the neighboring arteries into its substance, especially the chief artery of the region. The removal of an area of bone greater than 7.5 cm. (3 inches) square is rarely called for — and this would require a skin-flap at least 10 cm. (4 inches) broad. Operation. — (i) The incision passes everywhere through skin, fascia, muscle, aponeurosis, and periosteum directly to the bone. Or the incision may pass down to the periosteum — these allowed to retract, and periosteum cut on line of retracted soft parts, midw'ay betw-een the line of the skin incision and the line of the bone incision so that periosteal and skin cicatrices do not fall together, nor periosteal and bony cicatrices coincide. (2) A rim of periosteum, without separating the overlying soft parts, is carefully detached to the extent of about 1.2 cm. (i inch) around the horseshoe flap, separating it chiefly toward center of flap, and but slightly upon the outer edge of the incision. (3) Having exposed the entire area for the bone section, the bone is divided about 6 mm. (^ inch) inside of the division of the periosteum in one of the following ways: — (a) Division of horseshoe figure of bone by motor saw, preferably ])receded by a trephine-opening, and the brain guarded throughout by a dural separator traveling with the saw between the bone and dura — a motor saw capable of following a cur\'e is necessary, and very great care is needed in protecting the brain and in approaching the dura if a dural separator be not used. The saw should be held in such a wav as to bevel the bone-flap at the expense of its inner surface, so that, when re- placed, it will rest upon a ledge of bone furnished by the margin of the opening and be thus prevented from pressing upon the brain, (b) Division of horse- shoe figure of bone by Gigli saw, preceded by several small trephine-openings. Four or six small trephine discs of bone. 1.2 cm. (^ inch) in diameter, may tie removed along the line of section — a pliable dural separator is then passed from hole to hole, detaching and depressing the dura from the skull — a Gigli saw is then conducted beneath the bone by a special carrier, between two con- tiguous holes, and the bone divided — and this repeated until the section is completed — the saw beveling the bone as above, (c) Division of a horseshoe figure of bone by a specially grooved chisel which cuts a narrow furrow — but which also involves much jarring to the brain. (4) When the bone has been divided throughout down to the base of the bone-flap, provision must be made for the bending and breaking back of the bone at the site which 486 OPERATIONS UPON THE HEAD. will form the hinge of the osteoplastic flap — this hinging of the flap may be accomplished in one of sexeral ways ; — (a) When, all is in readiness, and without having previously partly divided the bridge of bone at the base of the flap, a stout steel elevator may be inserted under the edge of the con- vexity of the bone-flap (that part opposite the narrow base of the flap) so as to rest upon the intact portion of the skull — the fingers of the surgeon's left hand pressing upon the skull immediately below the line where it is sought to bend and break the bone — and then with a sudden, sharp (not slow and deliberate) movement of the lever the bone is sprung back — a id generally breaks accurately enough for all practical purposes, and drops outward and downward still clinging to its hinge of soft parts, (b) To insure a more accurate line of breakage, as well as against splintering of the bone and wounding of the brain, two small trephine-openings may be made im- mediately opposite each other, at the base of the bone-flap and on the line to be broken — a pliable dural eeparator is now passed between the open- ings — a Gigli saw is conducted beneath the bone — and the bone is sawed sufficiently far through, especially at its edges, to insure an accurate breakage and freedom from sphntering when the elevator is used as a lever as just desciibed. (5) As the bone is broken back, it is separated from the dura, where not already detached by dural separator or otherwise. The osteoplastic flap of bone and soft parts is allowed to fall back upon its hinge out of the wav. (6) Before proceeding, all bleeding from the diploe is con- trolled by pressure, plugging the openings with catgut cr sterilized wax, or bv gentlv crushing the bony opening tcgether with bone forceps. (7) The dura is now opened in the form of a flap, by picking it up with two forceps, incising with knife, and further cutting with curved, blunt scissors (just as described in trephining, q.v.), the division being made sufficiently far from the margin of the bone (at least 6 mm., or J inch) to allow of suturing — and this little flap should be so planned as to preserve the arteries intact which enter its base, ligating them with fine catgut only where they en ss the Hne of incised dura (they are best taken up in advance by passing a small, fully curved needle beneath them). The position cf the base of the small dural flap will be determined by the position of the dural vessels, and while it need not necessarily correspond with that of the osteoplastic flap, vet it usually does so in a general way. (8) The dural flap having been turned back out of the way, the surface of the brain is exposed and the special object of the operation accomplished. (9) Upon the completion of the operation the dural flap is sutured back with fine gut to the margin from which cut. (lo) The question cf drainage cf the cerebral structures will be determined by the special operation. If used, provision must be made for silkworm-gut or catgut strands to pass through an unsutured part of the dura, (n) The osseo-cutaneous flap is now turned back into place. The previously freed margin of periosteum clinging to the bone-flap is sutured with interrupted catgut sutures to the margin of the main periosteum from which cut. If muscles of any thickness have been involved, these are united by buried catgut sutures. Finally, the skin wound is ck sed with silk, silkworm-gut, catgut, or silk, by means of interrupted sutures. If drainage of the extra- cranial wound be indicated, it is accomplished by strands of silkworm-gut, horsehair, catgut, gauze, or fine drainage-tubing, brought out through an opening made by biting a half-button of bone from the edge of the bone-flap with rongeur forceps. If intracranial drainage be used, it is brought out through this half-button opening — and then serves as an extra-dural and extracranial drain as well. PARTIAL CRANIECTOMY. 487 Comment. — The narrower the pedicle of the horseshoe flap of bone, the easier it is to crack it across at its base, but it should be broad enough to insure nutrition of the osteoplastic flap. The edges of the bone of the osteoplastic flap and the margin of the cranium may be drilled and the borders of bone united (if thought necessary) by chromic gut sutures. If the osteoplastic flap be beveled, as always should be if possible, suturing is not necessary — and is not generally necessarj- anyhow, as the adherent scalp usually holds the bone up in place. It is best to open the dura in all cases caUing for osteoplastic resection of the skull. LINEAR CRANIOTOMY. Description. — The division of the cranial bones in one or more straight lines variously placed — an operation sometimes resorted to in microcephalus for the purpose of giving increased room to the brain. Xo portion of the bone is removed, except the buttons of bone from the trephine-openings made preliminary to the use of the saw. (While craniotomy is performed in micro- cephalus, craniectomy, or the removal of a definite piece of bone, is probably a preferable operation for this purpose.) The operation of craniotomy is included under that of craniectomy {q.V-)- PARTIAL CRANIECTOMY. Description. — Removal of a section of the cranial bones from one or both sides of the head. — an operation sometimes done in microcephalus for the purpose of increasing room for the growth of the brain. (Strictly, in trephining and other cranial operations where the button or part of bone is not returned, the operation becomes a Partial Craniectomv though the term is not here used in that sense.) Preparation and Position. — See under General Surgical Considerations in Cranio-cerebral Operations (page 478). Landmarks. — Nasion and inion, and the general bonv landmarks of the skuU. Control of Hemorrhage. — By means of a flat rubber tourniquet wound several times around base of skull, small compresses having been placed over the main arteries of the scalp and held in place by the tourniquet — as described under General Surgical Considerations in Cranio-cerebral Opera- tions. This method of control is generally indicated, as hemorrhage is apt to be marked. Incision. — From the junction of the skin of the forehead with the hair, to the inion — passing slightly external to the median line. Operation. — (i) The incision of the soft parts passes through the skin, fascia, muscle, aponeurosis, and periosteum to bone. Clamp all bleeding vessels uncontrolled by constrictor and ligate the chief ones with gut. (2) The soft parts are raised from the bone by periosteal elevator and turned downward, being held out of tlie way by retractor, or a stitch or two. The flap thus turned back will be represented by practically the soft parts of one entire side of the skull. (3) Having exposed a large area uj)on one side of the skull, and having controlled all further hemorrhage, the amount, posi- tion, and shape of bone section a'-e determined. .\n area of bone in the form of a narrow parallelogram represents the section of bone most usually removed, 488 OPERATIONS UPON THE HEAD. though other forms of bone-section are used. Supposing the parallel lines representing this figure to be 1.2 cm. (5 inch) or 1.9 cm. (f inch) apart, a trephine-opening is made at either end of this figure with a diameter of 1.2 cm. or 1.9 cm. (^ or J inch) accordingly. If the distance between the trephine- openings be too long for a dural separator and guide to travel, one or more intermediate trephine-openings should be made. A pliable dural separator is then passed from opening to opening between bone and dura and traveling in two parallel lines corresponding with the upper and lower margins of the circumference of the trephine-openings. A grooved guide is then passed in the tracks cleared by the dural separator to protect the brain, and the bone then divided in two parallel lines with an electric motor saw (the Powell electric saw answering the purpose well) — first in a line with the upper mar- gins of the trephine-openings and then in a line with the lower margins of these openings. By properly directing the saw both ends of the section may be pointed, going beyond the trephine-openings at both ends. The bone section is best made with a motor saw — it may be made with rongeur forceps — but preferably not with chisel, as chiseling causes too much jarring. In using an ordinary motor saw a trephine-opening is necessary wherever the direction is changed. A Gigli saw jjassed between the openings also answers well. (4) If there be no special indication for ex]jloration, the dura is not opened. If opened, it is so incised as to admit of subsequent suturing. (5) The bone, of course, is not replaced. The soft parts are sutured into position. No drainage is ordinarily used. Comment. — (1) Hemorrhage from the diploe is apt to be great and may have to be controlled by ]ilugging with catgut or aseptic wa.x, by crushing together the walls of the bony canals, or by gauze pressure. (2) Probably it is best to operate upon the second side of the head at a subsequent date. (3) A grooved director for the saw can be used — or the dural separator may be grooved. (4) Where craniotomy is done instead of craniectomy the saw travels only once between the trephine-openings, which are merely large enough to allow of separation of dura and passage of a guide — and no bone (other than the trephine-buttons) is removed. A crescent-shaped piece of bone may be removed, instead of a piece of the above-described shape. EXPLORATORY PUNCTURE OF THE BRAIN. Description. — For the purposes of exploration, the needle of an aspira- torv svringe mav be thrust into the brain substance, especially where pus and fluid tumors or hemorrhage are suspected — the brain having been ex- posed through a small trephine-opening. A solid needle, or special probe, mav be used for the detection of solid bodies. Preparations and Position. — See General Surgical Considerations in Cranio-cerebral 0])erations (page 478). Landmarks. — Position of some lesion and localization symptoms, taken in connection with the special structures to be avoided. Incision. — That for ordinary trephining. Operation. — (1) Is the same as that for trephining, up to the raising of the dural flap and the exposure of the brain. (2) The needle is then steadily thrust into the brain in a straight line in any direction indicated by the phe- nomena present, avoiding the venous sinuses, large vessels, basal ganglia), and ventricles (unless puncture of the latter be indicated). The needle should be withdrawn after each puncture. \\'henever it is desired to explore in another direction, the needle is reinserted and always carried in a straight OPERATION FOR INTRACRANIAL HEMORRHAGE IN GENERAL. 489 line, without side to side movement. (3) Having accomplished the object of the operation, or after meeting with a negative result, the wound is closed as after tre])hinin<;. Comment. — For further data as to exploratory puncture of the intra- cerebral structures, see Operations for Cerebral and Cerebellar Abscess (pages 496 and 497), Tumor (pages 498, 499), and Hemorrhage (page 489). OPERATION FOR INTRACRANIAL HEMORRHAGE IN GENERAL. Varieties of Intracranial Hemorrhage. — (i) lOpidural (Extradural); between cranial bones and dura — may be arterial or venous. If arterial — generally from middle meningeal or its branches. If venous — generally from the superior longitudinal, lateral, or occipital sinus. (2) Intrameningeal; if arterial, generallv from middle meningeal or branches. If venous, fre- quentlv from veins connected with longitudinal or other sinus. If capillary, generally due to traumatism, and site dependent upon trauma. If subdural (into subdural space), it may be caused either by rupture of dura, and is then generally from the middle meningeal vessels; or by a vessel of the pia rupturing through the arachnoid. If subarachnoidgan (between arachnoid and pia mater), it is due either to rupture of vessels of pia into the pia-arach- noid, or to rupture of middle meningeal through dura and arachnoid. (3) Intracerebral; generally from middle cerebral or one of its branches, especially the lenticulo-striate. Only the general features of intracranial hemorrhage will he here con- sidered. For specific operations for hemorrhage from the middle meningeal arterv and its anterior and posterior branches, and from longitudinal and lateral venous sinuses, see ligations of those structures (pages 47, 48, 49 and 490). Preparation and Position. — See General Surgical Considerations in Cranio-cerebral ()|)erations (page 478). Landmarks. — Determined by circumstances of particular case and by general cranio-cerebral topography. Site of hemorrhage may be determined bv external injury or bv localization svmptoms. Incision. — As for trephining or osteoplastic resection (according to size of opening required), and placed in accordance with nature of case. Operation. — (i) Having exposed the area involved, either by a trephine- opening or osteoplastic section (the steps of the operation up to this point being, in all essential features, those of one or the other of these procedures), the site of the blood-clot, if any, is located and the source of the hemorrhage traced. (2) The clot is carefully turned out with such an instrument as the handle of a thin silver spoon — the bleeding vessel is sought and doubly ligated with gut. The dura must, of course, be opened if hemorrhage be subdural — and it is even best to open it though hemorrhage appear to be only epidural, for the sake of verification. Where the hemorrhage comes from the middle cerebral an attempt should be cautiously made, when possible, to reach the site of hemorrhage, by carefully separating the lips of the sylvian fissure and doubly tying the artery wdth gut. If site of hemorrhage cannot be accurately ascertained and still continues, all that can be done is to carefully pack the region with gauze. (3) Finally, carefully irrigate with warm normal salt solution (except where packing is used) — drain if necessary — closing wound as after simple trephining or osteoplastic resection. Comment. — If no accurate data lead to source of hemorrhage, it is best 490 OrF.RATIONS UPON THE HEAD. to seek first in the position of the anterior branch of middle meningeal artery — then in the jiosition of the posterior branch. LIGATION OF TRUNK OF MIDDLE MENINGEAL ARTERY. See under Ligation of Arteries (page 47). LIGATION OF ANTERIOR BRANCH OF MIDDLE MENINGEAL ARTERY. See under Ligation of Arteries (page 48). LIGATION OF POSTERIOR BRANCH OF MIDDLE MENINGEAL ARTERY. See under Ligation of Arteries (i)age 49). LIGATION OF LONGITUDINAL OR LATERAL SINUS. Description. — The longitudinal and lateral sinuses arc sometimes accidentally injured in operation, or otherwise, or lie directly in the course of some operation — under which circumstances it becomes necessary to control hemorrhage from them, which, when possible, should be done by ligation. (See Figs. 321 and 342.) Preparation and Position. — See General Surgical Considerations in (.'ranio-cerel)rai Operations (page 47S). Landmarks. — Determined by site of sinus involved. Incision. — Often determined by a preceding injury or local condition — or circumstances calling for ligation may accidentally arise during the course of some other cranio-cerebral operation. If deliberately planned to tie the longitudinal or lateral sinus in the path of an operation (as, for e.xample, preliminarilv to exposing a surface of brain more or less covered by a sinus), two small trephine-openings are made on either side and very near the borders i!f the sinus, after having exposed the site of both trephine-openings by turning bacl^ a single oval flap. For course and deviations of the sinuses, see Surgical .\natom\' of the Cranio-cerebral Region (page 468). Operation. — (1) Complete the operation, up to the removal of the two buttons of bone, as an ordinary trephining. (2) The dura and, with it, the sinus are detached from the cranium by passing a dural separator between the bone and dura, from one to the other of these two small trephine-openings immediately adjacent to the outer borders cf the sinus. The bridge-work of bone between the two openings is then cut away, preferably with Gigli saw (cutting pliers or rongeur forceps). .\ limited longitudinal incision of the dura is made safely to the outer aspect of each side of the sinus, which enables a more intelligent and safer passage of the ligature than if it were simply carried blindly beneath the supposed lower limit of the sinus. The sinus is thereby fully exposed and is doubly ligated transversely with chromic gut, by passing a fully curved needle beneath the sinus and through the falx cerebri, and divided between the ligatures. If the sinus be wounded to a limited degree, it is often possible to either laterally ligate the rent, or suture it — as described under the ligation of veins. (3) The operation is completed as indicated by the special circumstances attending it — the button of bone LIGATION OF LOXGITLDINAL OR LATERAL SINUS. 49 1 being replaced, or not. according to the judgment of the operator. Drain- age would be used or not, as indicated (generally not, if all bleeding be con- trolled and wound be clean). The flap of soft parts is sutured into place. Figs. 321 and 322.— Ligation OF THK Longitudinal Sinus :— A, Exposure of longitudinal sinus by mtjans of two trephiiie-openings on either side, followed by cutting away the intervening bridge of bone; B, Scalp-flap turned back; C, Two irephine-openings made near the outer borders of the longitudinal sinus, with intervening bone cut away; D. Incisions through dura, on either side of sinus, for passage of needle and ligature ; E, Longitudinal sinus ; F. Cross-section of head, showing position of sinuses. OPERATIONS UPON THE HEAD. OPERATION FOR THROMBOSIS OF LATERAL SINUS. Description. — As ;i result cif oiiiis nu-dia, the ailjaccnt sigmoid and transverse portions of the lateral sinus frequently become infected and undergo sinus phlebitis and thrombosis, requiring their exposure, the removal of thrombosed contents and their obliteration by ligature or otherwise. The operation is intimately connected with that for the e.xposure of the mastoid antrum and cells, which should be reviewed in this connection (page 500). Preparation and Position. — See General Surgical Considerations in Cranio-cerebral Operations (page 478]. Landmarks. — Lines for sigmoid and transverse portions of the lateral sinus. (See Surgical .\natomy, page 468, and also Fig. 324, L M.) Incision. — Where this sinus, at junction of transverse and sigmoid portions, is independently exposed, a horseshoe flap is turned down, with pedicle below, so planned as to expose an area with its center about 2.5 cm. (i inch) behind and 6 mm. (^ inch) above the center of the external auditory meatus. Where the opening-up of the neighboring sinus is simply a con- tinuation of the mastoid operation (which is usually the case) the incision for tlie exposure of the sinus is prolonged from the original incision. Operation. — (i) Proceeding as in the operation of trephining, a trephine having a diameter of about 2.5 cm. (i inch) is applied over this center and a button of bone carefully removed, without injury to dura and without pre- mature opening of sinus. Whatever additional room may be required can be gotten by biting out the circumference of the trephine-opening by means of rongeur forceps. (2) Thrombosis having been determined by palpation and exploratory needle, the thrombosed sinus is now laid open longitudinally and the contents carefully turned out with a special scoop, as far as accessible in both directions, or until a patulous condition is reached, when the flow is controlled bv gut ligature of the sinus, if possible, or bv gauze packing. (3) The mastoid antrum and cells, the usual source of the original infection, are generally opened up into continuity with the .sinus by means of a gouge, sharp spoon, or chisel. (4) The internal jugular vein is often exposed in the neck, when found in a condition of thrombosis, and ligated. The throm- bosed vein mav then be opened above the ligature and the vein irrigated from the lateral sinus, and vice versa. (5) The wound is [lacked, and closed only in part, room being left for drainage. Comment. — If contents of lateral sinus be fluid, the sinus, if possible, should be ligated prior to opening the thrombosed part. A firm, healthy clot, about to undergo organization, may sometimes be left on the distal side of a ligature. TREPHINING FOR FRACTURE OF SKULL. Description. — The seat of fracture is exposed, the depressed pieces of bone are elevated to the common level, and any spicula; of bone which may be exercising pressure ujion the brain are removed. Preparation and Position. — See General Surgical Considerations in Cranio-cerebral Operations (page 478). Landmarks. — Determined by the nature and site of the fracture and general cranio-cerebral topography. Incision. — Where a skin wound exists, this is usuallv enlarged, or u'^ed. OPERATION FOR BILLET WOUND OF BRAIN. 493 as a part of the incision for the exposure. Where the skin is unbroken, the site of fracture is best e.xposed through a U-shaped flap, as in trephining. Operation. — (i) The soft parts, including the periosteum, are turned back, in the same manner as in trephining, and site of fracture thus exposed — hemorrhage being controlled as in that operation. Even where the bones of a depressed fracture can be raised by being levered back into position without exposing the brain (which often can be done), it is always best to expose the dura at least — and safer still to open the dura and examine the surface of the underlying brain. (2) The following steps of the operation aie conducted verv much as in ordinary trephining. The point of the trephine is placed upon sound bone that will resist pressure, avoiding the site of vessels and sinuses, and in a position from which the fractured bone can be best raised — with the major portion of the circle (which should be from 1.2 to 1.8 cm., or i to I inch) generally lying over sound bone, and the inner portion overlapping or coming in hne with the fractured margin. When the button of bone is removed, if more room be needed, it can be gotten by biting out portions of bone with rongeur forceps. (3) A blunt elevator (an osteotome answers well) is now carefully inserted beneath the fractured bone, resting upon the sound margin of bone, or upon an instrument or a finger stretched across the area as a fulcrum, and the fractured bone levered back into place, without disconnecting it from its natural attachments. (4) Sometimes judicious use of chisel or saw will aid in freeing the fragments. .-Ml sharp edges are rounded off. -All pieces likely to become detached are removed. (5) The dura, if deliberately opened by the operator, is repaired as after trephiningi — if wounded by fragments, is repaired by catgut suturing as fully as possible. (6) The manner of treating bone space left by trephining for fracture is the same as after simple trephining. Drainage is used, if indicated — and the wound entirely or partially closed in accordance. OPERATION FOR BULLET WOUND OF BRAIN. Description. — For the purpose of seeking the bullet, removing spicule of bone and foreign material, and for providing drainage. Preparation and Position. — See General Surgical Considerations in Cranio-cerebral Operations (page 478). Landmarks. — Determined by position of wound and position of im- portant underlving structures and areas. Incision. — .\n oval (or reversed U-shaped) flap, with pedicle downward, and center corresponding with wound. Operation. — (1) The soft parts are incised to the bone, the vessels clamped and tied, and the flap raised and turned back. If trephining were not con- templated, the periosteum need not be raised with the flap — but as the use of the trephine or that of the rongeur is practically always indicated, the bone should be completely bared. (2) Access to the brain may be gotten by biting out the circumference of the wound-opening with rongeur forceps, or, better, by trephining with a trephine whose diameter is sufficiently large to make a cut extending around the wound 1.2 to i.S cm. (^ to J inches), according to accompanying circumstances, and with the precautions observed in trephining for fracture ((/. f.). All fragments of bone are removed or elevated into position — and all foreign material is picked out with forceps as encountered. (3) Having thus enlarged the bullet wound, the bullet is sought along its track with such instruments as a long, delicate needle, Fluhrer's 494 OPERATIONS UPON THE HEAD. aluminium probe, or Girdner's telephone probe. If the bullet can be reached with special forceps, it may be withdrawn by that means through the original wound, especially if near it. If the bullet be near the far end of the wound- track, it is generally more readily and safely removed through a counter- opening. Such a counter-opening may be made at a point determined by thrusting a probe along the track of the wound, directly in the line of the bullet-track, to the inner wall of the opposite side of the skull — passing the bullet if it lie on the way — followed by tying a piece of silk to the outer end of the probe and carrying the silk across the shaved scalp at different points upon its contour — the common point at which these lines all intersect will indicate the point on the exterior of the skull opposite which the inner end of the prcbe has come into contact with the inner wall of the skull. At this point a trephine-opening is made. The counter-opening is made with a trephine of 3.8 to 5 cm. (ij to 2 inches) in diameter, as the bullet is apt to lie an inch or more below the pcint of striking the inner wall, and rorm is often necessary for manipulation and exploration. Upon a probe, a grooved director is carried down to the bullet, and upon the director a pair of bullet- forceps, with which the bullet is grasped and removed. When the region does not admit of a counter-opening, as toward the base of the brain, the bullet must be removed through a single opening. (4) Thorough drainage may be instituted by drawing, upon a long probe, a few strands of silk, silk- worm-gut, or rubber drainage-tube. (5) The wound is carefully irrigated, and then closed up to the points of drainage. Comment. — The bullet may sometimes be located by placing the patient so that the bullet-track is vertical, and then letting the probe drop into the wound as far as possible. It may also sometimes be located by means of -v-rav shadows taken in two directions. OPERATION FOR EXPOSURE OF A MOTOR CENTER. (ILLUSTRATED BY OPERATION FOR FOCAL EPILEPSY.) Description. — The operation performed for Focal Epilepsy consists in the exposure of an area to which attention has been called by convulsive movements beginning in those parts controlled by that area: — or in connection with which some injury has been received — the object being to remove the scurce of irritation, which mav be some form of pressure or an adhesion, or a part of the motor center itself may be removed to a limited extent — the area usually being exposed by trephining. It will be supposed, in the present case, that the epileptic seizures are preceded by muscular twitchings of the muscles of the right fingers, hand and forearm. The exposure of the cortical center presiding over these structures will be indicated, namely, the lower posterior part of the middle third of the scnsori-motor area of the left side. Preparation and Position.— See General Surgical C( nsiderations in Craniocerebral Ofierations (page 478). Landmarks. — Site of the motor center (here, for example, the center for the right fingers, hand and forearm) is determined by some form of local- ization method (in this instance, by Chipaulfs method, page 472). Incision. — .^n oval flaj) (U-shaped), with convexity above and base below, is outlined, having its center about i cm. (| inch) posterior to the junction of the lower third and fourth tenths of Chipaulfs rolandic line (see Chipaulfs method). For the bone-section, a trephine of at least 3.8. cm. (li inches) should be used. PUNCTURE AND DRAINAGE OF LATERAL VENTRICLES. 495 Operation. — (1) The steps of the operation, up to the removal of the button of bone, are the same as for trephining. (2) Open the dura in the form of a small flap, as heretofore described. As soon as the brain is exposed carefully examine for abnormal adhesions between dura and brain, and, if detected, free by cautiously sweeping a bent probe between these structures. If bony growths be found pressing upon brain, remove them by bone-section. (3) If part of a motor center is to be removed, incise the brain substance in the direction of the commissural fibers, making the incision carefullv with delicate knife or scissors. (4) Tie all bleeding meningeal and cerebral vessels with fine gut — dividing them in advance, where possible, between double ligatures. Harm pia mater as little as possible, and replace if pushed aside. (5) To avoid readhesion, if previous adhesion existed, or to avoid new adhe- sion, plates of very thin celluloid, gold leaf, gutta-percha, decalcified bone- plate, india-rubber, etc., are sometimes placed over the pia mater. (6) The dura is carefully sutured with fine gut. The liutton of bone is replaced or not, according to the surgeon's judgment. The scalp-flap is sutured, without drainage, and speedy union especially sought. PUNCTURE AND DRAINAGE OF LATERAL VENTRICLES. Description. — Puncture of the lateral ventricle and withdrawal of cerebro- spinal fluid by aspiration, simple drainage by cannula, or by capillary drainage. Indications; acute hydrocephalus (to withdraw excess of fluid and relieve tension); chronic hydrocepiialus (to withdraw e.xcess of fluid and relieve tension, or to inject medicated fluid); meningitis (for drainage). Preparation and Position. — See General Surgical Considerations in Craniocerebral 0])eratii:ns (page 478). Landmarks. — Junction of the third and fourth tenths of Chipault's temporo-sphenoidal line represents the posterior part of the body of the lateral ventricle. (For this, as well as for the descending and posterior horns, see Chipault's Cranio-cerebral Localization ■Method, page 47,^.) Incision. — .\n oval or inverted U-shaped flap with its center at the above point is outhned. The bone-section should be made by a trephine of at least 2.5 cm. (i inch) in diameter. Operation. — (i) Having made and turned down the flap of soft ])arts — controlled hemorrhage by clamps and ligature — applied trephine and removed disc of bone — the dura is exposed and a small dural flap turned down. (2) The needle of the aspiratory SATinge, or trocar and cannula, is then thrust directly into the substance of the brain, opposite the point indicated above, avoiding all visible vessels — and is made to penetrate horizontally inward for one-third of the transverse diameter of the brain itself (as determined after subtracting the thickness of the scalp and skull of both sides from the total thickness of the head on the line of puncture). (See Chipault's Method. Other Points and Lines, page 473.) Through the needle (or cannula) introduced fluid is withdrawn. (3) Sulisequently, before withdrawal of instrument, medicated fluid may be injected, if indicated. Where it is desired to introduce drain- age, silk, silkworm-gut, wick, gauze, or a drainage-tube may be introduced through the cannula, if a trocar and cannula have been used — or by means of special forceps alongside an ordinary aspiratory needle before its withdrawal. (4) If no drainage be instituted, the wound is closed as after simple trephining. If drainage be used, the dura and soft parts are only partially sutured, and the button of bone is either not returned, or only a part of it is returned. 496 opp:rations upon the head. Comment. — While it is more satisfactory to open the dura, thus exposing the condition of the brain and the position of the vessels, yet where drainage is not indicated, the lateral ventricles may be aspirated through the unopened dura. INCISION OF THE CEREBELLAR SUBARACHNOID SPACE FOR DRAINAGE. P.\KKIN'S Ol'KKATION. Description. — The exposure, by trephine, of the membranes in the cerebellar fossa, followed by the incision of the subarachnoid space below the tentorium cerebelli. Sometimes performed for the relief of intracranial pressure by dependent drainage of the cerebrospinal fluid in acute and chronic meningitis and in hydrocephalus. Preparation and Position. — See General Surgical Considerations in Cranio-cerebral Operations (page 478). Landmarks. — Lines of lateral and occipital sinuses. Incision. — An oval (or reversed U-shaped) flap is outlined, with con- ve.xitv upward and base downward toward the neck, and its center over the center of the right or left cerebellar fossa. Operation. — (1) The incision outlining the above flap is carried to the bone, the vertical portions of the incision passing, at this site, through con- siderable thickness of muscular tissue, and rather free bleeding may occur. All vessels are clamped and tied with catgut. The flap is retracted down- ward and the occipital bone exposed. (2) A trephine of about 1.2 cm. (i inch) diameter is so applied as to be safely below the lateral sinus, and safely to the outer side of the occipital sinus, and away from the thickness of the external occipital protuberance. The button of bone thus defined is removed, and the dura exposed. (3) The dura is seized with dehcate forceps and incised with knife or scissors sufficiently to make a satisfactory opening for drainage — and the subarachnoid space thus entered. (4) Drainage is accom- plished by strands of silk, silkworm-gut, wick, gauze, or tubing. (5) The button of bone is not returned. The wound is sutured in part, leaving open only enough space for drainage. OPERATION FOR CEREBRAL ABSCESS. Description. — Intracranial abscess may be extradural or intracerebral. The site of abscess (when not directly traceable to an evident cause) is deter- mined, in conjunction with constitutional symptoms, by local compression symptoms referable to the part of the brain pressed upon Ijy the collection of pus — and the operation is done over that area determined by these symp- toms. The most frequent causes of cerebral abscess are otitis media, first of all, and conditions of suppuration in the orbital and nasal cavities. .Abscess cccurs more frequently on the right side. Preparation and Position. — See General Surgical Considerations in Cranid-cerebral ( )])eratiiins (page 478). Landmarks. — The site of abscess, if not otherwise fixed, is determined by pressure symptoms, and localized by known position of center pressed upon. Incision. — An oval (or reversed U-shaped) flap is outlined for the ap[)li- OPERATION FOR CEREIiEIXAR ABSCESS. 497 ration of a trephine of about 3.8 cm. (li inches) diameter — the center of the trephine to be placed over the site determined as above described. A trephine-opening will generally suffice, though an osteoplastic flap is some- times raised. (See Comment.) Operation. — (i) The ordinary steps of a trephining (or the raising of an osteoplastic flap) are carried out, up to the exposure of the dura. (2) If an abscess be found between the cranium and dura, it is evacuated (pro- tecting the diploe as much as possible), irrigated, and loosely packed with gauze, a portion of the gauze serving as a drain. The scalp-flap is sutured back in place throughout its greater part, room being left for drain. The but- ton of bone is usually not replaced — if used at all, only a part of the button is returned, the rest being bitten off for drain-opening. (3) If pus be not thus found outside of dura, a flap of dura is raised, as in trephining, and the brain e.xposed and explored in various directions with a needle (see Exploratory Puncture of the Brain, page 488). Wherever found, especially if deep, the needle is left in situ and serves as a guide. The dura over the site is divided by a crucial incision (to provide free exit), a linear incision tending to close. If dura be divided before the presence of abscess is assured, a straight inci- sion of the membrane is made, admitting of subsequent suture if indicated. Before freeing the pus, the cut diploe should be protected from infection as well as [)ossible, by a strip of thin rubber tissue, or by smearing the bone- section with sterile vaseUne. The abscess cavity may be cut into by a punc- ture like thrust of a knife — or, probably better, a pair of special forceps (or ordinary dressing forceps) may be inserted closed, guided by the needle left in situ, and then opened to a limited extent, allowing the pus to drain along the handles, or a grooved director may be used. Two parallel pieces of small-calibered rubber drainage-tubes are then inserted, one serving for inflow of irrigant, the other for the outflow of pus — the tubes being held in place by transfixing them with a safety-pin resting upon the gauze which has been packed around them. (4) The dural and scalp flaps are partly sutureil into place, leaving room for drainage. Comment. — As the most general cause of cerebral abscess is otitis media, the most usual site for the abscess is in the temporo-sphenoidal lobe, in the middle fossa of the skull, adjacent to the antero-superior aspect of the petrous portion of the temporal bone — and the landmark for the operation is, there- fore, generally taken as a point 1.8 to 2.5 cm. (f to i inch) above Reid's base-line (see Reid's Method of Cranio-cerebral LocaUzation, page 476, also Fig. 317, S), on a line drawn vertically upward along the posterior border of the external auditory meatus, at right angle to the base-line — and this point is used as the point at which first to explore, where uncertainty exists. This site having been e.xposed, if evidence of pus be not found, explore with needle, of fair calibre, and preferably first through the unopened dura — first inward, forward, and downward toward the apex of the petrous por- tion of the temporal — then upward and forward, and backward and inward, and in other directions — but guarding the Ixisal ganglia and the petrosal sinuses. When pus is located, the dura is always incised. OPERATION FOR CEREBELLAR ABSCESS. Description. — Like cerebral abscess, cerebellar abscess may be extra- dural or intracerebellar. As the cause of abscess is generally, as in the case of the cerebrum, otitis media, the abscess is usually found in the vicinity 32 498 OPERATIONS UPON THE HEAD. of the posterior or postero-superior aspect of the petrous portion of the temporal bone. The site is usually e.xposed by a trephine-opening. Preparation and Position. — See General Surgical Considerations in Cranio-cerebral Operations (page 478). Landmarks. — The external auditory meatus and the lines of the sigmoid and transverse portions of the lateral sinus. Incision. — t)ra\v a line from the external occipital protuberance to the center of the external auditory meatus. To allow for an unusually low trans- verse portion of lateral sinus, trephine 1 cm. (y'j inch) below this line. And to avoid the sigmoid portion of the lateral sinus, and also the occipital artery trephine posterior to a vertical line placed 3.5 cm. (if inches) behind the center of the external auditory meatus. Outline an oval (or reversed U- shaped) flap with its center calculated to be over the center of the above indicated area — the limbs of the incision running well into the neck, as the occijiital fossa is to be opened below the nuchal furrow. Operation. — (i) Carry the incision outlining the flap to the bone — control hemorrhage, which is apt to be marked, by clamp and ligature. Retract this thick muscular flap downward, exposing the occipital bone below the superior curved line. (2) Apply, in the site indicated under Incision, a trephine of at least 2.5 cm. (i inch) diameter and remove the button of bone, e.xposing the cerebellar dura. (3) The abscess is now sought in a direction forward, upward, and outward; or forward, upward, and inward, in the same general manner as in cerebral abscess — and, if found, dealt with in the same fashion — and the wound finally similarly treated. Comment. — Cerebellar abscess is often encountered, when it exists, in the course of an operation upon the mastoid region — during an operation where the inner wall of the mastoid process has been exposed and removed, laving bare the lateral sinus and the dura anterior and posterior to it. Where the abscess follows disease of the inner mastoid wall, it generally lies behind the lateral sinus and in contact with the involved bone. Where the abscess is connected with involvement of the labyrinth, it lies in front of the lateral sinus and in connection with the internal meatus or vestibular aqueduct. A fistula generallv leads from the diseased bone to the abscess. OPERATION FOR CEREBRAL TUMOR. Description. — Removal, en masse, of growths from surface or interior of brain. Those involving the basal ganglia, internal capsule, and base of brain generally, are inoperable. Preparation and Position. — See General Surgical Considerations in Cranio-cerebral Operations (page 478). Landmarks. — Site of tumor will have been determined by localization svmptoms — and site of operation determined accordingly. Incision. — Amount of room required for recognition and removal of tumor generallv necessitates an osteoplastic resection of the skull, which should be planned with reference to the particular case. Or the overlying bone may be totally and permanently removed by making several small trephine-openings and connecting these — or a large trephine may be first used and the margins of the resulting opening bitten out with rongeurs as far as necessary — in either of which cases a horseshoe flap of soft ])arts is temporarily turned down and then replaced. Operation. — (1) The steps of the operation, up to the exposure of the dura, are the same as for osteoplastic resection of the skull, hemorrhage OPERATION FOR CEREBELLAR TL'MOR. 499 being controlled as during that operation. (2) The dural flap is turned back as in osteoplastic resection. The pia mater is divided in the direction of the length of the tumor — hemorrhage from the pia being controlled by slight tension upon it or by ligature en masse. (3) The situation and e.xtent of the tumor are now determined by palpation and e.xploration. (4) Having reasonably settled both of these questions, the tumor is to be excised. The incision into the brain substance is begun, where possible, at the apex of a convolution and is made in the direction of its commissural fibers — and rather over a convolution than over a sulcus, as there is less hemorrhage. If the tumor be encapsulated, divide the overlying brain and gently retract the cerebral substance, cutting from above downward, and enucleate with a spoon. If the tumor lie beneath the surface but not encapsulated, isolate by carefully incising its connections and enucleating with such an instrument as the curved handle of a thin silver spoon. Cystic tumors sometimes only admit of draining, cauterizing, and packing. (5) The cavity left is lightly packed with gauze if bleeding occurs. Where possible the brain incision is closed with catgut, with or without drainage, as indicated. The dura is sutured. Celluloid or metallic plates are sometimes used to reinforce the opening. The osteoplastic flap or flap of soft parts, according to method of ex[)osure used, is sutured into place, as in the osteoplastic resection or trephining operation respectively. Comment. — If working in the motor area, use of the faradic electrode mav corroborate diagnosis. OPERATION FOR CEREBELLAR TUMOR. Description. — The operation is similar to that for cerebral tumor, in essential details — with the following modifications (chiefly from the greater inaccessibility of the cerebellum) : — (a) A horseshoe flap of soft parts alone is used, with its base toward the neck, as the osteoplastic flap is not easily applicable: — (b) The opening in the bone is made with a trephine of as large a diameter as feasible, and is enlarged, if necessar\', bv biting out its circumference with rongeurs. Thinness of the occipital fossa; nearness of the sinuses of the occipital bone and proximity of the foramen magnum require especial care. OPERATIONS UPON THE MASTOID ANTRUM AND CELLS. See under Operations upon the Bony (.\ir) Sinuses of Head and Face (page 500). OPERATIONS UPON THE GASSERIAN GANGLION. See under Operations upon the Nerves, Plexuses, and Ganglia (pages 15s and 158). 5O0 OPERATIONS UPON THE HEAD. n. THE BONY ' AIR ) SINUSES OF THE HEAD AND FACE.* OPERATIONS UPON THE MASTOID ANTRUM AND CELLS. SURGICAL ANATOMY OF MASTOID ANTRUM AND CELLS. Muscles of the Mastoid Region. — Retrahens auR-m; occipitofrontalis; sternomastoid; splenius capitis; trachelomastoid ; digastric. K - Fig. 323.— SliRGlCAL Anatomy OF Middle Ear and Mas ioid Region :— With nienibrana tym- paiii removed and four windows chiseled into mastoid process : A, Pinna of ear stitched to cheek : B, Curved incision of exposure, back of ear ; C, Soft external auditory canal; D, Temporal fascia ; E, Mastoid cells ; F, Mastoid antrum ; G, Lateral siims ; H, Suprameatal spine ; I, Bony plate covering facial nerve ; J, Promontory and fenestrum rotundum ; K, .Malleus ; I-, Incus ; M, Stapedius muscle ; N, Tensor tympani muscle ; O. Chorda tvnipani nerve. (From drawing made from cadaver, in De- partment of Operative Surgerv. College of Physicians and Surgeons, by Dr. A. E. Schmitt.) Arteries of the Mastoid Region. — Posterior auricular and occijiital branches of external carotid. Veins of the Mastoid Region.— Posterior auricular (emptying into temporomaxillary vein); occipital (emptying into internal jugular). * Among the Bony (Air) Sinuses of the Head and Face, will be considered the Mastoid Antrum and Cells, the Frontal Sinus and the Maxillary Sinus— the Ethmoidal and Sphe- noidal Sinuses more properly belonging to the special surgery of the Nose. SURGICAL ANATOMY OF MASTOID ANTRUM AND CELLS. SOI Nerves of the Mastoid Region. — Posterior ;iuricular branch of facial; auricularis magnus from cervical plexus; occipitalis miliar from cervical plexus; auricular branch of occipitalis major; external branch of posterior division of second cervical nerve. Mastoid Antrum. — A retort-shaped cavity situated in mastoid portion of tem[)<)ral bone, communicating with mastoid cells posteriorly, and opening, anteriorly, through aditus ad antrum, into highest part of tympanic cavity, the epitympanic recess (attic of tympanum), thereby communicating with eustachian tube. The epitympanic rece.ss lies above the anterior three- fourths of the orifice of the opening of the antrum into tympanic cavity. The floor of antrum lies below the level of the entrance into antrum, generally Fig. 324.— Surgical Anatomy OF Mastoid Region and Middle Ear :— With membrana lym- paiii removed ; mastoid cells, mastoid antrum, and lateral sinus exposed ; and trephine disc removed just above temporal crest and ear ; A, Soft auditory canal in turned-back ear ; B, Temporal muscle; C, Temporal crest ; D, Horizontal semicircular canal ; E, Promontory ; F, Fenestrum rotundum ; G, Stapes; H, Facial nerve ; I, Mastoid cells ; J. Arrow passing from attic to antrum, along aditus ad antrum; K, Trcphinrnpcninq; exposing posterior branch of middle meningeal artery; L. Horizontal linjb of lateral siriii. , M. I >. -. L-iuiing limb of lateral sinus ; N, Begitming of internal limb of lateral aleral sinus ; P, Opening of k.ngitiulinal sinus ; Q, Opening of superior imen. ( From drawing made from cadaver, in Department of Operative and Surgeons, by Dr. A. E. Schmitt.) sinus; O, Opcnnm , petrosal sinus ; K.M.t^t Surgery, College of IMi; corresponding with level of center of auditory meatus, or even higher. The communication between antrum and epitympanic recess is triangular in shape, with base upward and rounded angle below; its lower portion being on level with superior wall of external auditory meatus; its measurement being about 4 mm. (fV inch) both transversely and vertically. The antrum lies from 7 to 14 mm. (-j-^ to ^ inch) from surface of mastoid bone; and from 7 to I 2 mm. (j\ to y\ inch) behind superior posterior margin of tympanic ring — the outer portion of overlying bone being hard, the inner portion more spongy. The antrum measures, longitudinally, 10 to 15 mm. (jV to |-°^ inch); vertically, 10 mm. (yV inch); transversely, 4 to 6 mm. (fV to y\ inch). In infancy and childhood the antrum is nearly full size, but the mastoid cells rarely develop before twelve years of age. The overlying bone is relatively thin in the young. 502 OPERATIONS UPON THE HEAD. Mastoid Cells. — Situated within mastoid process of temporal bone; opening, anteriorly, into mastoid antrum; and extending, postero-inferiorly, sometimes to tip of mastoid process. Relations of Mastoid Antrum. — (i) Superiorly; antrum is separated from middle cranial fossa of skull by a thin, bony plate, the tegmen tympani, sometimes partially deficient, a fibrous membrane and vascular tissue then intervening. Roof of antrum generally corresponds to supramastoid crest, though sometimes being upon a higher level than crest, in which latter cases the inferior temporal convolution of the cerebral hemisphere may overlap upper part of antrum. (2) Interiorly; floor of antrum is formed by mastoid portion of petrosal bone. (3) .\nteriorly; a thin wall of bone comes between antrum and deep portion of auditory meatus. (4) Posteriorly, e.xtends backward and outward, Iving nearer surface posteriorly than anteriorly, approaching sigmoid portion of lateral sinus, sometimes but a thin bony lamina intervening, though distance between the two generally averaging 5 to 10 mm. (f\ to -{'^ inch) and usually consisting of mastoid cells; the lateral sinus ordinarily lying nearer the surface than the antrum. (5) Externally; outer wall is formed by squamous portion of temporal below supramastoid crest. (Figs. 323 and 324.) Fig. 325. — Position of Incisions Exposing Mastoid Antrvm and Cells: — A. Incision for ex- posure of mastoid antrum and cells (Antrum Operation of Schwartze); B, Incision for Tympano-mas- toid E.xenteration ( Radical Operation of Schwartze-Stackel; C. Suprameatal crest : D, Suprameatal spine ; E, Suprameatal fossa; F. Position of mastoid antrum ; G. Auricle drawn forward ; H. Lateral sinus; 1, Occipital artery- SURFACE FORM AND LANDMARKS OF MASTOID ANTRUM AND CELLS. External auditory meatus — varying in shape, size, and in the direction of its longest diameter. Separated from mastoid process by the concha of the ear. SURGICAL CONSIDERATIONS IX MASTOID OPERATIONS. 503 External auditory canal — corresponds with general direction of approach to antrum through mastoid process. Mastoid process of temporal bone — contour generally capable of being outlined through the skin. Supramastoid crest (Hnea temporalis) — continuation of zygomatic ridge backward. Suprameatal triangle — site of approach to mastoid antrum; having follow- ing boundaries; Superiorly, supramastoid crest; Inferiorly and Anteriorly, outer margin of posterior superior quadrant of bony external auditory meatus; Posteriorly, vertical hne drawn upward along most posterior margin of bony external auditory meatus. (Fig. 325.) Suprameatal fossa (fossa mastoidea) — depression in upper posterior angle of suprameatal triangle. Suprameatal spine — crest of bone separating suprameatal fossa from external auditory meatus. Suprameatal line — line continuing level of suprameatal spine backward. Remains of masto-squamosal suture — sometimes e.xists, with small canals occupied by connective tissue and veins. GENERAL SURGICAL CONSIDERATIONS IN OPERATIONS UPON MAS- TOID ANTRUM AND CELLS. Site and Direction of Operation for Opening Antrum. — (1) Site lies in suprameatal fcissa, directly within suprameatal triangle, or immediately behind it. This generally brings upper edge of opening about 3 mm. (yV inch) below suprameatal line, and about 5 mm. (y\- inch) behind bony external auditorv meatus. (2) Direction of opening passes inward and shghtly upward and forward, following general direction of bony external auditory canal. This will open into anterior part of antrum, at distance of from 7 to 14 mm. (t\ to tV inch) (extremes, especially in disease, from 3 to 18 mm., or y\ to yf inch) from surface of mast(;id process. General Precautions in Operating. — (i) Keep below supramastoid crest — to avoid middle cerebral fossa of skull. Middle cranial fossa some- times dips down to quite a low level between petrous and squamous portions of temporal bone, and the roof of antrum and tympanum form part of floor of this fossa. The level of floor of fossa may vary as much as 2 cm. (yf inch) but is never as much as i cm. (y,y inch) below supramastoid crest. Where supramastoid crest cannot be felt, keep 3 mm. (y^g inch) below horizontal line running backward from upper edge of bony external auditory meatus, in order to avoid middle fossa. To further avoid the possibility of entering middle cranial fossa, make opening at first directly inward, penetrating from 5 to 8 mm. (y^^ to y\ inch) before taking an upward direction. (2) Do not go more than 2 mm. (between y^ and j-,j inch) behind posterior limit of suprameatal triangle— to avoid lateral sinus. (3) Check instrument as soon as antrum is entered — to avoid external semicircular canal and facial nerve. Special Structures to be Avoided. — (1) .\t inferior aspect of entrance into antrum, inner wall of antrum bulges slightlv over external semicircular canal, which lies on median side of aditus, superior to and separated from fallopian canal by thin lamina of bone. It may form the anteromedian wall of antrum, if it project backward. To avoid injury to external semi- circular canal, check instrument as soon as cavity of antrum is reached. The inner wall of antrum lies about 17 to 20 mm. (\^ to jf inch) from surface 504 OPERATIONS UPON THE HEAD. of mastoid. (2) On inner side of epitympanic recess, inferiorly and anteriorly to the bulging marking external semicircular canal, is the arching osseous canal of the facial nerve. The wall toward antrum is thin and partly wanting. Avoid facial nerve by not directing the opening too far forward. The per- pendicular portion of fallopian canal, with contained nerve, may be 3 mm. (j-jf inch) internal to posterior periphery of ear-drum, or its position may be almost immediately opposite this posterior periphery. (3) Between e.xternaj semicircular canal anteriorly, and lateral sinus posteriorly, the air-cells are separated from posterior fossa of skull by bony wall from i to 9 mm. (from less than y\j to ^ inch) thick. (4) E.\treme curvature of sigmoid portion of lateral sinus may occur. Where this exists, the sigmoid sinus may be in almost direct contact with outer cortex of mastoid, and it may come to within 3 mm. {j\ inch) of posterior wall of bony auditory meatus. As its course cannot be known in advance, it is best avoided by careful use of gouge or chisel (which are preferable tn all instruments which approach by boring their way). Manner of Making Bone-section. — Bone is divided either by chisels and mallet, aided l)y hand gouges and curettes; or by a burr driven by an engine or worked by hand, followed by use of gouges and curettes. INSTRUMENTS. (!) For incision and repair of soft parts, see instruments used in cranio- cerebral operations (page 480). (2) Special instruments used upon mastoid process, auditory canal, and tympanic cavity, are the following: small mallet; chisels; gouges; guard for gouge; scoops; curettes; elevators; small trephine; forceps; burr driven by hand or by engine; bradawl; two or three centi- meters of a metallic millimeter measure. (3) Special instruments for intra- tympanic work; straight and angled knives; tenotomy knives; synechia knives: ear-drum knives; incus hooks; fine forceps. OPERATION FOR EXPOSING MASTOID ANTRUM AND CELLS. ANTRUM OPERATION OF SCHWARTZE. Description. — In this operation only the antrum and cells of the mastoid process are opened up, without invading the cavity of the tympanum. Indi- cated in such conditions as empyema, osteitis, or osteomyelitis occurring in the mastoid process alone. In the following account the description of J. Orne dreen is largely followed. (See Fig. 326.) Preparation. — The ear is irrigated with antiseptic solution and packed with sterile cotton. The hair of the neighborhood is shaved, and the head and neck enveloped in sterile dressings. Position. — Patient rests upon side, with head elevated and so placed upon its o])posite side as to make mastoid region prominent, resting upon a lirm cushion to prevent jarring. Surgeon stands behind patient. Assistant stands opposite and to one side of surgeon. Landmarks. — External auditory meatus; supramastoid crest; mastoid process. Incision. — Slightly curvilinear, placed behind ear — beginning i cm. (y'V inch) above le\el of upper edge of auditory meatus and passing down- ward at a distance of 0.5 to i cm. (y\ to j'^ inch) behind insertion of auricle, and ending at tip of mastoid process. (See Fig. 325, A.) ANTRUM OPERATION OF SCHWARTZE. 505 Operation. — (1) Incision passes through skin, overlying muscles, and peri- osteum directly to bone (Fig. 326). (2) The soft parts are elevated from the bone with periosteal elevator — anteriorly, until the suprameatal spine is ex- posed — posteriorly, until the mastoid process is bared. (3) From the supra- meatal spine, draw a line horizontally backward. Make an opening with its upper edge 3 mm. ("y^ inch) below this suprameatal line, and its anterior edge 5 mm. (y\ inch) Ijehind the auditory meatus — which position will correspond with the suprameatal fossa (fossa mastoidea) when that depression is suffi- ciently marked for recognition. The area of operation, bounded as above, will e.xtend over a surface 7 to 10 mm. (^^ to y^ inch) in diameter. (4) By r; Kig. 326.— ExposcRE OF Mastoid Antrum and Cells (Operation of Schwartze):—.\, .A drawn forward ; B, Mastoid antrum; C, Mastoid Cells ; D, Periosteum drawn aside; E, Stern toid muscle ; F. Temporal muscle ; G, Posterior branch of posterior auricular arter>\ means of gouge and mallet the bone is removed in thin chips, always keeping the process of excavation in a line parallel with the auditory canal. The amount of bone to be removed varies from a thin lamina up to i cm. (^ inch) before the mastoid cells are reached. (5) As soon as the air-cells are opened, explore with probe — upward, to locate the roof of the mastoid — inward and backward, to locate the posterior fossa of the skull. (6) Break down the intervening wall between the cells, working directly inward for 5 to 8 mm. (fV to j\ inch). Thence work in a slightly upward and forward direction, with curette, until the antrum is reached, at a distance from the surface of 7 to 14 mm. (y\ to y''j^ inch). The excavation should not extend bevond 14 or 15 mm. (y\- or y^ inch) from the surface, which is as far as it is safe to go. (7) Carious bone should be removed wherever found, even if it be neces- sary to expose the dura — and whether the roof of the mastoid lie imme- diately beneath the cerebrum; or the inner wall, with the lateral sinus and cerebellum, lie just to the inner side. The dura is displaced with a dural So6 OPERATIONS UPON THE HEAD. separator and the bone is removed with a curette. (8) The interior of the mastoid process must be dealt with accordins; to indications. Pus should be evacuated — granulations removed and cell-walls broken down. In in- flamed diploe, the cancellated structure should be curetted away. In osteitis, curette away softened bone short of harming the labyrinth and facial nerve. The entire e-xternal aspect of the mastoid process may be removed to the tip of the process. (9) In completing the operation, pack the cavity left in the mastoid with gauze. Suture the periosteum partially, and the soft parts also in [lart, leaving room for drainage. Comment. — (i) Where the interior of the mastoid is partly or wholly diploetic, proceed with greater care, using curette or hand gouge. Pass directly inward parallel with auditory canal, for 5 to S mm. (j% to -j^'^ inch) — if no air-cells are reached by this time, pass slightly forward, upward and inward to the antrum — but do not go beyond 15 mm. (-pr inch) frcm the e.xternal surface of the anterior edge of the osseous opening, lest the facial nerve or horizontal semicircular canal be injured. (2) In a mastoid affected with osteosclerosis (from long suppuration or previous disease) the usual landmarks, gotten with a probe as one advances, are not so available. Proceed carefullv in the same directions and for the same distances as in the diploetic tissue just mentioned, but working with a chisel and mallet, instead of a hand gouge. Diploetic bone may be met after passing through 7 to 10 mm. (y\ to y\ inch) of sclerosed bone. Sometimes, though rarely, the antrum may be obliterated by osteosclerosis. (3) Where fistulae exist, these should be exposed and followed up, rather than to make another opening thrrugh healthy bone; or the fistulous tracks may be used in conjunction with the ordinary opening. An externally placed fistula is exposed by reflecting the periosteum from the external surface of the mastoid process. An anteriorly placed fistula is exposed by reflecting the periosteum from the posterior wall of the auditory canal. .\n inferiorly placed fistula is exposed by reflecting the periosteum from the tip of the mastoid process, toward the digastric groove. OPERATION FOR EXPOSING MASTOID ANTRUM AND CELLS. TO- GETHER WITH INTERIOR OF TYMPANUM AND MEATUS, AND THE EXENTERATION OF THE MIDDLE- EAR CAVITIES. THE TVMP.\NO-.M.\STOID EXENTERATION, OR R.ADIC.AL OPER.ATION. OF SCHVV.ARTZE-ST.ACKE (OR SCHWARTZE-ZAUF.XL I. Description. — This operation, much more extensive than the last, con- sists in the opening uj) of the mastoid antrum, mastoid cells, tymjianum, and meatus, and of the complete exenteration (evisceration) of the middle-ear cavities. The whole interior of the mastoid antrum, aditus, epitympanum. tvmpanum, and meatus are thereby converted into a single large and continu- ous cavitv — the smooth walls of which are made to heal throughout by epider- mization — the epidermis growing in from the meatus and the edges of the wound. Indicated in empyema, osteitis or osteomyelitis of mastoid process occurring in connection with osteitis of the aditus. epitympanum. tympanum, and meatus; and also in cholesteatomatous collections in those parts. In the following account the description of J. Orne Green is largely followed. Preparation — Position — Landmarks. — Same as in the Antrum Opera- tion (page 504). TYMPANOMASTOID EXENTERATION. 507 Incisions and Operation. — A. Formation of Skin-flap and Periosteal Flap, and exposure of Operation Site: — (I) Skin-flap — incision begins 3 mm. (j\ inch) above the anterior superior insertion of the auricle — passes downward about 3 mm. (^iy inch), posterior to and parallel with the auricle, to the tip of the mastoid process — thence about 12 mm. (^^^ inch) backward — thence upward and slightly backward over the posterior aspect of the mastoid to its upper part. (See Fig. 325, B.) The skin over this triangle is dissected off' from the remaining soft parts and displaced upward. (2) Partial separation of auricle — dissect off the auricle, without the periosteum, up to the postero-superior margin of the meatus and displace it forward. (3) Periosteal Flap — incise horizontally backward through the periosteum to bone along the supramastoid crest, from near the meatus to the upper end of the posterior skin incision — and also perpendicularlv downward near to meatus. Displace downward the triangular flap of periosteum thus made. Sometimes this order of raising the flaps is rexersed, the skin-flap being turned downward and the periosteal flap upward. Hemorrhage is controlled as encountered. B. Extirpation of lining of Superior and Posterior aspects of Osseous .•\uditory Meatus — (1) Detach the cartilaginous meatus from the osseous meatus, with periosteal elevator, along its superior and posterior aspects and displace it forward and downward with the auricle. (2) Incise the lining of the meatus along the antero-superior and postero-inferior walls, beginning at the drum-membrane and ending at the free margin — dicsarding the excised triangular portion of periosteum. C. Exposure of .\ntrum, with Removal of posterior wall of Osseous audi- tory canal, together with Membrana and Malleus — (1) Expose the antrum as in the ordinary antrum operation (r/. v.). (2) Chisel out a wedge of bone be- tween the anterior edge of the mastoid opening and the posterior edge of the meatus. As the lower chisel-cuts approach the floor of the meatus and grow deeper, they are directed somewhat upward, finally opening into the osseous auditory canal. (3) Dissect out the fibrous tympanic ring bv means of a special knife, and remove the membrana tympani and the malleus, if still present. (4) Pass a bent probe, or special guide, by the tympanic route, through the aditus into the antrum, and, upon this as a guide, chisel away the remaining wedge of bone between the antrum and aditus — making as wide an opening as the position of the facial nerve will allow. D. Extirpation of Epitympanum and Removal of Incus: — (i) Chisel away the outer wall of the epitympanum with a specially curved chisel, exposing the entire epitympanum. (2) Disarticulate the incus from the stapes with a sj)ecial knife, and remove the incus with forceps. E. Exenteration of entire Mastoid Antrum, .Aditus, and Epitympanum: — fi) Chisel away most of the outer cortex of the mastoid and its cancellated portion. (2) So chisel away the posterior wall of the osseous auditorv meatus as to leave a ridge of firm bone between mastoid and meatus, sloping outward and downward from the floor of the aditus. The fallopian canal lies inside this ridge, none of which is to be removed on the median side of the tvmpanic ring. (3) Smooth, by curette or surgical engine, all bony irregularities in the walls of the mastoid, antrum, epitym[)anum, and roof of tympanum. Espe- cially search for caries upon the posterior and interno-inferior aspects of antrum, lateral sinus, and roof of tymjxinum — exposing the dura if refjuired. (4) Guard the horizontal part of the fallopian canal through the tympanum, 5o8 OPERATIONS UPON THE HEAD. and the perpendicular part running down from tlie aditus — also the horizontal semicircular canal in the inner wall of the aditus. F. Splitting of Membranous Meatus and Suturing: — (i) Slit the car- tilaginous meatus throughout its posterior wall, from near the concha out- ward. Two triangular flaps are thus formed, whose corners are to be sutured with catgut to the e.xternal tissues, one being stretched upward, the other downward. (2) Suture the auricle back into its former ])osition as far down as the sui)ramastoid crest. (3) Turn the skin-flap and ])eriosteal flap into the cavity made, after cleansing and draining it — and tampon them with gauze. (4) Suture the skin over the lower part of the mastoid. (5) Apply a voluminous protective dressing. G. After-treatment: — Keep every crevice of cavity well packed with gauze, until the cavity fills with granulations, and until granulations are covered with epidermis — which epidermis is gotten partly from epidermization of granulations, partly from the skin-fla]) turned in — and may also be gotten from grafts. Comment. — The middle ear is sometimes first exposed by removing the upper and ])osterior wall of the osseous canal, and then, by means of a probe in the aditus ad antrum, the aditus and antrum are exposed. Thus antra King further forward than usual would lie exposed with less danger to the cranial cavity (Stacke). OPERATIONS UPON THE FRONTAL SINUSES. SURGICAL ANATOMY OF THE FRONTAL SINUSES. Description. — Two more or less triangular air-spaces of variable size, with bases anteriorly aad apices posteriorly, situated chiefly in antero-inferior portions of frontal bones, on either side of median line, anterior to ethmoidal notches, and separated from each other by an intervening bony sejitum. They lie at the antero-internal junction of horizontal and vertical piirtions of frontal bones, immediately internal to internal angular processes, lying above root of nose and more or less beneath inner portions of superciliary ridges. The sinuses begin to develop at two years, but are insignificant in size until after seven years. Muscles in Relation with Frontal Sinuses.— Frontal portion of occipito- frontalis; orbicularis palpebrarum; corrugator supercilii; sometimes the an- terior part of temporal. Arteries in Neighborhood of Frontal Sinuses. -Angular; termination of facial; frontal branch of ophthalmic ; supraorbital ])ranch of ophthalmic. Veins in Neighborhood of Frontal Sinuses. -Frontal (emjttying into nasal arch and supraorbital); supraorbital (forming, with frontal, the angular vein); angular (becoming the facial); anterior temporal (em])tying into common temporal). Nerves in Neighborhood of Frontal Sinuses.— Supraorbital and supratrochlear branches of frontal division of ophthalmic; sometimes the lachrvmal branch of ophthalmic. Walls and Their Relations.— (i) Anterior Wall: formed by vertical portion of frontal; extends from supraorbital arch below, a variable distance upward (v. i.); contains diploe; thickness of wall varies from i to 6 mm. (from less than yV to y^ inch) in different places, average being from 2 to 3 mm. (from about yV to y% inch); has, in relation, the soft parts mentioned above (see muscles, arteries, veins, and nerves). (2) Postero-superior Wall GENERAL SURGICAL COXSI DERATIONS. 509 (or roof): forms part of anterior boundary wall f.f anterior cranial fcssa; dense and brittle; has, in relation, the frontal k.be of brain and the olfactory lobe. (3) Inferi )r Wall (or floor): (a) Orbital Porti(3n: forms part of r<;of of orbit; of variable e.xtent; marked by depression for pulley of superior oblique muscle of eye; (b) Nasal Portion: (the part of greater surgical im- portance) ; articulates with anterior ethmoidal cells, nasal process of superior ma.xillary and nasal bones; infundibulum opens through this portion of inferior surface from frontal sinus into middle meatus of nose. (4) Internal Wall: formed by the antero-posterior septum between the sinuses, which generally deviates from median line. Extent. — (I) Laterally; Average of two hundred cases gave an e.xtension outward from median line of from 2 to 2.8 cm. (}| to i-j?^ inches) — Extremes, from mere slits in nasal part cf frontal, to cavities extending from median septum into external angular process of frontal. (2) Vertically; averages* from base to apex above, along its inner border (its highest part), from 1.8 to 2.5 cm. (f|- to I inch) — extremes, from nasofrontal suture to frontal eminence. (3) Floor, frequently e.xtends back as far as anterii r tthmcidal foramen — rarely back to lesser wing of sphenoid. The size of the frontal sinuses is not determined by neighboring bony prominences and depressions, as they may be largely formed at the expense of the inner table of the skull. It is also often said that one sinus may be absent or rudimentary, the opposite one extending acrrss the median line, but in Lothrop's examination of two hundred and fifty sinuses the orbital portion of the sinus was not once missing. Septum. — \ thin bony septum sejiarates the two sinuses, which mav deviate slightly or considerably to one side. Septum generally does deviate to one side, and this deviation may amount to 5 mm. {-^ inch) or more. When deviation is very marked, one sinus partly overlaps the other, an im- portant surgical fact. The septum is rarely absent. Perforation of septum is very exceptionally found (once in one hundred and eighty cases). Communication with Nose. — By infundibulum, which passes downward and backward liehind the nasal process of superior ma.xillary bone, through anterior portion of lateral mass of ethmoid, and opens into middle meatus of nose, under anterior end cf middle turbinated bone, and on a level with the palpebral fissure. SURFACE FORM AND LANDMARKS. No external guide exists as to the extent of the frontal sinuses — though, generally, the more prominent and larger the supraorbital area, inclusive of the superciliary ridges and nasal eminences, the greater the extent of the sinuses. GENERAL SURGICAL CONSIDERATIONS. It is not safe to make an opening for the exposure of the frontal sinus at any point external to the supraorbital notch — the site at which the sinus is most surely encountered being just above the antero-inferior aspect of the internal angular process of the frontal bone, at a position to one side of the median line sufficiently far to miss the average position of the septum. 5IO OrERATIOXS UPON THE HEAD. INSTRUMENTS USED IN OPERATIONS UPON THE FRONTAL SINUSES. See those mentioned under the Cranio-cerebral and Mastoid regions (pages 480 and 504). EXPOSURE AND DRAINAGE OF THE FRONTAL SINUSES. Description. — The frontal sinus is exposed through its anterior wall — and sul)sequently drained either through the original wound — or, where possible, through the infundibulum into the middle meatus of the nose, after closing the original wound — or through both routes. Preparation. — Shave eyebrow. Close eyelid and [)lace a sterile pad over it. Position.— Patient sujnne; shoulders elevated; head extended. Surgeon on side of operation, or behind head. ,'\ssistant opposite. Landmarks. — Supraorbital ridge; supraorbital notch (generally detectable through the skin, at the junction of the inner and middle thirds of the supra- orbital ridge) ; sagittal suture (middle line of head) ; nasofrontal suture (de- tectable when soft parts are retracted). Incision. — A horizontal incision is made, beginning to the outer side of the center of the supraorbital ridge, and continued inward to the median line, just above the supraorbital margin (Fig. 327). If more room be needed, this incision may cross the median line, or be curved upward or downward at the median line. (Instead of the horizontal, a vertical incision is some- times made in the median line, between the superciliary ridges — but leaves more of a scar than an incision through the eyebrow. Operation. — (1) The incision passes directly to the bone, through the skin, the fascia, transversely through the frontal portion of the occipito- frontalis, longitudinally between some fibers of the orbicularis palpebrarum and through periosteum to bone. The supraorbital vessels and the supra- orbital and supratrochlear nerves are cut — but the more important branches of the facial nerve to the occipitofrontalis, corrugator supercilii, and orbicu- laris palpebrarum are not cut. (2) The periosteum is elevated and, together with the soft parts, is displaced upward and downward by retractors. (3) The bone having been well exposed, and bleeding controlled, an opening is made with a small trephine or burr (or, less desirably, with chisel and mallet). The opening is placed just above the antero-inferior aspect of the internal angular process of the frontal bone — the inner margin of the opening should be external to the median line, to allow for deviation of the sejjtum — the outer margin should never extend beyond the supraorbital foramen — and the lower margin should be above the nasofrontal suture. (4) .'^fter pene- trating the anterior bony wall, with its diploe, the mucous membrane of the frontal sinus is encountered and divided. (5) Pass a probe through the trephine-opening into the sinus — thence through the infundibulum (which first runs downward and backward a short way, then sharply forward and downward) into the midiiin ul tympanic membrane for the purpose of drainage (if the l\nipanic cavit\' and for irrigation. Indicated chiefly in otitis media. Instruments Required. — Ear-speculum; double-edged paracentesis needle. Preparation. — Cleansing of auditory canal by antiseptic irrigation. Position. — Patient sits upright. .Surgeon sits opposite the involved ear. Landmarks. — Handle of malleus showing through the membrana tym- pani. Operation. — (i) Insert the ear-speculum — expose the membrana tympani in the field of the speculum — and recognize the handle of the malleus. (2) Incise the ear-drum, making the incision in the posterior half of the mem- brane, between the handle of the malleus and the posterior border of the membrana tympani, and enlarge the opening vertically — taking care not to wound the middle ear. INTRODUCTION OF THE EUSTACHIAN CATHETER. Place the patient in a chair opposite the operator, with head thrown back and supported upon the back of the chair or upon a rest. The surgeon, standing or sitting, places the fingers of his left hand upon the patient's fore- head, while his left thumb pushes the tip of the patient's nose upward (to bring the nostril on a level with the floor of the nose). Warm and lubricate the eustachian catheter, having atomized the nasal cavity with a local anes- thetic, if necessary — push the tip of the catheter, pointing downward, along the floor of the nose, until it touches the posterior wall of the pharyn.x — turn the point obliquely outward but not quite horizontal — withdraw the instru- ment until the point is felt to glide over the projecting posterior border of the eustachian tube — now turn the tip further outward, until the guide-ring at the posterior end of the catheter points to the outer canthus of the eye of Sl8 OPERATIONS UPON THE HEAD. the same side — when the (lirectinn of the beak will generally coincide with the axis of the eustachian tube. V. THE NOSE AND NASAL CAVITIES. For operations exposing the Xasal Cavities, see Excisions and Osteoplastic Resections (pages 455, 456). Most of the other operations upon the Nose and Nasal Cavities belong to the special field of Rhinolog}-. VI. THE TONGUE. SURGICAL ANATOMY. Connections of the Tongue. — (1) With Os Hyoides; by hyoglossi and geniohyoglossi muscles, and hyoglossal membrane. (2) With Stvloid Process; by styloglossi muscles. (3) With Inferior Maxilla; by geniohvoglossi muscles. (4) With Pharynx; liy superior constrictors and mucous membrane. (5) With Epiglottis; by median and two lateral glosso-epiglottic folds of mucous membrane. (6) With .Soft Palate; by anterior pillars of the fauces (/. e., the ])alatoglossi muscles covered by mucous membrane). (7) ^^'ith Gums and Floor of Mouth; by mucous membrane and fr^num lingua?. Muscles Entering into Formation of Tongue. — (i) Extrinsic Muscles (arising externally and terminating in tongue); styloglossi, hyoglossi, genio- hyoglossi, palatoglossi, pharyngeoglossal portion of superior constrictors, chondrogled, or other, incision. C)ne iialf of tongue, transversely or longitudinally, may be removed. The entire organ may be excised. (2) The tongue may be removed through the un- altered mouth; through an incision in the neck; through the mouth after splitting the cheek, or temporarily dividing the inferior maxilla; or after excision of the inferior ma.xilla. (3) It may be removed with or without INSTRUMENTS USED IN REMOVAL OF THE TONGUE. 519 previous ligation of the lingual arteries, either beneath the hyoglossi or at their origin — and with or without previous tracheotomy — dependent upon the difficulties and circumstances of the case. (4) It may be removed by scissors; by knife; by some form of ecraseur, applied through mouth or neck; by ligature; are permanently removed. While a considerable number of lamin.T mav be thus removed without materially 530 OPERATIONS LPON THE SPINE AM) SPINAL COKD. weakening the spine, it is natural to suppose that the individual would be better off if these lamin;e were preserved. In an Osteoplastic Resection of the Spine the laminae are temporarily turned back and subse(|uently replaced at the end of the operation, thus leaving the spine practically intact. Where practicable, therefore, an osteoplastic resection of the spine is preferable, to a laminectomy — and by means of Doyen's saw, and with the valuable aid to its accomplishment suggested by Hartley, the mechanical difficulties of the operation are now largely remoxed. INSTRUMENTS USED IN OPERATING UPON THE SPINE AND SPINAL CORD. Stout scalpels and bluntly-rounded knives; large, strong retractors of various shapes and depths of reach; hemostatic forceps; scissors, curved and straight, blunt and sharp; chisel or osteotome (for levering soft parts from vertebral grooves); chisels, different sizes (where necessary to complete a section begun with a saw, by a stroke or two) ; periosteal elevators; raspatory; Doven's saw (the instrument of choice for making the section of bone); Gigli, chain and Hey's saws; bone-cutting pliers; rongeur forceps; special bone-cutting forceps (such as Hoffman's, Horsley's, or Keen's); lion-jaw bone-holding forceps; curved sequestrum forceps; mallet; trephine; probe; dural separator; grooved director; dissecting forceps; toothed forceps; needle- holders, large and small; needles, small and fully curved for membranes, and large, straight, and curved, for the main wound, gut and silk sutures and ligatures; drains. LAMINECTOMY. Description. — Laminectomv, or Lamnectomy, signifies a complete per- manent removal of the laminse and spinous process of one or more vertebrae — for the jjurpose of exposing the spinal canal and cord. Preparation and Position. — See General Surgical Considerations. Landmarks. — The spinous processes corresponding with the laminaf to be renidved — remembering that in the greater extent of the spine the spinous processes extend considerably below the corresponding lamina;. Incision. — A median vertical incision is made directly over the tips of the spinous processes — the center of the incision being over the center of the area from which the posterior wall of the spinal canal is to be removed, and extending as far above and below the special lamina; to be exci.«ed as may be necessarv to expose thoroughly the site of bone section (which will neces- sitate its reaching one or two spines above and the same number below those to be removed, dependent upon the region of the spine). (See Fig. 332, A.) Operation. — (i) The incision is carried directly over the apices of the spinous processes, through skin and fascia — and then passes boldly down along one side of the spinous processes for the entire length of the wound, hugging the lateral aspect of the spines as closely as possible. This incision is preferablv made with a fairly large, stout knife having a somewhat rounded point — the cut being made toward the apex of the acute angle formed by the muscles and aponeuroses attached to the spinous processes. (See General Surgical (\)nsiderations.) (2) Considerable bleeding will occur in this long and deep wound — and is to be dealt with as described under General Surgical LAMINECTOMY. 531 Considerations — as is also the hemorrhage which occurs while exposing the laminte. (3) The entire spinal furrow on each side of the spines is to be now cleared. These furrows are bounded by the spinous processes, lamins, Fig. 332.— Regio.n of the Spi.nal Coumn and Cord -.—A. Posilion for incision in laminectomy of fourth, fifth, and sixth cervical vertebra; : B, Position for incision in Hartley's preliminary excision of a spinous process (of sixth dorsal vertebra) preceding osteoplastic resection; C, Position of inci- sion in an osteoplastic resection of seventh, eighth, and ninth dorsal vertebra; ; D, Lumbar puncture between the fourth and fifth lumbar laminae, for spinal anesthesia. and bases of the transverse processes. They should be thoroughly cleared of muscular and aponeurotic attachments and all hemorrhage controlled before the section of bone is attempted. They are most readily cleared by using a chisel, or osteotome, against the spinous processes as a fulcrum, and levering oPf all soft attachments from the base of the spinous processes and 532 OPERATIONS UPON THE SPINE AND SPINAL CORD. laminie toward the transverse and articular processes. Fibers which have escaped removal with chisel or osteotome thus used, may be removed with the raspatory. When one side has been entirely prepared, it should be firmly packed with gauze, while the opposite side is similarly prepared. The side last prepared is then packed — and the first side is now ready for the division of bone. (See Fig. ^^;i.) (4) Remove the packing and firmly retract the soft parts away from the spines, thus freely exposing the spinal furrow of that Fig- 333.— Laminectomy ; A, A. Saw-cuts through the laminje, just within their junction w iih the ■ticular processed ; B, Doyen saw in act of dividing the laniiiue, its guard (determitiing the depth of ■ctiou) being entirely raised at the beginning of the division : C, Knife dividing the ligamenta sub- tva ; D. Osteotome levering away the muscles of the vertebral grooves, using the spinous processes i fulcra. side, with the bared laminae lying at its bottom — no opening into the spinal canal itself being as yet made. Doyen's saw is now applied to those 1am- inas which it is intended to remove. The blade of the saw should be directed at a right angle to the surface of the lamina' which are to be cut — which means that the saw will be directed slightly toward the median line and will pass through the lamin<-E by the shortest route. If it be directed parallel with the spinous processes, it will pass with slight obliquity through the lamina; LAMINECTOMY. 533 and will, in addition, be apt to run into the articular processes, or into the bases of the transverse processes, and thus cause much difficulty. The saw should travel, at each stroke, the full length of the laminae to be e.xcised — and should cut to an equal depth throughout. The guard of the Doyen saw will prevent its cutting too deeply into the spinal canal. Even without the guard the progress of the section can be determined by the flat end cf a probe. Having completed the section upon one side, the opposite side should be divided in the same manner. The saw-cuts will end above at the upper border of the highest pair of laminas to be removed, and will end below at the lower border of the lowest pair. When the sections have been carried entirely through the laminae throughout, it will be found, by grasping the spinous processes, that the excised section can be moved from side to side, showing that the bone has been everywhere divided and that the laminas are still held in place by the ligamenta subflava, supraspinous and interspinous ligaments. (5) Grasping the spinous process just above the upper one to be removed, with lion-jaw forceps, draw it slightly backward and divide, in order, the supra- spinous and interspinous ligaments and the ligamenta subflava, connecting the spinous processes and the lamina". Similarly grasp the lowest of the spines to be removed and draw it backward from the spine next below and divide the corresponding ligaments — by carrying a knife obhquely between the spines down to and through the ligamenta subflava — being careful not to penetrate far enough into the spinal canal to do damage. (6) Nothing now should hold the excised area — which is grasped by stout bone-holding forceps and lifted out of its position. If it still be held in places by slight bonds, use an osteotome, or periosteal elevator inserted into the grooves made by the saw and lever it out — beginning the process of loosening from below. (Where the Doyen saw is not available, the section is probably best made with bone-cutting pliers in the following manner. Simultaneously retract the soft parts well on both sides, after having cleared both spinal furrow^s in the above fashion. Divide with a knife, or curved scissors, the supraspinous and interspinous ligaments extending between the apices and between the contiguous upper and lower borders of the spinous processes. Remove the designated spinous processes as near to their bases as possible, bv means of angular bone-cutting pliers, or by biting them off with rongeur forceps, or by the Gigli saw — in order to gain access to the spinal canal. Carefully divide the ligamenta subflava [interlaminous ligaments] between the laminic to be excised. This will open up the connective tissue between the periosteum of the spinal canal and the outer surface of the dura. Cau- tiously pass an angular or curved bone-cutting forceps between the laminae where the ligamenta subflava have been severed, and cut the indicated lamina vertically upward as near the base of the transverse process as possible — so as to remove a wide window of bone. Repeat this upon the opposite side, and remove the pair of laminEe wth the remnant of attached spinous process. Repeat this step with as many, pairs of laminae as must be removed — the subsequent laminae being much more readilv removed, and with less danger to the membranes and cord, than the first.) (7) Control, with gentle pressure and hot irrigation, the hemorrhage which is likely to occur from the posterior longitudinal spinal veins and their transverse branches. (8) The spinal cord is now exposed to view, suspended vi-ithin the spinal canal — often fat and veins intervening between the periosteum and cord. Its preservation from injury during the steps of the operation (for it is but very exceptionally in- jured) being largely due to its distance from the periosteum of the spinal canal, to its suspended position, and to the toughness of its membranes. 534 OPERATIONS UPON THE SPINE AND SPINAL CORD. For indications for opening the spinal membranes, see General Surgical Considerations. If it be decided to open the membranes, seize the dura by means of two pairs of toothed forceps, one held by the assistant and the other by the surgeon. While the membranes are thus steadied and drawn away from the cord, a median vertical incision is made in the posterior aspect, for as long a distance as considered necessary, passing between the grips of the two forceps. Having opened the subdural space, and then the sub- arachnoidean space (from which the cerebrospinal fluid will escape), these areas are carefully e.xamined by means of a bent probe — for tumors, hemor- rhage, adhesions, spiculas of bone, foreign bodies, bony irregularities, diseased products, etc. If the spinal nerve-roots have been severed, they are sutured prior to opening the membranes. (9) Having finally thoroughly examined the surface of the cord, the incised membranes are treated as indicated by the particular case. If infection be not anticipated, and where possible to do so (where that membrane has not been destroyed), the incised dura should be sutured with fme catgut, carried upon a fine, fully-curved needle. In other cases the dura should be allowed to fall into place as completely as possible, or may be sutured in part, and temporary drainage of the intra- membranous region be instituted by means of strands of silk, fine gut, or silkworm-gut introduced within the theca, and thence out of the general wound. (10) In any event, drainage down to the theca, through the depth of the wound, is instituted for a few days, that a free escape may be provided and pressure upon the cord structures be avoided — by means of rubber tubing or gauze. (11) The spinal muscles and aponeuroses are quilted together with chromic gut, in one or two tiers. (i3) The skin is sutured with silkworm- gut or silk, except where drainage comes through. .\n abundant aseptic dressing covers the site. Comment. — It is well to excise the spinous process of the vertebra above the highest one the lamin;e of which are to be removed, in order to furnish freer access. For the purpose of removing the scar of the skin wound from the lines of the spines and the deeper wound, some surgeons use a curved incision, its upper and lower ends crossing the median line and its vertical portion lying parallel with and considerably to the outer side of the median line — thus raising a curved lateral flap of skin and connective tissue — which is retracted to the opposite side — and then the muscles are incised and the operation completed as above. If, however, it be found necessary to expose additional spines, the incision becomes complicated. .A.lso for the same reason, some surgeons turn upward or downward a skin and connective-tissue flap, before proceeding to bare the spines. Sometimes after exposing the part as for ordinary Laminectomy, the laminae are removed by an osteoplastic operation. Keep the patient's head dependent while opening the membranes, to allow the cerebrospinal fluid to collect in the skull. OSTEOPLASTIC RESECTION OF THE SPINE. Description.— .\ flap composed of skin, fascia, muscles, together with spinous processes and lamina; (all parts composing the flap remaining adherent to each other and in their relative positions), is partially removed en iinisse and temporarilv turned upward and backward, to expose the portion of the cord or spine involved — and then dropped back into place at the end of the OSTEOPLASTIC RESECTION OF THE SPINE. 535 operation. Thus no part of the spine is permanently sacrificed, nor its strength impaired. In those regions of the spine where the spinous processes overlap it is impossible satisfactorily to turn this osteoplastic flap upward, in the ordinary method of doing the operation, owing to the interlocking of the two adjacent spines — and it is not easy to do so even where the spines do not actually overlap. To avoid this difficulty. Hartley begins the operation by e.xcising, by a separate incision, the spinous process just above the highest one which is to form part of the osteoplastic flap. For comparison between Laminectomy and Osteoplastic Resection of the Spine, see General Surgical Considerations. A special indication for thus Fig. 334. — Haki LEY'S Method of Pkellminarily Excising the Spinous Process I.mmedi- ATELY above THE LAMIN/E TO BE TEMPORARILY TURNED BACK IN OSTEOPLASTIC RESECTION OF THE Spinal Column. preserving the spines and lamina' is in Pott's disease, where the bodies of the diseased vertebr;e might be too weak if manv lamina; and spines were removed. Preparation — Position — Landmarks. — .As in Laminectomy. Incision. — (a) For the preliminary excision of the adjacent spinous process — a median vertical incision of 2.5 to 4 cm. (i to i^ inches) is made directly over the spinous process immediately above the highest one entering into the osteoplastic flap. (See Fig. 332, B.) (b) For the raising of the osteo- plastic flap — a U-shaped incision is outlined; its length determined by the number of lamina? to be removed; its convexity downward, crossing just below the last spine in the flap; its limbs parallel with the spinous processes and placed over the bases of the transverse processes (over the articular processes in the cervical region). (See Fig. 332, C.) Operation. — (i) In doing Hartley's modification of the operation (which 536 OPERATIONS UPON THE SPINE AND SPINAL CORD. has for its object the removal of the spine of the adjacent vertebra above, thereby making the turning back of the osteoplastic flap in all regions of the column an easier undertaking), the median vertical incision over this spine Fig- 335- — Osifc-oPLASTic Resection of the Spinal Col spinous processes, and ligamenta subflava turned back ; B, Spin branes incised and retracted, together with the nerves and their -.•:— A. Flap of muscles, la anal exposed, showing the rse to the spinal foramina. is deepened until its apex is reached, and is then carried along each side of the spine to its base. (3) The detached soft parts are retracted laterally and the spinous process bitten off close to its base with bone-cutting pliers, or, better, with Gigli saw. (See Fig. 334.) (3) If this wound be at once closed (which is generally best), the muscles are appro.ximated OSTEOPLASTIC RESECTION OF THE SPINE. 537 by two or three buried chromic gut sutures, and the superficial wound sutured. (If difficulty occurs in turning back the flap, or in replacing it at the end of the operation, this wound may be reopened, if it have been closed, and the manipulation aided by a finger introduced through it down to the bony structures.) All is now ready for the operation proper. (4) The incision for the U-shaped flap passes directly to the bone, the knife being directed obliquely so as to pass down along the median surface of the posterior aspect of the transverse processes and come upon the laminas at the inner margin of the articular processes (directly down to the junction of the lamina and articular processes in the cervical region). This cut passes boldly to the bottom of the spinal furrows along its vertical limbs, but the lower curved portion is made with special care where it passes between two contiguous spinous processes, cutting the supraspinous and interspinous ligaments and guarding against entering, at this stage, the spinal canal. (See Fig. 335.) (5) Hemorrhage is now controlled as in Laminectomy. (See General Surgical Considerations.) (6) The soft parts are well retracted (both toward the apices of the transverse processes and toward the spines) without detaching soft parts from bones, thus e.xposing a deep furrow upon one side of the spine, the bottom of which is formed by the lamina?. (7) Having again sto[)|jed all bleeding and thoroughly ex]3osed the lamina-, the periosteum of the lamina; is cut through-in a vertical line down their center by means of a stout knife, and the periosteum turned away with a periosteal elevator upon each side of this incision just sufficiently to form a bared path for the saw. (While this baring of the lamina; by turning back the perios- teum from the saw-groove is not always done, it is better to do so.) (8) This side is now firmly packed with gauze and the opposite spinal groove similarly prepared, before either is sawed. (9) The lamina are now divided in a vertical fine just within the articular processes, by means of Doyen's saw, in exactly the same manner as in Laminectom}- (see 4, under Operation, page 532). (10) The ligamenta subflava connecting the lower border of the lowest pair of lamina; to be removed with the upper border of the pair just below, is now carefully divided with knife or curved scissors. (11) By means of an osteotome used as an elevator the entire osteoplastic flap is now carefully elevated and turned upward upon the ligamenta subflava at the upper limit of the section, as a hinge. (12) The cord is thus amply exposed — and the steps of the operation which concern the cord and its membranes are identical with those in Laminectomy. (13) At the end of the operation all bony projections, both upon the spinal column and upon the lamina; in the flap, which are apt to interfere with exact apposition, are removed with the saw while grasped with bone-forceps, or by rongeur forceps. (14) The dura having been sutured (if opened and its closure not contraindicated) and all hemorrhage controlled, the large osteoplastic flap is allowed to fall back into place and is adjusted so as to accurately fit. (15) If necessary to temi)orarily drain the spinal canal, this should be done bv a few strands of silk, catgut, or silkworm-gut conducted into the wound, a small portion of the lower lamina; being bitten away. To provide for drainage of the wound of the soft parts, drainage tubing or gauze may be placed down to its bottom and come out between sutures which have been placed but not tied. (16) The muscles should be quilted in one or two tiers with chromic gut. The skin wound is closed, except where the drainage comes through. A volumin- ous aseptic dressing is applied. 538 OrERATIOXS UPON THE SPINE AND SPINAL CORD. SUBARACHNOID PUNCTURE FOR SPINAL ANESTHESIA. Description. — The injection into the subarachnoid space of the spinal cord of an anesthetic solution for the purpose of producing regional surgical anesthesia, or analgesia. Injections for this purpose have been made into various portions of the entire cerebrospinal tract — but the operation as practised for surgical pur- poses is practically limited to the lumbar region of the spine, .^s the cord ends at the lower border of the first lumbar vertebra, any intervertebral space below that may be used, namely, between the second and third — between the third and fourth — between the fourth and fifth — or between the fifth lumbar and sacrum. The space usually chosen is that between the fourth and fifth lumbar vertebra? — next, the lumbo-sacral space, or the space between the third and fourth lumbar. Various anesthetic solutions have been used — chiefly cocain or eucain B, used alone or combined with morphin. The cocain-morphin-saline solution of Matas (from whose writings the accompanving description is largely taken) consists of cocain hydrochlorate gr. A, morphin hydrochlorate gr. ^'^y, sodium chlorid gr. i, dissolved in 20 minims of water, the water first sterilized and the mixture subsec[uently resterilized by the fractional method, and injected warm b\' means of a special svringe. Preparation. — Thorough sterilization of the field of operation. Position. — Where possible, the patient sits upright upon the edge of the table, with feet upon a chair, and leaning forward, supporting himself by hands upon knees, so as to round out the liack convexly and increase the transverse width of the intervertebral spaces by 3 cm. (5 inch) — and also to cause the cerebrospinal fluid to gravitate. Where the patient cannot sit up, he ma\ lie upon his side in Sims's position with back similarly arched. Landmarks. — The spinous processes of the fourth and fifth lumbar vertebrie should be identified, which is not always easy in thickly covered backs. A straight line drawn transversely between the highest points of the iliac crests posteriorly, while the patient is as erect as possible, will cross the tip of the spinous process of the fourth lumbar vertebra. The point of injec- tion lies just below and slightly to the outer side of the junction of this line with the tip of the spinous process of the fourth lumbar vertebra. The spinous processes may be also identified by counting downward from the seventh cervical spine (the vertebra prominens). (See Fig. 332, D.) Operation. — (i) The skin having been thoroughly prepared — the im- mediate area infiltrated with a few drops of Schleich's cocain solution — the back rounded out by the patient's leaning forward — the tip of the spinous process of the fourth lumbar vertebra is marked by the left index-finger. The needle of an empty syringe (preferably a special syringe and one made without screw attachment for the junction with the needle) is entered at a point about i cm. (nearly J inch) to the right and just below the tip of this spinous process — and is made to penetrate slowly in a direction forward, inward (toward the median line), and slightly upward into the interspinous space between the fourth and fifth lumbar vertebra;, recognizing, if possible, the entrance of the needle into the subarachnoid space by the lessened resistance as the needle i)asses through a tense structure into a freer cavity. The distance thus penetrated is generally between 6.5 and 7.5 cm. (about 2§ to 3 inches). (2) The piston of the syringe is now drawn and, if the needle be in the subarachnoid space, the clear cerebrospinal fluid will aj)pear (if INTRASPINAL PARTIAL NEURECTOMY. 539 the needle be of fair size and not occluded). .\s soon as a few drops have flowed, the cylinder of the syringe is detached from the needle (which is left in situ), with the least possible loss of cerebrospinal fluid — and the cylinder of the svringe, now charged with the anesthetic solution, is reattached to the needle and the fluid carefully injected. The needle is allowed to remain in situ a few moments and is then withdrawn — and the needle wound sealed with sterilized cotton and fle.xible collodion. Anesthesia should follow in from ten to fifteen minutes. Comment. — Where the space originally sought cannot be found, or satisfactorily entered, resort to any available interlumbar space below that between the first and second. Sometimes an incision, under local anesthesia, has been made down to the ligamenta subflava. A Laminectomy has some- times been first performed. But these steps are unnecessary in the vast majority of cases. SPINAL PUNCTURE FOR DRAINAGE OF THE SUBARACHNOID SPACE. Description. — E.xcess of cerebrospinal fluid is sometimes removed for the relief of pressure in the cerebrospinal tract. This may be done through any of the interspinous spaces — but is usually done in the lumbar region, in the same space and in the same general manner as Subarachnoid Puncture for Spinal .\nesthesia. For the same purpose the occipital bone has been trephined and the basal subarachnoid space beneath the cerebellum entered and drained — see Incision of the Cerebellar Subarachnoid Sj)ace for Drainage, page 496. Drainage of the cerebros]jinal fluid is chiefly indicated in Menin- gitis and Hydrocephalus. Preparation — Position — Landmarks. — .As in Subarachnoid Puncture for S])inul .\nesthesia. Operation. — The steps of the operation are, in all practical respects, the same as in the preceding one. The cerebrospinal fluid may be withdrawn by trocar and cannula — or, better, by aspiratory syringe — preceded by in- filtration anesthesia. OPERATION FOR THE REMOVAL OF TUMORS OF THE SPINAL CORD. Description. — Tumors of ilie spinal cord are e.xposed by Laminectomy or Osteoplastic Spinal Resection. After exposure, their removal is conducted along the same general fines as is the removal of Cerebral and Cerebellar Tumors {q.v.). E.xtra-dural tumors and those of the meninges are those most favorable for removal. Intrameningeal tumors involving the structures of the cord in part only are removed, after opening the membranes, by careful excision of the tumor from the neighboring cord-structures. Intrameningeal tumors involving and completely infiltrating the cord are inoperable. Tem- porary intrameningeal drainage, as well as drainage of the main wound, are indicated, as a rule, after the removal of a tumor. INTRASPINAL PARTIAL NEURECTOMY OF THE POSTERIOR NERVE- ROOTS. Description. — In cases of inveterate neuralgia sections of the posterior nerve-roots, representing the nerves involved, have been removed, after 540 OPERATIONS UI'ON THE SPINE AND SPINAL CORD. opening the spinal membranes. In the cases operated upon the results have not been altogether satisfactory. If, as in one of Abbe's cases, the limb has been amputated and spasms still continue in the stump, as well as the mani- festation of pain, the motor roots may also be cut (neurotomy), besides the partial excision (neurectomy) of the posterior roots. In addition to the excision. Keen has suggested the breaking up of the ganglia upon the posterior nerve-roots, for fear of reestablishment of connection. The technique of the operation is simply that of a Laminectomy or, preferably, an Osteoplastic Spinal Resection, as far as the exposure of the membranes and cord are concerned. Care is exercised in choosing the site of the exposure, that the roots of the nerves involved may be accurately located. After the canal is exposed the membranes are opened as described under Laminectomy — the particular nerves are recognized — and as much of the posterior roots as can be resected within the dura is excised — and the membranes and the wound dealt with as in Laminectomy or Osteoplastic Spinal Resection. NOTE. For operations upon Bones, Muscles, Joints, Ligaments, Arteries, Veins, and Nerves of the Spinal Region, see General Surgery. CHAPTHR III. OPERATIONS UPON THE NECK. I. THE LARYNX. SURGICAL ANATOMY OF THE NECK. For Surc^ical Anatumy of the antero-luteral region of the Neck, see under "Lymphatic Glands and Vessels," page 133. For Surgical Anatomy of the posterior region of the Neck, see under ''Spine and Spinal Cord," page 526. SURGICAL ANATOMY OF THE LARYNX. Situation. — Lies in upper forepart of median aspect of neck — below tongue and hyoid bone — in front of pharynx — and between large vessels of neck. Relations. — Anteriorly, skin and cervical fascia; — Posteriorly, sepa- rated from fourth, tiflh, and sixth cervical vertebra? and prevertebral muscles by laryngeal portion of pharynx; — Laterally, sternohyoid; sternothyroid; thyrohvoid; superior end of lateral lobe of thvroid; portion of inferior con- strictor;— Superiorly, opens into pharynx; — Inferiorly, opens into trachea. Arteries. — Superior laryngeal branch of superior thyroid; inferior laryn- geal branch of inferior thyroid; dorsahs linguas of lingual. Veins. — Empty into superior, middle, and inferior thyroid veins. Lymphatics. — Drain into carctid glands and into glands in front of criciithyroid membrane, or into inferior laryngeal glands. Nerves. — From superior lar\-ngeal and recurrent laryngeal branches of the pneumogastric, and from the sympathetic. SURFACE LANDMARKS AND GENERAL SURGICAL CONSIDERATIONS. The contour of the thyroid and cricoid cartilages, with the intervening cricothyroid membrane, can generally be outlined in the average neck — with the thyrohyoid membrane extending upward from the upper border of the thyroid cartilages, and the rings of the trachea extending downward from the cricoid cartilage. The height of the cricothyroid space is about i cm. (nearly h inch) in the average adult. The internal (sensory) branch of the superior laryngeal ner\e pierces the thyrohyoid membrane above the superior laryngeal artery. The externa! ijranch (principally motor) of the superior laryngeal is distributed to the cricothyroid muscle and to the mucous membrane. The inferirr or recurrent laryngeal (motor) runs up in the groove between the trachea and esophagus, and reaches the larynx below the inferior constrictor and just behind the cricothyroid articulation, where it divides into anterior and postericr branches. The cricothyroid artery (branch of superior thyroid) crosses transversely 542 OPERATIONS UPON THE NECK. over the upper part of the cricothyroid membrane, and is the chief artery complicating larvngotomv. Small venous trunks cross the laryngeal region irregularly, chieliv emptying into the superior thyroid vein. INSTRUMENTS. Scalpels; scissors, sharp anrl likmt, i urved and straight; forceps; dis- secting, toothed, and artery-clani]); tenacula; wound hooks; laryngotomy ,<**s F'K- 336.~PosiTioN OF Incisions for Opening the Larvngo-tracheal Tract :— thyroid laryngolomy (subhyoid pharyngotomy) ; B, Thyroloiny ; C. Laryngotomy ; D.Hi otomy; E, Low tracheotomy. The corresponding skin incisions are longer than tht_- inc the laryngo-tracheal tract. tubes; tampon cannulae; artificial larynx; larynfjeal forceps; artificial feather for cleansintr tube; grooved director; mouth-^ag; tongue forceps; tongue depressor; wound retractors; dilator for laryngeal wound; laryngeal aspirator; spatuLx; needles, curved and straight; needle-holder; sutures and ligatures,. LARVNGOTOMY. 543 silk and gut; traction-ligatures; O'Dwyer's intubation set; shield fur mouth and eyes of operator; tracheotomy tubes. LARYNGOTOMY. Description. — Laryngotomy, or Infrathyroid Laryngotomy, consists in the o[)ening of the larynx through the cricothyroid membrane. The super- ficial incision is made in the median line of the neck, and the opening into the laryn.x is made transversely through the cricothyroid membrane, followed by the introduction of a special laryngotomy tube flattened from above down- ward so as to present an oval opening. Preparation. — The neck is shaved, if covered by hair. F'g- 337-— Laryngoto.mv:— A, Sternohyoid muscle; B. Sternothyroid muscle; C, Thyrohyoid muscle ; D, Cricothyroid muscle ; E, Thyroid cartilage ; F, Cricoid cartilage ; G, Cricothyroid artery ; H . Double tenaculum steadying thyroid cartilage ; I. Sharp-pointed knife completing incision of crico- thyroid membrane; J, Toothed forceps everting lip of laryngeal incision. Position. — Patient supine, shoulders supported and head thrown back, so as to round out and tense the laryngeal region. Landmarks. — Thyroid and cricoid cartilages and cricothyroid space. Incision. — A vertical incision is made exactly in the median line, from ^ to 4 cm. (about i| to i^ inches) long — beginning over the lower part of the thyroid cartilage, passing over the cricothyroid membrane, and ending at the lower border or just below the cricoid cartilage — while the larynx is steadied in the middle line between the left thumb and forefinger. (See Fig. 336, C.) Operation. — (1) Incise the skin, superficial fascia, platysma, and cervical fascia — dividing between ligatures any veins encountered. (2) Recognize the interval lietwcen the sternothyroid and cricothyroid muscles and open up this interval by blunt dissection, thus exposing the cricothyroid membrane (see Fig. 337). Retract the tissues laterally. Divide the cricothyroid artery 544 OPERATIONS UPON THE NECK. between two ligatures. (3) Steady the larynx b\' means of left thumb and forefinger and incise the cricothyroid membrane laterally, carefully stabbing, with a narrow, sharp knife, into the lumen at one side and incising trans- versely just above the cricoid cartilage in the act of withdrawing the knife. (4) Seize and evert one lip of the laryngeal wound with toothed forceps, and, parting the lips of the wound by a special laryngeal dilator, insert the oval laryngeal tube into the larynx, so that its greatest width corresponds with the length of the wound. Attach tube to the neck by means of a band. (5) If the superficial wound be long, its ends may be sutured, leaving less of an area for granulation. (6) A dressing should be applied between the flange of the tube and the neck. Comment. — Stab well into the lumen of the larynx (while guarding against stabbing too far), so as to avoid pushing the mucous lining of the larynx ahead of the knife and really not entering the lumen at all. Cut very near the cricoid cartilage, especially if compelled to operate hastily — as the cricothyroid artery runs nearer the lower border of the thyroid cartilage. Sometimes the cricothyroid membrane is incised vertically, just as the superficial wound — additional room being gotten by dividing the cricoid cartilage in the same line. The above is, however, preferable. Laryngotomy and Tracheotomy compared; — Laryngotomy is rapidly and easily performed — it is the operation where great haste is necessary and few instruments and limited assistance are at hand. It is inapplicable under thirteen vears (the space being too narrow). It is more difficult to insert a proper larvngotomy tube than a tracheotomy tube. The vocal cords are nearer and are more apt to be injured by wearing a laryngotomy tube. Laryn- gotomv is not applicable where a tube must be worn for some time. In Larvnifotcmv the cricothvroid arterv must be avoided or tied. THYROTOMY. Description. — Division of the thyroid cartilage, partially or completely, in the median line, in order to expose the cavity of the larynx. Resorted to for the removal of foreign bodies and growths. X'ocalization is apt to be permanentlv involved. The operation is very similar to Laryngotomy. Preparation. — As in Laryngotomy. In addition, a preliminary Trache- otomy is dt)ne (preferably several days in advance). (A preliminary laryngo- tomy may be done, but is less satisfactory.) The trachea should be jilugged, or a tampon cannula used after the tracheotomy. Position. — As in Laryngotomy. Landmarks. — Hyoid bone, thyrohyoid membrane, thyroid cartilage, cricothvroid membrane and cricoid cartilage. Incision. — .\ vertical incision is made exactly in the median line, henin- ning at the lower border of the hyoid bone and ending over the cricoid t arlilage — stead ving the larynx between the left thumb and forefinger (see Fig. 336, B). Operation. — (1) Incise skin, superficial fascia, platysma, and cervical fascia — encountering the terminal branches of the superficial cervical and inframaxillary nerves, the communicating branches lietween the anterior jugular veins, and some small superficial arterial and venous branches. (2) Open up the connective-tissue interval between the sternothyroid and crico- thyroid muscles by blunt dissection, exposing the thyroid cartilage and thyro- hyoid and cricothyroid membranes. (3) Divide tlie thyroid cartilage care- fully and exactly in the median line, by cutting from above downward and from without inward, with a sharp, fairly heavy, rounded knife. If the upper COMPLETE LARYNGECTOMY. 54S niarffin of the thyroid cartilage can be left uncut, better subsequent adjust- ment is obtained — but if necessary, not only the entire thyroid may be divided but as much of the thyrohyoid and cricothyroid membranes as indicated. This manner of division is safer than inserting the point of a knife below the thyroid and cutting upward from within. In calcified cartilages a small saw may be necessary. (4) The two ala; of the thyroid cartilage are now drawn aside with small, blunt hooks, exposing the interior of the laryn.x and enabling the special object of the operation to be carried out. If the ala; cannot be separated sufficiently for the object sought, divide the thyrohyoid or crico- thyroid membranes, or both, transversely near their cartilages. (5) Having accomplished the object of the operation, the severed borders of the thyroid are united by chromic catgut — (and the margins of membranes if cut). The external wound is left open in the center, having been closed at the ends. Temporary drainage is used. The tracheotomy tube is retained for several da vs. COMPLETE LARYNGECTOMY. Description. — Excision of the entire larvnx. Its removal may or may not l)c I'ollowed by the substitution of an arliticiul larynx. Generally resorted to f(]r malignant disease. Preparation. — As for Laryngotomy. In addition, a preliminary trache- otomy should be done ten days or one week in advance. Some form of tampon cannula should be inserted into the tracheotomy wound just before the major operation. Position. — Patient supine, shoulders elevated, head thrown back, neck prominent over a cushion or sand-bag. Surgeon to patient's right. Assistant opposite surgeon. Landmarks. — Hyoid bone, thyrohyoid space, larynx, cricoid cartilage and upper tracheal rings, sternomastoid muscles. Incision. — (i) Vertical incision, exactly in the median line, extending from the center of the thyrohyoid membrane to the second or third tracheal rings; — (2) Transverse incision, carried across at upper limit of vertical incision, passing from one sternomastind muscle to the opposite one. (See Fig. 343, B.) Operation. — (1) Having carried the above incisions through skin, superfi- cial fascia, platysma, and cervical fascia; ligated the superficial vessels; and encountered branches of the superficial cervical and inframaxillary nerves, the two rectangular flaps thus outlined are turned outward and downward, exposing the anterior margins of the sternomastoids, thyroid and cricoid cartilages, and trachea. (2) Divide, between double ligatures, the superior thyroid arteries, as they lie at the posterior border of the thyrohyoid muscles, near the superior margin of the thyroid cartilage. Similarly ligate and divide the inferior thvroid arteries at the posterior border of the sternothyroids, at the lower etlge of the larynx. The thyroid veins encountered are similarly dealt with. (3) The cricothyroid, sternothyroid, and thyrohyoid of one side, together with the adjacent soft parts, are retracted outward, while the larynx is retracted to the opposite side. (4) The inferior constrictor muscle of that side is now severed from the thyroid cartilage by a curved blunt dissector and scissors — the larynx is drawn forward and the tissues between the cut inferior constrictor and the ends of the superior thyroid arteries are divided — the superior laryngeal nerve is cut — and the thyroid gland is retracted out of the way. (5) The larynx is now drawn to the opposite (freed) side and 35 546 OPERATIONS UPON THE NECK. the same process of separation is repeated ujjon the second side. (6) Sever the thyrohyoid membrane and the thyrohyoid ligaments — divide the extra- laryngeal attachments of the epiglottis while putting the parts on the stretch (thyro-epiglottic ligament, hyo-epiglottic ligament, glosso-epiglottic folds, and aryteno-epiglottic folds). (7) Draw the larynx forward and complete the division of the connections of the larynx to the pharynx and esophagus, from side to side and from above downward, guarding the esophagus from injury. (8) If the trachea be bound in situ by the preliminarv tracheotomv, it will retain its position when cut — if not. it is to be steadied bv two silk sutures^ and then divided transverselv between the cricoid cartilage and the first ring of the trachea, from behind forward. (9) Secure the upper end of the trachea to the surrounding integument by a few interrupted silk sutures. A deeper la_\'er of silver wire or silk sutures may be put in to secure the deeper part of the trachea to the deeper surrounding parts — and another layer uniting the mucous membrane of the trachea to the skin, (lo) Suture the transverse part of the wound, packing the rest. The tampon cannula is to be left in situ for one or two days, then replaced by the ordinary tracheotomy tube. The patient is fed through a stomach-tube at first. An artificial larynx is to be inserted in from four to six weeks, if one be used. Comment. — (a) Some surgeons do the tracheotomv only at the time of the main ojieration. (b) All bleeding vessels are ligated or clamped as en- countered, (c) It may be necessary to divide the isthmus of the thyroid gland between ligatures, (d) All enlarged glands encountered are to be removed, (e) Hug the cartilages throughout the entire operation, (f) The larynx mav be detached from below upward, dividing transversely below the cricoid cartilage, (g) If in doubt as to the needs of removing the entire larynx, split the larynx and thoroughly examine, (h) The epiglottis is best removed — some leave it — it may interfere with the artificial larynx — or become the seat of returning disease, (i) The cricoid cartilage is best away. Some prefer to leave it as a support to an artificial larynx. Others think its retention interferes with swallowing;. PARTIAL LARYNGECTOMY. Description. — Ivxcision of one-half (in the middle line) of the larynx. Indicated in the partial involvement of the organ. Preparation. — Same as for Complete Laryngectomy, including the pre- liminarv tracheotomv. Position — Landmarks. — Same as in the complete operation. Incision. — Same as for total Laryngectomy, except that the transverse portion of the incision is made onlv upon one side. (See Fig. 343, B.) Operation. — Same, practically, as for the total excision, except that the thyroid cartilage is divided down its center and the involved half removed after being separated from its soft parts by carefully hugging the cartilage during the freeing. The superior cornu of the thyroid cartilage is divided at its base by forceps. The epiglottis is left, the aryteno-epiglottic fold of the involved side being severed near Wrisberg's cartilage — though one-half of the epiglottis mav be left and one-half removed. The cricoid cartilage may be left. The after-treatment is practically the same as for the total removal, except briefer. IXTL'BATION OF THE LARVXX. 547 INTUBATION OF THE LARYNX. O'DWVERS OPERATION. Description. — The introduction, by a special instrument (introductor). into the larynx of a special metallic tube — which, upon the accomplishment of the object, after a shorter or longer time, is removed by another form of special instrument (extractor). Intubation is used in cases of impeded breathing arising in the larynx or upper trachea from causes other than foreign body. Operation. — (i) Supposing the case to be a child — the nurse sits upright in a straight-back chair — the child, enveloped in a sheet or large bath-towel, thus pinioning its arms, is held upright in the nurse's right lap, her right arm passing forward around the child's shoulders and chest, her left forward around its hands and abdomen — its legs are placed between her knees — its head is thrown slightly backward over the nurse's right shoulder, and is steadied by an assistant standing behind the nurse — the child's mouth is gagged on the left side and the gag held by the assistant's left hand. (2) The surgeon, standing in front of the child (his mouth, eyes, and nose pro- tected from the cough, etc., of the patient, in contagious cases) — inserts his left index into the throat until in contact with the epiglottis, which he elevates by hooking forward and presses against the root of the tongue with the tip of this finger, at the same time also drawing the base of the tongue slightly forward. The tube, with its contained obturator attached to the introductor, is passed into the mouth parallel with the left index as a guide (the handle of the instrument, at this stage, being about parallel with the chest-wall) and is directed in the necessary curve by elevating the handle of the introductor — and is guided through the rima glottidis by the tip of the finger which has drawn the epiglottis forward. As soon as the instrument is felt to be engaged within the larynx, the left index-finger is shifted to the shoulder of the tube and aids in gently pushing it down into place between the cords. The obtu- rator is then detached from the tube by a special mechanical movement, controlled within the handle of the instrument, and is withdrawn together with the introductor. If the safety-thread (which has been jjreviously intro- duced through the eye of the laryngeal tube) be removed, the left index remains in contact with the tube until the thread is withdrawn. The thread is often retained as a means of hasty and easy withdrawal in case of need, and is tied about a tooth or the ear. (3) To withdraw the tube, let the same position of patient, surgeon, assistant, and nurse be assumed as before — similarly draw the epiglottis forward with the left index — and, having similarly guided the beak of the extractor into the lumen of the laryngeal tube, ex]iand the blades of the beak and withdraw the tube. If the thread have been left in silii, the tube may be withdrawn by it. Comment. — Always be ready, in advance, to do an immediate trache- otomy — in the event that intubation cannot be performed, or that tube get into trachea, or that membrane be protruded ahead of the tube and impede trachea and tube. To feed the child while the tube is in the larynx — place it upon its back in the nurse's lap — let its head bend over her knee, lower than its shoulders — feed it fluid food from a bottle on to the roof of its mouth (which is now lower than the floor) — the liquid will then flow over the soft palate on to the posterior pharyngeal wall, and thus nothing pass over the laryngeal tube. Some children, however, feed naturallv without trouble. The shoulders of the laryngeal tube are grasped by the superior or false vocal cords. 548 OPERATIONS UPON THE NECK. OTHER OPERATIONS UPON THE LARYNX. Suprathyroid Laryngotomy. — Same as Subhyoid Pharyngotomy (page 555). Sometimes employed to expose the upper [)art of the larynx and the region of the epiglottis. Laryngo-tracheotomy. — Larynx and trachea are both opened in one continuous median line — where more room is required than furnished by either laryngotomy or trache- otomy alone. Tamponing of Larynx. — The placing of gauze or sponge packing over the entrance of the larynx in order to prevent the entrance of fluids or blood into the air-passages during operations about the oral, pharyngeal, and nasal cavities — a preliminary tracheotomy having been done. Introduction of Artificial Larynx. — After the parts have healed, following a total laryngectomy, an artificial larynx is sometimes inserted through the wound in the neck — a mechanical contrivance having a longer tracheal tube which fits into the trachea, a shorter pharyngeal speaking-tube, with its vibrating ap])aratus, which passes up into the site occupied formerly by the larynx, and an external protected opening occupving the wound in the neck. Operation for the Removal of Foreign Bodies. — Foreign bodies are removed either bv means of instruments introduced into the larynx through the rima glottidis by way of the mcnith — or by opening the cavity of the larynx from without by means of one of the operations above described. Laryngoscopy. — Examination of the larynx by means of a laryngoscopic mirror introduced through the mouth. II. THE TRACHEA. SURGICAL ANATOMY. Situation. — The trachea extends from lower border of fifth cervical vertebra above, where it is continuous with the larynx, to fourth or fifth dorsal vertebra below, where it bifurcates into right and left bronchi. Its length is from 10 to 13 cm. (4 to 5 inches) — its width from about 2 to 2.5 cm. (J to I inch). It lies in a bed of lax connecti\e tissue. Relations. — (a) Cervical portion, — anteriorly ; skin ; superficial cervical fascia; anterior jugular veins; communicating l)ranch between anterior jugular veins; inferior thyroid veins; thyroidea ima artery (when present); sternohyoid and sternothyroid muscles, separated by deep cervical fascia, and partly overlapping sides of trachea; isthmus of thyroid gland; thymus gland (or its remains). Posteriorly; esophagus. Laterally; lateral lobes of thyroid gland (especially on left); inferior thyroid arteries; recurrent laryngeal nerves; sheath of common carotid, internal jugular and pneumo- gastric. (b) Thoracic portion, — anteriorly; sternum; remains of thymus; origins of sternohyoid and sternothyroid muscles; left innominate vein; transverse arch of aorta; innominate artery; left common carotid artery; deep cardiac plexus; left recurrent laryngeal nerve. Posteriorly; esophagus. Laterally; lies between the pleural sacs; pneumogastrics. Arteries. — From inferior thyroid branch of thyroid axis. Veins. — End in thyroid plexus. INSTRUMENTS USED IN OPERATIONS UPON THE TRACHEA. 549 Nerves. — From trunk of pneumogastric; recurrent laryngeal branch of pneumogastric; sympathetic. SURFACE FORJI AND LANDMARKS. The isthmus of the thyroid gland crosses the second and third tracheal rings in the adult. It is generally higher in the child. In an average adult, about 2 cm. (| inch) of additional trachea is drawn up into the neck in full extension of the cervical region. In infants under two years, the thymus gland extends upward nearly or quite to the lower border of the thyroid gland. Small venous trunks cross the tracheal region irregularly, chiefly emptying into the superior thyroid veins. A communicating vein between the superior thyroid veins crosses the trachea above the isthmus of the thyroid gland. Arteria thyroidea ima, when present, passes up from the innominate along the anterior surface of the trachea. The upper portion of the trachea is comparatively superficial. The lower portion is comparatively deep and the vascular relations more com- plicated. GENERAL SURGICAL CONSIDERATIONS. Tracheotomy may be done in three sites — (i) .Above the isthmus of the thyroid gland, or High Tracheotomy (the operation of election, because the trachea is here more accessible), — (2) Below the isthmus, or Low Trache- otomy, — and (3) Behind the isthmus (by its ligature and removal of the isthmus — hardly a separate operation, but generally added to one of the others where more room is required). Structures of the anterior aspect of the neck more or less involved in tracheotomy above the isthmus of the thyroid, — skin; superficial cervical fascia; superficial cervical nerves; inframaxillary nerves; cutaneous arteries; anterior jugulars and communicating vein; deep cervical fascia; superior thyroid arteries and veins; tracheal layer of deep cervical fascia. Structures of the anterior aspect of the neck more or less involved in tracheotomy below the thyroid isthmus, — the superficial structures men- tioned above; communicating branch between the anterior jugular veins larger; sternothyroids closer; inferior thyroid veins larger; arteria thyroidea ima possibly present; innominate artery may cross seventh tracheal ring; trachea deeper and more movable; thymus gland present up to second year. The innominate and common carotid arteries may be in the way of a low tracheotomv. The thymus gland or the isthmus of the thyroid gland is to be incised, between ligatures, if in the way. If the tracheal fascia be not well incised, there is a liability of working between the fascia and trachea rather than in the latter. INSTRUMENTS USED IN OPERATIONS UPON THE TRACHEA. Scalpels; scissors, sharp and blunt, curved and straight; forcejis, dis- secting, toothed, and artery-clamp; tenacula; wound hooks; tracheotomy tubes; tampon cannuls; tracheal forceps; artificial feather for cleansing tube; grooved director; wound retractors; dilator for tracheal wound; tracheal 55° OPERATIONS UrON THE NECK. aspirator; needles, curved and straight; needle-holder; sutures and ligatures; silk and gut; traction ligatures; Langenbeck's double tracheotomy hook, shield for mouth, nose, and eyes of operator. HIGH TRACHEOTOMY. Description. — The opening of the trachea above the isthmus of the thyroid gland. This is the operation of choice, because of the greater acces- sibilitv of the trachea here, and because of the fewer important relations. Preparation. — The neck is to be shaved, if necessary. Position. — Patient supine, at edge of table, shoulders elevated, head thrown back, neck made prominent by being bent well backward over a F'g- 33**.— High Tracheotomy :—.\, Sternohyoid muscle; B, Sternolhyioid muscle; C. Crico- thyroid muscle ; D, Cricoid i-artilage ; E. Tenaculum steadying cricoid cartilage ; F, Trachea, show- ing first, second, and part of third rings ; G, Tracheal branches of superior thyroid artery ; H, Thy- roid gland, with its isthmus retracted from second and third rings, and with branches of superior and inferior thyroid arteries seen upon its surface; I. Sharp-pointed knife completing incision into trachea ; J, Forceps evening lip of tracheal incision, after incision, preparatory to inserting tracheal tube. cushion or sand-bag, chin kept rigidly in median line. Surgeon to the right of patient. Assistant opposite surgeon. Landmarks. — Median line of neck; cricoid cartilage; u])f)er rings of trachea. Incision. — \'ertical incision made exactly in the median line of the neck, extending from the upper border of the cricoid cartilage downward for 2.5 to 4 ( m. (about i to i^ inches) — the skin and trachea being steadied between the left forefinger and thumb on either side. (See Fig. 336, D.) Operation. — (i) Divide skin, subcutaneous fatty areolar tissue, possibly the platysma, and the anterior layer of the cervical fascia, cutting between double ligatures anv communicating branches between the anterior jugular veins. (2) Recognize and open up the cellular interval between the sterno- HIGH TRACHEOTOMY. 551 hyoid and sternothyroid muscles by clean, full-length cuts — the inner border of these muscles being separated by blunt dissection. .\11 separated tissues are retracted laterally. (See Fig. 338.) (3) Divide the deeper cervical fascia overlving the trachea, cutting between double ligatures any veins crossing the line of incision — a small venous ple.xus lies over the isthmus, and a trans- verse branch between the superior thyroids, crossing above the isthmus, sometimes occurs — also abnormal branches of the superior thyroid arteries may cross the upper part of the trachea. The isthmus of the thyroid gland is exposed, and, if in the way, drawn down by a hook. The tracheal rings are felt for bv the finger-tip and exposed to view. The parts are still steadied laterally by the left thumb and forefinger, until the tracheal rings are well in the field. (4) All bleeding having been controlled and the white rings of the trachea being clearly defined, the trachea is to be steadied preparatory to opening. For this purpose, a tenaculum, or, preferably, Langenbeck's double tenaculum hook, is fastened by its point into the antero-inferior aspect of the cricoid cartilage and given to an assistant, who draws the cricoid cartilage upward and forw'ard directly in the median line, gently following the play of the larynx, thus steadying the trachea by making it tense. The tip of the surgeon's left forefinger feels for the upjjer border of the isthmus of the thyroid gland — and, with a sharp, slender knife, held with its cutting- edge upward, a quick, limited stab is made into the median line of the trachea, just above the thyroid isthmus, and the trachea divided upward toward the chin, to but not into the cricoid cartilage, in the act of withdrawing the knife. (5) Gently seize the right lip of the tracheal wound with toothed forceps held in the left hand, and evert it just sufficiently to cause a slight gap between the cut margins — into which gap gently, quickly, but steadily insert the tracheotomy tube — still steadying the cricoid with the tenaculum until the tube is in place. (6) Having seen that all hemorrhage is controlled, the tube is tied in place by bands passing around the neck, a dressing being applied between skin and instrument. The upper and lower ends of a long wound may be united by suture, to lessen the area to be closed by granulation. Comment. — Observe the following, — Incise only in the median line; See and feel bare tracheal rings before opening trachea; Be sure the opening is made into the trachea, and not into the surrounding areolar tissue. If possible, control all bleeding before incising the trachea — although often venous hemorrhage, otherwise difficult to stop, will cease as soon as air enters the lungs freely through the tracheal wound. Where the thyroid isthmus encroaches upon the field, draw it down with a hook or special retractor. Where the tissues of the neck are very thick, outward retraction by thread or instrument retractors aids in exposing the trachea and keeping the bottom of the wound freer from blood. It is easier to insert the tube if the neck be straightened just before everting the lip of the tracheal wound, to relax the tension of the structures. The lips of the tracheal wound may be held apart by a tracheal dilator while the tube is being inserted, or bv two tenacula. Modification. — Where it is found that the isthmus of the thyroid gland encroaches too much upon the site of operation to avoid it — or in those cases in which it is elected to perform tracheotomy beneath the isthmus — having incised and .separated the tissues down to the isthmus in the usual way, cut vertically directly through the center of the isthmus — immediately seize each cut half with clamp-forceps and allow the clamped ends to drop away from the trachea without any special effort to further dissect or retract them from 552 OPERATIONS LP().\ THE NECK. the trachea unless the opening be encroachefl upon. These cut portions are sulisequentlv gut ligatured. If time allow, the isthmus mav be doubly ligated in situ and divided between these ligatures. Modification. — Bose's Bloodless Method of Tracheotomy, — Make a median vertical incision from the middle of the thyroid cartilage downward for 4 to 5 cm. (about i^ to 2 inches) — the soft parts are retracted laterallv — incision is made through the deep layer of the cervical fascia along the upper border of the cricoid cartilage, covering the trachea and binding down the thyroid isthmus — this fascia is detached by blunt dissection and retracted downward by a special hook, carrying the isthmus and vascular supply covering the front of the trachea. The trachea being thus bared, the opera- tion is completed as above. LOW TRACHEOTOMY. Description. — Inferior or Low Tracheotomy consists in the opening of the trachea below the thyroid isthmus. The trachea is much deeper here and its relations much more important — and subsequent wound complications more serious. Preparation — Position. — .\s in High Tracheotomy. Landmarks. — Median line of neck; cricoid cartilage; rings of the trachea, recognizing the upper ones, if possible, so as to determine the site of the thyroid isthmus over the second and third tracheal rings. Incision. — \'ertical incision is made e.xactly in the middle line of the neck, extending from the lower border of the cricoid cartilage downward to within 2 cm. (about ^ inch) of the sternal notch — while the trachea is steadied by tlie left forefinger and thumb on either side. (See Fig. 336, E.) Operation. — (1) Divide skin, subcutaneous fatty areolar tissue, anterior layer of the cervical fascia, cutting between douljle ligatures communicating veins crossing between the anterior jugulars. (2) Having incised the connec- tive tissue, thicker here than in the high operation, expose and separate the inner borders of the sternothvroids and sternohvoids. (3) Incise the deeper cervical fascia, also thicker here than in the high operation, and divide between double ligatures the communicating veins between the inferior thyroids, and whatever other vessels may be encountered, including the thyroidea ima artery, if present — retracting all tissues laterally. (4) The trachea is brought within sight and touch — hemorrhage is controlled by pressure forceps — the trachea is caught by Langenbeck's double tenaculum hook, or an ordinary tenaculum, and lifted upward and forward — the thyroid isthmus being re- tracted upward if necessary — and a sharp, slender knife is thrust with a con- trolled stab-movement into the trachea and made to cut through three or four rings in an upward direction as it is withdrawn. (5) The tracheotomy tube (which must have a deeper curve than for the high operation) is inserted as in the higher operation. (6) The treatment of the tube and wound are the same as in the high operation. OTHER OPERATIONS UPON THE TRACHEA. Tracheo-laryngotomy. - .\n opening, bv median incision, invol\ing both the up]ier rings of the trachea and the cricothvroid membrane of the larvnx — performed where more room is required than furnished by either operation alone. INSTRUMENTS USED IX OPERATIONS UPON THE PHARYNX. 553 Taxnponing of Trachea. — The use nf some form of packing, or some form of inflation, applied around the stem of an ordinary tracheotomy tube, or a special form of tampon cannula, whereby fluids and blood are prevented from entering the lungs during operations upon the oral, nasal, and pharyngeal cavities. Operation for the Removal of Foreign Bodies. — Foreign bodies may be remo\eil l.iy means of special forceps introduced through one of the tracheotomy wounds above described. Tracheoscopy. — E.xamination of the upper part of the trachea by means of the laryngo- scopic mirror. Thoracic Tracheotomy. — Opening of the trachea in the posterior mediastinum (see page 593). III. THE PHARYNX. SURGICAL ANATOMY OF THE PHARYNX. Situation, Extent, and Structure. — A conical, musculo membranous sac (consisting of na.sal and buccal ])ortions) placed base upward, ape.x down- ward, behind the nose, mouth, and larvn.x. It e.xtends downward from base of skull to lower border of cricoid cartilage in front, and fifth (or between fifth and sixth) cervical vertebra behind. It is composed of three coats — Inner Coat, of mucous membrane: — Middle Coat, of pharyngeal aponeurosis (thickest above, where muscles are thinnest; and thinnest below, where muscles are thickest) : — Outer Coat, of muscles (inferior, middle, and superior constrictors, reinforced by stylopharyngeus, palatopharyngeus and salpingo- pharyngeus). Relations and Boundaries. — Superiorly, body of sphenoid; basilar process of occipital: — Interiorly, continuous with esophagus opposite fifth (or between fifth and sixth) cervical vertebra: — Anteriorly (incomplete), attached, from above downward, to internal ptervgoid plate, ptervgomaxillary ligament, inferior maxilla, tongue, hyoid bone, thyroid cartilage, cricoid cartilage: — Posteriorly, attached, by lax connective tissue, to prevertebral fascia, longi colli, and recti capitis antici majores muscles, and to cervical vertebral column : — Laterally, attached to styloid process and its muscles (styloglossus, stylohyoid, and stylopharyngeus); and in relation with common carotid, internal carotid, and ascending pharyngeal arteries, internal jugular vein, glossopharyngeal, yjneumogastric, hypoglossal, and sympathetic nerves. internal pterygoid muscle (above) and lateral lobes of thyroid gland. Openings Into. — Two posterior nares; two eustachian tubes; mouth; larynx; esophagus. INSTRUMENTS USED IN OPERATIONS UPON THE PHARYNX. Scalpels; scissors; forceps, dissecting, toothed and arterv-clamp; re- tractors; probe; grooved director; tenacula; wound hooks; mouth-gag; tongue forceps; tongue depressor; needles; needle-holder; ligatures and sutures; aneurism-needle. 554 OPERATIONS UPON THE NECK. MEDIAN PHARYNGOTOMY FV MEDIAN VKRTICAL INCISION THROCGH THE MDCTH. Description. — Incision of the posterior pharyngeal wall in the median line, through the mouth. Applicable to cases of retropharyngeal abscess of small size and due to temporary cause (e. g., an acute abscess). Preparation. — Mouth cleansed by frequent antiseptic washings. Position. — Patient on side, head elevated and turned to one side, with mouih dependent. Surgeon in front of patient. Landmarks. — Median line of the prevertebral region ; contour of involved region. Operation. — The mouth is gagged and so directed that pus or other fluid will flow out. .\ straight, sharp bistoury, protected by wTapping except for about i cm. (about ^ inch) at its point, is directed in toward the center of the posterior pharyngeal wall, or toward the most fluctuating point, guided by the left forefinger, which marks the site — an incision about i cm. (about i inch) long is then made vertically in the median line, either upward or downward. The incised wound is not closed by suture, but allowed to drain. LATERAL PHARYNGOTOMY BY rCRVED LATERAL INCISION IHR(ll(.H IIIl: M- CK — KOCHEUS OPERATION. Description. — Incision of the pharvn.x through the lateral wall of the neck — for the exposure of the lateral wall of the pharynx, together with the tonsil, base of tongue, and retrcpharyngeal sj)ace. Applicable to cases requiring the fullest exposure cf the pharynx. Preparation. — Shaving of the neck, if necessary. Cleansing of the throat with antiseptic washes. Position. — Patient supine, shoulders elevated, neck |)romincnt, head to opposite side. Surgeon either in frcnt cf or beliind the neck. Assistant o]jposite surgeon. Landmarks. — .\pex of mastoid [irocess; anterior border of sternomastoid muscle; hvoid bone. Incision. — Begins at the anterior border of the apex of the mastoid process — runs in a slight downward curve, with posterior convexity, crossing the anterior border of the sternomastoid about 2 cm. (about J inch) behind the angle of the jaw — ending at the middle of the hvoid bone. (See Fig. 3.39. a'.) Operation. — (i) Divide the skin, superficial fascia, and platysma along the above line — cutting between double ligatures the external jugular, facial, and temporofacial veins. (2) Expose the submaxillary region — dissect out the submaxillary gland and either throw it upward over the border of the inferior maxilla, or extirpate it — dividing the facial artery between two liga- tures — and preserving, if possible, the auricularis magnus and cervicofacial nerves. (3) The lingual, ascending pharyngeal, and ascending palatine arteries are tied, if necessary, close to their origin — or the external carotid itself. (4) Retract backward the great cervical vessels, with the pneumo- gastric and spinal acces.sory nerves — draw the hypoglossal nerve upward — the superior laryngeal nerve and superior thyroid artery remaining under the lower margin of the wound. (5) Work up along the internal surface of the inferior ma.xilla and of the internal pterygoid in the direction of the mucous membrane of the pharynx, in order to preserve the muscles lying anteriorly SUBHYOID rHARYXGOTOMV. 555 and connected with the act of swallowing. If the muscles must be sacrificed, so cut them that their innervated ends will be as long as possible — dividing the posterior belly of the digastric and stylohyoid near the hyoid (their supply from the facial entering posteriorly) — the styloglossus near the tongue, avoiding the lingual and glossopharyngeal nerves (unless involved, when they must be divided) lying upon it — the stylopharyngeus near the pharyngeal insertion — and the hy< glossus and mylohyoid, to the extent indicated, near their insertion into the hyoid. (6) The wall of the pharynx will now be exposed, the superior constrictor lying above and the inferior constrictor below. Having well retracted the sur- rounding parts and having incised the con- strictors, forming the lateral boundary of the pharynx, its interior is exposed. (7) Having accomplished the object of the operation, in clos- ing the wound suture up the pharyngeal wall as completely as pos sible, in so far as the mucous membrane is concerned — leaving the center of the outer wound unsutured and packed down to the mu- cous membrane with gauze, to provide for drainage both from pos- sible leakage from the mouth and from the fluids of the wound — the ends only of the outer wound being closed bv suture. Comment. — If a part of the wall of the pharynx be removed, the operation becomes a partial pharyngectomy. Compare this operation with that for exposure of the tonsils through the neck, page 565. Fig. 339. — Incisions E.xposing Pharyngo-esophaceal Re- gion: — .-V, Cun-ed lateral incision for lateral pharyngotomy. and for exposure of tonsil, base of tongue, and retropharyngeal space I Kocher's operation): B. Lateral cervical incision for exposing the retropharyngeal space (Chiene's operation); '^ ' ' vical esophagotorny. SUBHYOID PHARYNGOTOMY BY TR.\XSYERSE ClR\i:n INCISION THROIGII THE NECK. Description. — Subhyoid Pharyngotomy, or Suprathyroid Laryngotomy, consists in opening the phar3'nx through the thyrohyoid membrane, just below the hyoid bone. Chiefly done to expose the entrance of the larynx for the purpose of removing foreign bodies or growths from the upper air- passages, or for abscesses at base of epiglottis. Preparation. — As for Lateral Pharyngotomy. Position. — Patient supine, shoulders elevated, head thrown back, neck [ininiinent, resting upon a cushion or sand-bag. Surgeon on patient's right or left. Assistant opposite. 5S6 OPERATIONS UPON THE NECK. Landmarks. — Hyoid bone, upper border of thyroid cartilage. Incision. — Transverse curved incision along the lower border of the body and greater cornua of the hyoid bone. In very thick necks a vertical incision may have to be added to this. Operation. — (i) Having incised the skin, superficial cervical fascia, and platysma, divide between double ligatures the anterior jugular veins and their branches. Some branches of the superficial cervical and cervicofacial nerves are encountered. The hyoid arteries and veins along the hyoid bone are generally not injured — and the superior thyroid artery is generally avoided, running parallel with the incision. (2) Divide most of the muscles attached to the lower border of the hyoid bone (sternohyoids, omohyoids, and most but not all of the thyrohyoids). (3) The thyrohyoid membrane (its middle and lateral portions) is now exposed — and, together with the subjacent mucous membrane Iving between the base of the tongue and the superior border of the epiglottis, is incised along the inferior border of the hyoid bone, while a finger in the mouth guides the knife — keeping rather near the hyoid bone to avoid the superior laryngeal nerves piercing the lateral parts of the thyrohyoid membrane (because of the importance of preserving the sensi- tiveness, and thereby the expulsive power, of the larvnx). (4) Seize the epiglottis, which projects into the wound, with toothed forceps and draw it forward, when the interior of the larynx and the lowest part of the pharynx will be exposed to view. (5) Having accomplished the object of the operation, suture the mucous membrane throughout — suture the ends of the external wound — and pack with gauze the central portion of the wound down to the sutured mucous membrane. EXPOSURE OF THE RETROPHARYNGEAL SPACE BY L.ATER.^L CERVICAL INCISION ALONG POSTERIOR BORDER OF STERNO- MASTOID MUSCLE— CHIENE'S OPERATION. Description. — The retropharyngeal, or retro-esophageal, prevertebral areolar tissue is opened up — without incising the pharyngeal or esophageal wall. Indicated in cases of retropharyngeal abscesses due to protracted cause (e. g., chronic abscess, generally from tubercular disease of the cervical vertebra^) where drainage is apt to be prolonged; — also in large, acute retro- pharvngeal abscesses, especiallv where jaws can no longer be widely opened. Preparation. — Shave neck, if necessary. Position. — Patient supine, or turned slightly to one side, shoulders elevated, neck prominent, resting upon cushion or sand-bag and turned to one side. Surgeon on side of operation. .Assistant opposite. Landmarks. — Posterior border of the sternomastoid. Incision. — Along the posterior border of the sternomastoid, beginning at the mastoid process and descending as far downward as necessary, de- pendent upon the thickness of the structures of the neck. (See Fig. 339, B.) Operation. — (i) Incise skin and fascia in the above line — ligate super- ficial vessels encountered — avoid the transverse and the descending superficial cervical nerves. (2) Recognize the posterior border of the sternomastoid (which overlaps the scalenus anticus somewhat) and draw it forward — the intermuscular groove between the sternomastoid and the scalenus anticus, in the deep cervical fascia, is thus made evident. (3) Follow with a blunt dissector, closelv along the anterior surface of the scalenus anticus and in the connective-tissue plane between the scalenus behind and the common sheath SURGICAL ANAIOMV OF THE ESOPHAGUS. 557 of the great vessels in front, guarding the spinal accessory nerve beneath the sternomastoid as the dissection passes behind its posterior border. (4) Recognize the outer border of the longus colli muscle as soon as reached, and keep behind this, as well as behind the great vessels — and having passed beneath the longus colli the pre\ertebral areolar tissue of the retropharyngeal space is reached — and the pus thus evacuated through a route behind and comparatively free of important structures. (5) Free drainage is established from the bottom of the wound — only the ends of the original incision being sutured. Comment. — The retropharyngeal space may be also approached by in- cising along the anterior border of the sternomastoid, on the level of t-he laryn.x (Buckhardt's operation) — passing in front of the common sheath of the great vessels — retracting these and the sternomastoid backward, and the thyroid, larynx, trachea, and anterior cervical muscles forward — opening the fascia covering the longus colli and passing, anteriorly to it, transversely across to its inner side into the retropharyngeal or retro-esophageal pre- vertebral areolar tissue. IV. THE ESOPHAGUS. SURGICAL ANATOMY OF THE ESOPHAGUS. Situation and Extent. — A muco-areolar muscular canal, from 23 to 26 cm. (about 9 to 10 inches) long — beginning at lower boundary of pharyn.x, at upper border of cricoid cartilage, opposite fifth cervical vertebra (or between fifth and si.xth), passes down through superior and posterior mediastina along front of spine, lying at first behind left part of the aortic arch, then descending along right side of aorta until it curves forward anterior to and somewhat to left of aorta — to descend through esophageal opening in diaphragm into abdomen, ending in cardiac orifice of stomach, opposite tenth dorsal vertebra (or between tenth and eleventh). Curves of the Esophagus. — The antero-posterirr curves of the esophagus follow those of the vcrtcl)ral column. Laterally, it curves to the left at the root of neck, and at esophageal opening of diaphragm — and is in the middle line at fifth cervical and fifth dorsal vertebra'. Relations. — (a) In the neck : anteriorly, trachea, posterior part of left lateral lobe of thyroid, left recurrent laryngeal ner\e. Posteriorly, spinal column, left longus colli muscle, prevertebral fascia. Right, right common carotid, right recurrent laryngeal nerve. Left, left carotid, left inferior thyroid artery and vein, left subclavian artery, thoracic duct. (The relation- ships are more marked on the left.) (b) In the thorax : anteriorly, lower part of trachea, beginning of left bn nchus, trans\erse arch of aorta, left ccmmnn carotid, left subclavian, posterior surface of pericardium. Posteriorly, spinal column, longi colli muscles, thoracic duct, right inter- costal arteries and veins, left inferior azygos vein, inferior part of thoracic aorta. Laterally, pleura;, pneumi^gastrics (forming plexus guhe below root of lungs, thence left ])neumogastric passes to anterior surface and right pneu- mogastric to posterior surface of esoy)hagus). \'ena azvgos major lies on the right, and descending aorta on left. Arteries. — From inferior thyroid l)ranch of thyroid axis; descending thoracic aorta; gastric branch of ctrliac axis; left inferior phrenic. Veins. — Fmpty into inferior thyroid, azygos, and gastric veins. Lymphatics. — Empty into inferior ccr\'ical and posterior mediastinal glands. SS8 OPERATIONS UPON THE NECK. Nerves. — From recurrent laryngeals, pneumo<;astrics, and sympathetic. (The recurrent laryns^eal branches of the ])neumo,nastric run upward on both sides to the interval between trachea and eso|)ha}fus — the left nerve Iving^ somewhat anterior to the esophagus — the right nerve at some distance from it.) GENERAL SURGICAL CONSIDERATIONS. The narrowest ].)arts of the esophagus are — at its beginning (narrowest) — opposite the fourth dorsal vertebra — at the diaphragm. Distances (in the average adult) — from upper incisor teeth to diaphrag- matic opening, about 37 cm. (about 14^ inches) — from same point to aorta, about 23 cm. (about q inches) — from same point to upper end of esophagus, about 14 cm. (about 5^ inches). The deviation from the median line toward the left, in the cervical jiortion of the esophagus, amounts to about i cm. (about ^ inch). INSTRUMENTS USED IN OPERATIONS UPON THE ESOPHAGUS. Scal])els; scissors, blunt, sharp, straight, curved; forceps, dissecting, toothed, artery-clamj); retractors; probe; grooved director; tenacula; ligature- retractors; needles, straight and curved; needle-holder; ligatures and sutures, silk and gut; mouth-gag; tongue-forceps; esophageal forceps, various; com- bined mouth-gag and tongue depressor; esophageal bougies; blunt bistoury; drainage tubing and material; blunt dissector; wound-hooks; elevators; bristle probang; special foreign-body forceps and devices; stomach-tube; dilating bougies; esophagotomes; bougie with string attachment; tubage set. EXTERNAL CERVICAL ESOPHAGOTOMY. Description. — Incision of the esophagus in the neck — the opening ordinarily being made on the left side, opposite the natural curve of the esophagus, except when the object is more prominent and more easily reached on the right. Generally indicated for the removal of foreign body, and sometimes for tumor and for dilatation of the esophagus. Preparation. — The neck is shaved if necessary. Where the c)|)eration is for foreign bodv, the position of the bodv is sought bv instruments before incision, and the position of the incision regulated, as far as possible, by its situation. Position. — Patient supine, shoulders elevated, neck prominent, upon cushion or sand -bag, head thrown back and turned to opposite side (generally to the right). Surgeon on side of operation — .'\ssistant opposite. Landmarks.— Thyroid and cricoid cartilages; trachea; anterior border of sternoniastoid muscle. Incision. — Straight incision, generally made on the left side, 8 to 10 cm. (about 3 to 4 inches) in length, beginning opposite the upper border of the thyroid cartilage and continuing downward along the anterior border of the sterniimastdid, toward the clavicle, as far as necessary. (See Fig. 33c), C.) Operation. — (1) Incise skin, superficial fascia, and platysma. Ligate, between double ligatures, the communicating veins between the anterior and external jugular veins, and between the anterior jugular and facial, and possibly also the anterior jugular vein. Some branches of the suj)erficial EXTERNAL CERVICAL ESOPHAGOTOMY. 559 cervical nerve will also be cut. (2) Expose the anterior border of the sterno- mastoid and draw it outward — also the sternohyoid and sternothyroid and draw them inward — divide the omohyoid (unless it can be displaced down- ward). (See Fig. 340.) (3) Divide the thyroid fascia — which is deep cervical fascia forming the capsule of the thyroid gland — which is blended externally with the sheath of the large vessels — and which must be divided before the esophagus can be reached. After dividing this fascia, draw the thyroid gland, larynx, and trachea inward and forward — and the common sheath of the large vessels and pneumogastric, together with the descendens noni nerve, outward. (4) Ligate and divide between two ligatures the inferior ihvroid artery as it crosses the longus colli transversely, lying behind the common carotid — also the middle and superior thyroid veins if necessary. Carefully avoid the recurrent laryngeal nerve, ascending in the groove between Fig. 340.— Cervical Esophagotomv ;— A, Sternomastoid muscle; B, Stcrnohyoic Sternolliyroid muscle; D, Omohyoid muscle; E, Trachea; F, Esophagus, showing lips of esophageal wall retracted ; G. Recurrent laryngeal nerve; H. Common carotid; I, Inferior thyroid artery, ligaied ; J. Communicating vein between anterior and exterr.al jugular; K, Thyroid gland, showing superior and inferior thyroid arteries, and superior, middle, and inferior thyroid veins. the trachea and esophagus, drawing it downward and inward if neccssarv. (5) The esophagus, in the form of a red tube, will now appear in the bottom of the wound. Pass a sound or esophageal Vwugie into the esophagus through the mouth, so as to protrude the esophageal wall prominently into the wound. A vertical incision is now made through the lateral or posterolateral aspect of the wall of the esophagus, while steadieii with toothed forceps, carefully avoiding the recurrent laryngeal ner\e. (6) The lips of the wound in the tube are grasped in turn with toothed forceps and a tliread-retractor carried through each lip upon a fully curved needle — thus enabling the wound to be held widely open and the interior brought to view for the purpose of in- sjiection, removal of foreign body, or operation. (7) .At the conclu^'on of the operation, unless contraindicated by nature of operation (generally after the simple removal of foreign bodies), the lips of the esophageal wound should 560 OPERATIONS UPON THE NECK. be sutured with gut. The outside wound is sutured at its ends, lea\iniT the portion opposite the wound in the tube o])en and lightly packed with gauze, until the tube has healed and no longer danger of leakage exists from the esophagus. \\'here indicated, the wounds in the esophagus and in the neck are both left open until the esophageal wall has healed, when the outer wound is aided to granulate as rapidly as possible, or granulating surfaces may be brought together by suture and the process of union hastened. (8) The patient is temporarily fed by bowel at first — then by stomach-tube carefully introduced. Comment. — The wound in the esophageal wall is best closed by two rows of fine catgut sutures — one whipping together the edges of the mucous coat — the other passed a short distance from the margins of the wound, after the manner of a Lembert suture, approximating the connective-tissue coats. CERVICAL ESOPHAGOSTOMY. Description. — The making of an artificial opening in the esophagus through the neck. Generally resorted to below the site of an inoperable stricture, or during the treatment of an operable one, for the purpose, in the former case, of introducing food into the stomach, and, in the latter, of prac- tising mechanical dilatation. Preparation — Position — Landmarks — Incision. — As for Esophago- tomv. Operation. — .\11 the steps in the operation are the same as for Cervical E.sophagotomy, up to the opening of the esophagus. This having been accomplished, the edges of the esophageal wound (the walls of the esophagus) are sutured to or as near to the skin of the external wound as possible — the external incision being then closed up to the margin of the funnel-shaped wound leading into the esophagus. After healing, the patient is fed by an esophageal tube introduced through the cervical wound — or his stricture is systematically dilated through the same channel. (See Figs. 339 and 340.) Comment. — Where it is found that a single seance of dilatation, in the case of esophageal stricture, accomiilishes the object, the esophageal wound is closed at once — and the operation-wound becomes in name, and in all other respects, an Esophagotomy. PARTIAL CERVICAL ESOPHAGECTOMY. Description. — The excision of a portion of the cer\ical esophagus through- out its entire circumference — with the restoration of the severed ends by suturing, if possible — or as a preliminarv to a Cervical Esophagostomy. Generally done for malignant growth of the esophagus. Preparation — Position — Landmarks — Incision. — .\s for Cervical Esophagi itiimv. Operation. — (i) Having exposed the esophagus as in the above opera- tions, this tube is isolated, being separated by blunt dissection upward and downward — from the trachea in front — from the prevertebral areolar tissue behind — from the connective tissue, lateral lobes of the thyroid, recurrent laryngeal nerves, and the great vessels laterally. (2) The involved portion of the esophagus is then excised by transverse division with scissors above and below. (3) If the gap be not too great, and it be otherwise possible, the proximal and distal ends are now sutured by two tiers of chromic gut — OTHER OPERATIONS UPON THE ESOPHAGUS. 561 the first whipping the edges of all the coats of the esophagus together — the second being interrupted Lembert sutures passing through the outer walls of the esophagus a short distance from the lips of the wound in the tube — the suturing being done over an esophageal bougie passed through the mouth and distending the esophagus op])osite the site of suturing. (4) If the ends of the esophagus cannot Ije made to meet, the proximal end is closed, iirst by whipping, then by suturing the outer coats in the Lembert fashion — and the distal end is sutured into the wound in the neck permanently, as for esopha- gostomy, the entire circumference of the distal portion being sutured into the cervical wound (differing in this respect from the Cervical Esophagostomv above described, where only the lips of the lateral wound in the esophagus are stitched into the cervical wound). (5) The external wound is left open in either case — temporarily in the first instance — permanently in the second. Figs. 339 and 340 illustrate some common features.) INTRODUCTION OF ESOPHAGEAL BOUGIE. Description. — (i> Seat the ]>atient upright, preferably in a chair — head thrown back, and slightly to side away from surgeon, and steadied in this position by the individual or by an assistant. Gag the mouth, the handle of the gag being upon the patient's left. Place a small, thin napkin upon the tongue, extending well back. Lisert the left index-finger to the base of the tongue, both depressing it and simultaneously drawing it forward, the napkin giving a firmer hold. (2) Upon this left finger as a guide, introduce the lubricated bougie, held between the right index and thumb, straight into the mouth, until its tip reaches the posterior pharyngeal wall — then direct it downward and backward along the esophagus — causing the patient to swallow it as he gags — being guided as to the depth of introduction by the circum- stances of the case and the known distances of the structures from the up])er incisor teeth. (See General Surgical Considerations.) OTHER OPERATIONS UPON THE ESOPHAGUS. Esophagoscopy. — The introduction into the esophagus of a special instrument, elec- trically illuminated, and with or without mirrors (an esophagoscope) — wherebv the lumen of the canal may be examined as it is withdrawn from the stomach to the moutli (after the manner of an urethroscope). Internal Esophagotomy. — The division of the strictured esophagus upon the principle of the strictured urethra — by means of a cutting instrument passed through the narrowed portion upon a guide — or Ijv some special form of esophagotome. Operation for Foreign Bodies in the Esophagus. — Foreign bodies high up in the esophagus can often be seen or felt, and removed with special pharyngeal forceps. Those lower down, out of sight and reach, may still often be removed by special instruments for that purpose, introduced through the mouth. Impacted bodies not removable by instru- ments alone, are removed by instruments introduced, in the majority of cases, through an esophageal wound — generallv a cervical esophagotomv. Foreign bodies very low down ma\' be reached by forcejas or the fingers through the cardiac orifice of the stomach, introduced through a gastrotomv wound. 36 S62 OPERATIONS UPON THE NECK. Direct Dilatation of the Esophagus for Stricture. — The dilating bougies ur instruments of increasing sizes, are passed directly from the mouth through the narrowed esophagus, in the same manner as de- scribed tmder the Introduction of the Esophageal Bougie, the stricture being gradually distended. Direct Divulsion of Esophageal Stricture. — The passage, from the mouth, in quick succession, of increasing sizes of dilators — thus rupturing, in a minor degree, the surrounding contracted tissues. Retrograde Dilatation of the Esophagus for Stricture. — Here the dilating instrument is passeii from below — through a gastrotoniy wound, in cases where but one sitting of the retrograde method is necessary, followed by the immediate closure of the stomach wound, — or through a gas- trostomy wound, where frequent resorts to the method are necessary. Dila- tation may be begun by passage of the instrument from the stomach through the strictured esophagus (as the title indicates) — but is often commenced by causing the patient to swallow, prior to anesthesia, a thread with a split shot attached — this is found in the stomach, and upon it the dilating rubber tubes, or other instruments, arc drawn from the mouth, through the esophagus, out of the stomach wound — ur \ice versa. Retrograde Divulsion of Esophageal Stricture. — The same as Direct Divulsion — e.xcept performed in the reverse direction, through a gastrotomv or gastrostomy wound. Division of Esophageal Stricture by String Friction (Abbe's Opera- tion). — .\ preliminary gastrostomy is done — after recovery from which a small bougie, with attached silk thread, is passed from the mouth into the stom- ach — the ends of the thread are grasped by fingers at the mouth and stomach — the small bougie is then withdrawn — another large enough to gently engage the stricture is introduced — the thread is then drawn back and forth, and the frictioning process, as it passes between the engaged bougie and the esophageal wall, soon causes the engaged bougie to become loose — and it is then similarly replaced by a larger size, until the desired caliber is reached. Sometimes the thread is passed through a cervical esophagostomy wound, instead of through the mouth, and then out of the stomach. When sufficient dilatation has been secured, the gastrostomy wound is closed (and al.so the esophagostomy wound, if one have Ijceii made). Division of Esophageal Stricture by String Friction (Bryant's Operation). — .■\ S|)ecial form of bougie, carrying a thread passed through an opening near its tip and running over a concealed pulley, is passed through the mouth and down the esophagus, until well engaged in the stricture — when by the sawing motion of the thread the stricture is worn down as in the above operation. By this method, gastrostomy may often be dispensed with. Treatment of Esophageal Stricture by Permanent Tubage. — Consists in the passage through the stricture of a funnel-shaped rubber tube, by means of a guide, until the funnel ]>ortion of the tube rests above the stricture — a piece of silk attached to a hole in the tube being also tied to the ear of the patient. The tube remains in situ for ten days at a time, and is then cleansed and replaced — fluid food being taken through it. Applic- able to some otherwise inoperable cases of malignant disease. Tr).\SIIJ.OTOMV. 563 V. THE TONSILS. SURGICAL ANATOMY OF THE TONSILS. Situation. — In the recesses between the anterior pillars of the fauces (the palatoglossi muscles) and the jKisterior pillars of the fauces (the palato- pharyngei muscles) — corresponding, externally, to the angle of the inferior maxilla. Relations. — Externally, inner surface cf superior constrictor — which, together with the pharyngeal aponeurosis, separates the tonsil from the internal carotid and ascending pharyngeal arteries. Internally, free. Anteriorly, [)alatoglossi muscles. Posteriorly, palatopharyngei muscles. Arteries. — Dorsalis lingute cf lingual; ascending palatine of facial; ascending ])harvngeal from e.xternal carotid; tonsillar of facial; descending palatine of internal maxillary; branch from small meningeal of internal maxillary (or from middle meningeal). Veins. — Kmi in the tonsillar plexus, outside of the tonsil. Nerves. — From Meckel's ganglion, and from the glossopharyngeal. GENERAL SURGICAL CONSIDERATIONS. The internal carotid artery lies about 2 cm. (aliout | inch) to the postero- external aspect of the tonsil — and nearer when tortuous — separated from it by the superior constrictor, styloglossus, and stylopharyngeus. The facial arterv, when tortuous, may approach the anterior border of the tonsil. The ascending pharyngeal artery and the glossopharyngeal nerve lie to its outer side. INSTRUMENTS USED IN OPERATIONS UPON THE TONSILS. (I) For (Operations through the Mouth: — l.iistouries, straight and curved, sharp-pointed; Whitehead's combined tongue-depressor and mouth-gag; head-mirror; tonsillotomes; scissors, long-handled, sharp and blunt, straight and curved; forceps, long-handled; artery-clamp forceps, long-handled; tenacula, long-handled; aneurism-needles, long-handled, straight and laterally curved; sponge-holders; needle-holder, long-handled; curved needles; liga- tures; sutures. (2) For Operations through the Neck: — Same as those used for approaching the esophagus, omitting those for use within the esophagus. TONSILLOTOMY. Description. — Incision of the tonsil by means of a knife introduced through the mouth. Indicated in abscess. Preparation. — Mouth is washed frequently with antiseptic solutions. Position. -Patient sits upright in a chair, in a good light — mouth gagged on the opposite side — head thrown back and steadied. Surgeon sits in front — assistant stands behind patient's head, steadying it and gag, and pressing tonsil into the field by fingers in the neck. Operation. — A straight or slightly curved sharp-pointed bistoury, wrapped with jilaster or silk to within a little more than i cm. (about ^ inch) of its point, is made to enter the mouth flatwise (its surfaces looking upward and downward), with the back of the blade toward the cheek — it passes backward horizontally and is made to enter the protruding anterior border of the tonsil 564 OPERATIONS UPON THE NECK. (which border generally extends out beyond the anterior pillar of the fauces) in this position — passes into the gland parallel with its free inner surface — and cuts its way from within outward on to its free aspect, in the act of with- drawal. PARTIAL TONSILLECTOMY THROUGH THE MOUTH. Description. — E-xcisit)n of the free portion of the tonsil (generally hyper- trophicd) — by means of a special instrument (tonsillotome) — or by means of scissors or knife, aided bv forceps. Preparation — Position. — .\s for Tonsillotomy. Operation. — (a) With the Tonsillotome; Having applied a combined mouth-gag and tongue-depressor, introduce the tonsillotome flatwise, with blade drawn back, until the pharynx is reached — then rotate it through a quarter circle, holding its handle parallel with the median line — engage the tonsil in the ring of the instrument, encircling it everywhere to an equal depth, drawing the tonsil out with a tenaculum if necessary — push the blade home firmly and steadily — and withdraw the instrument with the attached portion of the tonsil, (b) With long, curved, blunt scissors; Having similarly applied a combined mouth-gag and tongue-depressor, and supposing the tonsil to be the left one, this tonsil is grasped with long forceps held in the operator's left hand — the scissors, held in the right hand, are introduced closed — and are then opened and made to seize the portion of the tonsil protruding beyond the pillars of the fauces, between the grasp of the forceps and the pillars, and to sever the tonsil with one stroke — which is withdrawn in the hold of the forceps. In operating on the right side, hold the instruments in the opposite hands, (c) With long straight, blunt bistoury; The operation is done as with scissors. COMPLETE TONSILLECTOMY THROUGH THE MOUTH. Description. — The entire tonsil is excised through the mouth — preceded, where difficulty i? anticipated, by a preliminary tracheotomy, a temporary ligation of the common carotid, and, if necessary, by a temporary splitting of the cheek. Indicated in those cases where the growth is limited to the tonsil, or but slightly involves the adjacent portion of the base of the tongue or ])i!lars of the fauces, but in which the tissues of the neck are not infiltrated. Preparation. — .\s for Tonsillotomy. Position. — Patient su])ine, shoulders and head raised, and head turned so as best to expose and illuminate field — Surgeon on side opposite operation — .Assistant opposite surgeon. Positions for the preliminary operations will be determined by those operations. Landmarks. — .Anatomical boundaries (.see Surgical .\natoniy, page 563). Preliminary Operations. — (a) Preliminary tracheotomy, with plugging of the larynx, or the use of a tampon-cannula — performed several days in advance of the operation, preferably (or may be done at the time of the opera- tion), (b) Preliminary temporary ligation of the common carotid — performed at the time of the operation, (c) Preliminary splitting of the cheek, if con- sidered necessary — from the angle of the mouth backward to the masseter, w'ith twisting or gut-ligaturing of both ends of the facial artery — [lerformed at the time of the main operation. Operation. — (i) Having completed the preliminary tracheotomy and the temporary ligation of the common carotid, expose the region of the tonsil COMPLETE TONSILLECTOMY THROUGH THE NECK. 565 by means of a gag on the opposite side, and by splitting of the cheek on the same side, and by drawing the tongue well out of the mouth. The tumor is now dealt with as indicated. (2) Where a movable, encapsulated tumor is encountered, the overlying mucous membrane is incised and the tumor shelled out by means of blunt dissection and the fingers. These simple cases hardly call for such e.xtensive preliminary operations. (3) Where the tumor is immovable, and involves to some extent the fauces and the base of the tongue, — the soft palate is divided in the middle line and thence outward, with scissors — the growth is seized with forceps or tenaculum and drawn toward the median line — while its boundaries are attacked with long, blunt, curved scissors, removing the pillars and tonsillar tumor en masse — together with the entire gland and growth, and as much of the fauces and tongue as necessary, all being deliberately dissected out of their bed — controlling hemorrhage by pressure-forceps, or by twisting or traction upon the tem- porary ligature around the common carotid until the vessels can be controlled. (4) No suturing of the parts about the bed of the tonsil is done. If necessary, the region is packed with gauze, and pressure kept up without and within. (5) The wound of the cheek is neatly repaired by interrupted external and internal sutures, the latter being applied first. The wound of the common carotid is closed. The tracheotomy tube is retained in situ for a few davs. The mouth is frequently rinsed with antiseptic washes. COMPLETE TONSILLECTOMY THROUGH THE NECK. CHEEVER'S OPERATION". Description. — The lateral pharyngeal wall is exposed by means of a careful dissection through the neck, and removed to the indicated extent, together with the tumor, tonsil, and all lymphatic glands and involved tissues adjacent. The operation is at first a cervical pharyngotomy, and becomes a partial pharyngectomy, in proportion to the amount of pharyngeal wall removed. Indicated in large, adherent diffused tumors of the tonsillar region, with lymphatic invoh'ement of the neck. Preparation. — Mouth frequently cleansed with antiseptic washes. Neck and side of face shaved, if necessary. Position. — Patient supine, shoulders elevated, head thrown back and to opposite side, over a cushion or sand-bag, rendering neck prominent — Surgeon on side of operation (or on opposite side leaning over) — Assistant opposite surgeon. Landmarks. — Lobule of ear; anterior border of sternomastoid; hyoid bone; lower border of inferior maxilla and its angle; known anatomical relations of the tonsil. Incision. — (i) Oblique incision begins ojjposite lobule of ear — passes down anterior border of sternomastoid as far as the level of the hyoid bone, or to below the level of the lower border of the tumor. (2) \ second nearly horizontal incision begins from the oblique one, opposite the angle of the jaw, and is continued transversely forward along the lower border of the inferior maxilla. (See Fig. 341, A.) Operation. — (i) These incisions are carried through skin, platysma, and superficial fascia — the external jugular and temporofacial veins are divided between two ligatures — branches of the cervicofacial nerve encoun- tered are guarded as far as possible. (2) The flaps thus marked out are drawn, the one upward and forward, the other downward and forward, and S66 OPERATIONS UPON THE NECK. the dissection carried on deeply in the submaxillary and superior carotid triangles (see Surgical Anatomy of the neck, page 133) — dividing the stylo- hyoid, styloglossus, stylopharyngeus, and probably the digastric — dividing the facial artery and vein between double ligatures — and guarding the hypo- glossal and glossopharyngeal nerves. (3) The parotid gland is displaced upward — the submaxillary gland forward — and the internal carotid artery and internal jugular vein outward — these structures being held out of the way by retraction. (4) The pharyngeal wall is now exposed and opened — and the tonsil removed, together with as much of the pharyngeal wall and adjacent tissues, including cervical glands, as are involved, by scissors or knife. f5) The pharyngeal wall, upon completion of the operation, is sutured as well as possible, and a temporary drain is placed from the pharyngeal wall Fig. 341. — Incisions for Excision of Tonsil and Parotid Gla.nd :~A. Incision for complete ton- sillectomy through the neck (Cheever's operation) ; B, Incision for excision of the parotid gland. thjough the lower part of the cervical wound, the remainder of the outer wound being sutured. Comment. — The operation mav be ai. Anteriorly; overlaps masseter muscle to a variable extent. Posteriorly ; external auditorv meatus; mastoid process; sternomastoid ; posterior belly of digastric (some- what overlapping it). Relations of Surfaces. — Anterior surface; grooved by posterior border of ascending ramus of inferior maxilla — lying, in front of ramus, over masseter muscle — and ])assing, Ijehind ramus, between external and internal pterygoid muscles. External surface ; lobulated and covered by parotid fascia, platysma, and skin, with several Ivmphatic glands resting upon it, as well as facial branches of auricularis magnus nerve. Internal surface ; in relation with styloid process and its muscles, and with internal carotid artery and internal jugular vein — and ])asses deeply into neck by three large processes — (i) Pterygoid process, running forward under ramus of inferior maxilla, between external and internal pterygoids — (2) Glenoid process, running inward under temporoma.xillary articulation into back of glenoid cavity — (3) Carotid process, running inward to surround st3'loid process and i)ass between carotid vessels. Separated from submaxillary gland by stylomaxillary ligament. Arteries. — From the external carotid and from its branches. Veins. — Empty into the external jugular. Lymphatics. — Empty into the superficial and deep cervical glands. Nerves. — Erom carotid plexus; facial; auriculotemporal; auricularis magnus. Structures Passing through the Parotid Gland. — Arteries; external carotid passes deeply into gland from Ijelow and posteriorly, and gives off within the gland — transverse facial, emerging from front of gland — temporal, emerging from above — posterior auricular, emerging from behind — and internal maxillary, passing inward between neck of jaw and internal lateral ligament. Veins; temporomaxillary; connecting vein from temporomaxillary to internal jugular. Nerves ; facial, entering gland at its posterior border, crossing external carotid in its passage forward, and dividing in the gland into — temporofacial division, emerging upward and forward from anterior border of gland — and cervicofacial division, emerging downward and forward from anterior border of gland; branches of auricularis magnus, entering from below to join facial; auriculotemporal branch of inferior maxillary, emerging from upper part of gland. Structures in Proximity to Bed of Parotid Gland. — Internal carotid artery; internal jugular vein; spinal accessory, glossopharyngeal, and pneu- mogastric nerves. Stenson's Duct. — Formed bv branches converging from anterior part of gland — runs transversely forward, crossing masseter muscle, piercing buccinator muscle, and pa.ssing obliquely forward between this muscle and the mucous membrane of the mouth, to open upon the inner aspect of cheek opposite the crown of the second upper molar tooth. Its general course is about a finger's-breadth below the zygoma. The transverse facial artery passes above it, and branches of the facial nerve below it. 568 OPERATIONS UPON THE NECK. Socia Parotidis. — Sometimes exists as a separate gland, lying upon the masseter between the zvgoma and Stenson's duct. INSTRUMENTS USED IN OPERATIONS UPON THE PAROTID GLANDS. See those mentioned under the Esophagus (page 558) and Tonsils (page 563) — especially those used in exposing these structures.' EXCISION OF THE PAROTID GLAND. Description. — The total removal of even the normal parotid gland is very difficult — and when involved by a large, adherent tumor, it is practically impossible to remove the entire gland. When the tumor is small and the combined mass of tumor and gland is movable, the excision is somewhat less difficult. Preparation. — Neck and side of face are shaved, if necessary. Position. — Patient supine, shoulders elevated, neck prominent, head turned to opposite side. Surgeon on side of operation. Assistant opposite surgeon. Landmarks. — Anatomical boundaries of the parotid, and the contour of the tumor. Incision. — Vertical incision beginning midway between mastoid process and condyle of jaw — extending downward parallel with the ascending ramus of the jaw to just below its angle — rounding thence forward just beneath the lower border of the inferior maxilla to the anterior Ixirder of the masseter muscle. Additional room may be gotten by adding a posterior incision to the vertical one opposite the forward curve just described. Also the vertical incision may be continued on downward along the anterior border of the sternomastoid below the point at which the anterior or posterior addition to the vertical incision comes off, as determined by the size and nature of the tumor, (See Fig. 341, B.) Operation. — (1) The flap of integuments marked out by the vertical incision with the forward curve beneath the inferior maxilla, should be raised and turned upward upon the face and stitched to the cheek — and the posterior margin cf the wound drawn well backward. Doubly ligate the superficial veins as encountered, and divide them between the ligatures. (See Fig. 342.) (2) The chief hemorrhage may be controlled in one of three ways, dependent upon the nature and extent of the operation and the judgment of the operator — (a) By the ligation of the vessels as encountered in the steps of the operation — (b) By the early exposure and double ligation of the e.xternal carotid with its division between the ligatures — (c) By the early exposure and temporary ligation of the common carotid. The first method may be resorted to in the simplest cases — the third in the most difficult. (3) The gland and tumor are approached from the inferior and posterior aspect — dissected from their bed and drawn upward and forward and held under traction of vulsella. During this step the external carotid will be brought into view and should be doubly ligated and divided between the ligatures (unless done as a pre- liminary operation — and should be done even if the common carotid have had a temporary ligature thrown around it, as the branches of the external carotid help to hold the gland in its bed). And all arterial and venous branches subsequently encountered entering or leaving the gland, as it is raised from its bed, are to be similarly divided between double ligatures. (4) The treat- exciskjx of the parotid gland. 569 ment of the facial nerve is difficult. If the nerve be involved in large, ad- herent tumor-growth, its sacrifice is almost certain — and, under these circum- stances, it is often deliberately divided. If the tumor be more friable, and danger of leaving infecting material not thereby materially increased, one should endeavor, by means of a blunt dissector and the fingers, to break away overlying and encompassing gland and free the main divisions (temporo- facial and cervicofacial) of the nerve and preserve them intact. In any event, where possible and not contraindicated, an attempt should be made to save the branches of the nerve as long as possible — and, where they have been divided, after the removal of the gland, to gut-suture the proximal and distal ends of those severed (neurorrhaphy). (5) The deeper portions of the gland (pterygoid, glenoid, and carotid lobes) are to be now dissected from Fig. ^2. — Excision of Parotid Gland: — .\. Parotid gland; B, Slenson's duct; C, Masseter . muscle; D, Stylohyoid muscle; E, Sternomastoid muscle; F, E.vternal carotid artery; G, Jugular vein ; H , H ypoglossal nerve ; I , Posterior auricular artery and vein ; J . Temporal artery and vein and auriculotemporal nerve; K, Transverse facial artery and vein. Temporofacial branches of facial nerve are seen emerging upward and forward from the gland— and cervicofacial branches downward and forward. The pterygoid, glenoid, and carotid processes of the gland are hidden from view. L, The flap stitched back to the cheek. their beds chiefly by means of a blunt dissector and curved scissors, witli extreme care — remembering that these processes of the gland rest upon the internal carotid artery and internal jugular vein — and that the pneumo- gastric, glossopharyngeal, spinal accessory, and hypoglossal nerves lie in comparatively close proximity. Injury to the internal jugular vein is the chief danger here. Slight additional room is gained at this difficult stage, in the deep wound between the jaw and the mastoid process, by pushing the jaw well forward and to the opposite side. Where difficulties appear in- surmountable, the deeper lobes, or parts of them, must be cut off and left behind. (6) The tumor is now drawn upward and the facial portion dissected out. (7) Stenson's duct is ligated with chromic gut and severed a short 570 ()PKRATI(.)\S UI'OX THE NECK. distance from the gland — its distal end being touched with the actual cautery, or carbolic acid, and left in situ. (8) All hemorrhage having been controlled, a dependent drainage is temporarily introduced and the remainder of the wound sutured and a firm compress applied. Comment. — The vessels from which hemorrhage is io be expected are the superficial temporal, transverse facial, occipital, posterior auricular, internal maxillary, and external carotid arteries; the external jugular and temporomaxillary veins, and branches between the external and internal jugular veins; and numerous unnamed and enlarged anastomoses. The ramus of the lower jaw may be turned aside in an osteoplastic flap to give more room. Where the tumor of the parotid is encapsulated, the tumor alone may be removed and the gland left intact, except for the incision into the gland for the enucleation of the growth. VII. THE SUBMAXILLARY GLAND AND WHARTON'S DUCT. SURGICAL ANATOMY. Situation. — The submaxillary gland lies below the base and internal surface of the inferior maxilla and above the digastric muscle — occupying the anterior jiart of the suiimaxillary triangle. Relations. — Covered by; .skin; platysma; superficial cervical fascia, facial vein, inframaxillary branches of facial nerve; deep cervical fascia; submaxillary fossa of body of inferior maxilla; lymphatic glands. Rests upon; mylohyoid in front; hyoglossus behind; styloglossus above; and also upon facial artery, mylohyoid branch of inferior dental artery, and mylohyoid branch of inferior dental nerve. Anteriorly ; anterior belly of digastric. Posteriorly ; stylomaxillary ligament, which separates it from parotid gland. Other Relations. — (a) Bulk of submaxillary gland is separated from sublingual gland by mylohyoid muscle, (b) Facial artery grooves posterior and superior aspects of the gland, (c) Lingual branch of fifth and hypo- glossal nerves lie between the gland and hyoglossus muscle. The glosso- pharyngeal nerve lies beneath the hyoglossus muscle, (d) Deep portion of submaxillarv gland passes around posterior free border of mylohyoid muscle on to the hvoglossus muscle. Arteries. — Submaxillary and submental Ijranches of facial, and liranches of lingual. Veins. — Branches corresponding with arteries. Nerves. — From submaxillary ganglion; mylohyoid branch of inferior dental; sympathetic. Wharton's Duct. — Runs inward between mylohyoid and hyoglossus — then between m\'loh}-cid and geniohyoglossus — and finally under mucous membrane of mouth, between geniohyoglossus and sublingual gland — to empty at side of fra,'num linguc'e. It runs between the lingual of fifth and hypoglossal nerves on hyoglossus muscle — passing under lingual nerve at anterior border of hyoglossus, and then lying above it. INSTRUMENTS. See those used in exposing Esophagus and Tonsils. EXCISION OF SLB.MAXILLARV GLAND. 571 Fig. 343. — Position of Incisions for Operations upon the Larynx and Submaxillary AND Thyroid Glands: — A, Excision of submaxillarx' gland; B. Total Iar\ngectomy ; C, Partial thyroidectomy ; D. Total thyroidectomx . EXaSION OF SUBMAXILLARY GLAND. Description. — The submaxillary gland is frequently removed for tumor. Preparation — Position. — As for the Parotid Gland (page 568). Landmarks. — .■Vnatomical boundaries of the gland, and the contour of the tumor. Incision. — Curved incision, with downward convexity, extending from just below median line of inferior ma.xilla to just below angle of inferior maxilla — reaching below to hyoid bone. (See Fig. 343, A.) Operation. — (i) Incise skin, platysma, superficial fascia along above line — di\'iding, between double ligatures, the superficial veins encountered (tributaries of facial, anterior jugular, external jugular). The inframaxillary branches of the facial nerve are encountered crossing the line of incision and are safeguarded as far as possible by retraction. (2) The flap of super- ficial structures thus formed is dissected back — retracted upward toward the face — and either held out of the way, or stitched to the cheek. (3) The special compartment of deep cervical fascia enclosing the submaxillary gland is now incised transversely at its lower part and the gland exposed. The connective tissue attachments of the gland to the hyoid bone and digastric tendon are divided. (4) The gland is now raised from the m}lohyoid and hyoglossus and retracted upward over the lower border of the jaw. (5) The facial artery is tied and cut between two ligatures as soon as it presents in the field. The h\-poglossal nerve is guarded as it lies between the sub- maxillary gland and the lower part of the hyoglossus; and the hngual of the fifth as it lies behind the gland and the upper part of the hyoglossus and styloglossus; (the glossopharyngeal lying beneath the hyoglossus and out of the way). (6) The gland is now drawn downward and outward and separated from the submaxillary fossa of the inferior maxilla by blunt dissection — and its deep portion drawn and dissected out from behind the mylohyoid muscle. (7) Wharton's duct is ligated a short distance from the gland and di\ided — 572 OPERATIONS UPON THE NECK. and its distal end touched with the actual cautery or carbolic acid. (8) Temporary drainage may be used at the dependent angle of the wound — which is elsewhere closed — and a firm compress applied. VIII. THE SUBLINGUAL GLAND AND DUCT OF BAR- THOLIN. SURGICAL ANATOMY. Situation. — The sublingual giant] lies beneath mucous membrane of forepart of mouth, near to frjenum hnguaj, in contact with sublingual fossa of inferior maxilla, and rests upon mylohyoid and genioh^-oglossus muscles. Relations. — Superiorly; mucous membrane of mouth. Inferiorly; mvlohvoid muscle. Anteriorly; sublingual fossa of inferior maxilla; its opposite fellow. Posteriorly; deep part of submaxillary gland (m}-lohyoid separating it from bulk of submaxillary gland) . Internally ; geniohyoglossus, from which lingual nerve and Wharton's duct separate it. Arteries. — Sublingual and submental. Veins. — Correspond with arteries. Nerves. — From gustatory and sympathetic. Duct of Bartholin. — The main duct of the gland — running along with, and opening in common with, Wharton's duct. Ducts of Rivinus. — Eight to twenty secondary ducts — opening on floor of mouth. INSTRUMENTS. See those used in exjKising the Esophagus (page 558) and Tonsils (page 563)- EXCISION OF SXmLINGUAL GLAND THROUGH FLOOR OF MOUTH. Description. — The subHngual gland may require removal for tumor, or for embedded calculus. Preparation. — Frequent antiseptic rinsings of mouth. Position. — Patient supine, shoulders and head elevated, mouth gagged open and tongue held to opposite side — Surgeon on side of operation^ Assistant opposite. Landmarks. — .Anatomical relations of gland, and outline of tumor. Incision. — \ straight incision made in floor of mouth, beginning at the median line, a short distance back of the alveolar margin, and carried obliquely backward and outward, parallel with the alveolar margin, for about 4 cm. (about li inches). Operation. — (i) Having incised mucous membrane of mouth and re- tracted margins of wound, the upper aspect of the gland is e.xposed imme- diatelv beneath it. (2) Having well exposed the upper portion of the gland bv retraction of the margins of the wound, the gland is seized with toothed forceps and drawn upward, while being separated by means of a blunt dis- sector — from the mylohyoid muscle below — from the geniohyoglossus muscle, lingual nerve, and Wharton's duct internally — from its opposite fellow in front and on the opposite side — and from the deep part of the submaxillary gland behind. (3) Having raised it from its bed, its ducts are divided. (4) The mucous membrane is sutured over its site — one end being left open for temporary drainage, if thought necessary. PARTIAL THVROIUECTTOIV. 573 Comment. — The gland may be partially excised (in cystic enlargements) by picking up its upper wall with toothed forceps and cutting out a large piece of the wall and gland with curved scissors. IX. THE THYROID GLAND. SURGICAL ANATOMY. Situation. — The thyroid gland is situated at the upper part of the trachea — consisting of two lateral lobes, which extend from nearly as high as the oblique line on the ala of thyroid cartilage, down to fifth or sixth tracheal ring — and of an isthmus from 0.5 to 2 cm. (about i to J inch) broad, which generally covers the second and third (and sometimes fourth) tracheal rings. Relations. — Anteriorly; covered Viy sternohyoid; sternothyroid; omo- hyoid; and slightly overlapped by anterior border of sternomastoid. Later- ally; sheath of great vessels. Upper part of lateral lobe lies between the sternothyroid and inferior constrictor, the latter separating it from the ala of thyroid cartilage. Posteriorly; embraces trachea and larynx, reaching backward to lower part of pharynx, and, especially on left, to esophagus; recurrent laryngeal nerves; branches of inferior thyroid artery. Middle or Pyramidal Process. — May be developed in connection with the thyroglossal duct — extending upward from the isthmus or left lobe — and connected to the thvrohvoid membrane or Ijodv of the hyoid bone. Suspensory Ligaments of the Thyreoid Gland. — Two ligaments pass from inner and posterior aspect of lobes upward to sides of cricoid cartilage. Recurrent laryngeal nerves lie in contact with their outer surface. Arteries. — Two superior thyroid arteries from external carotid to superior, internal and anterior parts of lateral lobes; two inferior thyroids from thyroid a.xis to external and posterior parts of lateral lobes; and sometimes thyroidea ima from innominate or aorta. Veins. — Two superior and two middle thyroid emptying into internal jugular; two inferior thyroid, emptying into innominate. These veins form a plexus upim the surface of the gland and trachea. Lymphatics. — Empty into thoracic duct and right lymphatic duct. Nerves. — From inferior and middle cervical ganglion. Other Relations. — Recurrent laryngeal ner\es ascend' obliquely to side of trachea, running either behind or in front of inferior thyroid arteries — requiring, therefore, special care to avoid them. Middle cervical ganglion — lies opposite sixth cervical vertebra — generally lying upon or near the inferior thyroid artery. It is necessary to distinguish the deep cervical fascia surrounding the thyroid gland from the capsule of the gland itself. INSTRUMENTS. See those used in exposing the Esophagus (page 558) and Tonsils (page 563)- PARTIAL THYROIDECTOMY BV AN'GULAR INTISION — Korl I KRS OI'ICR.ATION. Description. — Consists in the removal of one lobe of the thyroid gland. The features of the removal of a large goitrous thyroid can be but very 574 OPERATIONS L'I'ON THE NECK. imperfectly illustrated upon a normal thyroid gland — but the steps of the ojieration for the former condition will be given. Preparation. — Neck shaved. Position. — Patient supine, shoulders elevated, neck prominent, head at first slightly to opposite side and then held in median line. Surgeon in front of neck, on side of lobe to be removed (or on opposite side leaning over). Assistant opposite surgeon. Landmarks. — Outline of sternomastoid muscle; upper Ijordcr of thyroid cartilage; anatomical position of thyroid gland; contour of tumor. Incision. — Begins over the prominence of the sternomastoid muscle, on a level with the thyroid cartilage — runs forward nearly transversely, to median line, inclining slightly downward in the crease of the neck — thence passes vertically downward to the suprasternal notch, or, in large tumors, on to the manubrium. (See Fig. 343, C.) Operation. — (1) The above incision passes through skin, superficial fascia, and platysma. (2) In the Horizontal Portion of the Wound; — the anterior jugular and connecting branch between it and the external jugular are divided between double ligatures. (The external jugular lies behind the posterior end of this incision.) Branches of the superficial cervical and inframa.xillary nerves are encountered and are guarded as well as possible by retraction. Externally, the anterior edge of the sternomastoid is exposed, freed, and drawn backward. Internally, the sternohyoid and sternothyroid are exposed, the overlying fascia being displaced upward. (3) In the \'ertical Portion of the Wound; — the cervical fascia between the sternohyoid and sternothyroid is divided. The transverse vein above the suprasternal notch is divided between double ligatures. The inner margins of the two above muscles are freed and partly divided toward their upper ends, with double ligature and division of the vessels encountered. (4) The Outer Capsule of the Goitre now alone intervenes between the Gland; — divide this and separate it from the lateral aspects of the goitre with blunt dissector — dividing between double ligature the superior and inferior accessory veins which may pass from the capsule to the goitre. Displace the outer capsule of the goitre, with the overlying muscles, by passing a finger beneath the goitre from the outer side. (5) Dislocation of the Goitre is now done; which is accomplished, after inserting a finger beneath the goitre, by lifting it forward out of its bed and turning it toward the opposite side — e.xercising care that the vessels, especially the inferior thyroids, are not stretched sufficiently to give way. (6) The Chief Vessels are now Ligated between Double Ligatures; — these are brought into the field in proportion to the dislocation of the tumor from its bed. The inferior thyroid artery and vein are first sought by drawing the tumor upward and forward — the artery is isolated with especial care, as the recurrent laryngeal nerve is in very near relation, either anteriorly or poste- riorly to it — and if any doubt exist, it should be left until the last. The supe- rior thyroid artery and vein are sought above the isthmus, being freed with blunt dissector while the tumor is drawn downward and forward. The middle thyroid vein and the branches of unnamed enlarged vessels are similarly tied and divided. (7) Isolation of the Isthmus; — expose if possible, and divide between double ligatures, a superior and inferior communicating vein, and probably some arteries, at the upper and lower borders of the isthmus. By means of a director, or blunt dissector, the isthmus is separated from the trachea — a stout double ligature is passed beneath, tied on either side, and the isthmus divided between them — while the tumor is further lifted out of its bed and away from the trachea by fingers passed beneath the growth. COMPLETE THYROIDECTOMY. 575 Be especially careful of the recurrent laryngeal nerve in the separation of the posterior portion of the gland from the trachea — for which reason it is well to cut through the posterior portion of the capsule of the gland in order to protect the recurrent laryngeal nerve. (8) The depth of the wound is tem- porarily drained — the major portion of the wound being sutured — and a firm, compressing dressing applied. Comment. — Many additional unnamed vessels are present in large goitres. COMPLETE THYROIDECTOMY BY TRANSVERSE CURYED INCISION — KOCH ER'S OPERATION. Description. — Where both lobes of the thyroid gland are involved, both lobes of the gland are removed — e.xcept that a small portion of the healthy gland tissue is left, if possible, in order to maintain the special function of the gland and thus prevent the cachexia strumipriva which is apt to supervene when the entire thyreoid gland tissue is removed. The full difficulties of the operation are verv imperfectly appreciated in the excision of a normal gland, as compared with those encountered in a large goitrous tumor. Preparation. — Neck shaved. Position. — As for Partial Thyreoidectomy, except that the position of the head is changed from time to time to meet the indications of the steps of the operation. Landmarks. — Those of the [xirtial operation. Incision. — Transverse curved incision, with sliglit downward convexity, is made across the prominence of the tumor, so as to subsequently fall along the cleavage line of the neck — extending laterally over the sternomastoids — and extending further upward and liackward on the side of greater enlarge- ment. (See Fig. 343, D.) Operation. — In all essential features the operation is similar to the one just descrilied, with such modifications as the larger size of the tumor suggests. (I) .\fter having cut through skin, superficial fascia, and platysma, and ligated the superficial vessels, the sternohyoid, sternothyroid, and omohyoid muscles (which are often thinned over the tumor by pressure) are divided transversely over the tumor, internally, and their ends drawn upward and downward, — and the sternomastoids are partly cut through (entirely if neces- sary) from their anterior border and the uncut portions retracted outward. (2) The tumor is thus completely exposed, covered by its outer capsule — and its further removal is accomplished practically as in the partial thvroidectomy. First one lateral lobe and then the other is attacked — dislocated — and its vessels tied — the isthmus isolated and divided between ligatures — the details of the steps and the termination of the operation being similar to the unilateral operation. Comment. — The least amount of transverse division of muscles done the better, as marked retraction and deformity are apt to follow if the muscles do not reunite. All muscles severed, whether wholly or in part, should be repaired with catgut suture at the end of the operation. The transverse curved incision, where the muscles do not have to be divided, makes a better skin scar — and the angular incision leaves a more marked skin scar but does not divide the muscles. Goitres are also treated by Enucleation-resection — by Enucleation — by Exothyropexy (freeing the gland from the capsule and fixing superficially in the wound to granulate and shrink) — by injection — etc. CHAPTER IV. OPERATIONS UPON THE THORAX. I. THE THORACIC WALL AND CONTENTS. SURGICAL ANATOMY. Boundaries of Thorax. — Anteriorly; manubrium, gladiolus, and ensi- form portions of sternum; costal cartilages; muscles of anterior thoracic region; vessels and nerves. Posteriorly; dorsal vertebra;; ribs, from vertebral extremities to angles; muscles of posterior thoracic and spinal regions; vessels and nerves. Laterally; ribs, from costal cartilages to angles; muscles of lateral thoracic regions; clavicles and their muscles; scapulae and their muscles; vessels and nerves. Superiorly, upper opening of thorax. Inferiorly, lower opening of thorax, closed 1)V diaphragm. Contents of Thorax. — Heart and pericardium; lungs and pleurse; trachea and bronchi; esophagus; thoracic vessels and nerves; thoracic duct; superior, anterior, middle, and posterior mediastina; thoracic aspect of diaphragm. (For contents of mediastina. see each mediastinum, pages 587, 588, and 592.) Boundaries of Upper Opening of Thorax. — .\nteriorly; upper border of manubrium sterni. Posteriorly; body of first dorsal vertebra. Laterally; first rib. Dimensions; averages 12.7 cm. (5 inches) transversely, and b.3 cm. (25 inches) antero-posteriorly. Structures Passing through Upper Thoracic Opening. — (i) Centrally; sternohyoid and sternothyroid muscles; thin layer of deep cervical fascia; thymus gland (in infants) or its remains; middle thyroid artery (sometimes); trachea; esophagus; prevertebral fascia; longi colli muscles. (2) Laterally; innominate artery (on right side) ; common carotid and left subclavian arteries (on left); internal mammary and superior intercostal (on both sides); in- nominate and inferior thvToid veins; pneumogastric, cardiac, phrenic, sympa- thetic, left recurrent laryngeal, and anterior branches of first dorsal nerves; apices of lungs and their pleura; thoracic duct (on left); right lymphatic duct (on right). Boundaries of Lower Thoracic Opening. — Antericrly; ensiform car- tilage; cartilages of seventh, eighth, ninth, tenth, and eleventh ribs. Poste- riorly; body of twelfth dorsal vertebra. Laterally; twelfth ribs. Floor; formed bv diaphragm, varving in elevation with resiiiration. Structures Passing through Floor of Thorax: (Diaphragm). — Through .\ortic Opening of Diaphragm; aorta; vena azygos major; thoracic duct; left sympathetic nerve (occasionally). Through Esophageal Opening; esophagus; pneumogastric nerves; esophageal branches of thoracic aorta. Through Caval Opening; vena cava inferior; branches of phrenic nerve. Through Right Crural Opening; greater and lesser right splanchnic nerves; right sympathetic nerve. Through Left Crural Opening; greater and lesser left splanchnic nerves; vena azygos minor; left sympathetic nerve (generally) - (For attachments, relations, and position of diaphragm, see thit structure.) Structures of Thoracic Wall Opposite an Intercostal Space (between costal cartilages and angles of ribs). — Integument; sujierficial fascia, with 576 SURGICAL ANATOMY OF THORAX. 577 superficial arteries, veins, lymphatics, and nerves; special thoracic muscles overlying ribs (dependent upon site) ; deep fascia ; external intercostal muscles ; intermuscular areolar tissue between intercostal muscles, with intercostal arteries, veins, lymphatics, and nerves; internal intercostal muscles; endo- thoracic fascia; subpleural areolar tissue; parietal pleura. (The external intercostal muscles extend from tubercles of ribs, posteriorly, to costal car- tilages, anteriorly, and from the anterior ends of the e.xternal intercostals the external intercostal fascia is continued to the sternum. And beneath this fascia, the internal intercostal muscles intervening, lies the triangularis sterni muscle, e.xtending from second or third costal cartilage above, to seventh costal cartilage below, and to outer end of costal cartilages externally. The internal intercostal muscles extend from the sternum, anteriorly, to the angks of the ribs, posteriorly, and from the posterior ends of the internal intercostals the internal intercostal fascia is continued to the vertebral column. And beneath this fascia, the external intercostal muscles intervening, lie the infra- costales muscles, extending from the angles of the ribs toward the vertebral column.) Structure of Thoracic Wall Opposite a Rib (between costal cartilages and angles of ribs). — Integument; superficial fascia, with superficial arteries, veins, lymphatics, and nerves; special thoracic muscles overlying ribs (de- pendent upon site); deep fascia; external layer of costal periosteum; rib; internal laver of costal periosteum; endothoracic fascia; subpleural areolar tissue; parietal pleura. Relations of Overlying Bones to Chest-wall. — Clavicle; its inner end articulates with supero-external as])ect of manubrium (forming the lateral boundaries of suprasternal notch). The inner third of clavicle passes obliquely over the manubrium, costal cartilage, and inner end of first rib, lying 0.6 to 1.2 cm. (\ to ^ inch) above rib, and passes thence outward to its articulation with acromion, crossing about the center of second rib, from 3.2 to 3.8 cm. (ij to i^ inches) above the rib. Scapula; rests upon postero-external aspect of thorax, from second to eighth ribs. When arms are by side, superior angle is on level with upper border of second rib (opposite interval between first and second dorsal spines), inferior angle being on level with seventh intercostal interval, or sometimes upper border of eighth rib (between seventh and eighth dorsal spine.s), and root of s[)ine on level with interval between third and fourth dorsal spines. Muscles Covering and Forming Thoracic Wall (extracostal, inter- costal, and intracostal muscles). — Anteriorly; pectoralis major; subclavius, internal intercostals; triangularis sterni (and attachments of sternomastoid, sternohyoid, and sternothyroid to manubrium; and attachments of aponeuroses of external oblique, internal oblique, and transversalis abdominis and dia- phragm to ensiform cartilage). Laterally; platysma myoides; pectoralis major; pectoralis minor; latissimus dorsi; serratus magnus; external inter- costals; internal intercostals; diaphragm (and parts or all of some of the more particularly clavicular and scapular muscles — subclavius; deltoid; omo- hyoid; supraspinatus; infraspinatus; subscapularis; teres minor; teres major; trapezius, — and parts of some of the muscles attached to the upper ribs — scalenus amicus and medius, — and parts of some of those attached to the lower ribs — external oblique; internal oblique; transversalis abdominis). Posteriorly: trapezius; latissimus dorsi; quadratus lumborum; serratus magnus; levator anguli scapuli; rhomboideus major and minor; scalenus posticus; serratus posticus superior and inferior; splenius capitis and colli; ilio-costalis; musculus accessorius ad ilio-costalem; cervicalis ascendens; 37 578 OPERATIONS UPON THE THORAX. longissimus dorsi; transversalis colli; trachelomastoid; spinalis diirsi; com- plexus; bi venter cervicis; semispinalis dorsi and colli; multifidus spinas; rotatores spina;; supraspinales; interspinales; intertransversales; levatores costarum; internal intercostals; infracostales; diaphragm. Chief Arteries of Thoracic Wall. — Internal Mammary of thyroid axis, giving off following branches — sternal; anterior intercostal (two in each of five or six upper spaces); perforating (five or six branches to the five or six upper spaces) ; musculophrenic (furnishing anterior intercostal branches for five or six lower spaces). Superior Intercostal of thyroid axis, to first intercostal space. Suprascapular of thyroid axis. From Trans- versalis Colli of thyroid axis — posterior scapular. From Axillary — superior thoracic; acromial thoracic; long thoracic; alar thoracic; subscapular. From Thoracic Aorta — ten or eleven aortic intercostals, giving off anterior and posterior branches — the anterior, or true intercostal arteries, dividing into superior and inferior, supplying each intercostal space from the second to the space below twelfth rib, and anastomosing with anterior intercostals of internal mammary and musculo])lirenic. From Abdc^minal Acrta — phrenic arteries. Chief Veins of Thoracic Wall. — Correspond with arteries. Chief N3rves of Thoracic Wall. — From Posterior Divisions of Cervical Nerves — branches from third, fourth, lifth, sixth, seventh, and eighth nerves. From Cervical Plexus — supraclavicular branches; deep muscular branches. From Brachial Plexus — muscular branches; posterior thoracic; suprascapular; anterior thoracic; subscapular. From Dorsal Nerves — anterior branches of upper ele\en nerves (the intercostal nerves); posterior branches of upper eleven nerves. SURFACE FORM AND LANDMARKS. Suprasternal Notch is formed by upper border of manubrium and inner aspects of non-articular portions of inner ends of clavicles. Superior border of sternum (during inspiration) is on lc\el with carti- laginous disc between second and third dorsal vertebra. Transverse ridge at junction of manubrium and gladiolus corresponds with costal cartilage of second rib, and is opposite fifth dorsal vertebra. Lower end of gladiolus is opposite ninth dorsal vertebra, and corresponds with termination of seventh costal cartilages. Infrasternal depression lies between seventh costal cartilages, and corre- sponds with ensiform cartilage. Structures behind manubrium sterni — Left innominate vein lies slightly below superior border; Innominate, common carotid, and sulxdavian arteries come off from aortic arch about 2.^ cm. (one inch) below upper border; Trachea bifurcates opposite manubrio-gladiolar junction; Esophagus. Pectoral furrow (sternal furrow) is the median vertical furro\\- between pectoral muscles, its bottom corresponding with center of sternum. Subcostal (abdomino-thoracic) arch is formed by ensiform cartilage and cartilages of seventh, eighth, ninth, and tenth ribs and extremities of eleventh and twelfth ribs. The subcostal angle varies from 60 degrees to 80 degrees, averaging about 70 degrees in male and 75 degrees in female. Apices of lungs, with their pleura;, rise from 1.2 to 4.4 cm. (4 to 1} inches) above clavicle. Right sterno-clavicular articulation is in relation with innominate artery, right innominate vein, and pleura. SURGICAL AXATdMV OK MAMMAkV Gl.AXI). 579 Left sternoclavicular articulation is in relation with left innominate vein, left carotid and pleura. First rib is almost covered by clavicle and scapula. Infraclavicular fossa is the space, or hollow, between lower border of clavicle and upper border of second rib. Coracoid process lies about i inch below junction of outer and middle thirds of clavicle. Nipple, in male, lies over infero-external part of pectoralis major, gener- ally between fourth and fifth ribs, about J inch to outer side of junction of ribs and costal cartilages, and a little more than 4 inches from median hne. Inferior border of pectoralis major corresponds with fifth rib. Internal mammary artery is 0.5 to 1.5 cm. (\ to f inch) from outer border of sternum, above — and i to 2 cm. (^ to |f inch) from it below. Costo-vertebral groove is occupied by the erector spina? and multifidus spinas, and their subdivisions. Tips of the spinous processes at the upper and lower parts of thora.x correspond, approximately, with the neck of the rib below the particular spine, but the tips of those spines near the center of the series about correspond with the neck of the second rib below. Distance from upper central incisor teeth to bodies of first, second, third, fourth, fifth, and tenth dorsal vertebr;c is, approximately, 20.3, 21.8, 23.8, 25.7, 28, and 38 cm. (8, 8f, 9J, loj, ir, and 15 inches) respectively, in the average person of 5 feet 8 inches, as measured by esophageal route (which data are of use in locating obstructions of the esophagus). INSTRUMENTS USED IN OPERATIONS UPON THE THORAX. Exploratorv svringe; cannula and trocar; scalpels; cartilage knives; probe- pointed bistourv; dissecting forceps; toothed forceps; artery-clamp forceps; tracheal and esophageal forceps; scissors, curved and straight; retractors, various; saws, Gigli's, chain, Doyen's; probe; large sound; grooved director; tenacula; periosteal elevators, straight and curved; costotome; bone-cutting forceps; rongeur forceps; bone-holding forceps; bone-drill; wire; aneurism- needles, straight and curved; needles, various; needle-holder; sutures and ligatures of silk, plain and chromic gut, and silkworm-gut; drainage-tubes; gauze. OPERATIONS UPON THE THORACIC WALL AND CONTENTS. For operations upon the Th.\. Description. — Consists in complete excision of breast, together with removal of sternal part of pectorahs major entirely; and also in removal of entire pectorahs minor, or a simple turning back of its divided ends; with clearing out, en tnassc, of fatty-areolar-glandular tissues of axilla, aided by a transverse division of clavicular portion of pectorahs major; and the forma- tion of one or two cutaneo-areolar flaps from the lateral thoracic wall to cover over the main wound, in conjunction with its own margins. Preparation — Position — Landmarks. — Same as in the Radical Excision of the Breast by Halsted's method (page 582). Incisions. — (i) Outer Primary Incision (Fig. 344, S) begins at anterior margin of axilla, at its junction with the arm, and passes along just above anterior border of axilla and the lower margin of pectoralis major, encircling the lower circumference of the breast to its inner and lower quadrant. (2) Inner Primary Incision (D C) begins at center of anterior axillary border (D) and, passing inward and downward, diverges from first incision to encircle upper and inner part of circumference of breast and meet first incision at point of its ending (C). (3) Upper Secondary Incision (E F) is made later, passing from point E, on upper primary incision, to clavicle (F), dividing the clavicular portion of pectorahs major at right angle to its fibers. (4) Lower Secondary Incisions (H and I) are made at end of operation, for the purpose of raising flaps to cover the main wound, the incisions (one, or both if necessary) begin from lower primary incision at point G (not shown in figure), and pass upward (I) and downward (H). Operation. — (i) Incise through skin and fatty-areolar tissue along above primary lines, clamping all bleeding vessels. (2) Dissect back margins of wound so as to expose base of gland in its entire circumference, carrying incision to pectorahs major, which is freely exposed along entire upper inci- sion. (3) Divide sternal portion of pectorahs major from thorax, and throw entire mass outward and downw-ard. (4) Sever humeral insertion of pectoralis major, exposing pectoralis minor and axilla. (5) Upper secondary incision is now made, to expose axillary vessels up to where they pass beneath the clavicle. (6) Divide the pectoralis minor transversely and reflect halves outward and inward, or entirely remove them. (7) Clear, by careful dis- section, axilla of all extraneous tissues and unimportant vessels, from clavicle to lower part of axilla, including all fatty, glandular, and areolar tissue lying in front and behind the vessels, as well as the areolar tissue between serratus magnus and subscapularis. Branches of axillary vein and artery are tied close to their vessels, and any thoracic or scapular nerves which are in the way of thorough clearing of the axilla are sacrificed, unless they can be tem- porarily displaced. (8) Reflect mamma, with pectoral muscles and adherent axillary contents, outward and sever them from thorax in one continuous mass by a few sweeps of the knife along the outer j^imary incision. (9) Lower secondarv incisions are now made, and the cutaneo-areolar flaps represented bv them are raised bv undercutting, and are ready to be shifted inward, (lo) ORDIXARV EXCISION OF MAMMARY GLAXD. 585 Margins of original primary incisions, together with the margins of the flaps raised for that purpose, are approximated by suture, so as to entirely, if possible, cover in the whole wound and secure primary union. (11) Tem- porary horsehair or gauze drainage is used for twenty-four hours. (12) V'oluminous dressings, including binding of arm to chest, are used. Comment. — Whatever muscle tissue has been divided and not subse- quently removed, should be repaired by chromic catgut suturing at the end of the operation. If indicated, the upper secondary incision may be con- tinued above the clavicle and the supraclavicular glands removed from the posterior cervical triangle. ORDINARY EXaSION OF MAMMARY GLAND IIV EI,1,II>TICAI, 1XCISR).\. Description. — Breast is circumscribed by an elliptical incision, wth a straight continuation outward to the center of the a.xilla, and another straight '■'ig- 345— Excisions of thk Mammary Gland:— .\, Excis eiliplical incision, llie upper end of the ellipse being extended breast subcutaneously, by an inferior curved i incision continued downward toward the sternum. Mamma is simply dis- sected from pectoralis major muscle. A.xilla is not invaded unless glands are felt through upper end of wound, and, if so, these glands are removed by blunt dissection through a limited exposure of axilla. Preparation. — Same as for Radical Excision (page 582). Position. — Same as for Radical Excision (q. v.). Or patient's hand mav be placed behind nape of neck. Surgeon may stand on side of operation, cutting from above downward on right, and from below upward on left; or 586 OPERATIONS UPON THE THORAX. may stand on right side for either breast, leaning over thorax and cutting from aljDxe downward when ojierating on left side. Landmarks. — Same as for Radical Excision {q. v.). Incision. — An elliptical incision is made, with its long axis parallel with anterior axillary fold (with arm in above position) ; its center corresponding with nipple; its width regulated by size of breast (or tumor); its upper and lower angles being just bevond the mamma. The ellipse itself does not extend the full length of the incision. From the upper angle of the ellipse a straight incision is carried up to opposite the center of the axilla. From the lower angle of the ellipse another straight incision is also carried down- ward a short distance below the breast. (See Fig. 345, A.) Operation. — (1) Keeping parts tense by left hand, the full length of the incision, including upper curve of ellipse, is completed at one stroke. The lower curve of the ellipse is made with a second stroke of the knife, joining the straight portions of the first incision at upper and outer and at lower and inner circumference of breast, respectively. Incise through skin and super- ficial connective tissue throughout. (2) Having clamped bleeding vessels, the incision is carried down to pectoral muscle along upper line of ellipse, while skin above is drawn upward by assistant and breast downward by surgeon's left hand, the incision passing well above the upper limit of the breast. (3) Draw-ing breast away from thoracic wall, surgeon frees it from pectoralis major, beginning along the up)per line. (4) .\ssistant now draws breast upward, and surgeon, retracting skin downward with left hand, cuts down to thoracic muscles along lower line of ellipse, the incision passing well below the lower limit of the breast. (5) While under traction, the con- nective tissue of breast to thorax is now severed toward its a.xillary aspect, together with the vascular connections, which are the last cut, and the breast thus freed from chest. .\11 vessels cut are at once clamped, and clamped in advance of section, where possible. The pectoralis major is left bare. (6) Right index-fi^nger is inserted into axilla through upper end of wound and enlarged glands felt for. If none be found, axilla is not opened up further. (7) If enlarged axillary glands be felt, the incision is continued upward into armpit, the a.xillary space exposed, and the glands removed with as little disturbance and damage to neighboring tissues as possible, and generally by blunt dissection. (8) Margins of wound, even the elliptical portion, are generally capable of being brought into apposition, and are sutured throughout. (9) If temjxirary drainage be indicated, it is provided for at the lower angle of wound, .\bundant dressing is applied and arm bound to side. Comment. — Where breast is involved by small innocent tumor, merely the ellijjtical jiortion of the above incision is used, the straight portions ex- tending above into axilla and below toward sternum being omitted. SUBCUTANEOUS EXaSION OF MAMMARY GLAND KV l\l KRIOR Cl'RVF.D INTISION Description. — Through a curved incision made in the inferior mammary fold, the breast is turned upward and dissected (enucleated) in whole or in part from out of its overlying capsule of skin and fascia, generally leaving the nipple intact. Indicated in non-malignant conditions for partial or com- plete removal of the mamma. Preparation — Position. — Same as for Radical I-^xcisinn. THE SL'PERIdR MEDIASTIXLM. 587 Landmarks. — Inferior mammary fold (at junction of lower circumference ■of breast with chest- wallj. Incision. — Curved incision passing around beneath the lower margin of breast in the mammary fold, extending sufficiently far up on either side to enable breast to be turned upward and backward. (See Fig. 345. B.) Operation. — Incise through skin and fascia down to pectoral fascia. Having gotten between the deep layer of the superficial pectoral fascia and the sheath of the pectoralis major, the breast is readilv detached bv blunt dissection and turned upward and outward — and then freed from its cutaneo- areolar covering from behind forward. The nipple is left, if possible, to lessen disfigurement. .AH bleeding vessels are ligated with gut. The remain- ing portion of the breast, if any, is returned to its normal site (otherwise the cutaneo-areolar capsule of the enucleated breast is turned back into place) and the margins of the wound are carefully sutured to avoid scarring. No drainage is used. .\ snug dressing is applied, to obliterate dead spaces. III. THE SUPERIOR MEDIASTINUM. SURGICAL ANATOMY. Description. — The mediastinum is the region of the thoracic cavitv be- tween the pleur;L' laterally, and the thoracic walls anteriorly and posteriorlv. That portion above the upper le\el of the heart is the superior mediastinum. That portion below the upper level of the heart is divided into anterior, middle, and posterior mediastina. the anterior being in front of the heart, the posterior behind the heart, and the middle enclosing the heart. Boundaries of Superior Mediastinum. — .\nteriorly, manubrium sterni. Posteriorly; bodies of lirst, second, third, and fourth dorsal vertebrae. Later- ally; pleunv. Superiorly; upper opening of thora.x. Inferiorly; plane passing horizontally backward from manubrio-gladiolar junction to lower portion of body of fourth dorsal vertebra — nearly coinciding with upper portion of pericardium. Contents of Superior Mediastinum. — Origins of sternohyoid and sternothyroid, and lower ends of longi colli muscles; transverse arch of aorta; innominate, thyroidea inia, left carotid, and left subclavian arteries; in- nominate, superior vena cava, and left superior intercostal veins; pneumo- gastric, left recurrent laryngeal, phrenic, and cardiac nerves; trachea; esopha- gus; thoracic duct; thymus gland, or its remains; bronchial lymphatic glands; superior sterno-pericardiac ligaments. SURFACE FORM AND LANDMARKS. The planes limiting the upper and lower boundaries of the superior mediastinum are, respectively, those corresponding with the upper opening of the thorax above, and the junction of the manubrium and gladiolus below. GENERAL SURGICAL CONSIDERATIONS. The superior mediastinum (as well as the anterior and middle mediastina) is exposed in the operation of anterior mediastinal thoracotomv (page 588). It is also exposed in the operations upon the innominate artery, in e.xcisions of the sterno-clavicular articulation and of the manubrium. 588 OPERATIDNS Ul'OX THE THORAX. IV. THE ANTERIOR MEDIASTINUM. SURGICAL ANATOMY. Boundaries. — Anteriorly; all of gladiolus sterni, with parts of left fourth, fifth, sixth, and seventh costal cartilages. Posteriorly; pericardium. Laterally; pleurre. Contents. — Origin of triangularis sterni muscle; areolar tissue; lymphatic vessels and glands (anterior mediastinal glands) ; th_ymus gland (or its remains) ; inferior sterno-pericardiac ligaments. ANTERIOR MEDIASTINAL THORACOTOMY BY LONT, MEDI.\N INCISION — MILTON'S OSTEOPLASTIC .-\NTERIOR MEDIASTINOTOMV. Description. — Exposure of the superior, anterior, and middle mediastina through a lem])orary longitudinal division of the sternum in the median line. (The posterior mediastinum may also be reached, in part, by this incision, but is better approached by a separate operation.) Resorted to for gaining very free access to the entire contents of the mediastina mentioned, especially for the removal of anterior mediastinal growths and pus, — the esophagus, trachea, and bronchi being more readily reached and treated from behind (Posterior Mediastinotomy). Preparation. — Beard and presternal hair shaved, if necessary. Position. — I^atient supine, shoulders elevated, head supported, neck prominent — Surgeon to right — .\ssistant opposite. Landmarks. — Median line of neck and sternum; thyroid cartilage; ensiform cartilage. Incision. — From lower part of thyroid cartilage to base of ensiform cartilage, made in median line of neck and sternum. (The cervical portion of the incision is to give room for the lateral retraction of the split sternum.) (See Fig. 346, A.) Operation. — (i) Incise through the skin and superficial connective tis- sue along the neck — and down to the bone over the full length of the sternum. Clamp or ligate superficial vessels. (2) Deepen the cervical incision by re- tracting the sternoh)'oid and sternothyroid muscles and dividing the deep- cervical fascia, controUing all vessels encountered. The trachea is thus e.xposed from the thyroid cartilage to the episternal notch, except that the isthmus of the thyroid gland is not divided. If necessary, it may be divided between two hgatures. E.xpose the episternal notch by separating the fascia from it outward on either side to the origins of the sternomastoids. (3) Free the posterior surface of the manubrium sterni downward as far as possible, by means of curved periosteal elevator and finger, depressing the important structures downward. The more nearly this is done subperiosteally, the greater the protection to the soft parts adjacent. (4) By means of a thin, special saw, divide the sternum longitudinally in the median line, from above downward — dividing it through its entire thickness above, where the saw- teeth can be protected by a thin metallic guide or spatula slipped behind the upper portion of the sternum — but dividing it elsewhere, at first, very nearly but not quite through, and not extending the division below the base of the ensiform cartilage. (5) Detach the ensiform cartilage from the gladiolus by stout, curved, blunt scissors or bone-forceps, avoiding the neighboring struc- tures of importance, especially the peritoneum. (6) Grasp the margins of ANTERIOR MEDIASTINAL THORACOTOMY. 589 the sawed sternum on both sides by means of broad retractors with teeth — and steadily and carefully draw the divided bones apart by outward and shght upward traction. Draw the ensiform cartilage downward. Pass a director or thin spatula upward, inserting it between the lower end of the gladiolus and the disconnected ensiform cartilage, hugging the posterior surface of the lower portion of the gladiolus — and, upon this protector, com- plete the division of the lower part of the gladiolus by means of the special saw or bone-cutting forceps, working from below upward. (7) The bony division having been completed, additional traction is made upon the divided edges of the sternum, the separation being started by prizing the split sides of the sternum asunder with some stout, blunt instrument — detaching by Fig. 346. — Incisions for Exposing the MiiDiASTi.NA : — A, Milton's anterior mediastinal thor- acotomy, for e.\posing the superior, anterior, and middle mediastiiia ; B, Incision for anterior medi- astinal lltoracotomy by ati osteoplastic resection of tlie part of the sternum corresponding with the third, fourth, and fifth costal cartilages (e.xposing the anterior and middle mediastina). blunt dissection all binding tissues, or dividing them with scissors, as soon as revealed Vjy the gradual separation of the parts, and, where necessary, taking renewed holds upon the edges of bone with the retractors, as the gap increases. (8) An interval of between 5 and 8 cm. (about 2 to 3 inches) is thus ordinarily attainable. Through this opening the contents of the superior, anterior, and middle mediastina are readily reached — and even the posterior mediastinum may also, though of course less easily, be thus reached on the right side, after separating the pericardium and pleura. The further steps of the operation will depend upon the object for which performed — but, in any case, should be carried on with e.xceptional care, owing to the unusually important nature of the parts involved, and should be done chiefly by means 590 Ol'ERATIOXS UPON" THE THORAX. of blunt dissection. (0) At the close of the operation, the edges of the sternum are approximated by four to si.x silver-wire sutures passed through drill-holes — gauze or other drainage having been temporarih- introduced behind the sternal notch and below the lower end of the gladiolus — and the skin wound closed e.xcept opposite the drainages. Comment. — The pleura and peritoneum are both in great danger of injury — wounds of these should be immediately closed by circular ligation of their mouth, if small; and by suture, if large. The principal tissues which interfere with the separation of the parts are those aljout the left innominate vein, crossing behind the manubrium sterni, in the line of the division, above; and about the ensiform cartilage below. Especial care is necessary as to respiration, due to collapse of lungs, and a Fell-O'Dwyer instrument should have been pro\ided previously for main- taining artificial respiration. Costal breathing ceases with division and separation of the sternum, though the lungs may not collapse on that account alone. In special cases where dyspnoea may be anticipated, a preliminary tracheotomy is sometimes done. ANTERIOR MEDIASTINAL THORACOTOMY BV OSTEOPL.\STIC RESECTION OF P,\RT OF STERNUM COKRESPOXDIXG WITH THIRD, FOURTH, AXD FIFTH COSTAL CARTILAGES. Description. — The anterior mediastinum, and also the middle medias- tinum, may be e.xposed by the osteoplastic resection of that portion of the sternum corresponding with the third, fourth, and fifth costal cartilages — which portion is temporarily turned back, exposing a large part of the anterior and middle mediastina and their contents. This operation is less extensive and severe than ^Milton's, and is indicated where a more limited exposure will suffice — especially for the removal of glands, small growths, evacuation of pus; and for the exposure of the heart and pericardium in the treatment <:f wounds and evacuation of pus. Preparation. — Chest-wall shaved, if necessary. Position. — Patient supine, chest elevated and resting upon some object which will render the anterior thoracic aspect prominent. Surgeon on left. Assistant opposite. Landmarks. — Gladiolus sterni, betw^een chondro-sternal articulations of third, fourth, and fifth costal cartilages; line of internal mammary artery (see page 59). Incision. — (1) Upper transverse incision passes on a level with the upper border of third costal cartilages, not extending more than 1.2 cm. (about J inch) beyond either sternal border (to avoid the internal mammary artery). (2) The lower transverse incision passes similarly on a level with the lower border of the fifth costal cartilages, between points about 1.2 cm. (about i inch) beyond the sternal borders. (3) The vertical incision joins the left ends of the two transverse incisions, passing down between the left internal mammary artery and the left margin of the sternum. These incisions outline three sides of a square, having the hinge of the flap at the right margin of the sternum. (See Fig. 346, B.) Operation. — (i) Incise through skin, fascia, and fibers of the pectoralis major, down to the sternum and intercostal membranes, using care over the intercostal spaces that the knife does not penetrate the thorax. Clamp and ligate the superficial vessels cut along the lines of incision — but do not separate the skin and fascia from the sternum. (See Fig. 347.) (2) The costal ANTERIOR MElilASTIXAI, THORACOTOMY. 591 cartilages are well exposed where the vertical incision crosses them and are divided with blunt-pointed cartilage-pliers with great care, to avoid injury to pleura and pericardium. This having been done, the left margin of the sternum, thus freed of its third, fourth, and fifth cartilages, is now drawn slightly forward with toothed retractor, and, while held in this position, the posterior surface of that portion of the sternum is freed of triangularis sterni muscle and connective tissue by means of a slightly curved periosteal elevator. (3) The sternum is now divided where the upper and lower transverse inci- sions cross it — and this is best accomplished, in those cases where it has been possible to clear the posterior surface of the sternum entirely across to the opposite border, by means of a Gigli saw conducted beneath the sternum, with which the section is readilv made. In other cases the section mav be made (though with less neatness and precision and more danger) by means of stout, curved, blunt-pointed, bone-cutting pliers, the lower blade hugging the sternum closely. (4) This section of the sternum having been freed upon , / W ' B — % H - a 1 — ti C J ju^— r: I'lK- 347- - Anierior Mediastinal Thoracotomy, by an Osteoplastic Flap Consisting of Soft Parts and Sternum Corresponding with Third, Fourth, and Fifth Costal Carti- lages:— A, Osteoplastic flap turned to left ; B, Pectoralis major muscle ; C.C, Intercostal arteries ; D, Costal cartilage divided b\- instrument ; E, Costal cartilage partly broken in hinging back the flap: F, F, Drill-holes: G. Triangularis sterni muscle; H,H, Lungs and pleurce, the hitter e.\tending further toward the middle line; I, Heart and pericardium. three of its sides, its posterior surface having been cleared, and with the soft parts still adherent to its anterior surface, it is now to be partly turned, partly broken back upon the structures along its right margin, as upon a hinge, the costal cartilages generally snapping in part or entirely, though sometimes bending. (5) The anterior mediastinum, and also the middle mediastinum (although of course less fully), are now exposed — and their contained struc- tures may be reached by gentle manipulation and blunt dissection — and the special object of the operation accomplished. (6) At the close of the opera- tion, the osteoplastic flap is turned back into place. It is well to drill holes (two above and two below) for chromic gut ligatures, or silver wire, along the upper and lower transverse divisions of the sternum, before replacing the fl;ip (holding the detached piece of sternum with strong bone-forceps while drilling; and protecting the inferior surfaces of the margins of the upper and lower intact pieces) — and tightening the sutures when the piece is in place. 592 UPERATI(.>\S Ul'OX THE TIIUKAX. If thought necessary, the costal cartilages may be similarly drilled and tied on either side of the line of section. (7) Temporary drainage should be pro- vided — which may be done by excising a small portion of one of the costal cartilages at its articulation with the sternum, as well as a limited portion of the margin of the sternum at that point, in the form of a semicircle. The skin-portion of the osteoplastic flap is sutured throughout most of its e.xtent, leaving an opening for drainage. Comment. — Instead of the above window opening lateralh' upon a vertical hinge, one may be (though less easily) formed opening upward or downward upon a transverse hinge across the sternum, bv making two vertical incisions just outside of the borders of the sternum and the transverse incision on a level with the lower border of the fifth costal cartilage (where the hinge is to be above). The window mav be placed higher or lower than indicated in the above operation. OTHER OPERATIONS UPON THE ANTERIOR MEDIASTINUM. See all operations ujjon the Heart and Pericardium — which, Iviiig in the middle mediastinum, are reached through the anterior mediastinum. V. THE MIDDLE MEDIASTINUM. SURGICAL ANATOMY. Boundaries. — Anteriorly; limits of anterior mediastinum. Poste- riorly; limits of posterior mediastinum. Laterally; pleune. Contents. — Heart and pericardium; ascending aorta; pulmonary artery and its two branches; arteries of the phrenic nerves; superior vena cava; right and left pulmonary veins; vena azygos major; phrenic nerves; roots of lungs; bifurcation of trachea; two bronchi; lironchial lymphatic glands. OPERATIONS UPON THE MIDDLE MEDIASTINUM. For ci|)erations upon the Middle Mediastinum, see operations ujion the Heart and Pericardium (pages 614 and O19). For other operations exposing the Middle Mediastinum, see operations upon the .\nterior Mediastinum (pages 588 to 592). For operations upon the thoracic esophagus and trachea and upon the bronchi, see Posterior Mediastinal Thoracotomy (page ^qt,) — the first being in the Posterior Mediastinum — the last two in the Middle Mediastinum, but best reached through the Posterior Mediastinum. VI. THE POSTERIOR MEDIASTINUM. SURGICAL ANATOMY. Boundaries. — Anteriorly; pericardium; roots of lungs. Posteriorly; \ertci)ral column (below inferior border of fourth dorsal vertebra). Laterally ; [)leura\ Contents. — Descending aorta; greater and lesser azygos veins; pneumo- gastric nerves; splanchnic nerves; esophagus; thoracic duct; posterior medias- tinal lymphatic glands. POSTERIOR MKDIASTIXAL THORACOTOMY. 593 POSTERIOR MEDIASTINAL THORACOTOMY BV THORACOPLASTIC FLAP — BRYANT'S OPERATION. Description. — E.xposure of the posterior mediastinum by means of an osteoplastic flap about 8 to lo cm. (about 3 to 4 inches) square, and generailv including the width of three ribs raised over the site of the operation — part of the central rib being permanently sacrificed from angle to outer end of transverse process, and similar parts of the other two returned. Usually performed for the removal of foreign bodies in the esophagus, trachea, and bronchi, and for the evacuation of pus. Some of the more posterior contents of the middle mediastinum are thus also accessible from this opening. Position. — Patient partially upon side and chest, with the side of opera- tion uppermost, and resting upon some object in order to increase the width of the intercostal intervals at the site of operation. The scapula is drawn forward to increase the in- terval between the vertebra; and the vertebral border of the scapula. Surgeon on side of operation. .Assistant oppo- site. Landmarks. — Position of upper ribs; spinous processes of up[)er dorsal vertebra, with corres[)onding ribs; ver- tebral border of scapula; root of spine of scapula (which generally corresponds to the interspace between third and fourth dorsal spines). The site of the operation is deter- mined by the position of the foreign body to be removed. Parts of three ribs are gener- ally included in the operation, the central one being at the center of the field. Some- what readier access is gotten to the esophagus from the left side, though at the level of the usual operation the esophagus is practically in the middle line. The trachea usually bifurcates opposite the fourth dorsal vertebra (sometimes the fifth). Where the site of the operation cannot be previously determined, the left fourth, fifth, and sixth ribs are generally chosen. Incision. — In the form of three sides of approximately a three-inch square — the fourth side being represented by the spinous processes of the vertebrse. This area is so placed as to have its center over the central one of the three ribs to be removed — the upper and lower parallel incisions passing above and belo\v the other two ribs respectively. (See Fig. 348, A.) Operation. — (i) Incise the three sides of the outline indicated above, through skin, fascia, and muscles down to the ribs, carefully avoiding pene- trating the intercostal spaces. Clamp all cut vessels. Free up the thick tlap of soft parts from the ribs and turn it over the spinous processes to the opposite side. Ligate the previously clamped vessels, and others as exposed. 38 Fig' 348.— Operations i'pon the Thoracic Cavity: —A, Posterior mediastinal thoracotomy, by thoracoplastic flap ; B, Position for paracentesis thoracis in the eighth in- tercostal space in the line of the inferior angle of the sca- pula. The scapula is here represented retracted slightly outward, to increase working-space between vertebrae and ■scapula in the removal of parts of the fourth, fifth, and sixth ribs. 594 OPERATIONS LTOX THE THORAX. (See Fig. 349.) (2) Make a longitudinal incision over the center of the outer aspect of the central one of the three ribs, through the periosteum, from the outer end of the transverse process of the vertel^ra to the angle of the rib — free it subperinsteaily with curved periosteotome (or by a piece of silk con- ducted between bone and periosteum) — pass a Gigli saw between rib and periosteum, guarding the pleura, and remove the portion of rib above indi- cated, and discard. (3) The inner and outer ends of the exposed portions of the upper and lower ribs are now similarly exposed subperiosteally, without self n.i ^1 , 1;, !■ :ird; C, I'Lij. TOM^', BY THORACOPLAST ,t[' of p:irt of fourth rib a irrioslal muscles turned d. ; i E, Intercostal aner.v.v6 r.AP:-A. Skin and ntercostal muscles rard ; D. D, Verte- ,F, F, bral ends of fourth ; Fourth, fifth, and sixth dorsal nerves exposed and retracted ; G, Pleura and lung; H, Broad retractor displacing pleura and lung; I, Thoracic aorta; J, Left bronchus; K. Esophagus protruded into wound by sound introduced through mouth. The operations of Bronchotomy and Thoracic Esopha- gotomy are shown at J and K, respectively. The pulinonar>' and bronchial vessels are omitted, foi clearness. freeing the intervening portions more than can be helped, and especially without isolating the upper rib from its upper attachment and the lower rib from its lower attachment. Two holes are drilled at either end of the yet undivided ribs for future wiring. Both ribs are then divided between the pairs of drilled holes, by means of a Gigli saw. (4) The intercostal arteries in the field are now ligated at the inner and outer side of the wound. The intercostal nerves are carefully retracted throughout the operation, it being imnecessarv to divide them. The periosteum forming the bed of the central SURGICAL AXATOMY OF THE DIAPHRAGM. 595 rib is now \erv carefully divided lengthwise of its course. Through this opening the pleura is carefully detached and is further separated b}' the finger from the muscular and bony wall of the thorax corresponding to the extent of the wound, the separation being accomplished during e.xpiration. At either side of the wound, in Une with the divided ribs, the remaining chest-wall is divided while the pleura beneath is carefully guarded by an instrument or the finger. These two vertical incisions last made, crossing the transverse one through the bed of the middle rib's periosteum, make, by an H-shaped incision, two small flaps — the upjier one, containing the upper rib as extensively adherent as possible (for nutrition), is now turned upward upon its hinge of soft parts — and the lower cne, with the lower rib similarly attached, is turned downward in like fashion — care being taken not to injure the intercostal vessels and soft ti.ssues above the upper rib, nor below the lower rib. (5) The posterior mediastinum is thus exposed — and its contents, as well as some of the mere posteriorly situated contents of the middle mediastinum, are accessible after careful separation of important structures by means of blunt dissection, instrumental retraction, and the use of the fingers. The pleura, especially, is carefully ])ushed externally out of the way and so guarded as to avoid opening it. The trachea, bronchi, and esophagus may be both felt and seen. The important vessels of the posterior and middle mediastinum (see Surgical Anatomy) are to be carefully guarded. When trachea, bronchi, or esophagus are to be opened, they are incised, after being steadied with toothed forceps, in their longitudinal axis — and subsequently not sutured — but the wound packed down to the incised tube, for the escape of all drainage through a drainage-tulje placed in the center of the gauze packing. (6) In completing the operation, the middle one of the three ribs is not replaced — the upper and lower ribs are turned back into place and wired (or sutured with chromic gut) through the previously drilled holes. The drainage will pass out of chest through the incision in the bed of the middle rib — and will escape externally through a convenient opening left beneath the skin and muscle flap which is only partially stitched into place. Comment. — (i) The scapula should be dis].)laced forward out of the way, and so held by an assistant. (2) It might be better to plan the skin incision on a somewhat larger scale (say 2.5 cm., or about i inch, larger) so that the skin suture-line would not directly coincide with the Ijone-sections. (3) .\11 bleeding should be controlled as encountered — first by clamp, then by liga- ture. (4) The pleura is to be widely separated around the margin of the opening by the finger — to enable freer displacement of the mediastinal con- tents. (5) Below the arch of the aorta the esophagus is more readily reached from the right — above the arch, it may be reached from either side, although somewhat better from the left. (6) Removal of a body from the esophagus below the body of the ninth dorsal vertebra is \-ery diflicult and hardly justi- fiable. (7) The left bronchus is reached with greater difliculty and risk of hemorrhage. VII. THE DIAPHRAGM. SURGICAL ANATOMY. Attachments of Diaphragm. -Anterior (sternal) part; inferior and posterior border of ensiform cartilage; neighboring posterior surface of ante- rior aponeurosis of transversalis muscle. Lateral (costal) part; inferior border and inferior surface of the cartilages and bony parts of the sixth or 596 OPERATIONS UPON THE THORAX. seventh inferior ribs. Posterior (vertebral) part ; (a) ligamentum arcuatum e.xternum (the thickened anterior layer of lumbar fascia extending from tip of transverse process of second lumbar vertebra to tip of twelfth rib) ; (b) ligamentum arcuatum internum (the thickened iliac fascia arching over the psoas, from the side of body of second lumbar vertebra to tip of transverse process of same vertebra), (c) right crus of diaphragm (arising from anterior surface of bodies of first to third, or fourth, lumbar vertebra; from inter- vening tibro-cartilages; from anterior common ligament); (d) left crus of diaphragm (arising from anterior surface of bodies of first to second, or third, lumbar vertebra; from intervening fibro-cartilages; from anterior common ligament I. The insertion of these various origins is into the ante- rior, posterior, and lateral as[)ects <>f the central tendon of the dia|:)hragm. Structures in Relation with Diaphragm. — Superiorly (thoracic cavity); pleuras and lungs; peric.rdium and heart. Inferiorly (abdominal cavity); peritoneum; liver; stomach; spleen; pancreas; kidneys; suprarenal capsules. Upper Limits of the Diaphragm. — Right Leaflet, on level with junction of fifth c( stal cartilage with sternum (about 2.5 cm., or i inch, below the nipple). Left Leaflet, on level with junction of sixth costal cartilage with sternum. Central Tendon, about on level with end of sternum, or seventh chondro-sternal articulation. Boundaries of Lower Thoracic Opening. — See Thoracic Wall, page 576. Structures Passing through Floor of Thorax (Diaphragm). — See Thoracic Wall, page 57O. Other Relations of Diaphragm. — (a) The fibers of diaphragm are absent or deficient in the interval between the sides of the muscular strip from ensiform cartilage to cartilages of neighboring ribs — areolar tissue occupies this position, covered above by pleura, and below by peritoneum. (b) The central tendon of the dia])hragm is blended with the pericardium. (c) After forced expiration, the right diaphragmatic arch is on a level, ante- riorly with fourth costal cartilage; laterally, with fifth, sixth, and seventh ribs; posteriorly, with eighth rib; similar measurements on left generally being from one to two ribs' width lower. In forced inspiration, there is a descent of from 2.5 to 5 cm. (about i to 2 inches), (d) Circumferentially, the diaphragm is higher in the median line, and lower at the sides — but the central tendon supporting the heart is lower than the sides, (e) For a narrow interval around the lower and pcsterior circumference, the diaphragm is not covered bv pleura, but is in immediate contact with the chest-wall, (f) The costo-phrenic sinus is tliat area over which the parietal and visceral layers of the pleura are in constant contact, whether in inspiration or ex- piration — and is represented by the line of reflection of the dia[)hragmatic pleura onto the intrathoracic wall. TRANSTHORACIC EXPOSURE OF DIAPHRAGM r.v r.\RTi.\i. i:x(isi()\ di-- two ok three ribs. Description. — The upper (thoracic) surface of the diaphragm is exposed (at the site of the diaphragmatic lesion) by means of the partial excision of two or three ribs performed subperiosteally, through a single incision between them. Or the site may be exposed liy turning back a flap of overlying soft parts and then excising the indicated parts of the ribs, — or an osteo-thoraco- plastic flap may be temporarily turned aside and replaced at the end of the TRANSTHORACIC EXPOSURE OF DIAPHRAGM. 597 operation. (See operations upon the pleura and heart.) Having opened the chest-wall over the area, the diaphragm may be approached in one of several wavs — below the reflection of the pleura, — subpleurally (after detaching and pressing back the unopened pleura), — transpleurally (the pleura* being non- adherent), — or through adherent pleural surfaces. Indicated for the evacua- tion of pus in subphrenic abscess; for the repair of wounds of the diaphragm; for hernia through the diaphragm. In subphrenic abscess, the approach is usually made by the lumbar, iliac, or lateral thoracic routes, in order of preference — parts of the ninth and tenth ribs being incised in simple sub- phrenic abscess — and part of the eighth if the pleura be involved. The site of the operation may he on either side and will be determined by the lesion and the phy.sical signs. Generally from 7.5 to 10 cm. (about 3 to 4 inches) of the ninth and tenth ribs, between the anterior axillary and scapular lines, Fig- 350- — Transthoracic E.\posl're of Diaphragm through the Right Ninth Inter- costal Space : — A, Latissimus dorsi muscle ; B, Serratus magiius muscle ; C. Obliquus extenius ab- dominis muscle: D. D. Resected ends of ninth and tenth ribs, the periosteal bed extending between the exposed ends, the intercostal vessels and ner\-es showing through the periosteum ; E. Anterior layer of periosteum retracted and e\erted ; F, Posterior layer of periosteum, together with e.vtenial and internal intercostal muscles, retracted ; G. Pleura displaced upward ; H, Diaphragm. as indicated, are excised through a single incision made between them, in the case of an abscess between the liver and diaphragm, which is usually ap- proached subpleurally. Where the abscess is near the dome of the diaphragm, the transpleural approach at a higher level generally must be used. The excision of one or more costal cartilages in the mammary line may suffice. For operations for hepatic abscess and empvema, see Operations upon the Li\cr and Pleura. Position. — Determined by the lesion — and will be such as to conve- niently expose the area — in this case in the semi-prone position. Landmarks. — Site of lesion; line of pleura; line of diaphragm. Incision. — In the center cf the interspace between the ninth and tenth ribs — the center of the incision being midway between the anterior axillary and scapular lines — and about 13 cm. (about 5 inches) in length, so as to provide for the removal of about 9 cm. (about 3^ inches) of each rib. 59'"^ OI'KKATIUNS UPON THE THORAX. Operation. — (i) Incise through skin, fascia, and overlying thoracic muscles, down to the plane of intercostal muscles, clamping all bleeding vessels. Free back the upper and lower lips of the wound upon this same plane, until the ninth and tenth ribs are reached and e.xposed in their entire width — the soft parts being retracted well above and below their limits. (2) Subperiosteally excise about 9 cm. (about 3^ inches) of each rib, in the usual manner (see the Subperiosteal E.xcision of the Ribs, page 447) — carefully guarding the parietal pleura from the slightest nicking or injurv (Fig. 350). (3) Incise the intercostal tissues longitudinally in the center of the interspace between the two e.xci.sed ribs. If necessary, the interccstal arteries of the excised ribs may be ligated at both ends, though this may be omitted generally, as they are usually not in the way unless it be indicated to carry an incision across their course. Preserve the intercostal nerves by retraction. The re- moval of these two ribs generally gives ample room for exposure when the upper and lower limits of the wound are well retracted. (4) Five methods of reaching the diaphragm are now open to the operator; (a) If the site of operation be below the level of the reflected pleura, where the diaphragm and chest-wall are in contact, the diaphragm may be approached at once, — (b) If the pleura be encountered as soon as the chest-cavity is opened, its parietal layer should be most carefully detached with the fingers and by means of blunt dissection and peeled back from its connection with the endo- thoracic fascia and surface of the diaphragm — peeling it backward with the tips of the fingers and constantly pushing it from the freed area with the back of the fingers — continue this freeing back of the unopened pleura until the site of the diaphragmatic operation is reached — and then held the pleura in place by gauze packing, — (c) If both surfaces of the pleura are found adherent, thus shutting off the general pleural cavity, the incision may be carried directly down to the diaphragmatic site without danger of entering the pleural cavity (unless the adhesions be pulled apart in the manipulations), — (d) If the two pleural surfaces are not adherent, and it be impracticable to detach the pleura as described under (b), the two pleurs may be united by suture around an area sufficiently large to admit of operating within and thus reaching the diaphragm at once, (e) If the two pleural layers be found not in contact by adhesion, and cannot be separated and displaced upward as mentioned under (b), and if time be to spare, adhesion between the two surfaces may be brought about by gauze packing, with the accomplishment of the rest of the operation two or three days later, when the cavitv will have been closed off by adhesions. Where it is possible to choose the route, it is better to approach the diaphragm either below the level of the pleural reflection — or to detach the unopened pleura and reach the diaphragm beneath the pleural cavity. (5) The surface of the diaphragm having been exposed, the special object of the operation is now accomplished — the abscess incised — the wounded diaphragm sutured — or the hernial opening closed — upon the same principles practised elsewhere. Owing to the constant move- ment of the diaphragm, it is somewhat more difficult to deal with its struc- ture. .An abscess cavity should be evacuated by the most direct route, especially guarding the pleural ca\ity from infection. If a newly made wound exist, it is sutured at once. If the wound be old, or the opening be a hernia, the edges are seized with toothed forceps to steady them and then freshened with curved blunt scissors — the mo\ing lung being held cut of the way, if necessary, by gauze packing — and with a fullv curved needle, held in special needle-holder, the margins of the wound or opening are brought together with chromic gut sutures. (6) The pleural sue, previously held SURGICAL ANATOMY OF THE TLEUR.^^. 599 out of the way by packing;, is now allowed to fall into place. Temporary drainage is established, if indicated, through an unsutured jjart of the ex- ternal wound — the remaining portion of the outer wound being closed. Comment. — (a) If the pleura be nicked, ligate or suture it at once, (b) If necessary to gain more room, free back the soft parts and excise the same amount of the rib above or below — especially is this the case when it is needed to reach the diaphragm nearer its dome, (c) .\ U-shaped flap, with base forward or backward, may be used to expose the ribs, (d) (-)n the left side all calculations are made somewhat lower. VIII. THE PLEURA. SURGICAL ANATOMY. Relations. — (J) Pleura costalis (Parietal Layer of Pleura); beginning at sternum, pleura hnes thoracic cavity, covering inner aspect of costal car- tilages, ribs, intercostal muscles — passing, posteriorly, over heads of ribs, thoracic ganglia and branches, lateral surfaces of bodies of dorsal verteljne — thence to side of pericardium, which it partiallv covers — thence to root of lung, where it becomes pleura pulmonis. (2) Pleura pulmonis (Msceral Layer of Pleura) ; beginning at root of lung, pleura passes around posterior border, over convex outer aspect, from base to summit — over sides of fissures between lobes — around its anterior border — on to anterior aspect of root — thence upon pericardium to inner asjject of sternum. (3) Pleura cervicalis ; apex of ])leura closelv covers apex of lung, projecting, with it, from 1.3 to 4.5 cm. (about i to i| inches) above the first rib — but not above le\el of neck of first rib. Subclavian artery arches over it, grooving its internal and anterior aspect just below its apex. Scalenus anticus and medius muscles are in contact with it externally. (4) Pleura diaphragmatis ; covers superior surface of diaphragm, except narrow iiitcT\al along its circumference, which is in contact with costal ]iarictcs. (5) Pleura mediastinalis ; forms lateral boundaries of mediastina. Relations of Margins of Pleurae to Chest-wall. — (i) Anterior mar- gin ; extending from apex of lung, passes from sterno-clavicular articulation downward and inward, meeting opposite pleura at upper border of sternum — thence both pleurre descend in contact to upper margin of fifth costal cartilages, whence they diverge. Right Pleura continues nearly vertically downward to lower end of gladiolus, thence turns outward. Left Pleura diverges from median line at upper margin of fifth costal cartilage, so as to be 1.5 cm. (about f inch) to outer side of left border of sternum at level of sternal end of fifth costal cartilage — 2 cm. (about If inch) at level of sternal end of sixth — 3.5 cm. (about if inches) at level of sternal end of seventh (Luschka). In manv cases this deviation of left pleura is not so marked, the margin lying much nearer the median line. (2) Lower margin ; reflected on to diaphragm along line extending from lower end of sternum outward behind seventh costal cartilage nearly to sternal end of rib. (Melsome says this margin follows lower border of sixth costal cartilage on left side.) The lower border of the pleura corresponds in height with the following structures at the following points: — In the Xipple line, with eighth rib, — In Mid-axillary line, with tenth rib on left, and ninth rib on right, — In Posterior Scapular line (vertical line from tip of inferior angle of scapula), with twelfth rib, — At Spine, with vertebral end of twelfth rib; sometimes with transverse process of first lumbar vertebra. The lower margin of the lung will correspond with a point two ribs higher in each case. 6oo OrERATIOXS UPON THE THORAX. Attachments of Pleurae. — (i) Ligamentum latum pulmonis, passes from lower portion of posterior part of root of lung to diaphragm — formed by two layers of pleurae continuous above with the layers in front and behind root of lung. (2) E.xpansion of fascia covering and strengthening ape.x. and e.xtending across from posterior border of first rib to anterior border of trans- verse process of seventh cervical vertebra — and further strengthened by few fibers of scalenus anticus. (3) Interpleural Ligament, passing between two pleurie behind esophagus and in front of aorta. Supplemental or Complemental Pleural Spaces. — These spaces are situatiiins where twn porticms u( parietal jjleura- are in contact, even during forcible inspiration — (i) Between Chest-wall and Diaphragm (Costo-phrenic sinus), where costal pleura is reflected on to diaphragm, best marked poste- riorly, where costal and diaphragmatic parts of pleurre are in contact from about tenth to twelfth ribs, — (2) Between Chest-wall and Pericardium on left, opposite lower portion of gladiolus. Arteries. — From intercostal, internal mammary, musculophrenic, thvmic, pericardiac, bronchial. Veins. — Correspond with arteries. Nerves. — From phrenic and sympathetic. SURFACE FORM AND LANDMARKS. The interval between the two pleurae is considerable above and below, but opposite the gladiolus (second, third, and fourth costal cartilages) thev are more nearlv approximated, or are in contact. The anterior margins of the two pleura; are more nearlv parallel and in a vertical Hne than the corresponding margins of the lungs, that is, the left anterior pleural margin extends further over the pericardium than does the lung. The right pleura is shorter and wider than the left (owing to the liver), though it reaches slightly higher in the neck. There is a tendency for the left pleura to extend lower down than the right — most markedly upon the lateral aspect of the chest-wall — somewhat so upon the anterior aspect — and even slightly so behind. In some cases the pleura has extended into the abdomen, beneath the ligamentum arcuatum externum, and uncovered by diaphragm at this site. The outer surface of the ])leura is firmly adherent to the surface of the lung, to the pulmonary vessels emerging from the pericardium, to the upper surface of the diaphragm, and to the triangularis sterni — elsewhere it is less firmly adherent. If the twelfth ril) be well developed and full lergth, the pleura is generally in contact with only its inner half. If the twelfth rib be very short, the pleura mav be in contact with all of its anterior surface — and the pleura may e.xtend to the transverse process of the first lumbar vertebra. The outer margin of the erector spina" muscle cuts the twelfth rib about its middle. Where the twelfth rib is present and extends beyond the outer border of the erector spina;, the lower border of that portion of the rib ex- ternal to the border of the muscle can be cut upon with reasonable certainty of not opening the pleura. Where the twelfth rib is absent or short, the above is not available Never take for granted that the last rib is the twelfth rili — always count from the first rib. If the twelfth were absent and one were to cut down INTERCOSTAL THORACOTOMY. 6or upon the eleventh (mistaking it for the twelfth), the pleura would almost certainly be opened. Where the twelfth rib is absent or short, one mav cut to within 2.5 cm. (about I inch) of the apex of the angle formed by the outer margin of the erector spinas and the lower border of that portion of the eleventh rib pro- jecting to the outer side of the muscle — that is, one should not cut higher than the position the twelfth rib would occupy if present (Melsome). PARACENTESIS THORACIS. Description. — Paracentesis thoracis (thoracentesis, or pleuracentesis) consists in the jjenetration of the pleural cavity by means of a hollow needle or cannula, for the purpose of exploratorv aspiration or the evacuation of fluid. Sites usually Selected for Thoracentesis. — Sixth (or seventh) inter- costal space in the mid-axillary line; eighth (or ninth, especially on left) intercostal space in the posterior scapular line. Position. — Patient supine at edge of table for lateral punctures — and rolled slightly forward for posterior punctures — with arm of aft'ected side elevated above head (to widen intercostal spaces, and draw skin upward, which will subsequently come back into place valve-like over the opening). For simple puncture, if patient can sit upright in a chair, this position will better enable lluid to gravitate downward. Landmarks. — Sixth (or seventh) intercostal space in the mid-axillary line — or the eighth (or ninth) space in the line of the inferior angle of the scapula. The posterior puncture secures better drainage. (See Figs. 352, C, and .u8, B.) Operation. — Having cocainized the part, grasp a needle, or cannula and trocar, so as to control its progress and limit the depth of the puncture — and having displaced the skin upward with the left thumb and forefinger, so as subsequently to form a valve — the point is entered nearer the upper than the lower border of the ribs limiting the special interspace (in order to escape the more important lower interccstal artery, while also missing the upper one) — and is made to pass inward and upward (so as to avoid wound- ing the lung and diaphragm) — passing through skin, fascia, thoracic muscles, intercostal muscles, endothoracic fascia, and parietal layer of pleura — its entrance into the free jileural cavity being recognized by the sensation imparted to the finger guarding its onward progress. When the needle, or cannula point, is felt to be within the pleural cavity, the contents are slowly withdrawn, the opening being subsequently sealed with sterilized cotton and collodion. Comment. — Puncture may be made wherever physical signs indicate fluid within the area of the pleura — but the above sites are the most usual. The puncture may be preceded by a limited incision of the skin alone — or, if difficulty occur, the incision mav extend down to the intercostal muscles. To avoid the intercostal arteries, the ])uncture should not be made posteriorly to the angle of the ribs. INTERCOSTAL THORACOTOMY. Description. — Intercostal thoracotomv, (^r pleurotomv, consists in the exposure anfl incision of the pleura in an intercostal space for the evacuation of fluid. A simpler though generally less satisfactory operation than thora- 6o2 OPERATIONS UPON THE THORAX. cotomy through the partial excision of a rib, though often sufficient in minor cases. Sites Usually Selected for Intercostal Thoracotomy. — In the sixth (or seventh) intercostal space in the mid-axillary line ; in the eighth (or ninth, especially on the left) intercostal space in the posterior scapular line — /. e., in the same sites as for paracentesis, avoiding a position in which the dia- phragm or scapula would interfere with free diainage. Position. — As for paracentesis thoracis — except that here the opening must not be valulvar, but, on the contrary, it is jlanned that the cutaneous and pleural openings are opposite. Landmarks. — .\s for paracentesis thoracis. Incision. — ^lidway between the two ribs, in the long axis of the inter- costal space — extending about 5 cm. (about 2 inches) in a thin chest-wall, and about 7.5 cm. (about 3 inches) in a thick chest-wall — the center of the incision being, as above indicated, generally in the mid-axillary line for the sixth intercostal space, and in the posterior scapular line for the eighth inter- space. Operation. — (i) Incise through skin, fascia, external thoracic muscles (serratus magnus in sixth space; chielly the latissimus dorsi in eighth space), and intercostal muscles down to the endothoracic fascia. Clamp and ligate all bleeding vessels encountered — the incision lying between the upper and lower intercostal arteries and not generally involving them. Retract the soft parts upward and downward, including the ribs bounding the space — and the parietal pleura is exposed. (2) The tense pleura is then deliberately incised in the axis of the intercostal space (not by stabbing) — preceded, if necessary, by an exploratory puncture — the opening being increased, if indicated, upon a grooved director, or with blunt scissors or blunt bistoury — and the fluid evacuated. (3) Drainage is then established b_\' some form of not easily collapsible drain (to withstand the tendency of the adjacent ribs to narrow the opening). The ends of the external wound are sutured, leaving room for the exit of the drain. Comment. — Where the incision can be made to the outer margin cf the latissimus dorsi, lesser thickness of muscle presents. THORACOTOMY BY PARTIAL EXCISION OF ONE OR MORE RIBS. Description. — Exposure and incision of pleura through a thoracic open- ing made by the excision of parts of one or two (or more) ribs. Generally resorted to for the evacuation of intrapleural fluids where a larger opening is required than furnished by an intercostal thoracotomy. Part of one rib alone is generally excised — where more room is required jiart of the rib above or below, or both, may be excised. From 2.5 to 5 cm. (about i to 2 inches) of bone are ordinarilv removed — and more if necessary. Sites usually Selected for the Excision of Ribs. — \\herevrr a collec- tion of lluid is indicated 1}\' iilnsical signs (that is, determined 1)\' the phvsical signs of loc dized collection) — where the collection is a localized one. Where the fluid is in the free pleural cavity, the site generally chosen is the sixth or seventh rib in the mid-axillarv line — or the eighth or ninth rib just external to the posterior scapular line — the latter situation usuallv being preferable. (Kocher gives thj sixth rib in the mammarv line — the ninth rib on the right, and the tenth on the left, in the lal'^ral line — and the twelfth on both sides posteriorly in the scapular hne.) But the position should Ije so chosen that THORACOTOMY BY PARTIAL KXCISION OK RIBS. 603 the drainat^e will not he interfered with by either diaphragm or scapula in the functioninji of these structures. Position. — .\s for Intercostal Thoracotomy (page 601 j. Operation by Partial Excision of One Rib. — (i) An incision of about 8 cm. (about 3 inches) is made directly over the center of the chosen rib, passing through skin, fascia, overlying muscles, and periosteum. (See Fig. 351.) (2) The rib is then freed subperiosteally for nearly 5 cm. (about 2 inches), carefully avoiding injury to the intercostal vessels and pleura — which are in safety as long as the operation is subperiosteal. .About 2.5 to 4 cm. (about i to i^ inches) is now removed with a Gigli saw, as in the ordinarv partial excision of a rib. (3) The intercostal vessels are then easily isolated in the bed of the rib, and are treated according to circumstances — they may be tied at both ends of the wound and divided, where they are likely to be Fig. 351. — Thoracotomy by Partial Excisio.n of a Rib ;—.\, Thoracic muscles divided down to 1 ib. direclly over its center ; B, Periosteum raised and turned back, in the subperiosteal exposure of the rib ; C, Transverse section of rib, indicating portion of rib removed by means of a Gigli or chain saw conducted between rib and periosteum; D, Knife incising through periosteal bed and endotho- racic fascia into pleural cavity. injured — or they may be left intact, the incision into the pleura being made between and paralhl with the upper and lower intercostal vessels. (4) An incision of about 2.5 to 4 cm. (about i to i^ inches) is now carefully made through the center of the p;riosteal bed and in the axis of the former rib, passing through the costal periosteum, endothoracic fascia, and parietal pleura into the pleural cavity — and drainage thus established — the drain used being so placed and of such a nature as not to impinge upon the lungs during resjiiration. Operation by Partial Excision of Two or More Ribs. — (i) If it l>e found, after excising part of one rib, tliat it is desirable to excise part of the rib above or below, or both, add two vertical incisions to the horizontal one, extending from the ends of the former horizontal incision upward to the upper border of the rib above — or two vertical incisions extending downward 604 OPERATIONS UPON THE THORAX. to the lower border of the rib below — or both. A flap of overlying soft parts may thus be turned upward or downward, or in both directions, exposing the two or three ribs — which are then partially e.xcised just as a single rib in the above operation. (2) Where it is wished, from the first, to excise parts of two ribs — make an incision of about 10 cm. (about 4 inches) midway between the two ribs — passing through skin, fascia, and overlying muscles, down to the level of the outer surface of the ribs and intercostal muscles — then retract the upper lip cf the wound upward until the upper rib is well exposed — and the lower Up downward until the lower rib is similarly exposed — incising muscle tissue, or separating by blunt dissection, in the approach toward the upper border of the rib below and the lower border of the rib above, maintaining an even thickness of soft covering everywhere. The ribs thus exposed are partially resected as in the single rib operation. (See Figs. 350 and 351.) (3) Where it is wished to excise parts of three ribs from the first, make an incision in the long axis of the middle one of the three ribs — join this by a vertical incision at either end of the transverse incision, from the upper border of the rib above to the lower border of the rib below (making an H-shaped incision) — and turn one flap upward and the other downward (as explained in (1) above). Parts of three ribs are then excised — the intercostal arteries are ligated at both ends — the nerves are retracted — and an incision made vertically in the center of the area. At the end of the operation, the external wound is closed along the lines cf incision, except that drainage is provided for through an unsutured part of the wound. (4) Where more than part of a single rib is excised, the soft parts which intervene between the beds of the excised ribs, and includ- ing the beds, are carefully incised in a vertical direction, down to the endothoracic fascia — and the pleura is then incised in the same direction. Prior to this, the intercostal vessels corresponding to each rib are ligated at either end of the original wound, so that when divided in their center no bleeding of any consequence occurs. The nerves are drawn out of their beds and retracted upward and downward, out of the way, if possible. Comment. — Parts of three ribs may be excised by a single incision (about 15 cm., or 6 inches, long), made over the central rib, followed by good retraction. After making a thoracic opening at the chosen site, lower openings, or counter-openings, for better drainage, can be made by cutting down upon a curved sound introduced through the original opening and directed to a lower part of the cavity THORACOPLASTY. esti,.\i:nders operation. Description — This operation, suggested by Warren Stone, and estab- lished by Estlaender, consists, as now practised, in the subperiosteal excision of parts of several contiguous ribs over a pleural cavity, together with the removal of their peritisteum, the intercostal tissues, endothoracic fascia, ard the parietal pleura — thereby allowing the corresponding soft thoracic wall to sink in and obliterate the abnormal cavity by the approximation and union of this thoracic wall of integumentary and muscular tissues to the visceral pleura, which has been freshened by curettage. The number of ribs which are partially excised, and the amount of each rib removed, will depend upon the position and extent of the involved area, as determined by the physical signs before operation; or by probing, or by the amount of fluid ccntained. THORACOIM.ASTV— ESTLAENDER'S OPERATION. 60s after openinsr the c:\vh — and usually corresponds with that area. From the second to the ninth ribs, inclusive, have been excised — but generally from the second to the seventh, inclusive, are the ones taken. From the costal cartilages to the tubercles, in amount, has been resected — but the average is from about 13 to 15 cm. (about 5 to 6 inches)- — the amount being greatest where the cavity is widest, and vice versa. The operation is appli- cable to long-standing cases of empyema which have resisted drainage, and in which the lung no longer expands and t'le pleura is much thickened. Originally Estlaender did not remove the c( stal periosteum and intercostal tissues, nor the parietal pleura. The pleural sur- faces were allowed to fall into contact if possible. The pleura was not open- ed, other than for the drainage which may ha\e been previously resorted to — but the external wall with its parietal pleura, minus ribs, was merely allowed to come into con- tact with the visceral pleura Now both the costal periosteum is ex cised (to pre\ent regrowth of bone) together with the intercostal muscles and fascia, and the parietal pleura and endothoracic fascia removed, and even the visceral pleura scraped (to destroy pyogenic mem- brane and to approximate fresh surfaces for union) — and the outer wall held in contact with the visceral pleura by dressings, as far as possible. Preparation. — The thoracic wall is shaved, where necessar}'. Position. — Patient is so placed as to best expose the special site involved, generally resting upon one side — surgeon usually stands in front in operating upon the left side, and behind in operating ui:)on the right side — assistant stands opposite surgeon. Landmarks. — Outline of the empya'mic cavity to Ije obliterated, as determined by physical signs; normal limits of lung and pleura; relation of important adjacent organs. Incision. — Supposing that parts of the second to seventh ribs, inclusive, are to be removed, from the right antero-lateral aspect of the chest-wall — say 8 cm. (about 3 inches) of second rib — 10 cm. (about 4 inches) of third — 13 Fig. 352. — Operations vpon the Pleural Cavity: — A, Incision for Esllaender's thoracoplasty (removing, in this case, parts of second to seventh ribs, inclusive, througli three inter- costal incisions) ; B, Schede's thoracoplasty (removing nearly all of the second to ninth ribs, inclusive! ; C, Position for para- centesis thoracis in the sixth intercostal space, in the mid-axillary 6o6 OPERATIONS UPON THE THORAX, cm. (about 5 inches) of fourth — 15 cm. (about 6 inches) of fifth — 18 cm. (about 7 inches) of sixth, and 20 cm. (about 8 inclies) of seventh — then transverse incisions somewhat longer than the length of the part of the rib to be removed (to allow for sufficient retraction of soft parts to get at the recjuired length of rib) are made in the center of the long a.xis of each alternate inter- space, as follows — between the second and third ribs, for removal of those ribs — between the fourth and fifth ribs, for the removal of those ribs — between the si.xth and seventh ribs, for the removal of those. If an uneven number of ribs were to be removed, three of them could be removed through an incision placed over the central one of the three. The greatest length will be removed from that rib which spans the greatest width of cavitv, whether at the middle cr either end — and narrower lengths toward the tapering or narrowing aspects of the cavity. An equal length of each rib is sometimes removed. (See Fig. 352, A, where a kite-shaped e.xcision is shown.) Operation. — (1) Incise through skin, fascia, and overlying thoracic muscles, until down to the e.xternal intercostal muscles (on a level with the ribs). Tie all bleeding vessels. Retract upper lip of wound, in its full thickness, upward, e.xposing the rib above — cutting, where necessary, muscular fibers close to the level of the external intercostal muscles and external aspect of the rib (so as to keep as thick a flap of soft parts as possible). The lower lip of the wound is similarly retracted, expcsing the lower rib. (2) The upper and lower ribs are now excised subperic-teally to the requisite extent. (3) The above steps are repeated for the second and third pairs of ribs. (4) The intercostal vessels are now tied at both ends of each intercostal bed. (5) There are now three long incisions, and two bridge-like strips of external soft parts, composed of skin, fascia, and outer thoracic muscles. These bridge-like parts are carefully preserved. Beneath these lie a deeper con- tinuous layer of soft parts compcsed of costal periosteum (beds of ribs), external and internal intercostal muscles, endothoracic fascia, and parietal pleura (the last often very much thickened) — all forming the outer wall of the empytemic cavity. Having retracted upward (/. e., outward), out of the way, the above-described bridge-like strips of soft parts, this deeper layer of soft parts just mentioned is all cut away with scissors — well within the ligated intercostal arteries, on either side — and along the highest and lowest inter- costal space of the involved and freed area. (6) The visceral pleura, espe- cially if much thickened, is advantageously curetted. (7) The three original incisions are now sutured throughout, except a part of the lowest is left open for drainage, where drainage is instituted. The new outer wall of soft thoracic tissues is now allowed to come into contact with the freshened visceral pleura — and is held in contact by dressings as far as possible, to prcmotc union and obliteration of the cavitv. Comment. — Considerable hemorrhage occurs throughout the operation, which is controlled by clamp, ligature, pressure, and hot solution. There is not, as now practised, as distinct a difference between Est- laender's and Schede's operations of Thoracoplasty as formerly — modern operators using the good features of both in each. The second rib is left where possible. The external soft parts may be raised as one flap (as Schede does) — cr as several smaller flaps (as Jacobson advises) — or the necessary amount of ribs over a small cavity may be exposed by a vertical incision over the desig- nated ribs, followed by firm retraction (as Pearce Gould suggests). A cavitv wider than long requires the excision of more of fewer ribs — a cavitv longer than wide requiring the excision of less of more ribs. 11 1( )RAi;oPI,ASTV— SCHF.DE'S OPEKATK iX. 607 Where the cavity involves the posterior part of the upper ribs (those behind the scapula), their anterior ends may be severed in the usual way — the posterior ends being severed from the interior of the chest with stout, curved cutting-pliers — after freeing the rib of soft parts. THORACOPLASTY. SllIl;i)i;S (.ll'ERATIDN'. Description. — This operation, more extensive than Estlaender's, differs ill detail from the latter, while being conducted upon the same general prin- ciple, and in the same general type of cases. A large U-shaped flap is raised, corresponding in extent to the underlying cavity (sometimes to nearly the entire pleural cavity) and consisting of all the soft parts overlying the ribs. The ribs, intercostal tissues, endothoracic fascia, and parietal pleura outlined by this incision are then excised en masse — the visceral pleura scraped — and the external flap allowed to fall into contact with the freshened pleura, being sutured back in place and held in contact with the visceral pleura by the dressings — opening for drainage being left. Generally resorted to in old empysemic cases of the worst type, especially where the pleurae are very much thickened, and vi^hich have resisted all other measures, and represents the most radical operation of its kind available, consisting, practically, of the removal of nearly the entire chest-wall of one side beneath the plane of the thoracic muscles. The number of ribs removed is determined by the vertical extent of the cavity, but is generally from the second to the ninth inclusive. The amount of each ril) removed is likewise determined by the width of the cavit\-, but is often from the costal cartilages to the tubercles of the ribs. Preparation — Position. — As for Estlaender"s Thoracoplasty (page 604). Landmarks. — \\'here adapted to a localized cavity, the outline of that cavitv and tlie position of important adjacent structures will determine the landmarks. Where the ma.ximum removal of the thoracic wall is indicated, that amount of each rib (from and including the second downward) which is in contact with the pleural cavity — in the average case, from the second to the ninth, inclusive, and from the costal cartilage to the tubercle. This latter extent will be understood in the following operation. Incision. — Begins anteriorly at the upper border of the second ccsto- chondral articulation (about 2.5 cm., or i inch, from the sternal border) — passes downward following the curve of the chondro-ccstal articulations slightly outward (the cartilages increasing in length as they descend) to the eighth rib in the nipple-line — to the ninth rib in the mid-axillary line on the right side (the tenth on the left) — thence transversely backward to the poste- rior scapular line — thence upward along a line midway between the vertebral border of the scapula and the spinous processes of the verlebra\ to the second rib. (Some surgeons begin the incision at the outer border of the pectcralis major, above the level of the fourth rib — and retract from this point upward to expose the third and second ribs.) (See Fig. 352, B.) Operation. — (i) Incise down to and upon the ribs and intercostal muscles throughout the line of incision — bearing lightly over the intercostal spaces to avoid penetrating the thorax. (2) This entire flan of overlying soft parts is dissected eii masse from the bony and intercostal muscular wall of the thorax, hugging the ribs and intercostal muscles closely (so that the extensive flap may be as thick and well nourished as possible). The scapula, with the subscapularis muscle, are drawn upward and away from the trunk so as to 6o8 OPERATI(_)N.S UPON THE THORAX. give access to the upper ribs and to enable the anterior ])art of the upper ribs, especially where the incision only extends upward anteriorly to the fourth, to be freed. (3) The ribs are now to be divided in front and behind, about 1.5 cm. (about k inch) within the line of division of the soft parts (so that the cicatrix will not fall directly over the line of the ends of the divided ribs). This division is best accomplished in the following wav, devised by Hartley, — Where each rib is to be divided, anteriorly and posteriorly, the periosteum is divided over the center of the rib, midway between upper and lower borders, bv an incision about 4 cm. (about ij inches) long, with the center of the incision at the point where each section of rib is to b^ made. To this more or less horizont2.1 incision, at the two ends of the ribs, add a vertical incision through the periosteum, beginning at the center of the hori- zontal incision, or at both of its ends, and ending at the lower border of the rib. With a curved periosteal elevator, free the lower half of anterior and posterior ends of the ribs where the sections are to be made, for the extent of about 1.5 cm. (about h inch) — especially freeing the intercostal groove with the intercostal vessels. Complete this process of freeing at each end of each rib befcre proceeding to the next step. Now grasp the lower half of each rib, where cleared of periosteum, with rongeur forceps, inserting the lower lip cf the rongeur forceps, between bone and periosteum, and bite out a half-button of bone (O:) which will include the subcostal grcove, and the removal of which will well expose the intercostal vessels. Complete this half-button excision at the inner and outer ends cf each rib befcre proceeding further in the operation. (4) The intercostal vessels are all now ligated at both ends of the e.xposed part of each rib, being easily accomplished by passing a curved needle armed with chromic catgut, beneath them as they lie fullv exposed — plainly in view, or very accessible in their beds, or are made accessible by a very little dissection. The arteries and veins should be picked up separately or together — but especial care should be exercised not to include the intercostal nerves. The vessels thus tied are the inferior intercostal vessels. The upper intercostal vessels are generallv much smaller and may usuallv be taken up with clamp forceps and tied as divided in the csseo-pericsteo-muscular flap. If con- sidered necessary, the superior intercostal vessels may be expcsed in the same manner as the lower ones, by biting cut part cf the upper border of the rib with rongeur forceps. (5) The ribs may now be freely divided at both ends by passing a Gigli saw between periosteum and bene — the saw-carrier easilv passing between the rib and the separated part cf the peril steum which had been freed in excising the half-buttons of bone, and for the balance of the way from the end of the separated area up to the upper border of the bone, hugging the rib closely on its inner aspect and emerging between the upper border of the rib and the position of the superior intercostal vessels. Both ends of all the ribs are thus divided. (6) Nothing now remains but to divide with blunt-pointed scissors the intercostal tissues in the line of the severed ribs on both sides, along the upper border cf the second rib above, and along the lower border of the ninth rib below — thus removing the entire lot of ribs, intercostal tissues, endothoracic fascia, and parietal pleura en masse in a single sheet. (7) The thickened visceral pleura covering the remnant of contracted lung is thoroughly scraped and as much adventitious tissue removed as possible. (8) The flap of skin, fascia, and muscles is now allowed to fall into contact with the freshened visceral pleura — its margin being sutured to the margin of the thoracic opening, except a dependent opening left for drainage. The region is so dressed as to keep the flap in contact SURGICAL AXATOMV OF THE LUXGS. 609 with ttie freshened visceral pleura and aid in early union of the surfaces and obliteration of the cavity — the arm being bound to the side. In this step of closing the wound, all divided thoracic muscles along the line of incision are quilted together by means of a buried row of chromic gut sutures, before placing the final tier of sutures. Comment. — (i) After the flap of soft parts has been turned back each rib may be excised subperiosteally and then the intercostal tissues cut awav, as in Estlaender's operation — but much more time is consumed. (2) While removing the deeper flap composed of ribs, intercostal muscles, endothoracic fascia, and parietal pleura, a sound or a finger within the cavity should guide the scissors along the contour of the portion being excised. (3) The second rib is left where possible. (4) The scapula is displaced forward during the posterior incision. (5) The upper ribs may be removed from within the cavity, after division at laoth ends, as explained in Estlaender's operation. OTHER OPERATIONS UPON THE PLEURiE. See Operations upon the Lungs (pages 609 to 614) — and Operations upon the Liver (pages 800 to 815). IX. THE LUNGS. SURGICAL ANATOMY. Relations. — Apex; extends from 1.2 to 4.5 cm., averaging 2.5 (from ^ to I J inches, averaging i), abo\e level of first rib into the neck (but not e.xtending higher than the neck of the first rib) — lying beneath subclavian artery, and behind interval between two heads of sternomastoid and inner end of clavicle — and covered by subclavian artery and scalenus anticus. Right apex may project slightly higher than left. Base ; rests upon convexity of diaphragm. External suriface ; chietly corresponds to cavity of thoracic wall. Internal surface; in contact with pericardium and lateral pleural wall of mediastina. Anterior border; overlaps anterior surface of pericardium on right, and partially so on left. Posterior border; fits into concavity on either side of vertebral column. Inferior border; fits into space between inferior ribs and costal attachment of diaphragm. Relations of Margins of Lungs to Chest-wall. — Anterior margins; extend from their apices (at an average point of 2.5 cm., or i inch, above the first rib, and nearer posterior than anterior border of sternomastoid) downward and inward across sternoclavicular articulation and manubrium sterni to near center of articulation of manubrium and gladiolus, where the two margins meet, or very nearly meet — thence both borders descend parallel to each other and just beyond the middle line (the ri'^ht sometimes slightly overlapping it) to midway between the level of the articulations of the fourth costal cartilages with the sternum— from which point they diverge unequally. Right margin continues to descend almost vertically downward to si.xth chondro-sternal articulation (sometimes to lower end of gladiolus), whence it curves downward and outward along that cartilage to sixth costo-chondral articulation. Left margin, from j)oint of divergence, passes along lower border of fourth rib outward with a downward inclination, and then down- ward across fourth interspace and fifth rib with an outward inclination to apex of heart (a point 3.8 cm., or 1} inches, below, and 2.5 cm., or i inch, to inner side of left male nipple in fifth interspace) — thence to sixth costo- 39 6lo OPERATIONS UPON THE THORAX. chondral articulation. Lower margins ; marked by a slightly curved line, with downward conve.xity, extending from si.xth costo-chondral articulation to spinous process of tenth dorsal vertebra — crossing (while arms are elevated at right angle) the nipple-line at sixth rib — mid-axillary line (arms still raised) at eighth rib — scapular line (arms now lowered) at tenth rib. Lower margin of left lung starts on level with si.xth costo-chondral joint, but much further out than right — about 7.5 cm. (3 inches) to left of median line in fifth inter- space. Sometimes lower margin of left lung may be one rib lower than right. Posterior margins ; marked by line from level of spinous process of seventh cervical vertebra, passing vertically downward on either side of spine, over the costo-xertebral articulations, to spinous process of tenth dorsal vertebra. Excursion of Lower Borders of Lungs in Forced Respiration. — Extend about 3.S cm. (1^ inches) below the line given above for the rela- tion of the lower margin, in deep inspiration — and rise above it in forced expiration. Relations of Fissures of LungS to Chest-wall. — (i) Great or Lower Fissure of Right Lung: — draw line from fourth dorsal \ertebra forward and downward around chest to intersection of anterior margin of lung and seventh rib. (2) Lesser or Upper Fissure of Right Lung: — draw line from point of intersection of preceding line with mid-axillary line, to fourth chondro- sternal articulation. (3) Fissure of Left Lung: — draw line from third dorsal vertebra forward and downward around chest to intersection of anterior margin of lung with sixth costal cartilage. Structures of Roots of Lungs, and their Relations. — Structures of each root; bronchial tube, pulmonary artery, pulmonary veins, bronchial arterv (generallv one on right and two on left), two bronchial veins, anterior pulmonarv plexus of nerves, posterior pulmonary plexus of nerves, bronchial Ivmphatic glands, areolar tissue — all being enclosed within pleura. Rela- tions of right root : .\nteriorly; right auricle, superior vena cava, ascending aorta, phrenic nerve, anterior pulmonary plexus. Superiorly; vena azygos major arching to join superior vena cava. Posteriorly; pneumogastric nerve, posterior pulmonary plexus. Inferiorly; ligamentum latum pulmonis. Relations of left root: .-Xnteriorlv; phrenic nerve, anterior j)ulmonary plexus. Superiorlv; arch of aorta. Posteriorly; descending aorta, pneumo- gastric ner\e, posterior pulmonary ])lexus. Inferiorly; ligamentum latum pulmonis. Order of structures of right root: From Before Backward; pulmonarv \-eins, pulmonary artery, bronchus, and bronchial vessels. From .■\bove Downward; bronchus, pulmonary artery, pulmonary veins. Order of Structures of left root: From Before Backward; pulmonary veins, ])ulmonarv arterv, bronchus, and bronchial vessels. From .-Vbove Downward; pulnionar\' arterv", lironchus, pulmonary veins. Position of Hilum of Lung. — Upon inner aspect, slightly above middle, and much nearer posterior than anterior border — on level with Ijodies of fifth, sixth, seventh, and sometimes eighth dorsal vertebra\ Bifurcation of Trachea and Bronchi. — Trachea bifurcates opposite the spinous process of fourth dorsal \ertebra — right bronchus passing nearly horizontally outward and (lixicjing into three chief Ijronchial tubes — left bronchus passing more directlv downward and dividing into two chief liron- chial tubes. Arteries. — Pulmonary; bronchial. Veins. — Pulmonarv; bronchial. Nerves. — From anterior and posterior pulmonary plexus, formed mainly by svmpathetic and pneumogastric. Lymphatics. — End in bronchial glands. PXEUMOTOMV. 6ll PNEIMOTOMY THROUGH A THORACOPLASTIC FLAP. Description. — Incision of lung tissue through a temporary opening made in the chest-wall. This opening may be made in the form of an intercostal thoracotomy, — through the partial resection of one or more ribs, — or through an osteothoracoplastic flap. In the present instance, a partial resection of three ribs will be made, after raising a thoracoplastic flap. Generally resorted to in cases of abscess, gangrene, hydatid cyst, and sometimes for bronchial dilatation and tuberculous cavities. Preparation. — Chest-wall is shaved where hairy growth e.xists. Position. — Patient so placed as to render site of operation accessible during exposure of lung — but placed so as to render site dependent before cutting into lung tissue (that fluid may not flow into bronchial tubes opened by incision, in addition to that which may be drawn into them). Surgeon on side of operation — assistant on same side, or opposite. Landmarks. — Determined by physical signs locating disease, and gener- ally \critied by preliminary exploration; known position of important struc- tures. Incision. — .\ U-shaped flap is outlined, with base generallv upward and convexity downward — usually e.xtending over two or three ribs, and of sufficient size to well include the incision into the lung, with room for manipu- lation. (Vitality of flap would be better assured if base were forward or backward and convexity in opposite direction.) Operation. — (i) This U-shaped flap of all the soft parts down to the ribs and intercostal muscles is raised. (2) Having controlled hemorrhage, the necessary parts of the indicated ribs are excised subperiosteally — calculating that the line of division of the ribs will fall about i cm. (nearly ^ inch) within the line of flap-incision (that cicatri.x of latter may not fall over ends of ribs). (3) An exploratory needle may now be introduced through the periosteal bed of a rib, thus avoiding the intercostal vessels — and the needle mav be left in situ as a guide. (4) .\n incision is now carefufly made in the long axis of a space, or, preferably, in the bed of a rib, avoiding intercostal vessels, — if in a space, passing through intercostal muscles and endothoracic fascia — if in the bed of a rib, passing through periosteum and endothoracic fascia. In the transverse incisions sufficient room can usually be gotten bv upward and downward retraction of the soft parts, without requiring the division of the vessels. If it be elected to make a vertical opening, after removing the ribs, then the intercostal vessels are ligated at both ends of the exposed beds of the excised ribs — so that when the vertical incision is made in the center of the e.xposed area, little or no hemorrhage will occur. This vertical incision is in the center of the area from which the ribs have been partially excised, and extends between the intact ribs above and' below. In any event, the incision should be made, if possible, down to but not directlv through the parietal pleura, at this stage. (5) Here one of two conditions will be found; — (A) The parietal and visceral pleurae may be adherent — the general pleural cavity will then be walled off, and the incision may be made directly into the lung tissue — having determined its depth by exploratory puncture. (B) Parietal and visceral pleuras may be non-adherent; (a) If it be nece.ssarv to proceed with the operation at once, .suture the two surfaces of the pleurae together with catgut, in a sufficiently large circle — thus closing off the general pleural cavity by suture and by packing the outer circumference of the circle with gauze. The incision may be then made at once into the lung through 612 OPERATIONS UPON THE THORAX, the above circle, (b) If no need of haste exist, pack the wound with gauze a Httle firmly, so that the pleural surfaces are held in contact — and in two or three davs the surfaces will be united for some distance around, and incision into lung tissue may be made through the united surfaces, without fear of invading the general pleural cavity. This adhesion is made more certain and firmer by also suturing the pleune in a circular manner at the time of the exposure. (6) Incision into the lung is usually made in the direction of the original incision by which it has been approached — the incision extending through the full thickness of the variously thick layer of lung tissue overlying the cavity. (7) Drainage is provided for — the drain coming out through an unsutured lower part of the tJap, the remainder of the flap being sutured back into place — or the drain may come out through a convenient opening in the flap, the circumference of the flap being sutured throughout. Comment. — (i) Usually the removal of parts of one or two ribs suflfices to expose the site. (2) The distance of the cavity from the surface should be determined by needle before incising. (3) The following methods of incising the lung tissue are used; — actual cautery — best for soft lung tissue; incision by knife — safe in hardened lung tissue; e.xploratory needle and small groo\'ed director introduced simultaneously — the needle is withdrawn and director left in silii — upon which dilators of increasing size are sHpped into cavity, which is then dilated; blunt dissection; trocar and cannula. (4) If hemorrhage occurs from lung tissue, pack with gauze. (5) Collapse of lung is very apt to follow going through the opened pleural cavity (where the two surfaces are not united by adhesion) — requiring the use of a Fell-O'Dwyer instrument. (6) Pneumotomy may be performed by means of an osteo- thoracoplastic flap, as described under Pneumectomy — or b_\- any method which satisfactorily exposes the lung. PARTIAL PNEUMECTOMY THRfHT.H AN OSTEO-Tl !( )RArol'LASTIC FI.Ar. Description. — The excision of part of a lung involved in some lesion — an uiuiimmon though possible operation. Access may be obtamed by the permanent excision of parts of several ribs, after raising a thoracoplastic flap, as described under Pneumotomy — or, belter still, by the turning back tem- porarily of a window consisting of the entire thickness of the soft and bony parts of the chest-wall. The operation has generally been resorted to for the removal of malignant and hydatid tumors of the lungs — and also for localized tuberculosis. In the latter cases the part excised has usually been the apex. Preparation — Position — Landmarks. — As in Pneumotomy. Incision. — (1) Supposing the tumor to be of the middle lobe of the right lung — an incision is to be planned outlining an upper, a lower, and an anterior side of a square or rectangle, the fourth or po.sterior side forming the hinge — the square including the antero-lateral aspect of the fourth, fifth, and sixth ribs. The upper line will lie in the middle of the third interspace, in its long axis — the lower line will be similarly placed in the center of the sixth interspace — the anterior line will run verticnllv about 2.5 cm. (i inch) outside of the costal cartilages — and the posterior side will be parallel with the anterior and from 10 to 13 cm. (about 4 to 5 inches) behind it. (2) Supposing the case to be one of localized tuberculosis of the apex of the left lung — a U- shaped flap is planned, with its convexitv over the middle of the sternum; its PARTIAL I'XKUMECTdMV. 613 base reaching nearly to the anterior axillary line; its upper horizontal limb in the middle of the first intercostal space; its lower horizontal limb in the middle of the third intercostal space. Operation. — Carrying out the steps of the operation indicated in the first incision given above — (i) Incise through skin, fascia, and overlying thoracic muscles; down to the ribs and intercostal muscles, along the upper, lower, and anterior sides only. (2) Along the anterior line, where the ribs are intersected by the vertical portion of the incision, retract the soft parts a limited distance on each side over the ribs — and make a short incision directly over the center of their long axes, passing through the periosteum (not through the skin) — free the circumference of the ribs here subperiosteally with a curved periosteal elevator over the least width of rib possible to accomplish its freeing. Do not yet divide the rib. (3) A short incision is now made directly over the center of the long axis of the ribs posteriorly, through all the overlying soft parts down to and through the periosteum — the center of each incision being an imaginary line connecting the posterior ends of the upper and lower lines (just as the center of the trans-periosteal incisions anteriorly was the real line connecting the anterior ends of the horizontal lines of incision). The ribs are here freed subperiosteally as in front — their circumference being bared over the smallest space practicable. (4) A Gigli saw is now carried beneath the freed portions of the ribs in front and behind — thus entirely freeing the bony connections of the flap. (5) The upper, lower, and anterior sides of the square, or rectangle, are now carefully incised through their soft structures not already divided, down to the endothoracic fascia, carefully avoiding penetration of the parietal pleura. (6) This large cutaneo-musculo-osseous flap is now carefully elevated and turned backward upon its posterior hinge (which hinge, as far as the soft parts and the integrity of their blood-supply go, has been very little injured by the longitudinal cuts over the ribs) — carefully separating it from the parietal pleura as it is turned backward. (7) If it be found that the two surfaces of pleur;c are not ad- herent, the wound is rather snugly packed with gauze — the flap turned as far back into place as the gauze will allow — and adhesion is awaited for three or four days. Or the vitality of the flap and the firmness of adhesion would probably be more safely and thoroughly secured if the parietal and visceral pleura- were sutured around the extreme margin of the wound with catgut — allowing the flap to fall fully into ])lace, where it could either rest, or be sutured, the necessary time for adhesions to form — and subsequently raised for the excision of the growth. Or the pleura may be incised and the opera- tion completed immediately, after the suturing together of the pleural sur- faces. (8) At the time of the removal of the tumor, the method of the removal will be somewhat determined by the character of the tumor. Whether fluid (e.g., hydatid cyst) or solid (e.g., primary malignant tumor), if its accessi- bility will allow, it is best to ligate off the surrounding lung tissue by carrving chromic gut in a large, fully-curved needle around the growth in segments — and then excise by actual cautery, knife, or blunt dissection, where possible. (See Pneumotomy, page 611.) Sometimes previous ligation is impossible — the tumor is then removed without it, and hemorrhage controlled by packing the cavity with gauze. It sometimes happens in hydatid cysts that the tumors have to be incised, their contents evacuated and their walls curetted, the remainder being allowed to slough out — although complete removal of their walls is much preferable. (9) The cavity left by the removal of a tumor should be temporarily packed with gauze — which is brought out for drainage through a convenient opening made at a margin of the flap — the flap being 6X4 OPERATIONS UPON THE THORAX. elsewhere sutured hack into its normal position. As the ribs are adherent to the soft part of the flap, which will be sutured to the thorax around its margin, the ribs will thereby be held in place and prevented from being materially displaced. If, when the section of the ribs is made, it be done in a beveling fashion (at the e.xpense of the inner aspect of the parts of the ribs in the flap), when the flap is turned back into place this beveling will addi- tionally steady the rib ends in place. If desired, the contiguous ends of the severed ribs, in front and behind, can be united by chromic gut or silver wire, after having been previously drilled. Comment. — (i) In carrying out the steps of the operation indicated in the second incision given above, the description given under Pneumotomy bv a Thoracoplastic Flap will sufficiently cover, being practically similar. The indurated apex of the lung, when exposed, is seized with forceps — de- taching it, if necessary, from its adhesions — and withdrawn through the thoracic opening — a chromic gut ligature is then carried below the involved portion — or a double ligature is passed through upon a needle and each side tied separately — the apex is now excised — the lung replaced, after bringing together the raw surfaces of the lung by gut suture, if possible — and the edges of the parietal pleura; sutured with catgut. The operation is completed as in Pneumotomy by Thoracoplastic Fla]x (2) Tuffier has removed portions of tubercular lung through a simple intercostal thoracotomy in the second interspace — opening the pleura and delivering and excising the involved portion of lung. (3) Where the ligature is not used, the actual cautery is the safest means with which to excise lung tissue. (4) The operation is simplified if the neighboring healthy lung is adherent to the parietal pleura. Collapse is also much less likely. (5) The lower two-thirds of the first rib are sometimes alone excised. X. THE PERICARDIUM. SURGICAL ANATOMY. Position. — Occupies middle mediastinum of thorax, lying between anterior mediastinum, in front (opposite sternum and third, fourth, fifth, sixth, and seventh costal cartilages) — posterior mediastinum, behind — and pleuras, laterally. Consists of visceral and parietal layers. Has general outline of heart, exce|it where reflected on to great vessels at base of heart. Attachments. — Apex; covers great vessels for about 5 cm. (2 inches) and is held in position by them. Base; attached to central tendon of dia- phragm and adjacent surface. Anterior surface of pericardium ; attached to posterior surface of manubrium and ensiform process by superior and inferior stcrno-pericardial ligaments. Relations.— Superiorly ; great vessels of heart. Inferiorly ; diaphragm. Anteriorly; thymus gland (or remains); areolar tissue; margins of lungs (especially left); sterno-pericardial ligaments; triangularis sterni muscle; internal mammary vessels; anterior mediastinum; sternum. Posteriorly; bronchi; esophagus; descending aorta; pneumogastric nerves; posterior medi- astinum. Laterally; pleura;; anterior margins of lungs (especially left); phrenic nerves; accom])anving phrenic vessels. Structures Covered by Pericardium. — .Aorta; superior vena cava; pul- monary artery and bifurcations; ductus arteriosus; four pulmonary veins. Arteries. — Pericardiac and musculophrenic from internal mammary; PARACENTESIS PERICARDII. 615 pericardiac, esophageal, and bronchial from descending aorta; coronary from ascending aorta; phrenic from abdominal aorta. Veins. — Pass to azygos, internal mammary and phrenic trunks, cardiac veins emptying into right auricle. Nerves. — Branches from pneumogastric, phrenic, and sympathetic. Lymphatics. — Em]3ty into mediastinal glands. SURFACE FORM AND LANDMARKS. The anterior surface of the upper portion of the pericardium is from 3 to 5 cm. (about i| to 2 inches) posterior to the sternum — and the anterior surface of the lower portion is about 1 cm. (about f inch) posterior to the sternum. Normally there is a collapsed cul-de-sac at the base of the anterior portion of the pericardium, which is much distended in effusion. This is the site sought in drainage. According to Voinitch-Sianojentsky, the interpleural pericardial area extends vertically from the lower border of the left fifth chondro-sternal articulation to the left seventh chondro-sternal articulation — lying mainly behind the sternum but also corresponding to the sternal end of the sixth intercostal space — wherefore, puncture of the pericardium in the sixth space may be made directly inw-ard — whereas it should be directed very obliquely downward if made in the fifth interspace, to avoid the heart (that is, it runs parallel with the heart after entering the pericardium). A cartilaginous bridge unites the sixth and seventh costal cartilages — and sometimes also the fifth and sixth — and thereby the intercostal area for puncture, between the inner border of the cartilaginous bridge and the left border of the sternum, may be considerably encroached upon. The internal mammary artery runs down at an average distance of about 1.2 cm. (about ^ inch) to the outer side of the sternal border — to the sixth interspace, where it divides into the superior epigastric and the musculo- phrenic. For outline of Pleura, see Anatomv of Pleura. PARACENTESIS PERICARDII. Description. — Penetration of the pericardium by a hollow needle attached to a vacuum svringe — for the purpose of exploration of contents, or aspiration of fluid. Preparation. — Region shaved, if necessary. Position. — Patient supine, preferably resting upon some object which will render chest prominent and increase the width of the intercostal spaces. Surgeon on left of ])atient. Sites of Puncture.— Puncture may be made in either the fifth or sixth interspace — and either internal to or external to the internal mammarv arterv. In the fifth interspace, the width is greater near the sternal border, and is the space usually chosen. In the sixth interspace, the internal mammary artery and the pleura are both further from the left sternal border, and puncture may be made more directly inward, ^^"here sufficient width of space exists, the sixth interspace may be chosen. Puncture should, by preference, be made internal to the internal mammary artery, as the pleura is in less danger of injury, especially in the fifth space — and even in the sixth space, the punc- 6i6 OPERATIONS LI'OX THE TIUJRAX. ture would have to be about 2.5 cm. (about i inch) outside of the border of the sternum to be sure of avoiding the internal mammary artery, and then it is apt to strike the pleura. (See Fig. 353, G.) Landmarks. — Fifth left intercostal space (or si.\th) ; left margin of sternum; course of internal mammary artery; anterior border of left lung and pleura; right border of heart. See the Surgical Anatomy of these structures. Operation — ( 1) An incision should be made in the long a.xis of the sternal end of the fifth intercostal space, through skin, fascia, pectoralis major, down to the intercostal membrane, clam])ing all bleeding vessels. (2) Expose the in- tercostal membrane by retraction of the edges of the wound. Grasping the needle with right forefinger and thumb, so placed as to prevent its suddenly entering too far, pierce the fi f t h intercostal space near the left bor- der of the sternum, and near the upper border of the sixth costal carti lage — penetrate straight backward about 0.8 cm. (about j\ inch), which is, approximately, the thickness of the stern- um — then penetrate in- ward toward the poste- rior surface of the stern- um for I to 2 cm. (f to || inch), to avoid the pos sible forward extension of the pleura — thence penetrate downward and inward through the peri- cardium — the sensation generally indicating when the pericardium is entered. Briefly stated — pass backward, in ward, and downward (Delormeand Mignon). Where the sixth inter costal space is used, the needle is passed directly inward and backward, close to the sternum and in the middle of the interspace (\'oinitch-Sianojentsky). Comment. — Puncture may be made without prexious incision, but pre- liminary incision is better, as the intercostal space and border of the sternum are exposed, and the course and depth of the needle and entrance into the pericardium are better appreciated. Also the bridge of cartilage across the intercostal space, when present, may be avoided. Fig. 353. — Incisions and Paracenteses about the Heart AND Pericardium :— A. Outline of right iuiig; B. Outline of left lung; C, Outline of heart ; D, Elevation of diaphragm ; E, Para- centesis of right auricle ; F. Paracentesis of right ventricle ; G, Paracentesis of pericardium ; H, Pericardiotomy through an inter- costal space ; I. E.vposure of pericardium and heart by excision of left fifth costal cartilage. (Modified from Gray.) PERICARDIOTOMY THROUGH AN IXTKRCOSTAL INCISION. Description. — Incision of the pericardium through the fifth intercostal space — generally resorted to for purposes of drainage. The method here EXPOSURE OF PERICARDIUM AND HEART. 617 described will be the simpler one of exposing and incising the pericardium through an intercostal incision. The more e.xtensive exposures involve the removal of part of the cartilaginous or bony wall of the thorax. The inter- space where the operation of intercostal pericardiotomy is usually done is so narrow that the o])eration b}- excision of the fifth costal cartilage is much [)refcral)le. Preparation and Position. — As for Paracentesis Pericardii. Landmarks. — Sternal end of left fifth intercostal space (between fifth and >ixth rib-cartilages); and other landmarks mentioned under Paracentesis Pericardii. Incision. — Incision in center of fifth intercostal space, parallel with its long axis — beginning at the left sternal border and extending 5 to 7.5 cm. (about 2 or 3 inches) in length. (See Fig. 353, H.) Operation. — (1) Incise skin, fascia, pectorahs major, external intercostal membrane, internal intercostal mu.scles — ligating all bleeding vessels. (2) Internal mammary artery is either divided between two ligatures, or, prefer- ably, drawn outward. (3) Triangularis sterni muscle is divided, or its fibers separated by blunt dissection. If the pleura be in the field, it will be ex-posed after passing through the triangularis sterni, and should be carefully dis- placed outward. (4) The pericardium is now within sight and touch — and is carefully seized and steadied by two toothed forceps and incised for i to 2.5 cm. (about i to i inch) between them, in a direction downward and out- ward from the border of the sternum. (5) The edges of the pericardium are sutured into the deeper plane of the thoracic wound — that is, at the opening through the internal intercostal muscle. Drainage is established from the interior of the pericardium through the lowest part of the outer wound, the upper ]jortion of which may be closed. Comment. — (a) The pericardium should be opened with scissors, and t' e opening increased by blunt-pointed sci.ssors or probe-pointed knife, (b) Pericardiotomy may also be performed, but less safely, through the costo-xiphoid angle (Larrey's space). EXPOSURE OF PERICARDIUM AND HEART l;\' I-;.\(.1SI()X OF LEFT FIFTH CciSTAL C.\RTIL.\GF. Description. — Exposure of pericardium and heart after e.xcision of the left fifth costal cartilage — and, where more room is required, also of the fourth and sixth costal cartilages. Generallv resorted to for suturing wounds of the heart and pericardium and for drainage of the latter — especially in those cases where more space is required than attainable by the intercostal operation. Preparation— Position. — .\s for Paracentesis Pericardii. Landmarks. — Left fifth costal cartilage; and other landmarks men- tioned under Paracentesis Pericardii. Incision. — Directly over center of fifth costal cartilage — beginning over center of sternuin and ending just bevond chondrocostal articulations. (See Fig. 3s;v I;) Operation. — (i) Incise skin, superficial fascia, pectoralis major, and deep fascia directly down upon the full length of the fifth costal cartilage, ligating all vessels severed. (2) Isolate the fifth costal cartilage from its neighboring structures (external interco.stal membrane, internal intercostal muscle, and triangularis sterni, if any of the last be attached) as completely 6l8 OPERATIONS UPON THE THORAX. as possible, by hugging and clearing the cartilage closely. Divide its sternal and costal ends with blunt-pointed pliers — or, preferably, with Gigli saw. (3) Ligate the intercostal vessels at both ends of the wound and divide them between the ligatures. Divide tissues which intervene between bed of carti- lage and internal mammary artery. Cut the internal mammary artery be- tween two ligatures, or draw it outward. Incise the triangularis sterni if necessary, or separate it from the sternum and push it to the right. Displace the pleura outward, after careful separation from the pericardium and sternal structures. (4) The pericardium is now in the tield, and is treated as indi- cated by the object of the operation; — In Pericardiotomy (for drainage) the pericardium is steadied between two toothed forceps and carefully incised obliquely downward and outward from close to the border of the sternum; — In Pericardiorrhaphy (for incised wounds of the pericardium) the lips of the pericardial wound arc approximated and so sutured with catgut as to bring Fig. 354. — Exposure of Pericardium and Heart by Partial Excision of Lefi' Fifi h Costal Cartilage : — A, Pecloralis major muscle retracted, overlying the retracted intercostal muscles and membrane ; B, Internal mammary vessels ; C, Intercostal vessels ; D, Sternum and part oi fifth costal cartilage; E, Pleura and lung retracted; F, Pericardium, incised and margins retracted ; G, Heart, showing incised wound being sutured. the serous surfaces together. (5) Where the pericardium has been incised for drainage, it is sutured into the lower plane of the outer wound — that is, the triangularis sterni and internal intercostal muscles. The external wound is closed in greater part, and drainage provided from the interior of the peri- cardium through the part of the thoracic wound left open. \Miere the peri- cardium has been sutured, temporarv drainage of the external wound only is instituted, through a limited opening — the remainder of the thoracic wound being closed. (See Fig. 354.) Comment. — (a) This mav be considered the best manner of exposing the pericardium and heart — and the opening of the pericardium after free exposure may, ordinarilv, be considered safer than puncture or aspiration through an unopened thorax, (b) Having excised the fifth costal cartilage by the above incision, if more room be recjuired, or it be desired also to remove the fourth and sixth costal cartilages in addition, the object may be accom- plished by making a vertical incision at the inner end of the original inci-sion, SURGICAL ANATOMY OF THE HEART. 619 down the center of the sternum, and another vertical incision at the outer end of the original incision. Where both the fourth and si.xth costal cartilages are to be removed, these two vertical incisions will e.xtend from above the fourth to just below the sixth cartilages, thus making an i-i-shaped incision, and enabling two llaps of soft parts down to the cartilages to be turned, the one upward, and the other downward. If it be desired to remove onlv the fourth cartilage in addition, then only the upper parts of the vertical incisions are added. If only the sixth cartilage must be additionally removed, then only the lower parts of the vertical incisions are used. If it be known from the start that two or more costal cartilages must be removed, an oval or modi- fied horseshoe flap of soft ])arts with its base over the sternum and its con- vexity extending beyond the outer limit of the excision, may be used, — or an I-shaped incision, the vertical portion being from i to 2 cm. (about ^ to | inch) from the sternum, the transverse parts corresponding with the uppermost and lowermost ribs to be removed, may be used, the two flaps thus outlined being turned inward and outward. .Additional room may always be gotten by resecting, with rongeur forceps, the left border of the sternum. EXPOSURE OF PERICARDIUM AND HEART BY OSTECJ-THORACOPI.ASTIC RI'.SECTKlX OF AXTKRIOR CHEST-WALL. See the osteoplastic resection of the chest-wall for e.xposure of the anterior and middle mediastina (page 590). Used where the most extensive exposure of the pericardial and cardiac regions is indicated. PERICARDIORRHAPHY. Consists in the suturing of W(iunart of left. Posterior surface; formed mainly by left ventricle. Relations of Heart to Chest-wall. — Base; corresponds to line from point on lower horrier of second left costal cartilage 2.5 cm. (i inch) from sternum, to upper border of third right costal cartilage 1.2 cm. (about \ inch) 620 OPERATIONS UPON THE THORAX. from sternum. Apex; corresponds to [joint 3.8 cm. (aliout lA inches) below, and 2 cm. (| inch) internal to left m;de nipiile — which is about q cm. (about 3^ inches) to left of median line, and between fifth and si.xth costal cartilages, and just internal to end of fifth rib. Lower border; corresponds to line from apex, with slight downward convexity, to seventh right chondro-sternal articulation. Right border; represented by line joining right extremity of base-line with right extremitv of lower border-line (seventh right chondro- sternal articulation), with a slight outward convexitv projecting about 3.8 cm. (about I7 inches) from median line. Left border; represented by line joining left extremity of base-Hne with apex-point, with slight convexity to left — extending about 7.6 cm. (about 3 inches) to left of median line of sternum. Relations of Parts of Heart to Chest-wall. — Right auricle; behind sternal ends of third, fourth, fifth, and sixth costal cartilages of right side; corresponding intervening spaces; right border of sternum. Right auricular appendix; behind or to left of median line, on level with third costal cartilages. Left auricle ; extends vertically from level of lower border of second left costal cartilage to upper border of fourth — and corresponds, hori- zontally, with body of seventh dorsal vertebra and heads of adjoining left ribs. Apex of left auricular appendix ; behind third costal cartilage, about 3.2 cm. (ij inches) to left of sternum. Right ventricle; extends from third costal cartilage abo\e, to sc\enth costal cartilage below, on left side. Right auriculo-ventricular sulcus; line obhquely upward, from sternal end of sixth right costal cartilage, to third left costal cartilage. Left ventricle; not in contact with chest-wall, except small part of ajjex of left ventricle during expiration. Relations of Orifices of Heart to Chest-wall. — Pulmonary crifice (Pulmonary Semilunar ^'alves) ; behind junuion of upper border of left third costal cartilage with sternum. Aortic orifice (Aortic Semilunar Valves) ; behind left half of sternum, opjiosite lower border of third costal cartilage. Left auriculo-ventricular opening (Mitral Valves); behind sternum, to left of median line, opijosite fourth costal cartilage. Right auriculo-ven- tricular opening (Tricuspid \'al\es); behind center of sternum, oppi site fourth intercostal space. Relations of Uncovered Area of Heart to Chest-wall. — The triangular area of the heart uncovered by pleura is represented within the three following lines; — (a) Draw line downward and to left from middle of sternum, between fourth costal cartilages, to apex of heart; (b) Draw line from starting-point of first line down the lower third of the central line of the sternum; — (c) Draw line from sternal end of si.xth right costal cartilage through seventh left costal cartilage. Arteries. — Anterior and posterior coronary. Veins. — Corresjxmd with arteries, emptying into right auricle. Lymphatics. — End in thoracic and right lymphatic ducts. Nerves. — From cardiac plexus. PARACENTESIS OF RIGHT AURICLE OF HEART. Description. — Puncture of right auricle of heart by needle of aspiratory svringe — for the purpose of withdrawing a portion of the blood in cases where tiie right side of the heart is engorged from obstruction to the circulation through the lungs. Preparation — Position. — As for Paracentesis Pericardii. Landmarks. — Position of right auricle. CARDIORRHAPHV. 621 Operation. — An aspiratory needle, so held as to control the depth of puncture, is entered in the right third intercostal space, close to the margin of the sternum — and thrust directly backward through skin, fascia, pectoralis major, external intercostal membrane, internal intercostal muscle, probably through fibers of triangularis sterni, through areolar tissue of anterior medi- astinum, both layers of pleura, periphery of right lung, into the right auricle — its entrance generally being recognized by the sensation, and verified by the free flow of blood into the syringe. The requisite amount of blood is with- drawn — and the wound is sealed with sterile cotton and collodion. (See Fig. 353, E.) Comment. — (a) .\ preliminary incision may be made in the intercostal space, down to the intercostal membrane — whereby the entrance of the needle into the auricle, especially in thick thoracic walls, is more readily recognized. However, in using a vacuum syringe, this is not generally neces- sary, (b) It is necessary to withdraw blood by suction, as the blood-pressure in the right auricle is not sufficient to cause spontaneous flow, (c) The right auricle is preferable to the right ventricle for operation, because its position is not apt to be altered and its internal antero-posterior diameter is greater than that of the right ventricle. PARACENTESIS OF RIGHT VENTRICLE OF HEART, Description. — Puncture uf right ventricle of heart Ijy needle of aspiratory svringe, or bv fine trocar and cannula — in the same cases as mentioned under Paracentesis of Right .\uricle (i\'s an! and coccygei muscles ("diaphragm of pehis "). Laterally ; lnwer llmracii , and abdominal and pelvic walls. Boundaries of Abdominal Cavity. — Superiorly; central tendon of dia- phragm (rising to about inferior end of sternum, or seventh chondro-sternal joint); right half of diaphragm (to about level of fifth rib, or about 2.5 cm., or I inch, below right male nipple); left half of diaphragm (rising not quite so high as right) ; costal arches and ensiform process of sternum. Inferiorly ; ileo-pectineal lines, laterally; crest of pubic bones, anteriorly; base of sacrum and sacro- vertebral angle, posteriorly; Poupart's hgaments, superficially. Boundaries of Pelvic Cavity. — Superiorly; ileo-pectineal lines, later- allv; crest of pubic bones, anteriorly; base of sacrum and sacro- vertebral angle, posteriorly. Inferiorly; Anteriorly; pubic arch and subpubic liga- ment; rami of os pubis and ischium; — Posteriorly; great sacro-sciatic liga- ments and tip of coccyx; — I^aterally; tuberosities of ischia. Regions of the Abdomino-pelvic Cavity and Their Contents. Basis of divisions; Two horizontal lines are drawn — one corresponding with the lowest part of the tenth costal arch — the other with the mo.st prominent lateral points of the iliac crests; — and two vertical lines are made to intersect these passing upward from the center of Poupart's ligaments — thus forming the nine following regions (Quain);— Epigastric; most or all of left lobe of liver; part of right lobe of liver; gall-bladder; part of body and cardiac and pyloric orifices of stomach; first and second parts of duodenum; duodeno-jejunal flexure; pancreas; supero-internal part of spleen; parts of both kidneys; suprarenal bodies. Right hypochondriac; most of right lobe of liver; hepatic flexure of colon; part nf riLdit kidney. Left hypochondriac; por- tion of stomach; greater part of spleen; tail of pancreas; splenic flexure of colon; part of left kidney; part of left lobe of liver (sometimes). Umbilical ; most of transverse colon; third part of duodenum; some convolutions of jejunum and ileum; part of mesentery; part of great omentum; jiart of right kidney (sometimes parts of both). Right lumbar; ascending colon; portion of right kidney; part of ileum (sometimes). Left lumbar; de scending colon; part of jejunum; small part of left kidney (sometimes) Hypogastric; convolutions of ileum; bladder in children (and in adults when distended); gravid uterus; sigmoid loop; upper portion of recturn._ Right iliac; caecum, with vermiform appendix; end of ileum. Left iliac; sig moid colon; convolutions of jejunum and ileum. Apertures in the Abdominal Wall.- Above; those through the dia phragm (see that structure, jjuge sof ). Belov/ ; for femoral vessels: for sper matic cord. Anteriorly; umbilicus. 624 SL'KGICAL ANATOMY OF THE ABDOMIXO-PELVIC WALL. 625 Structures of Antero-lateral Abdominal Wall. — (From without in- ward) — skin; superficial fascia, superficial and deep layers; general areolar tissue overlying external oblique muscle, and special intercolumnar fascia of external abdominal ring; external obUque and its aponeurosis; internal oblique and its aponeurosis; transversalis and its aponeuro.ns; rectus; pyramidalis; fascia transversalis; subperitoneal areolar tissue; peritoneum. Structures of Posterior Abdominal Wall. — (i) Osseous Portion — five lumbar vertebra; and interarticular fibro-cartilages; postero-lateral portions of ilia; — (2) Soft Portion (from without inward) — skin; subcutaneous areolar tissue; lumbar aponeurosis (posterior layer); erector spin;L>; lumbar aponeu- rosis (middle layer) attached to trans\'erse processes of lumbar vertebrae; quadratus lumborum; lumbar aponeurosis (anterior layer); psoas; crura of diaphragm; kidney, areolar tissue, and colon; subperitoneal areolar tissue; peritoneum. Arteries of Antero-lateral Abdominal Wall. — Superficial epigastric, superficial circumllex iliac, and superlicial external pudic from femoral; lowest two intercijstals from thoracic aorta; abdominal branches of lumbar arteries from abdominal aorta; iho-lumbar from internal iliac; deep circum- flex iliac and deep epigastric from external iliac; superior epigastric and musculophrenic from internal mammarv. Arteries of Posterior Abdominal Wall. — Lumbar branches of abdom- inal aorta. Veins of Antero-lateral Abdominal Wall. — Correspond, chietly, with the arteries. Veins of Posterior Abdominal Wall. — Correspond, chiefly, with the arteries. Lymphatics of Antero-lateral Abdominal Wall. — Superficial vessels above umbilicus em]jty into axillarv glands: — su])erficial vessels below um- bilicus empty into inguinal glands: — deep x'e.s.sels abo\e umbilicus empty into sternal glands (probably) : — deep vessels below umbilicus emjity into iUac glands. Lymphatics of Posterior Abdominal Wall. — Median (aortic) lumbar glands: — lateral (]isoas) lumbar glamls. Distribution of Nerves to Antero-lateral Abdominal Wall. — Lower intercostal nerves; emerging from intercostal sjjaces liehind costal carti- lages (except twelfth, which is subci stal), they pass forward between internal oblique and transversalis (generally intercommunicating here) — penetrate outer edge of sheath of rectus — supply rectus — pass through its substance — penetrate anterior layer of rectal sheath — and are distributed to skin. Lateral cutaneous branches of lower intercostal nerves ; divide into .\nterior Branches (to skin up to outer border of rectus, and superficial part of external obli((ue) and Posterior Branches (to skin of outer part of back). Sixth intercostal; supplies region between lower end of sternum and tip of en^i- form cartilage. Seventh intercostal ; distributed to region near lower end of ensiform cartilage. Eighth intercostal ; runs up under cover of costal arch and supplies area of middle linea transversa, between tip of ensiform cartilage and umbilicus. Ninth intercostal ; runs directly forward on level with ninth costal cartilage and supplies region just above umbilicus. Tenth intercostal; runs directlv forward on le\cl with tenth costal cartilage and sup- |)lics skin about umbilicus. Eleventh intercostal ; runs forward and down- ward, supplying the region a little below the umbilicus. Twelfth intercostal; passes in front of quadratus lumborum, along lower border of twelfth rib — pierces transversalis and runs forward between transversalis and internal 40 626 OPERATIONS LTO\ THE AHDOMIXO-rELVIC REGION. oblique — (a) Anterior Branch of Twelfth Intercostal, penetrates rectus and is distributed below a point midway between umbilicus and pubis — (b) Lateral Cutaneous Branch of Twelfth Intercostal, penetrates internal oblique, then emerges from external oblique from 2.5 to 8 cm. (about i to 3 inches) abo\-e the iliac crest, and is distributed to skin over front of hip. Ilio-hypo- gastric branch of first lumbar ; emerges from upper outer border of psoas — runs in front of quadratus lumborum to iliac crest — piercing transversalis posteriorly, and divides between transversalis and internal oblique, about 6.5 cm. (about 2i inches) posterior to anterior superior iliac spine into — (a) Hypogastric Branch, passing forward between transversalis and internal oblique, pierces internal oblique, then pierces aponeurosis of external obhque about 2.5 cm. (about i inch) above and just to outer side of external abdominal ring, and supplies skin of hypogastric and external ring region, — (b) Iliac Branch, piercing internal oblique and external oblique directly above crest of ihum, and supplying skin of gluteal region posterior to lateral cutaneous branch of twelfth dorsal nerve. Ilio-inguinal branch of first lumbar; passes from outer border of psoas just inferior to ilio-hypogastric — runs obliquely across quadratus lumborum and iliacus — penetrates transversalis near anterior part of iliac crest (communicating here with iho-hypogastric) — runs forward between internal oblique and transversahs, piercing internal oblique a little in front of anterior superior iliac spine — passes forward beneath aponeurosis of external obhque, accompanying cord through inguinal canal and emerging at external abdominal ring — supplying skin of u])[)er and inner aspects of thigh — and scrotum in male, and labium in female. Distribution of Nerves to Posterior Abdominal Wall. — Posterior divisions of lumbar nerves ; dividing into internal and external branches. Genitocrural nerve; arising from tirst and second lumbar nerves, passes obliquely through psuas, emerging from its inner border opposite disc between third and fcurth lumbar vertebrae — passing downward upon anterior surface of psoas and dividing, at outer side of external iliac artery, into — (a) Genital Branch, piercing fascia transversahs and descending on posterior part of spermatic cord through inguinal canal — emerging at external abdominal ring and supplying cremaster muscle in male, and round ligament in female. — (b) Crural Branch, descending on external iliac artery and piercing femoral sheath about 5 cm. (about 2 inches) below Poupart's ligament, to be dis- tributed to skin of upper central part of thigh. External cutaneous ; arising from second and third lumbar nerves, emerges from center of outer border of psoas and runs obliquely over iliacus muscle to notch just below anterior su])erior iliac spine, where it escapes l>eneath Poupart's ligament on to thigh. Anterior crural; obturator; accessory obturator nerves — descend to their distributions through the ])ostero-lateral aspect of the abdomino-])elvic wall. Summary of Distribution of Anterior Abdominal Nerves. — Seventh and eighth run upward and inward and su]jplv upper third of al)dominal wall; — ninth and tenth run nearly transversely inward and supply middle third; — eleventh and twelfth, and Ilio-hypogastric and Iho-inguinal, run downward and inw-ard and supply lower third of abdominal wall. Anterior Sheath of Rectus. — Formed, aliove, by blending of aponeu- roses of external (ibli<|ue and outer lamella of internal oblique — below, by blenrling of apoiieuniscs of external oblique, internal oblique, and trans- versalis. Posterior Sheath of Rectus. — Formed, above, by blending of aponeu- roses of inner lamella (if internal oblique and transversalis; next to which SURFACE FORM AND LANDMARKS OF ABUOMIXO-PELVIC WALL. 627 come, in order, transversalis fascia, subperitoneal areolar tissue, and parietal peritoneum, — below semilunar fold of Douglas, by transversalis fascia alone; next to which come, in order, subperitoneal areolar tissue and parietal peri- toneum. Linea Alba. — .\ tendinous raphe, extending from ensiform cartilage to symphysis pubis, down median line of abdominal wall, and formed by the union of the aponeuroses of the obliquus e.xternus and internus and the trans- versalis, between the inner margins of the rectus muscles. Most distinct just above the umbilicus. Practically absent below semilunar fold of Douglas — because from that line downward the aponeuroses of e.xternal oblique, internal oblique, and transversalis all pass in front of rectus (the linea alba being formed by the junction of the anterior and posterior aponeuroses which form the sheath of the rectus). SURFACE FORM AND LANDMARKS OF THE ABDOMINO-PELVIC WALL. Linea alba — extending from apex of ensiform cartilage to symphysis pubis — broader above, narrower below the umbilicus — incomplete posteriorly (only) in its lower fourth, where the transversaUs fascia replaces it. One or both borders of the recti are apt to be incised in operating below the umbilicus. Represents junction of inner borders of aponeuroses of the flat abdominal muscles. Lines semilunares — represent the line of division of the aponeuro.ses of the abdomen — correspond with the outer borders of the recti muscles — e.xtend from lowest part of seventh costal cartilages to spines of cs pubis, so curved that opposite the umbilicus they are 6 to 7.5 cm. (2^ to 3 inches) from the median line. Linea? transversa; — three tendinous intersections in the substance of the recti muscles, forming transverse furrows upon their surface — the upper one, opposite, or just below, the tip of the ensiform cartilage, — the middle one, between the tip of the ensiform cartilage and the umbilicus (about opposite the tenth costal cartilage), — the lower one, opposite the umbilicus, — (and sometimes a fourth one, below the umbihcus). Semilunar fold of Douglas — below which the posterior sheath of the recti is formed by transversalis fascia alone — about opposite the junction of the upper three-fourths and the lower fourth of the recti muscles — about 3 cm. (ij inches) below the umbilicus. Abdominal furrow — extends from infrasternal fossa to, or a little below, the umbilicus, where it becomes lost. Its bottom is formed by the linea alba. Umbilicus — situated in the linea alba — always above the level of the highest points of the crests of the ilia (generally from 2 to 2.5 cm., J to i inch, above) — from 2 to 2.5 cm. (f to i inch) above and to the inner side of the bifurcation of the abdominal aorta — opposite the tip of the third lumbar .spine, or the intervertebral disc between the third and fourth lumbar vertebra?. Spine of the os pubis — found by following up the tendon of the abductor longus — nearly on the same horizontal line as the upper edge of the great trochanter — gives attachment to the outer pillar of the external abdominal ring. .\nterior superior iliac spine — the most prominent landmark of the lower antero-lateral abdominal wall. Crests of the iliac bones — continuations backward of the anterior superior iliac spines — found at the bottom of the iliac furrows, in the fleshy. 628 OPERATIONS UPuN THE AKDOMINO-PELVIC REGION. Poupart's ligament — represented by a line curved slightly downward, be- tween the anterior superior iliac spine and the pubic spine. Iliac furrow — corresponds to the iliac crests — and formed by the attach- ment of the external oblique muscles to these crests. Sacral promontory — represented by a transverse line between the two an- terior superior iliac spines. Internal abdominal ring — situated about 1.3 cm. (i inch) above the center of Poupart's ligament. E.xternal abdominal ring — situated just superior and external to the crest of the OS pubis. Aponeuro-muscular limits of external oblique — the line representing the junction of the aponeurotic and muscular portions anteriorly, is one passing from the anterior superior ihac spine to the ninth costal cartilage (or one slightly anterior to these points); — The lower limit of the fleshy part of the external oblique is represented by a transverse line from a point on the iliac crest 2.5 to 5 cm. (i to 2 inches) posterior to the anterior superior iliac spine, to a corresponding point on the opposite side. The fibers of the muscle and aponeurosis run about at a right angle with a line from the anterior superior iliac spine to the umbilicus. Aponeuro-muscular limit of the internal oblique — Above, by an oblique line from a point below the anterior end of the twelfth rib extending u]nvard parallel with the costal arch, — Internally, by a line extending from the middle of Poupart's hgament upward and slightly outward. The upper line marks the upper limit of the mu.scular part. Aponeuro-muscular limit of the transversalis — the median limit of the fleshv part of the transversalis is nearer the middle line of the body above and below than at the center. Deep epigastric artery — runs from a point just internal to the middle of Poupart's ligament upward and inward to the inner aspect of the internal abdominal ring — thence still upward and inward to about midway between the pubes and umbilicus — and, passing beneath the semilunar fold of Douglas, runs between the sheath of the rectus and the muscle, finally piercing the muscle. Abdominal aorta — bifurcates about 2 cm. (| inch) below and to left of the umbilicus. Coeliac axis — situated from 10 to 12.5 cm. (about 4 to 5 inches) above the umbilicus. Superior mesenteric and suprarenal arteries — arise just below the cccliac axis. Renal arteries — arise about t.2 cm. (i inch) below the superior mesenteric. Inferior mesenteric — arises about 2.5 cm. (1 inch) above the umbilicus. Peritoneal reflection from bladder on to lower abdominal wall — see under the Bladder, page 877. Posterior superior spinous process of ilium — generally marked b\- a de- pression on a level with, and on either side of, the spinous process of second sacral vertebra. Spinous process of third sacral vertebra — generally to be felt below the second sacral vertebra, which last is nearly always detectable. Outer border of erector spin;e — generally felt by deep palpation made to the outer side of and parallel with the vertebral column. See Surgical Land- marks of the Kidney, page 839. GENERAL SLR(;ICAL CONSIDERATIONS. 629 GENERAL SURGICAL CONSIDERATIONS IN OPERATIONS UPON THE ABDOMINO-PELVIC CAVITY. Guide to the choice nf s|)ecial abdominal incisions — that incision should be chosen which most satisfactorily accomplishes the following (in order of importance) : — free access — avoidance of nerves — separation of muscular and aponeurotic fibers rather than their division — avoidance of vessels. Separation of the fibers of muscles and aponeuroses in their cleavage line should alwavs be done in preference to a division of those fibers transverselv or even obliquely. Blood-vessels, as compared with nerves, are of secondary importance — though the deep epigastric artery (the most important of the abdominal wall), and its anastomosis with the superior epigastric of the internal mam- mary, should be spared when possible. Better to cut through muscle than through aponeurosis (where cleavage separation is not possible) — as the former is more resistant to hernia (Hyrtl). Median Incisions — available for parts most accessible thereby. Through a median incision above the umbilicus; the stomach, liver, pancreas, and intestines mav be reached. Through a median incLsion below the umbilicus; the intestines, bladder, ureters, uterus, and ovaries may be reached. Lateral Vertical Incisions — (along the outer border of the rectus) — not ad- visable ordinarily, as they divide the motor nerves to the rectus muscle, and thereby predispose to hernia. When done, generally done for the gall-bladder and ducts, duodenum, ascending and descending colons, spleen, and kidneys. Transverse or slightly Oblique Incisions — preferable for reaching those sites laterally placed. The incisions are more or less parallel with the nerves — the muscles are separated in their cleavage lines, where possible, and re- tracted — the nerves are recognized in the intermuscular planes (especially between internal oblique and transversalis) and held to one side. This incision may be used for the appendi.x, ascending and descending colons, kidneys, stomach, liver, gall-ducts, intestines, and ureters. Special Abdominal Incisions — see the different methods of abdominal section following. In the above summary of abdominal incisions no hard-and-fast rule e.xists as to their application — it merely being meant to mention some cases in which each categor_\- of incisions may be used — more specific data being given under the different viscera. All abdominal incisions should avoid, where possible, the anterior branches of the dorsal and lumbar nerxes — which run obliquely from behind downward and forward between the muscular abdominal planes. The lower abdominal nerves run inwardly somewhat more transverse!}/ than do the fibers of the external oblique mu.scle and aponeurosis — so that in an oblique incision parallel with the fibers, one or more nerves may be encountered — but should be recognized, and can generally be spared. .All vertical incisions of the abdominal wall, of any length, except those in the median line, cut one or more nerves. \'ertical incisions over the center of the rectus divide the motor nerves to the inner half of the rectus muscle. Long cutaneous and fascial incisions are harmless — and are desirable if thereby free access to the site be gained. Longer incisions are necessary in the intramuscular separation than where the muscle-fibers are cut. Longer incisions are necessarv in verv fal and thick abdominal walls. 630 OPERATIONS UPON THE ABDOMINO-PELYIC REGION. Hernia is more apt to follow incisions in the lower than in the upper part of the abdomen — and in the anterior rather than in the lateral and posterior portions. Linea alba is broader above than below the umbilicus, hence both inner rectal borders are more likel\' to be e.xposed by a median incision below than above the navel. If it be desired to identify the linea alba, after cutting through the superficial fascia, make a slightly oblique superficial incision over the median line — until the linea alba is recognized as a white fascial line or as a cord e.xtending between the inner borders of the recti. Pyramidales (one or both) may overlap the median line and their fibers may be divided in a median abdominal section performed low down. LinesB trans\'ersa; do not e.xtend all the way through the rectus to its posterior aspect. Avoid cutting through the umbilicus, ordinarily. Also pass slightly to its left to avoid the round ligament. Incision may be made directly through the center of the umbilicus itself — inclining slightly to the left just above it, to avoid the round ligament. Kelly mentions, after cutting through the um- bilicus, that it is well, in closing the wound, to " split it on each side before putting in sutures, to convert the naturally thin surface between skin and peritoneum into a broader area for better approximation." If the round ligament of the liver be cut during operation, no harm of consequence is done. It should be repaired with chromic gut suture. Peritoneum is more loosel}' connected with the linea alba above and below the umbilicus — and more closely in the neighborhood of the umbilicus. A transverse vessel in the subcutaneous fat, about 2 cm. (f inch) above the symphysis pubis, is mentioned by Kelly, which spouts arterial blood from one side and venous blood from the other when cut. He also mentions one or more veins ("celiotomy veins") lying just over the peritoneum in the lower third of the linea alba, running very nearly parallel with the linea alba and ending in the vesical plexus at the neck of the bladder. Empty the bladder before operating — and, if necessary-, outline the bladder with a sound during operation. In all operations involving the pelvic and lower abdominal regions, the Trendelenburg position is desirable — causing a displacement of the intestines and viscera above away from the field of operation. It should be assumed just before the operation and continued during it — at an angle of from 18 to 45 degrees, the average being about 30 degrees. Intestines and viscera are best held out of the way by means of flat pads of sterilized non-absorbable cotton cox-ered with non-absorbable gauze. As soon as the peritoneum is incLsed, and in order to make less likely the stripping of the jjeritoneum from the muscular wall, a silk ligature may be passed into either lip of the peritoneum, including the muscular wall, and used as a retractor, after being knotted. In incising the abdominal wall the peritoneum is at first only ojjened to a limited extent — the opening being increased after intra-abdominal examina- tion by means of a finger introduced. Avoid mistaking the transversalis fascia for subserous areolar tissue — and subserous areolar tissue for omentum — and especially intestine for peritoneum. In cleansing the abdomino-])elvic cavity, the natural fossa; should receive especial attention — especially Douglas's cul-de-sac. rectal, duodenal, jejunal, renal, and ctecal. Part or all of the omentum may be ligated off and removed. Suture-materials — For peritoneum; fine, i)lain catgut. For fascial and MEDIAN ABDOMINAL SECTION. 631 aponeurotic planes; chromic gut, kangaroo tendon, silk, silver wire. For muscles; chromic gut, plain gut, silk, kangaroo tendon. For subcutaneous tissue; plain or chromic gut, silk. For skin; silkworm-gut, silk (gut). Avoid including omentum and intestinal walls in the tightening of sutures. Just before tightening the last suture or two, press upon the abdominal wall to e.xpel air or fluids. Quilt sutures may be used for the fascial planes of suturing. Rela.xation sutures may be used — about 2.5 cm. (i inch) ajiart, and from about 1.2 to 2 cm. (i to J inch) from the edges of the wound. In all kinds of suturing the process is aided by the use of wound -hooks, which render the edges straight, parallel, and tense, and lift away the abdomi- nal wall from the underlving intestines and viscera. Sutures are removed from the tenth to the fifteenth dav. INSTRUMENTS USED IN OPERATIONS UPON THE ABDOMINO-PELVIC WALL. Scalpels; probe-pointed bistoury; scissors, pointed and blunt, straight and curved; forceps, dissecting and toothed; artery clamp forceps; retractors, various; probe; grooved director; tenaculum; wound-hooks; sponge-holders; aneurism-needle ; needles, curved and straight ; needle-holder; ligature-car- riers; ligatures and sutures, plain and chromic gut, silk, silkworm-gut; gauze pads; drainage-tubes. MEDIAN ABDOMINAL SECTION. Description. — The opening of the abdominal or abdomino-pelvic cavitv through an incision in the median line of the abdomino-pelvic wall. The site of this incision may be anywhere between the tip of the ensiform cartilage and the symphysis pubis — dependent upon the object of the operation. Ab- dominal section, except in cases where done for e.xploration, is generallv but the preliminary step preceding some special operation. Preparation. — Anterior abdominal wall shaved, especiallv along site of linea alba. Recesses of navel thoroughly cleansed. Bladder is emptied, especially if incision is to extend very low. Position. — Patient supine, at edge of table, with arm beneath back. Oi)eration-site is walled off with sterilized towels. Surgeon on right, cutting from abo\e downward. Assistant opposite. Landmarks. — Median line (linea alba). The center of the lower portion of the sternum, the umbiUcus, and the suprapubic notch all are in the median straight hne of the body in the normal abdomen. Incision. — Is placed directly in the median line — above, below, or in- cluding the umbilicus, as indicated. If more room be needed than planned in the original incision, it may be gotten by continuing the incision upward or downward, .\fter incising to within 5 cm. {2 inches) of the bladder, great care should be exercised and the bladder protruded awav from the line of incision by the fingers of the left hand — for, although empty, if adherent unusually high, it may be wounded. In passing the site of the umbilicus the incision may be carried directly through its center, with a slight tendency to the left just above the umbilicus, to avoid the suspensory ligament of the liver — or may pass, when cjuite near the upper or lower aspects of the um- bilicus, in a curved direction around it — the curve passing to the left, thereby 632 OPERATIONS UPON THE ABDOMIXO-PELVIC REGION. avoiding the round or suspensory ligament (the remains of the fetal umbilical vein) between the umbilical fissure of the liver and the umbilicus — which is, in consequence, left adherent to the right lip of the wound. (See Fig. 355, A and B.) P"'g- 355- — Incisions for Abdo.min ical ; B. Median Abdominal Seclioii. infra-u superior iliac spine; D. Anterior superior Abdominal Section; F. Incision (skin port Sections:— A, Median Abdominal Section, supra-umbil- -umhilical : C. Iniaginar\' line I'rom umbilicus to anterior c spine; E, Incision for McBurney's Intramuscular 1 for Weir's prolong-ation of the antero-lateral Intra- ular Abdominal Section; G. The Battle-Jalaguier-Kammerer Incision; H, Superficial trans- versely cur\-ed incision of Pfannenstiel's Median Inferior Abdominal Section ; I, Deep vertical inci- sion of Pfannenstiel's Median Inferior Abdoinitial Section ; J. Meyer's " Hockev-stick " Incision ; K, Fowler's Angular Incision ; L. Oblique Subcost.il Incision ; M. 'V'ischer's Lumbo-ili; Position of deep epigastric vessels. Operation. — (i) Having steadied and rendered tense the abdominal wall by left thumb and forefinger (or middle finger) on either side of the median line, the incision is made the full length of the predetermined distance, at one clean sweep of the knife, passing through skin and connective tissue. MEDIAN ABDOMINAL SECTION. (^33 In very fat subjects the skin and thick fatty areolar tissue may be divided by two or three successive sweeps of the knife. Throughout the passage tJirough the abdominal wall, all incisions should be made the full length of the original skin incision. (See Fig. 356.) (2) Clamp all bleeding vessels upon the hps of the wound, and subsequently tie with gut those likelv to bleed. (3) Continuing to retract the lips of the wound with left thumb and Fig- 356— Median Abdominal Section :— A, Skin ; B, Fascia ; C, Inner borders of the i pyramidales muscles ; D, Transversalis fascia and subperitoneal areolar tissue; E, Perito Forceps grasping and lifting up the peritoneum ; G, Scissors cutting through the fold of peritoneum made prominent by traction ; H, Clamp-forceps controlling severed vessels. forefinger, incise the aponeurosis of the recti directly to the median line. While aiming to cut between the inner margins of the recti muscles, along their line of junction, without dividing their muscular fibers, it is found, especially when operating below the umbilicus, that frequently one or both recti, together with their sheaths, are cut, or the pyramidales, where the latter overlap inwardly. The linea alba is not as distinct below the umbilicus as above it. In the upper three-fourths of the anterior abdominal wall. 634 OPERATIONS UPON THK AP.nOMINO PELVIC REGION. directly in the median line, after passing through the skin and fascia, one divides the aponeurosis between the inner borders of the recti; and just to one side of the median hne, one divides the outer layer of the rectal sheath, the rectus muscle, the inner layer of the rectal sheath (which inner layer is formed by the aponeurosis of the transversalis and inner lamella of the internal oblique). In the lower one-fourth of the anterior abdominal wall, directly in the median line, after passing through skin and fascia, one divides the aponeurosis between the inner borders of the recti; and just to one side of the median line, one divides the outer layer of the rectal sheath, the pyrami- dalis, the rectus muscle, and comes directly down upon the transversalis fascia, which here alone forms the posterior layer of the rectal sheath. All bleeding vessels encountered in passing through the aponeurotic and muscular planes of the abdominal wall are clamped or tied. (4) The fascia transversalis is now exposed in the whole length of the wound, lying beneath the posterior layer of the rectal sheath in the upper three-fourths of the linea alba — and forming the posterior layer in the lower fourth — and is similarly incised. (5) The subperitoneal areolar tissue lies between the transversahs fascia and the peritoneum, and is generally divided together with the transversalis fascia. It may be quite thick in the very fatty. All clamped vessels are now tied before opening the peritoneum. (6) The peritoneum is now encountered lying directly beneath the subperitoneal areolar tissue — its position being anticipated by a recognition of the structures and layers through which the incisions have passed — and its actual presence is further recognized by its commoner characteristics, available in the majority of cases — its glistening, bluish, arborescent surface, and tough nature (which are less available in adhesions and other abnormalities). Having controlled all bleeding, the ])eri- toneum, the final barrier to the peritoneal cavity, is now to be opened. It is important that the peritoneum should be isolated from all underl\ing structures, and especially the intestines, before being incised. This is best done by picking it up lightly with a pair of toothed forceps, in the form of a small fold. Thus grasping the peritoneum, the forceps should be shifted laterally and vertically to determine that they hold nothing in their teeth but peritoneum alone. Should intestines, omentum, or other structures have been grasped, in addition to the peritoneum, a new and lighter hold should be taken. While thus held in the grasp of the forceps — or, better still, between the grasps of two pairs of forceps, one held by the surgeon and the other by the assistant — the peritoneum is at first opened to a very limited extent, by making a carefully guarded scissors-cut or knife-incision, in the median line, near the tip of the single pair of forceps — or between the tips of the double pair. One limb of a pair of straight, blunt scissors, or a probe-pointed bistoury, is now introduced into this small opening, and the incision enlarged by cutting in the median line — introducing the left first and second fingers as a guicie (formed bv their palmar surface) as soon as sufficient opening has been made — after which the ])eritoneal opening is enlarged to correspond with the length of the rest of the wound, which should nowhere be funnel- shaped, but of equal depth throughout. (7) Having opened the peritoneum and widely retracted the lips of the abdominal wound, the special object for which the abdominal section was made is now carried out. (8) Having completed the object of the operation, and prior to closing the abdominal wound, the abdominal cavity should be cleansed of all fluid, by means of gauze mops or sponges — especially in the regions of Douglas's pouch, in the female, the iliac fossa?, the renal and hepatic regions, and among the intestinal coils and recesses. Where the abdominal cavitv has been extensivelv soiled, MEDIAN ABDOMINAL SECTION. 63 s especially by tenacious fluids, a general flushing of the cavity may be indicated, until the irrigating fluid comes away clear, followed by light sponging with gauze mops. Having cleansed the cavity, stopped all bleeding bv ligature, and counted aU instruments and Sjjonges, or pads, used in the oper- ation, the abdomen is ready for closure, (o) Sexeral methods of su- turing the lips of the wound are in use. Preceding the adoption of any particular method, the underlying in- testines and viscera are protected and held out of the way by a broad pad of absorbable gauze. This pad also absorbs an}- suture-bleeding which may occur, and remains /;; situ until nearly the entire length of the deepest layer (or nearly all of the single la_\'er, where but one la\er of sutures is used) is placed and tied (if interrupted), or tightened (if continuous) — and is then withdrawn through one end. (a) In- terrupted sutures of all layers in a single tier: — Having armed a fully curved needle, held in a needle- holder, with fairly stout silk, the su- tures are passed from without into the abdominal cavity through one wound- lip, and thence outward through the opposite, passing through all of the constituents of each li]), in the follow- ing manner: While the Kps of the wound are held under slight tension by wound-hooks at either end, the sur- geon grasps the entire thickness of one lip between his left thumb and finger and sees that all of the component structures of that lip are brought into line at the margin of the wound, so as to be within bite of the point of the needle. This is particularly neces sary in the case of the peritoneum, which is often partially separated from the rest of the abdominal wall in the subperitoneal areolar plane and is thus apt not to be included in the suture. While thus holding the lip of one side, the needle is passed from without inward, passing through all the structures of the lip at the same distance from their free edge and entering the abflominal cavity. The opposite lip is similarly grasped and the needle similarly passed — but from within outward, emerging at a corresponding point on the side opposite to that entered. Each of the in- Fi>;. 357.— TlER-SUTl'RING OF THE WoUND FOLLOWING Median .Abdominal Section : — A. Continuous suture approximating edges of peritoneum; B, Interrupted suture bringing to- gether llie cut margins of the subperitoneal areolar tissue, transversalis fascia, and recti and pyramidales muscles {and also the aponeuroses of the rectal sheath); C, Continuous suture of the fascia; D. Continuous subcuticular suture ■ if the skin. 636 OPERATIOXS UPON THE ABDOMIXO PELVIC REGION. terrupted sutures will penetrate the lips of the wound at about 0.5 cm. (j"^ inch) from their edge, and will be about i cm. (f inch) apart. When all are placed, the free ends of the sutures on either side should be grasped and drawn upon, to see if the lips come well and evenly together. While the lips are still under tension the sutures are tied, generally beginning at one or the other end. Just prior to completing the tying, the gauze pad over the intestines must be withdrawn. Superficial sutures ma\- be put through the skin and connective tissue between the others, if necessarv. Where much tension e.xists, deep rela.xation sutures, placed about 1.2 cm. (5 inch) from the lips of the wound, and about 2 cm. (| inch) apart, may be placed. Chro- mic gut may be similarly used. Silkworm-gut may be used, but requires especial care in tying the knot, (b) Tier-suturing: — First Tier — peritoneum. (To shut off the abdominal cavity.) A buried, continuous (may be inter- rupted), tine, chromic catgut suture, passed upon a straight needle, at a distance of about 0.3 cm. (| inch) from the edge. Second Tier — aponeuroses of rectal sheath, including transversalis fascia and subperitoneal areolar tissue, and margins of recti where they have been cut. (Chief suture of strength.) Interrupted, buried, chromic catgut suture, introduced upon a curved needle, about 0.5 cm. (y\ inch) from the edge and about i cm. (f inch) apart. Third Tier — subcutaneous areolar tissue, that is, all tissues between the outer layer of the rectal .sheath and the skin. (To obliterate dead spaces.) A continuous, buried, chromic catgut suture, introduced upon a straight needle. Fourth Tier — skin. (To shut oft" outside contamination.) A continuous, subcuticular silk suture passing through the tough corion. intro- duced upon Keith's long, straight abdominal needle. (See Fig. 357.) Inter- rupted silkworm-gut maybe used for the fourth tier (though stitch-abscesses are more frequent). Or strong, fine catgut may be used — and need not be removed. Interrupted silk sutures are often used. The tier method of suturing is prefer- able to the single- layer suture. Often but three tiers are used — Continuous chromic suture of peritoneum; — Interrupted chromic gut suture of subperi- toneal and transversalis fascine, rectal aponeuroses (or recti themselves) en masse: — Interrupted silkworm-gut, or silk suture, of skin and subcutaneous fascia. Sometimes only two tiers are used — Continuous chromic gut of peri- toneum; — and Interrupted silk or chromic gut of the remaining tissues. (10) No drainage is ordinarily used. Se\eral layers of gauze and cotton are placed over the wound — and one of the various forms of abdominal binders applied. Complications Occurring during Abdominal Section. — (a) Adhe- sions; — (i) .\dhesions of the intestines, \isccra. or omentum with each other, or with the parietal wall, may be encountered. (2) When, in the presence of adhesions, there is doubt as to whether the peritoneal cavity has been reached, pick up and roll the tissues between the finger-tips, thus judging of their nature. (3) The general principle to be adopted in the management of adhesions is to find the plane of cleavage in the abnormal union — and, following it up, separate it as carefully as possible by fingers or blunt dissection. Where this is impossible, areas, dependent upon their nature, have to be ligated or clamped and cut, with the sacrifice of some portion of the least important structure. Ligatures are best made with plain gut for small adhe- sions, and chromic gut for large adhesions. While slighter adhesions may be mechanically separated, denser ones are to be clamped or ligated, en masse or piecemeal, and cut. (4) Intestinal .\dhesions. Thin membranous adhe- sions may be stripped apart. Dense, organized adhesions must be separated by careful dissection, requiring especial care, as no part of the entire thirkness AXTERO-LATERAL ABDOMI.NAI, SECTION. 637 of the adhesion can be taken from the one and left as a patch on the other, as may be done in some adhesions in other localities. (5) Omental Adhesions. These must be stripped off, or ligated and excised. The entire omentum may be ligated and excised, if necessary. Omental adhesions are ligated on their proximal side — by pushing forceps through the free spaces and drawing back the gut ligature and tying — and repeating the step, always tj'ing over the free edge left by the preceding ligature. See Omentum, page 652. (6) Visceral .Adhesions: — Where separation cannot be accomplished — and where the step is possible, a layer, or the entire thickness, of the less important structure is left attached to the more important one — after ligaturing and blunt dissection or incision. The serous covering of the viscera should be preserved wherever possible — thereby aiding in the preservation of nutrition and the avoidance of adhesions and sloughing. Such denuded surfaces may have omental grafts applied. See Omentum, page 6^2. In the median ab- dominal section it is to be remembered that an adherent bladder, though empty, may not be able to descend out of the way of the incision, — and thereby may not escape injury unless specially guarded. For further consideration of adhesions, see the Peritoneum, page 647. Also ^ee Fig. 362. (B) Hemor- rhage : — Tie, where possible, all vessels prior to their division, or immediately afterward — as encountered in the steps of the operation after entering the abdominal cavity. Vessels which have been cut without recognition, should be immediately clamped and then tied. In the abdominal incision, prior to enter- ing the cavity, the vessels are clamped as cut and tied before opening the peri- toneal cavity. Gauze pressure and hot douching often control bleeding from indefinite sources. (C) Irrigation : — Unless the abdominal cavity be contami- nated or soiled, or unless much hemorrhage have occurred, irrigation is gen erally not indicated. If indicated, hot normal salt solution is used. Localized infection can often be treated by localized flushing and wiping — general infection by general flushing and drying with gauze mops. (D) Drainage : — Not indicated in uncomplicated cases. Indicated in (a) Localized and general infection (in the former, generally — in the latter always), — (b) .\fter intestinal or hollow-visceral suturing, where there is uncertainty of efficiency of the suturing or integrity of the intestine or viscus, — (c) In persistent hemor- rhage. Nature of drainage materials, — gauze, rubber tubing, glass tubing, strands of gut, silk, or horsehair. Where drainage is used, the wound should have the suturing placed throughout, and just as though the entire wound were to be closed — and those at first left untied for the passage of the drain, should be tightened and tied when all occasion for drainage has ceased. Comment. — See under General Surgical Considerations, page 625. ANTERO-LATERAL ABDOMINAL SECTION BVMcBUKXEVS l.\TR.\MLSCri-.\K I" GRIDIR(5X " I IN'CISIOX. Description. — Having divided skin and fascia, the various musculo aponeurotic planes of the abdominal wall are divided in the order^encountered and in a line with the muscular and tendinous fibers composing those planes — thus avoiding the division of any important nerves; the transver.se division of any of the component muscular fibers; the retraction of transversely cut mus- cular and tendinous fibers — and, therefore, avoiding the consequent paralysis of parts supplied by severed nerves, and weakening of cut muscles. While McBurney's operation is chiefly applicable to the antero-lateral abdominal region (where the external and internal oblique and the transver- 638 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. salis muscles are all present), the principle of intramuscular separation should be applied to all sites of the abdominal wall where it is possible to do so. The operation is principally resorted to for the removal of the appendix verniiformis, especially in the quiescent stage of appendicitis. Preparation. — Site of incision to be shaved. Position. — As in Median .\bdominal Section. Landmarks. — Where the operation is done in connection with .\ppendic- ectomy, McHurney's point is located, which is a point on an imaginary line extending from the anterior superior iliac spine to the umbilicus, at a distance of 3.8 cm. (ij inches) internal to the anterior superior iliac spine. Incision. — In cases of .\]jpendicectomv, the incision commences about 2.5 cm. (i inch) abo\x' the imaginarv line just mentioned, and passes obliquely downward and inward in the direction of the tibers of the external oblique Fi^. 358. — Antero-lateral Abdominal Section ry McBurney's Intramusci'lar ('■ Grid- iron ") Incision: — A, E.xteriial oblique muscle; B, Imeriial oblique muscle; C, Transversalis muscle; D, Transversalis fascia, subperitoneal areolar tissue, and peritoneum; E, Coils of small intestine; F.Branch of deep circumflex iliac, or of one of the lumbar arteries; G, Twelfth inter- costal, or iliohypogastric iier\'e; H, A superficial vessel. muscle and aponeurosis — crossing the above line at JNIcBurney's point — and ending about the same distance below as above it. The length of the incision may be greater or less than the above, according to the space required. A free skin incision greatly aids the muscular retraction. (See Fig. 355, E.) Operation. — (1) Having incised the skin and fascia in the above line (which will correspond with the cleavage line of the skin), and having con- trolled hemorrhage and retracted the lips of the wound, the muscular and tendinous fibers of the external oblique will be exposed. (See Fig. 358.) (2) Incise the external oblique, with a sharp scalpel, directly in a line with its muscular fibers above, and their tendinous continuation in the aponeurosis below — continuing the separation with scalpel or scissors, incising between the fibers without severing them. The two lips of the incised external oblique are drawn respectivelv upward and inward, and downward and outward — ANTERO-LATERAL ABDOMINAL SECTION. 639 thus exposing the intermuscular fascia between external and internal oblique. (3) The sheath and fibers of the internal oblique (the muscle being here quite thick) are now similarly separated by scalpel, scissors, or blunt dissection, in the line of their cleavage (which is nearly at a right angle to the cleavage line of the fibers of the external oblique), the center of the separation of the fibers being about opposite the anterior superior iliac spine. The lips of the internal oblique are now retracted respectively upward and outward, and downward and inward — thus exposing the intermuscular fascia between in- ternal oblique and transversalis. Guard with especial care all nerves lying in this intermuscular plane. (4) The fibers of the transver-salis, which, for practical purposes, run very nearly in the same direction as those of the internal oblique, are now similarly separated in their cleavage line. The lips of the transversalis may be separately retracted upward and downward, but are generally included in the grasp of the same retractors which retract the internal oblique. The transversalis fascia at the bottom of the wound is thus exposed for an inch or more. (5) The transversalis fascia is grasped with forceps and divided in the line of the transversalis muscle (transversely) — when the subserous areolar tissue and peritoneum will be exposed. (6) The peritoneum is grasped with two delicate-toothed forceps, manipulated as in the median abdominal section, and divided with scissors to a limited and guarded extent. One blade of the scissors is then carefully introduced within the abdominal cavity and the opening enlarged toward the median line and the anterior superior iliac spine. The subperitoneal areolar tissue, trans- versalis fascia, and peritoneum may be simultaneously incised — but it is better to incise down to and recognize the peritoneum, and then incise the peritoneum separately and alone. (7) The special object of the operation is now accom- plished. The wound is then ready for closure. (8) Separate continuous suturing of the following layers with catgut is made ; — (a) peritoneum, sub- serous areolar tissue, and transversalis fascia — (b) transversalis — (c) internal oblique — (d) external oblique — (e) subcutaneous fascia, especially where thick — (f) and the skin is closed by subcuticular silk suture, or interrupted silkworm-gut. The subcutaneous areolar tissue and skin are often included in one tier, where interrupted suturing of these two structures is done. All parts are thus lirought together along their original cleavage lines and accu- rately approximated. Comment. — (i) But small part of the muscular portion of the external oblique is exposed. (2) The twelfth intercostal nerve, and, when the incision is long, the iliohypogastric nerve are in danger (as they run somewhat more transversely than the fibers of the external oblique) and should be retracted out of danger. (3) This is the best method of entering the abdominal cavity, where applicable. ANTERO-LATERAL ABDOMINAL SECTION THK .\\TI:K(i4.ATI- 5HK.\TH, WITH TK OF THE RECTl^S. Description. — Having entered the abdominal cavity by the intramuscular operation just described, an extension or enlargement of that incision, with a fuller exposure of the abdominal, pelvic and iliac cavities, may be obtained by continuing that incision to the outer border of the rectal sheath, tearing off the "denuded fascia of the external olslique muscle." incising transversely the remaining structures forming the anterior layer of the rectal sheath and 640 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. displacing the rectus muscle toward the median line, followed by the transverse division of the posterior rectal sheath. While the operation is chiefly appli- cable to the region of the appendi.x, it may be used on either side of the abdomino-pelvic region, and also in the region of the liver and gall-bladder where additional room is necessary. It will be here described in connection with appendicectomv. Preparation — Position. — .\s in McBurney's Intramuscular Operation (page f)^^7). Landmarks. — McBurney's point (see McBurney's Operation, Landmarks, page63S); linea alba; semilunar line. Incision. — Begins as an ordinary McBurney intramuscular incision — and, after prolonging the incision to the outer border of the rectus, and after Fig. 35g. — .Antero-lateral Abdominal Section by Weir's Method :— A. E.xteriial obliqut muscle; B, E.\lernal oblique being separated from the anterior layer of the rectal sheath ; C, Internal oblique muscle ; D. Transversalis muscle; E, Transversalis fascia, subperitoneal areolar tissue, and peritoneum; F, Anterior layer of rectal sheath; G, Posterior layer of rectal sheath; H, Rectus muscle : I. Deep episastric vessels ; J, Branch of deep circumflex iliac, or of one of lumbar arteries; K. Twelfth intercostal, or iliohypogastric ner\e ; L. .A superficial vessel ; M, Coils of small intestine. tearing off and retracting inward the fascia of the external oblique from the sheath of the rectus, the incision is continued across the anterior layer of the sheath of the rectus in a prolongation of the same line with the intra- muscular opening into the peritoneum (or may be continued transversely across) — followed by the inward retraction of the rectus muscle and trans- verse division of the posterior rectal sheath. (See Fig. 355, F.) Operation. — (i) Proceed e.xactly as in the McBurney operation, up to the point of entering the abdominal cavity — whether operating upon the right or left side. (2) Continue the separation of the fibers of the external oblique muscle and aponeurosis, in the line of their cleavage, right up to the linea semilunaris (outer border of the rectal sheath). Also continue the separation of the fibers of the internal oblique and transversalis until the inner aspect of the common opening is brought up to the outer margin of the rectal sheath. ANTERIOR ABDOMINAL SECTION THROUGH RECTAL SHEATH. 641 (See Fig. 359.) (3) The already denuded fascia of the external oblique is now separated by blunt dissection from the anterior layer of the sheath of the rectus, from the linea semilunaris inward to the median line — retracting or dividing the overlying structures where necessary. (4) \\'hile the denuded and displaced fascia of the e.xternal oblique is held retracted, the remaining structures forming the anterior layer of the rectal sheath (aponeuroses of in- ternal oblique and transversaUs) are divided transversely, or slightly obliquely, inward, in a line continuing the e.xternal oblique intramuscular incision — or, if the abdominal cavity have been already opened and more room be needed, in a line with the intramuscular opening into the peritoneum. (5) Separate the outer border of the rectus from its sheath and retract the muscle inward as far as necessary, lifting it away from the posterior layer of the sheath. (6) Doubly ligate and divide the deep epigastric artery and veins l\ing upon the transver- salis fascia — unless they may be temporarily displaced by retraction. (7) Incise transversely the posterior layer of the sheath of the rectus (which, in the lower part of the abdomen, consists of transversalis fascia alone) and peritoneum, both in the same line as the incision through the anterior layer — thus opening u]) the abdomino-pelvic cavity toward the median line. (S) The abdominal, pelvic, and iliac cavities are thus e.xposed and the object of the operation accomplished. (9) The suturing of the general wound is done as in the McBurney operation (page 639, paragraph 8j. In closing the portion involving the rectal sheath, the posterior layer of the sheath is sutured with continued catgut — the rectus muscle is then allowed to fall back into place — and the anterior layer of the sheath is similarly closed. Comment. — .\dditional exposure is secured by the Trendelenburg posi- tion, or by sand-bags under the hips. This is the best one of the modifications of the intramuscular operation, for giving increased room. ANTERIOR ABDOMINAL SECTION THROUGH THE RECTAL SHEATH, WITH TEMPORARY DISPLACEMENT OF THE RECTUS, V.\ THE B.VTTl.E-J.M.Ar.riER-K.AMMERKR METHIlD. Description . — Consists, after a vertical incision of skin and fascia, in the vertical division of the anterior layer of the sheath of the rectus, with the retraction of the entire rectus inward — followed by the vertical division of the posterior layer of the rectal sheath, somewhat nearer the median line, together with the subserous areolar tissue and peritoneum. .\t the end of the operation the rectus is allowed to resume its normal position, and the divided rectal sheath is repaired. Chiefly used in the quiescent stage of appen- dicitis — and also applicable in some operations upon the stomach, liver, and gall-bladder. Preparation — Position. — As in Median Abdominal Section. Landmarks. — Linea alba and linea semilunaris, forming, res])ectivelv, the inner and outer boundaries of the rectal sheath. Incision. — \"ertical incision about 7.5 cm. (3 inches) long, and calculated, as nearly as possible, to fall from i to 2.5 cm. (J to i inch) internal to the outer border of the rectus. (See Fig. 355, G.) Operation. — (i) Incise skin and fascia in the above line — clamp vessels — retract overlying tissues — and expose the rectal sheath. (2) Incise the ante- rior layer of the sheath of the rectus vertically, at a distance of from i to 2.5 cm. (f to I inch) internal to its outer border. (See Fig. 360.) (3) Retract outward the outer portion of the divided rectal sheath, so as to expose the 642 OPERATION'S UPON THE ABDOMINO-PELVIC REGION. outer border of the rectus muscle — and then retract the intact rectus muscle inward. (4) Incise the posterior layer of the rectal sheath somewhat nearer the median line than in the case of the anterior layer. Or, in operating in the neighborhood of the deep epigastric artery, in order to avoid this vessel, the incision in the posterior laver may be made somewhat further outward than the incision through the anterior layer. The artery may, howeVer, be readily ligated if in the way. (5) In the same line as the division of the posterior layer of the rectal sheath, incise vertically the subjacent tissues — which will consist of transversalis fascia, subperitoneal areolar tissue, and peritoneum, except below the semilunar fold of Douglas, below which line Fig. 360.— .\rdominal Section by the Battlf-Jai terior layer of ri;ct;il sheath ; B, Posterior layer of rectal of rectal sheatli ; D, Left rectus muscle displaced toward layer of rectal sheath (further toward tnedian line than im coils of intestine; F, 1 ransverse fascia, subperitotieal ar -ugh posterior -■ath) exposing I ; G, A super- the posterior layer of the sheath itself consists of transversalis fascia alone, and the subjacent tissues consist of subperitoneal areolar tissue and perito- neum. (6) Having accomplished the object of the operation, the structures are to be sutured in the following layers, — peritoneum, subserous areolar tissue, and posterior layer of the rectal sheath, with interrupted or continuous catgut suture; — anterior layer of rectal sheath with interrupted gut sutures, which also pass partly through the rectus muscle (the displaced border of the rectus should also be sutured to the outer margin of the rectal sheath); — the fascia with gut — and the skin with subcuticular silk, or interrujited silk- worm-gut sutures (or skin and fascia may be sutured together). MEDIAN INFERIOR ABDOMINAL SECTION. 643 Comment. — The chief objection to the operation is the division, of the nerves corresponding with the incision, and consequent atrophy and paresis of the rectus. The nerves severed in the site where the operation is usually performed (for appendicitis) being generally the tenth, eleventh, and twelfth dorsal, with or without the iliohypogastric. The deep epigastric artery is usually divided, although this is of no great consequence. Fig. 361. — Abdominal Section by Pfannenstiel's Superficial Transversely Curved and Deep Vertical Incisions ; — .\. Flap, with anterior laverof rectal sheath adherent, turned upward ; B, Linea semilunaris; C. Rectus muscle; D. Pyramidalis muscle; E. Transversalis fascia, subperi- toneal areolar tissue, and peritoneum; F, Coils of small intestine; G, Uterus; H. Bladder; 1. A superficial vessel. MEDIAN INFERIOR ABDOMINAL SECTION Description . — A method of entering the peritoneal cavity in the lower median abdominal region — by means of a superficial curved incision, with downward convexity, just above the inner halves of Poupart's ligaments and the symphysis, with an upward retraction of the outlined flap of skin, fascia, 644 OPERATIONS UPON THE ABDOMIXOPELVIC REGION. and anterior rectal sheath — followed b}' a deep vertical division in the median line. A median scar is avoided, and the transverse scar lies partly hidden b}' the hair-line. Hernia is sujjposed to be less a]Jt to follow. Chietlv used for limited operations upon the tul)es, ovaries, uterus, bladder, and pelvic cavity. Preparation — Position. — .\s for Median Abdominal Section. Landmarks. — Linea alba; position of deep epigastric arteries; Poupart's ligaments; symjjhysis pubis. Incision. — (i) Superficial transversely curved incision, with downward convexitv, beginning and ending over the deep epigastric arteries, passing just above the inner halves of Poupart's ligaments and the symphysis pubis, in the hair-line; — (2) Deep vertical incision, after the anterior layer of the rectal sheath has been retracted, jiasses between the inner borders of the recti muscles, in the median line, from just above the symphysis pubis upward. (See Fig. 355, I and H.) Operation. — (i) Incise skin, fascia, and anterior layer of rectal sheath in the superficial transversely curved incision. Clamp vessels. Dissect and retract the curved flap thus formed upward, including the anterior rectal sheath, thereby e.xposing tlie bared recti muscles. (See Fig. 361.) (2) Incise between the inner borders of the recti and pyramidales muscles, just as m median abdominal section, until the peritoneal cavity is reached, which is entered just as in that operation. (3) Having accomphshed the object of the operation, the wound is sutured in the following manner; — the posterior layer of the rectal sheath is closed with continued catgut suture, including the edges of the peritoneum and subserous areolar tissue — the inner margins of the recti are ne.xt sutured with gut — the cut edge of the transversely divided anterior rectal sheath is similarly sutured with gut — and the skin wound is closed with silk, or silkworm-gut. Comment. — Care is necessary to avoid wounding the bladder, which should be empt\- at the time of operation. INFERIOR ANTEROLATERAL ABDOMINAL SECTION BY M1-.V1:RS ■HOCKEY-STICK" IXCISIOX. Description. — .\ method of entering the lower antero -lateral abdominal cavity, partly by intramuscular separation, partly by transverse division of muscle, by means of an incision shaped somewhat like a " hockey-stick. " Resorted to for the purpose of gaining a greater degree of e.xposure of the abdomino jielvic cavitv than afforded by the simple McBurney incision. Used bv its originator for some complicated cases of appendicitis. Preparation — Position. — .\s in McBurney's Operation. Landmarks. — Imaginary line from umbilicus to anterior superior iliac spine, with the location of McBurney's point (see McBurney's operation. Landmarks, page 638); Poupart's ligament; outer border of the rectus; deep epigastric artery. Incision. — (i) Primary Incision. — begins about 1.3 cm. (A inch) above an imaginary line from the umbilicus to the anterior spine of the ilium, at a point 2 cm. (f inch) to the inner side of the anterior superior iliac spine (that is, midway between McBurney's point and the anterior superior iliac spine), and pa.sses thence in a direct line toward the point where the femoral artery runs under Poupart's ligament, ending about 1.3 to 2 cm. (\ to f inch) above Poupart's ligament. (2) Secondary incision, which is only made sub- INFERIOR ANTEKO-LATERAL ABDOMINAL SECTION. 645 sequently, for the purpose of gaining more room, passes upward and inward, or curves directl_v inward, from the lower end of the primary incision toward the outer border of the rectus. (See Fig. 355, J.) Operation. — (i) Incise skin and fascia in the line of the primary inci- sion — clamp vessels — and retract margins of wound. (3) Split the fibers of the external oblique muscle and its aponeurosis in their cleavage line. (3) Divide the internal oblique and transversalis in the same line as made by the separation of the fibers of the external oblique — which will cut the fibers of the internal oblique transversely and those of the transversalis obliquely. (4) Incise the transversalis fascia, subserous areolar tissue, and peritoneum transversely. (5) If more room be now necessary, the left index is passed into the abdominal cavity to the deep epigastric artery, as a guide and pro- tector, and the lower end of the incision is extended upward and inward, or directly inward, to the outer border of the rectus muscle. (6) If still more room be needed, the rectus muscle itself can be displaced inward and the peritoneum incised beneath it. (7) The object of the operation is now accom- plished. The wound is then closed by tier-suturing. Comment. — The deep epigastric vessels are doubly ligated and divided, if necessary. INFERIOR ANTERO-LATERAL ABDOMINAL SECTION BY FOWLER'S ANGULAR INXISIOX Description. — Founded, in part of its application, upon the same principle as McBurney's intramuscular operation — and planned to give freer access to the contents of the ileo-ca?cal region, and especially to the base of the appendix. Especially intended by its author for cases of appendicitis in which the process is still limited to the appendix. Preparation — Position. — .\s in McBurney's operation. Landmarks. — Anterior superior iliac spine; outer border of the rectus. Incision. — Begins at the upper border of the anterior superior iliac spine — runs horizontally inward to the outer border of the rectus muscle — curves thence downward and runs parallel with the outer border of the rectus for 5 to 7.5 cm. (2 to 3^ inches). (See Fig. 355, K.) Operation. — (i) Incise skin and fascia in the above line — clamp vessels — and turn downward and outward this triangular flap of skin and fascia, exposing the aponeurosis of the external oblique beneath. Place retractors at the center of the transverse incision and at the lower angle of the wound, and retract in the cleavage line of the external oblique. (2) Incise the ex- ternal oblique muscle and aponeurosis in the cleavage line of their fibers, and retract in the direction opposite to their cleavage line. (3) E.xpose and open the .sheath of the rectus and retract the rectus muscle, with the deep epigastric vessels, strongly toward the linea alba — while retracting the aponeu- rosis to the outer side. (4) Incise transversely, in line with the horizontal part of the skin incision, the internal oblique and transversalis muscles, transversalis fascia, subserous areolar tissue and peritoneum, all as one structure — beginning at the outer margin of the retracted rectus. And retract the deep lips of the wound, exposing the abdominal cavity. (5) The special object of the operation is now accomplished. (6) .At the completion of the operation, the structures are sutured in the following order; — peritoneum, subserous areolar tissue, transversalis fascia, transversalis and internal oblique muscles are all sutured in one layer, with continuous chromic gut; — the rectus is allowed to fall back into place; — the external oblique aponeurosis and 646 OPERATIONS UPOX THE AUDOMINO-FEI.VIC REGION. muscle are sutured with continuous kangaroo tendon, in which laver the rectal sheath is also included ; — and the skin is closed by a subcuticular silk suture (and the fascia separately with gut, if it be very thick). Comment — In applying the above operation to cases of appendicitis Fowler considers the base of the appendix to be most generally found at the intersection of a transverse line between the anterior superior iliac spines with a vertical line running midway between the median line of the body and the anterior superior iliac spine. This operation gives no more room than Weir's — and the latter operation does not divide muscle-fibers transverselv. SUPERIOR ANTERO-LATERAL ABDOMINAL SECTION r.\ OBLIQL'E Sl'BCOSTAL INXISiON. Description. — A method of entering the abdominal cavity i arallel with and a short distance below the costo-chondral arches. Generally resorted to f2. A.) Visceral Adhesions to the Abdomino-pelvic Wall. — When entering the alxiominal cavity where adhesions may be suspected, or where, in the PARACENTESIS ABDUMIMS. 651 neighborhood of known adhesions, it is uncertain as to whether the peritoneal cavity have been entered, the underlying tissues should be picked up and rolled between the fingers, to enable a judgment to be formed by the sensation imparted. If the peritoneal cavity be entered in the immediate vicinity of an adhesion, this should be at once recognized by sweeping the finger around the vicinity of the opening — and the adhesion separated by blunt dissection, or divided between double ligatures if necessary. Where the opening made comes directly down upon adhesions, these shou'd be recognized as soon as possible, that the progress toward the peritoneal cavitv may be known — and then an endeavor be made to reach a free margin of the adhesion, from which the remainder of the separation, or division, may be made on the general principles mentioned. (See Fig. 362, A, C.) Intestinal Adhesions. — The thin, membranous or velamentous adhesions may generally be separated by blunt dissection with the fingers — by putting the parts gently upon the stretch and keeping the adhesion in a broad, thin layer, rather than in a thick, twisted cord. Dense, organized adhesions require careful (li.sectiun — that no part of either wall may be dangnrou;ly thinned. (.See Fig. 362, H, D.) Inter-visceral Adhesions. — Or adhesions between growths and vi.scera — should be dealt with by putting the adhesion upon moderate stretch — by traction ujjon one or both viscera, until the bond of adhesion is demonstrated — then first ligate or clamp on each side, safely to the outer side of the viscus, and divide the adhesion between the ligatures or clamps. Omental Adhesions. — Adherent omentum may often be stripped off v.ith the fingers. If too dense, or too firmly united for this, it should be ligated with a single ligature, or in sections, and divided. Large portions of the omentum — and even the entire omentum — may be amputated. The omentum mav require onlv a proximal, or mav require double ligaturing. (See Fig. 362, E, F, F.) Comment. — (•) While the separation in the plane of the abnormal adhe- sion should always be the course attempted, where this is impossible it often happens that areas, dependent upon their nature, have to be ligated, or clamped, and cut, with the sacrifice of some portion of the least important structure. (2) Where the separation of an adhesion between viscera and neighboring structures (visceral or otherwise) is impossible, and where the step is permissible, one or more layers, or even the entire thickness, of the less important structure is left attached to the more important one — after ligating and blunt dissection, or incision, of the adhesion — thus leaving a limited area of adherent tissue attached to an organ, rather than risk injuring the organ by further attempt at removal. In such cases the portion left is reduced to its smallest and thinnest size. (3) It is always desirable to preserve the serous covering of a viscus (to aid nutrition and avoid adhesions and sloughing) — and sometimes surfaces left raw by separating adhesions mav be covered, and hemorrhage also controlled, by suturing adjacent serous surfaces over them — or by attaching omental grafts. (See page 654.) Xole. — For further consideration of this subject, see Complications of Median Abdominal Section, page 6j6. PARACENTESIS ABDOMINIS. Description. — Puncture of the peritoneal cavity for diagnostic purposes, or fur exacuation of lluid. 652 OPERATIuXS UI'OX THE ABDUMINO-PELVIC REGION. Preparation. — Shave abdominal wall. Empty bladder and bowels. Area of dulness verified by percussion immediately before paracentesis. Cocainization of the area of puncture. Position. — Patient, where possible, sits upright in chair — where impossi- ble, lies upon edge of bed. A many-tailed, sterilized bandage, or ordinary towel, with a central opening corresponding to the site of paracentesis, is placed around the patient, and tightened posteriorly by an assistant as the abdominal enlargement decreases with the evacuation of fluid. Surgeon sits immediately in front of patient. Landmarks. — Linea alba; umbilicus; limit of upper aspect of bladder (see that structure, page 877). Special Instruments. — For exploratory punctures, aspiratory syringes with needles of small caliber. For evacuation of considerable quantity of fluid, a straight cannula and trocar of fairly large size is used. Aspirators of the Dieulafoy and Potain type may be employed. Where the skin is to be preliminarily incised, a knife is necessary — and a needle and thread, where the incision, or trocar-wound, is to be closed by suture. Site of Paracentesis. — Generally in the linea alba, midway between umbilicus and symphysis pubis. Sometimes the puncture is made in the lower half of either semilunar line. Operation. — (1) Having so placed the broad bandage that the opening is opposite the site of paracentesis, and having grasped the e.xploratory or asjjira- torv needle, or trocar, in such a way as to predetermine, by means of the right index, the depth to which it is to enter, which will be decided by the estimated thickness of the abdominal wall, the instrument is quickly but guardedly thrust through the abdominal wall into the free peritoneal cavity, in a single movement. In the case of the exploratory syringe, sufficient fluid is with- drawn for examination — the needle withdrawn, and the wound closed with collodion and cotton. (3) In the case of the evacuation of large amounts of fluids by means of cannula and trocar (or aspirator) the trocar is with- drawn and the cannula left in silu — the fluid is then allowed to flow, the bandage being tightened pari passu. At the end of the operation, the can- nula is withdrawn — and, if it have been of large size, an interrupted gut suture is made to close the opening by being passed on a curved needle, from side to side, through a part of the thickness of the abdominal wall. The outer aspect of the opening is then closed with collodion and gauze, or cotton. Comment. — (1) Where a large size instrument is used, it is best to make a small preliminary incision through the tough skin. (2) \ cannula should preferably be used the end of which is not pointed or sharp. (3) If the cannula be obstructed during the flow, it may generally be freed by the passage of a sterile probe down its length. (4) As the fluid escapes, the inner end of the cannula (especially if dull) may be shifted so as to furnish the best evacuation. (5) The fluid should be made to escape slowly — and may be retarded by a compress over the outer end of the cannula — to avoid svncope. III. THE OMENTUM. SURGICAL ANATOMY. Description. — The omenta are folds of peritoneum connecting the stom- ach with other viscera. They consist of the great or gastro-colic, small or gastro-hepatic, and gastro-splenic omenta. LICATION OF THE OMENTUM. 653 Great or Gastro-colic Omentum. — Passes down from the greater curva- ture of the stomach as an apron in front of the small intestine, thence upward to be fused with the transverse colon, being connected with the gastro-splenic omentum on the left, and with the hepatic flexure of the colon and descend- ing colon on the right; — consisting of four layers, two descending and two ascending; the two middle layers belonging to the lesser sac and the two superficial layers to the greater sac; — its vessels coming chiefly from the gastro-epiploica sinistra of the splenic artery, and to a less extent from the gastro-epiploica dextra of the gastro-duodenal branch of the hepatic artery. Small or Gastro-hepatic Omentum. — Extends from transverse fissure of liver to lesser curvature of stomach, being continuous on the right with the first part of the duodenum (there forming the ligamentum hepato-dno- denale), and, on the left, with the gastro-splenic omentum; — formed of two layers, one from the lesser and one from the greater sac; — and having the following relation of vessels between the layers of the hepato-duodenal portion of the gastro-hepatic omentum: ductus communis choledochus, on the right: hepatic artery, on the left: vena portse, between the two and somewhat pos- terior to them. Gastro-splenic Omentum. — Extends from the fundus of the stomach to the gastric surface of the spleen; — and transmits the vasa brevia of the splenic artery to the stomach. GENERAL SURGICAL CONSIDERATIONS IN OPERATIONS UPON THE OMENTUM. The remarks made under this head in connection with the Peritoneum are applicable to this section. See page 649. LIGATION OF THE OMENTUM. Description. — In the course of intra-alidominal operations, it is often necessary to ligate portions of the omentum, either for the purpose of freeing adhesions, or as a preliminary step to the removal of a part, or even the whole, of the great omentum. Ligation of Omental Adhesions. — The general principle of dealing with adhesions by separation by blunt dissection, or by ligature and division, described under the operations for peritoneal adhesions (see page 649), applies equally to those of the omentum. Where the separation can be accomplished by blunt dissection, this should be done. Where division bv knife or scissors is necessary, this should generally be preceded by ligation with chromic gut. The ligature may be conveniently pas.sed by means of an aneurism-needle — either around a single band of adhesion, or in sections through broader extents of adhesion. The omentum is then divided distally to the ligature — or, where indicated, as is generally the case in dense adhe- sions, between double ligatures. (See Fig. 362, E. F, F.) Ligation of the Omentum Preparatory to Removal of Larger Por- tions. — The omentum mav tie so irre^ularlv and completeh' bound down as to require ligature and division in piecemeal, as in tying off adhesions, as just described. Where, however, it is largely or entirely free, a tier of ligatures may be quickly run across the free portion just above the line of subsequent division. This tier may be applied in sections by means of an aneurism-needle. (See Fig. 362, E.) Or it may be more quickly placed by holding the ligature in contact with the back or opposite side of the omen 654 OPERATION'S L'POX THE ABDOMIXO-PELVIC REGION. turn, and then, at proper intervals, piercing the omentum from the front with a pair of catch-forceps, or a Cleveland ligature-carrier, grasping the ligature and drawing it through — it is then cut at each opening through which drawn, interlocked with its neighbor by a half-turn, and tied — as shown in Fig. 362, F, F. OMENTAL GRAFTING. Description. — Consists in the using of isolated pieces of omentum to repair jieritoneal defects. These pieces of omentum are excised from the great omentum and sutured to wounded or denuded surfaces, or suture- lines, of the abdomino-pelvic viscera normally covered by peritoneum. They are especiallv used to reinforce suspicious intestinal sites — but may be applied to an\- of the serous surfaces of other viscera. They become adherent within a few hours — and thus strengthen weakened sites. Operation. — The application of omental grafts is called for during the course of intra-abdominal operations — and the technic of the operation is simple. .\ small piece of the great omentum, preferably its free aspect, Fig- 363.— O.MENTAL Grafting :— Graft of omentum reinforcing circular enterorrhaphy, sutured to the mesentery and partly sutured to the intestine. calculated in shape and size to cover the defect by a good margin, is cut awav with scissors, distally to previously placed ligatures of gut— and this graft is placed in contact with the area to be reinforced, preceded or not bv slight scarification of the site with a needle-point— and is held in contact by means of a few loosely applied, interrupted, tine gut-sutures. If the grafts cannot be used immediately after being cut, they are placed in warm normal salt solution until required, when they are partially dried between gauze. The grafts used to reinforce circular enterorrhaphy generally average from 4 to 5 cm. (lA to 2 inches) in width, and should be long enough to completely surround the site in question. (See Fig. 363.) IV. THE MESENTERY. SURGICAL ANATOMY. Description.— The mesenteries are peritoneal folds connecting any por- tion of the gastro-intestinal tract to the posterior abdomino-pelvic wall. SURGICAL ANATOMY OF THE SMALL LXTESTINES. 655 Divisions. — Mesogastrium; mesoduodenum; mesentery proper; mesen- teriolum (mesentery of the vermiform appendix); ascending mesocolon (some- times present); transverse mesocolon; descending mesocolon (sometimes present); sigmoid mesocolon; mesorectum. Mesentery (proper). — A fan-shaped fold of ])eritoneum beginning at the spinal column and following and covering the anterior aspect of the superior mesenteric vessels to the loops of the small intestine, enveloping all the coils of the jejunum and ileum (but not those of the duodenum) — returning thence along the posterior aspect of the superior mesenteric vessels to the vertebral column. The root of the mesentery e.xtends from the left lateral aspect of the body of the second lumbar \ertebra downward — crossing obliquely the spinal column, aorta, vena cava inferior, and third portion of the duodenum, ending at the right sacro-iliac synchondrosis, or in the right iliac fossa. It contains, between its right upper and left lower layers, the mesenteric arteries and veins, lacteals, lymphatics and nerves, all held together by fatty areolar tissue. The right upper layer of the mesentery passes from the root of the mesentery to the lower layer of the transverse mesocolon. Laterally the layers are continuous with the inner lamellae of the right and left colons. Below, the left layer is continuous with the peri- toneum covering the lumbar vertebra, and passing thence over the pelvic organs. In dimensions, its length (convex intestinal border) is about 6.45 m. (21 feet) — its width averages 20.5 to 23 cm. (8 to 9 inches), its greatest width (opposite the central and lower loops of the intestine) being from 20 to 25 cm. (8 to 10 inches). GENERAL SURGICAL CONSIDERATIONS IN OPERATIONS UPON THE MESENTERY. The mesenler\' is involved surgicallv chiellv in the operation of partial entercctomv. PARTIAL EXCISION OF THE MESENTERY. See under Partial I-",nterfit(im\-, page 672. SUTURING OF THE MESENTERY. See under Partial Enterectomy, page 672. V. THE INTESTINES. SURGICAL ANATOMY OF THE SMALL INTESTINES. Description. — Extend from ])yl()rus of stomach to ileo-ca;cal valve. Aliout -.h meters (25 feet) long. Divisions. — Duodenum (from 25.5 to 30.5 cm., or 10 to 12 inches) — con- sists of First or Superior Curved Portion (Superior Hepatic Curve) (not quite 5 cm., or 2 inches); — Second or Descending (Vertical) Portion (not quite 7.5 cm., or 3 inches); — Third or Transverse (Preaortic) Portion (about 12.5 cm., or 5 inches); — Fourth or Ascending Portion (about 2.5 to 5 cm., or I to 2 inches); — Fifth or Duodenojejunal angle. Jejunum — about upper two-fifths of remaining small intestines (about 2.9 meters, or 9 feet 7 inches) Ileum — about lower three-fifths of remaining portion (about 4.3 meters, or 14 feet 5 inches). 656 OPERATIONS ITOX THE ABUOMINO-PELVIC REGION. General Form of Duodenum. — Usually has the form of a U, with which the above description corresponds — but is sometimes V-shaped. Course and Relations of First or Superior Curved Portion (Superior Hepatic Curve) of Duodenum. — Course; from [)\iorus, passes ujjward and backward to right, cnrrhaphv by cushing-s suture. 669 the wound, the thread is knotted in the ordinary manner — the needle is then carried outside of the intestinal wall onward to a point a short distance to one Fig. 36S. — Enterorrhaphy by Ccshing's Right-angled Conti.nuous Sutlre. side of the edge of the wound — passes beneath the serous, muscular, and into the submucous coat, parallel with the edges of the wound — emerges a short distance beyond — crosses, outside, at a right angle to the wound — to a point Fig. 369. — ENTERltKKHAPHY BY Co.MBl.NED OvERHAND CoNTIM;ors SATIRE lATs, Followed by Interrupted Le.viberts of the Olter Coats :— A, Comii lure; B, Interrupted Lemberts. on the other side directly opposite its last emergence — travels similarlv for- ward beneath the serous, muscular, and part of the submucous coat for a 670 OPERATIONS UPON THE AKDOMINO-PELVIC REGION. short distance — thence back across the wound at a right angle, to tlie original side — and thus on to the opposite end of the wound, beyond which it is carried a short distance and then knotted. Before the tinal knotting the thread is drawn tight, thus infolding tlie margins of the wound and appro.xi- mating the serous surfaces. (3) For manner of application, see Fig. 368. Comment. — Cushing's method of knotting, at either end, is unnecessarily complicated. ENTERORRHAPHY BY COMBINED OVERHAND CONTINUOUS SUTURE OF ALL COATS. FOLLOWED BY INTERRUPTED LEMBERT SUTURING OF OUTER COATS. Description. — (i> This method consists, first, in whipping together the edges of the wound by a simple, running, continuous, overhand suture, passing through all the coats of each margin of the wound, as a preliminary suture of approximation and strength —which is then followed by a secondary tier of generally either the interrupted or continuous Lembert sutures passing through the serous, muscular, and part of the submucous coats. (2) For manner of application, see Entero-enterostomy by simple suturing (page 676), for the general description of the method, — and Fig. 369, for its apphcation to a limited wound. ENTERORRHAPHY FOR WOUNDS OF THE INTESTINE. Description. — Wounds of the intestines may be divided into five classes; (a) Longitudinal wounds, incised or lacerated; (b) Transverse wounds, in- cised or lacerated; (c) Irregular wounds, incised or lacerated; (d) Complete iransverse division of the intestine; (e) Contused wounds. Preparation — Position — Landmarks. — As for median abdominal sec- lion. Incision.— In the majority of cases the incision will Ije in the median line, as for median abdominal section. If the abdominal v.ound, which may already e.xist, lie outside of either rectus, and especially if it be indicated that the wound has not ranged toward the median line, the incision is fre- (juentlv made vertical over the e.xternal abdominal wound. Operation. — (1) Having entered the abdominal cavity, the edges of the wound should be well retracted in order to expose the involved coils of intestine. (2) .\11 bleeding vessels should be controlled by clamp and gut- ligature before proceeding to the intestinal o]5eration. (3) If the omentum be found wounded, the lips of the wound should be approximated by gut- suture. (4) Unless the wounded coil of intestine be readily detected, it is best to systematically examine the intestines, beginning at the stomach — lifting the stomach and transverse colon to trace the tluodenum- and then, catching up the beginning of the jejunum beneath the ligament of Treitz. follow dowai the rest of the small and large intestines. (5) Some surgeons clamp each wound, in the case of gunshot wounds, as found— and suture none until all are clamped — in order to control intestinal contents. (6) Coils of intestine temporarily removed from the abdominal cavity should be surrounded with warm, wet, sterilized gauze or towels, with or without a preliminary enveloping with sterile rubber tissue. (7) All escaped intes- tinal contents should be wiped away with gauze, or, if excessive, by irrigation. (8) If the mesentery be wounded, the edges of the wound should be sutured E.XTliKORRlIAPlIV FOR WOUNDS OF THE INTESTINE. 671 with gut sutures. (9) Having brought the involved portion of intestine into the field of o]3eration, the wound is repaired as indicated by the special case. (10) Simple longitudinal wounds are closed by a line of interrupted Lembert sutures. (11) Simjile transverse wounds are closed in the same manner as longitudinal ones. (12) In irregular wounds, if consisting of a transverse and longitudinal wound (the two arms crossing each other at a right angle or diagonally) and not too extensive, the part of the transverse wound on one side of the longitudinal wound should be first closed with interrupted Lembert sutures — then similarly the part of the transverse wound on the other side — then the entire length of the longitudinal wound by interrupted Lamberts placed transversely to its length. (See Fig. 370.) Sometimes the two parts of the transverse wound and the ends of the longitudinal are closed as just described — and then the remaining portions of the sides of the longitudinal are sutured after the fashion of suturing the intestine in Enteroplasty for stricture. (See Comment.) Such an irregular wound as that made by a bullet, if not too large, may be treated as an ordinary wound, being sutured with Lembert sutures in such a wav as to infold its margins. Sometimes the Pig- 570- — Enterorrhaphy in Irregular Wounds of the Intestines :— The two limbs of the transverse wound being first sutured with interrupted Lemberts. and then the two limbs of the longitudinal wound. ragged edge of a bullet wound may be advantageouslv trimmed with curved scissors before suturing. Where destruction has been great, resection of a portion of the intestine, followed by some form of intestinal anastomosis, is generally safer. (13) Complete transverse division of the intestine will necessitate an end-to-end anastomosis, by means of a simple suturing or some mechanical device. (14) Contused wounds, if at all bad. should be treated as lacerated wounds, as the walls of such wounds are rendered of lowered vitality by the traumatism. The contused surface is thus turned into the lumen of the gut by Lembert sutures, where, if sloughing of the portion within the line of sutures occurs, no harm is done. (15) The injurv to the intestine having been repaired, the abdomen is closed as in median alidoniinal ^ection, with or without drainage, as indicated bv circumstances. Comment. — (•) Lembert or Halsted interrupted sutures are generally best in suturing intestinal wounds. (2) If any doubt e.xist as to the efficiency of the first row of sutures, a second tier, generally continued Lembert. may be put in, burying the first. (3) Areas of suspicious suturing mav be strength- ened by suturing o\er them omental grafts (elliptical pieces taken from the omentum followed by suturing up the lips of the wound thus made in the 672 OPERATIONS UPON THE AIJUOMINO-PELVIC REGION. omentum) — these are a])plied over the intestinal suturing and held in place by two or three (jut sutures. (4) Resection, followed by an entero-enteros- tomy, is preferable to any form of suturing, if by such form of simple suturing the lumen of the gut will be reduced to less than half its diameter. (5) Trans- verse suturing interferes less with the vascular supply than the longitudinal — especially when the longitudinal is near the mesenteric border. (6) A longi- tudinal wound of considerable length, and more or less breadth, the ordinary suturing of which might reduce its cahbre too greatlv, mav be repaired bv what is termed "elbowing" (such as is seen in the joining of segments of stove pipes . The intestine is bent somewhat upon itself, the center of the bending being the center of the wound — then one half of one side of the wound is joined, by interrupted Lembert sutures, to the other half of the same side — and the same steps are carried out on the opposite side. This is applicable only to wounds on or toward the antimesenteric border. The edges of the wound may be sometimes trimmed prior to suturing. Too great narrowing, as might result from simple suturing, or even resection, is hereby avoided. PARTIAL ENTERECTOMY. Description — By partial entercctomy is meant the excision, or resection, of a part of the intestinal canal, with or without the e.xcision of the corre- sponding portion of the mesentery. By prefixing the name of the part of the canal, the site of the partial excision is designated — Partial Duodenectomy, Jejunectomy, Ileectomy, Ciccectomy, Colectomy (ascending, transverse, or descending). Sigmoidectomy, Rectectomy. By the term Enterectomy alone is usually understood an excision of some part of the small intestine. As, of course, excision of the whole intestine is never considered, Enterectomy is generally used in the sense of a partial excision, without the preceding word " partial. " Enterectomy carries with it the idea of three operations — partial excision of the intestine — partial excision, or incision, of the mesentery — intestinal junction. The operation is generally resorted to where the disease or injury to a part of the intestine, or its mesentery, is so extensive that a portion of the intestine must be cut out and sacrificed. Preparation ~ Position — Landmarks — Incision — As for median ab dominal section (]3age 631). Operation — (i) Having of)ened the abdomen, the portion of intestine inxohcd is Ijrought out into the field of operation. (2) Before excising any [jortion of the intestinal tract, the contents of that part should be removed from it as much as possible — which is best accomplished by "milking" the intestines in opposite directions from a central point, the center of the part to be excised — and then clamping the intestines, proximally and distally, beyond the site to be removed. Various forms of clamps are used for this purpose, which may be divided into three categories; — (A) Special intestinal clamps, which are generally best (Fig. 371, C) ; — (B) Improvised clamps may be used, such as; (a) Pierce the mesentery near the intestinal border with the closed ends of a pair of forceps — grasp a small rubber tube in the bite of the forceps and draw it through the mesentery — and tie the two ends over the intestine (Fig. 371, E); (b) Pass a sterilized wooden toothpick through the mesentery, near the intestine, and make a figure-of-8 with a rubber band over it, compressing the intestine between toothpick and rubber band (Fig. 371. D); (c) Pass the pin of a safety-pin through the mesentery, near the intestine — and fasten, in the act of closing the pin, a small piece of flat sponge over the intestine (Fig. 371, A), (d) Pass PARTIAL ENTERECTOMV. 673 a piece of gauze through the mesentery, near the bowel, and tie over the intestine after the fashion of the rubber tube in (e) above: — (C) The thumb and index of each hand of an assistant may be used to compress the intestine in the position a pair of clamps would occupy — after having pressed away the intestinal contents (Fig. 371, B). (3) The indicated por- tion of the intestine is now excised — by dividing the gut on either side of the segment to be removed, with scissors or knife, exactly at a right angle to the length of the intestine at the part divided — so that the cut ends may be afterward approximated without any tension at either mesenteric or anti- mesenteric aspect. (There is somewhat greater retraction of the antimesen- F'g- 371- — Methods ok Controlling the Intestinal Contents di'ring Partial En- TERECTOMv : — A, Mauiisell's method by means of .=;ponge and safety-pin ; B, Digital compression ; C. Special intestinal clamps ; D, Toothpick, or similar object, piercing the mesentery, with an ordinary rubber-band passed over it in figure-of-eight fashion ; E, Rubber tube passed through mesentery and tied over the intestine. (Whichever method of control be used, the same method isgeneralh' applied on each side of the area to be excised.) teric border naturally.) Division of the intestine with a knife is better than by means of scissors, which latter compress the edges somewhat. It is well to have, if possible, a good artery left just to the proximal side of the proximal intestinal incision, and one on the distal side of the distal intestinal incision — to furnish nourishment to the uniting edges. The triangular space, at the separation of the leaves of the mesenterv, will be opened up — and care should be exercised not to bare the intestinal tube further than necessary. (4) The treatment of the mesentery corresponding with the excised portion of the intestine differs — one of the following methods may be used: — (a) Probably the best plan, after having excised the portion of intestine, is to remo\-e a triangular or V-shaped piece of the mesentery — whose base will be a little 674 OPERATIONS UPON THE AliUOMINO-PELVIC REGION. narrower than the section of the intestine removed — whose sides will pass down obliquely toward each other in the direction of the root of the mesentery, but meeting midway between the two free ends of the intestine and before reaching the root of the mesentery. The division is made with a knife or scissors, from a line with the free ends of the divided intestines at their mesen- teric borders — taking care to preserve the artery supplying the free end of the intestine, pro.ximally and distally. In suturing, the edges of the cut mesentery are approximated with gut by continuous or interrupted suture (Fig. 372, A and B). Or the edges may be slightly overlapped and then sutured, uniting laterally (Fig. 372, C). All vessels w-hich fall along the line of division of the mesentery, whose position is shown through the thin mesentery, should be ligated, proximally in advance of the division — by fif Fig. 372.— Methods V-shaped portior with suturing of edge to suture; D. Mesentery left fold of ; Same, with suturing of both free border together with closure by continuous suture of entrance teric vessels are shown ligated, by the passage of needl< SUTtiRlNG THE MESENTERY IN PARTIAL EntERECTOMV : — A, e.xcised. with suturing of edge to edge b\' continuous suture ; B, San ige b>' interrupted sutures: C, Same, with edges overlapped by runnii tact, with free edges sutured togethci in < -uii iimons ,>\ .-rhand stitch ; ■dun ral 1 passing a curved needle armed with gut, beneath them, — or the vessels may be clamped immediately after division and then ligated (see Fig. 372). This method is especially advisable in malignant disease where the mesenteric glands may be invohed. (b) .'\nother method is, after dividing the intestine at both ends, simply to cut away the excised portion close along the mesenteric attachment, after having ligated its vessels as in the above method. In suturing, the redundant mesentery is simply folded upon itself and a few gut sutures passed from side to side, along the angle of junction with the rest of the mesentery — and by whipping the free margins with a gut suture, to prevent a hernia occurring through the opening. This method probably insures a better blood-supply to the intestine (Fig. 372, D). (c) In addition to the steps mentioned in the last method, the entire triangular fold may ENTERO-ENTEROSTUMV. 675 be sutured back to the general mesentery by sutures along its folded border, as well as along its free border (Fig. _:;72, E). Comment. — Partial Enterectomy is an incomplete operation in itself — and naturally carries with it the idea of suturing together the two free ends of the intestinal canal left open after the excision, and thus repairing the intestinal tract— but since the junction of these two ends is accomplished b\' a separate and distinct operation, it will be treated of separately. (See Entero-enterostom V. ) ENTERO-ENTEROSTOMY. Intestinal Anastomosis was originally ajjplied to the operation of estab- lishing a coninuniicalion between the intestine above and the intestine below the seat of obstruction, without the removal of the portion of intestine in which the obstruction was situated. As a result, the larger part of intestinal contents would flow by the new route, thus " short-circuiting " the obstruction, while the smaller portion would flow through the partially obstructed canal, until the obstruction was relieved or became complete. As, in such cases, no portion of the intestine was removed, the Anastomosis was always a Lateral Anastomosis, that is, the joining of the lateral aspect of one coil with the lateral aspect of another coil. Subsequently, however. Intestinal Anastomosis came to be used, by many surgeons, in the same sense as Intes- tinal Approximation, and applied to both end-to-end and to lateral joinings. Intestinal Approximation was originally used to signify the union of the portions of the intestinal tract following the excision of a part of the canal — the appro.ximation being either end-to-end or lateral. In End-to-end Intestinal Approximation, after the excision of a part of the intestine has been accomplished, the free ends of the intestine above and below are ap- proximated and united. In Lateral Intestinal Approximation, after the partial enterectomy has been performed, the free ends of the intestine above and below are closed by suture, and then the lateral aspect of the closed upper end is approximated and united to the lateral aspect of the closed lower end. Intestinal Implantation has generally been used to signify the implanta- tion, or union, of the end of one piece of intestine into an opening in the lateral, antimesenteric aspect of another coil — following the excision of a seg- ment of intestine. This process of union imitates the union of the ileum with the colon (caecum). Entero-enterostomy signifies the junction of the lumen of some part of one intestinal coil with the lumen of some part of another. Strictly speaking, therefore, Entero-enterostomy is a term of broader significance than those above used, and includes .Anastomosis, Approximation, and Implantation. No hard- and-fa.st rule, however, exists as to the use of the terms designating the union of coils of intestine, but the shades of difference expressed in the terms Intestinal Anastomosis, Approximation, and Implantation might probably be more accurately expressed by the terms Entero-enterostomy by Lateral An- astomosis — Entero-enterostomy by End-to-end Approximation —Entero-en- terostomy by Lateral Approximation -Entero-enterostomy by End-in-side Implantation. While, therefore. Entero-enterosiomv expres.ses the junction of lumina of segments of intestine, the method of that junction is best expressed by following the term with some qualifving words. 676 OPERATION'S UPON THE ABDU.MINO-PELVIC REGION. The Scope of the Methods of Intestinal-joining.— Many of the methods used f(ir \arii)u>ly unitiiiL; sej^Tiienls of ihf intestines to each other are also used to unite portions ol tiie intestines with dilTerent parts of the stomach — and also with the gall-bladder. The range of usefulness of any method of intestinal joining, therefore, is measured by the ability of that special method to meet the requirements of the following operations involving the intestines;— Entero- enterostomy by Lateral Anastomosis; Entero-enterostomy by End-to-end Appro.ximation ; Entero-enterostomy by Lateral Approximation; Entero en- terostomy by End-in-side Implantation; Simple Gastroenterostomy (by lateral anastomosis, or end-in-side implantation); Gastro-enterostomv fol- lowing pvlorectomy ; Cholecystenterostomy. The Methods of Accomplishing Intestinal Joinings — (1) Union of portions of Intestinal, Gastro-intestinal, and Gholecyst-intestinal tracts by simple suturing; — (2) Union of portions of Intestinal, Gastro-intestinal, and Cholecyst-intestinal tracts by absorbable mechanical devices; — (3) Union of portions of Intestinal, Gastro-intestinal, and Cholecvst-intestinal tracts by non-absorbable devices; — (4) Union of portions of Intestinal, Gastro-intes- tinal, and Cholecyst-intestinal tracts by mechanical means temporarily used during suturing. Note. — In the various operations of Entero-enterostomy it is not necessary that any previous excision (partial enterectomy) must have been done — though such an excision may have been done. In the following operations of Entero- enterostomy the joining of the portions of intestine will (to make the operation more complete) be supposed to follow, in the majority of cases, e.xcision of some part of the gut. Of course, the same operations which are applicable after the excision of a part of the intestine are also applicable after a circular division (circular enterotomy) of the gut without any excision of a part of the canal. (A) ENTERO-ENTEROSTOMY BY METHODS OF SIMPLE SUTURING IN CENER.AL. Union is here accomplished by the ordinary methods of suturing, unaided by mechanical devices other than sutures. (i) For the general jjrinciples of intestinal suturing, see Enterorrha]:)h\- in General. (2) Fine silk or fine chromic gut may be used throughout. Or silk may be used for the first tier and chromic gut for the second. This applies whether the first tier includes all the coats or only the mucous membrane. (3) Some surgeons prefer to use only interrupted sutures throughout in intestinal suturing— upon the ground that in continuous suturing (especially when of silk) the size of the opening becomes more or less fixed and less capable of the distention which, on the other hand, may readily occur in all forms of inter- rupted sutures. (4) It is well to bear in mind that sometimes Lembert inter- rupted sutures which may appear to be near enough in the undisturbed condi- tion of the gut become too far apart when it is distended. (5) No matter what form of suturing be used for the first tier, the second tier should include only the serous, muscular, and, if possible, part of the submucous coats — and shou'd bury in the first tier. (6) DitBculties encountered in placing sutures may be largely overcome bv seizing the site to be sutured with delicate forceps and thus causing that part to meet the needle with its proper aspect rendered prominent by eversion, inversion, traction, etc. (7) When segments of unequal size are to be approximated end-to-end, the only way this can be done by simple suturing ENTEROEXTEROSTOMV BY SIMPLE SL'TL'RING. 677 is either, (a) to partially close the opening of the larger gut down to the size of the smaller, which may be accomplished by taking a V-shaped piece out of the antimesenteric aspect of the larger gut and then suturing together the edges of the V before making the junction, — or (b) by cutting the opening of the smaller gut obliquely (Wehr's method) instead of transversely, at the expense of the free border, and thus increasing its size to match the larger gut. The best methods, however, of uniting segments of unequal size are probably either by the Murphy button or the ^launsell method. ENTERO-ENTEROSTOMY BY SIMPLE CONTINUOUS OVERHAND SUTURE OF ALL COATS. FOLLO^X^ED BY INTERRUPTED OR CONTINUOUS LEHBERT SUTURES OF OUTER COATS. Description. — The first tier of suturing is for a]ipro.\imation and strength — the second, for union of the serous surfaces and occlusion of the intestinal lumen. Preparation — Position — Landmarks — Incision. — As for median ab- dominal section. Fig- 373- — Entero-enterostomy bv Simple Continvous Overhand Sl'turingof .■\ll Coats. FOLLOWED BY INTERRUPTED OR (CONTINUOUS) LeMBERT SUTURES OF OUTER COATS : — A method of holding the intestine and introducing the first tier of simple continuous overhand suturing of all coals. .-Author's method. End-to-end Approximation — Author's Method. — (i) Open the ab- domen — isolate and firing forward the indicated coil of intestine — press away the intestinal contents — apply intestinal clamps, pro.\imally and dis- 678 opi:rations upon the audomino-pelvic region. tally, to the site to be excised — and excise the portion of intestine, with or without the corresponding portion of mesentery (see Enterectomy). The two ends of the intestine are now brought into convenient apposition for suturing, and are held in apposition during the placing of the first tier of sutures. (2) The first row of continuous suturing passes through all the coats of proximal and distal segments of intestine, and consists of a continuous silk or gut suture carried upon a straight needle held in the lingers. The surgeon holds the approximated borders of the two coils of intestine over the radial aspect of his left first finger, approximating the op- posite borders with the left second finger and thumb (or holds them over his Figs. 374-376.— De IF Simple Coniincoi'S Overhand Suturing of All Coats, shown knotting and beginning suture, at a — traversing posterior edges of intestines— and including laniince of mesentery at b, wfience tlie suture starts to return ; B, Manner of traversing anterior edges of iTUestines— and ending the suture at a, preparatory to knotting: C, Manner of tying final knot of first tier of sutures at a, and appearance of suture-line and approximated leaves of mesentery. Author's method. left second finger, approximating with his left index :ind thumb). (See Fig. 373 ) Four thicknesses of gut are thus brought together, two from the prox- imal and two from the distal end of the divided intestine. The adjacent aspects of the apposed edges should be first sutured. (See Fig. 374, A.) The needle should first enter at the antimesenteric borders, the first stitch lieing so placed as to leave the free end of the suture, after knotting, on the outside, which is done by beginning the stitch from w^ithout and then passing the needle back into the lumen after tying the first knot. After the needle has passed back into the lumen it should always, in going toward the mesenteric attach- ment, travel from within outward through the wall of the intestine on the right (nearer the operator) — then from without inward through the wall of the intes- tine on the left (further from the operator) — and so on, descending toward the ENTEKO-ENTEROsroMV BV SIMPLE SUTURING. 6/9 mesenteric aspect. The last stitch, before beginning the return, includes, besides the two thicknesses of the gut, also the two lamina; which are adjacent (one from the pro.ximal and one from the distal portion of gut). .\nd the first stitch, after beginning the return, includes, besides the two thicknesses of gut, also the two lamina? of mesentery (one from the proximal and one from the distal por- tion of gut) which are furthest from each other at the taking of the stitch, but which will be brought into contact by the stitch. (See Fig. 375, B.) The suturing is then continued back to the antimesenteric aspect in an overhand stitch, as before — passing, now, from without inward through the wall of the intestine nearer the operator, and from within outward through the wall of the intestine further from the operator. When the last stitch is reached, its free end on the outer side is knotted to the free end left on the outer side at the start. Fig. 377.— Entero-entkrostomy by Simple Continuous Overhand Suturing of All Coats. FOLLOWHD BY INTERRUPTED (OR CONTINUOUS) LEMBERT SuTURES OF OUTER COATS : — .\ method of holding llie intestine and iiurodiicing llie second tierot interrupted Lembert sutures, which is seen burying in the first tier of continuous overhand suturing. The assistant's hands are held in pronation while suturing the anterior, and in supination while suturing the posterior aspect. Author's method. (See Fig. 376, C.) During the return-row of suturing care is taken that the stitches do not penetrate the coats already whipped together by the first row — which is easily avoided, as the edges are all in ]jlain view as each needle-punc- ture is made. (3) The second row of suturing consists of interrupted Lembert sutures passing through the serous and muscular, and jsrobably also the sub- mucous, coats. The sutures are silk or chromic gut, carried upon a straight needle held in the fingers. The barrel of intestine is now held out straight bv an assistant, who grasps it about 10 cm. (4 inches) on either side of the suture line — while the operator picks up a transverse fold of the gut wall near the origi- nal suture line by means of delicate forceps held in his left hand — and a similar fold just beyond the suture-line — passing the needle through both folds in the ordinary Lembert fashion. (See Fig. 377.1 One half of the circumference of 68o OPERATIONS UPON THE AUDOMINU-PELVIC REGION. the gut is sutured from one side, after which the intestine is turned over and the other half sutured from the opposite side. The sutures are inserted in the usual manner of the Lembert method — the forceps picking up the tissue in transverse folds and thus drawing it away from the opposite wall, thereby mak- ing the passage of the suture easier, and the penetration of the opposite wall impossible. Especial care is neces.sary as the diverging lamins of the mesentery are encountered, in order that each lamina may be closely approximated to the barrel of its own segment of intestine and to the opposite lamina on the same side of the intestine. The Lembert sutures should, therefore, be continued on F'gs. 37S and 379. — Entkko-enterostomv by Simple Contini'oi's Ovhrhand Si'tcking of All Coats, followbd by Interri'pted (or Continuous) Lemberi Si'tl'res of Outer Coats: — A. Another method of liolding the intestines and introducing the first tier of simple continuous suturing of all coats ; B, Diagram showing manner of introducing the three preliminary traction- sutures. Author's method. down to the very junction of the mesentery with the intestine and slightly beyond. Note. — Instead of holding tlie inte.stines as above described during the placing of the first tier of sutures, several methods of holding them in apposition may be employed. Three interrupted sutures may be placed and knotted in loops as temporary traction-sutures — each including all the coats of the two adjacent walls of the pro.ximal and distal segments of intestine — one placed at the mesenteric aspect — and the other two dividing the circumference of the severed ends into three equal parts. An assistant now draws these three loops in different directions (which a single assistant can do by hooking them over his fingers, if the loops are not too long) — whereby two objects are accomplished; ENTERO-ENTEROSTOMV BV SIMPLE SUTURING. 68r — one-third of the margins of each gut are brought into contact, — and the mar- gins of the other two-thirds are held out of the way (and thus the penetration of their wall by the needle rendered imjjossibJe). While held in this manner, the adjacent margins of each third are whipped together by a continuous overhand suture — after which the temporary traction-loops are cut and withdrawn (or may be tied and cut short, as permanent interrupted sutures reinforcing the continuous ones). (See Figs. 378 and 379.) The second tier of interrupted Fig. 380. — I.ATERAL Intestinal Approximation by Simple Continuous Overhand Suturing OF All Coats, followed by Interrupted {or Continuoi's) Lembert Sutures of Outer Coats :— A, Showing manner of placing sutures along posterior aspect and at ends of Incisions ; B, Manner of liolding end of intestine between tliumb and itidex while placing the double suture; C, Manner of holding the ends with temporary traction-sutures passed through outer coats, while invaginating. Lembert sutures is applied as just described. Or the traction sutures may be retained until the Lemberts are placed, to draw the edges parallel. Lateral Approximation. — (1) Excise the indicated portion of intestine, with or without the corresponding i)iece of mesentery, as described under Enterectomy. (2) The pro.ximal and distal free ends of the intestine are now each closed by one of the following methods; — (a) Hold the free end of the in- testine lietween the left thumb and index, and whip together the parallel walls by an overhand continuous suture of all the coats — followed by an invagination of this line of suturing by means of a line of interrupted or continuous Lemberts 682 OPERATIONS UPON THE A15DOMIXO-PELVIC RECION. (see Fig. 380, B). — (b) Pass a traction-suture at the mesenteric aspect, and an- other at the antimesenteric aspect, near to but not quite at the free margins — and, while these are drawn upon by an assistant, whip the free edges together as above — and, while further drawing upon them, invert the first suture-hne with a probe, and place a row of Lemberts so as to permanently invaginate the first tier (.see Fig. 380, C). — (c) The free ends of the intestine may be closed by a continuous overhand suture of all the coats while the walls of the intestine are still held in contact by the special forceps grasping the whole width of intestine, and along which they have been divided in the operation of enterectomy — fol- low-ed by an invaginating Lembert tier, as above (see Fig. 381, B). — (d) The free end of each piece of intestine may be gathered together by an ordinary Fig. 381.— Lateral Intestinal .Apprcximation bv Simple Continlious Overhand Suti'ring OF All Coats, followed by Interrupted (or Continl'ol's) Lembert Sutures of Outer Coats : — A, Showing manner of carrying suture around ends and along anterior aspect of incisions ; B, Manner of holding end of intestine with clamp-forceps while suturing ; C, Manner of closing end of intestine with purse-string suture preparatory to placing final tier of end-sulures. purse-String suture — and this first tier then further invaginated by a second tier of Lemberts, as above described (see Fig. 381, C). (3) Having closed the open ends of the gut, appro.ximate these ends so that they overlap about 5 to 7.5 cm. (2 to 3 inches), with their antimesenteric aspects in contact — and have an a.ssistant hold them in this position. (4) Place a tier of continuous Lembert suturing, of gut carried upon a curved needle held in a needle-holder, along what w'ill be the posterior line of union between the serous surfaces — extending the line of suturing out at either end, in a somewhat elliptical form, beyond the limits of the future incision — leaving one end of the suture, after knotting, long and free — and the other end, also after half knotting, long and threaded upon the needle. (See Fig. 380.) (5) Incisions in the long axis of both pieces of inte.tine are now made opposite each other in tlie corresponding aspects of ENTERO-EXTEROSTOMV liV SIMPLE SUTURING. 683 the guts — and sufficiently far from the posterior suture-line to leave two free edges for suturing — and equidistant from what will form the anterior suture-line of the serous surfaces. These incisions will begin and stop short of reaching the outer limits of the surrounding Lembert suture-line which will enclose them. (6) The corresponding free margins of the wounds are now sutured with con- tinuous overhand silk suture, carried in a curved needle held in a needle-holder. Begin the suturing at the right end of the posterior aspect (furthest from oper- ator) — knot the suture and leave one end of the thread free — and continue the suturing toward the operator, until the [josterior lips are united. Having reached the limit of the posterior aspect of the opening, the direction of the suturing now changes and is made to traverse the anterior aspect of the wound, similarly whipping together the anterior lips of the intestinal incisions from Fig. 382.— Lateral Intestinal Anastomosis by Simple Continuovs Overhand Siti king OF All Coats, followed by Intkrripted (or Contini'ol's) Lembert Si'tvres of Outer Coats : — A, Simple continuous overhand suture of all coats ; B, Continuous Lembert suture of outer coats. The intestinal current passes as indicated by arrows, "short-circuiting" the cancerous growth. left to right, away from the operator — until the point of beginning is reached, when the end from which the needle has just been withdrawn is knotted to the end previouslv left free — thus completely appro.\imating the lips of the open- ings throughout. (7) The threaded needle of the original serous suture, which had been temporarily dropped, is now taken up — and this line of continuous Lemberts is carried on around the outside of the line uniting the edges, at the same distance from their edge as the posterior serous line passed — until the free end of line of serous suture, left at starting, is reached, when they are knotted together. — which completes the union tietween the intestines. (See Fig. 381.) (8) The mescnterv is now sutured as indicated. Lateral Anastomosis. — The operation is here performed in a precisely similar manner to the last (Lateral .\ppro.ximation) — omitting the e.xcision of any jjortion of the intestinal canal — the antimesenteric aspects of the gut being 6S4 OPERATIONS UPON THE ABUOMI NO PELVIC REGION. brought into apposition. Care is taken that the intestinal coils are not twisted out oi their natural relations. (See Fig. 382.) Note. — In Lateral Appro.ximation and Lateral Anastomosis, in order to prevent bagging, and sagging away of the intestines near the site of union, it is well to slightly scarify and suture (or suture alone) the free portions of the in- testine together for about 2.5 cm. (i inch) on either side of the union. End-in-side Implantation. — (1) Following e.xcision (for example, of the caecum) the free end of the intestine, the lateral aspect of which is to receive the implanted gut, is closed by a double line of suturing in precisely the same man- ner as described under Lateral Intestinal .Ajiijroximation. (2) An incision is Fig. 383. — End-in-side Intestinal Implantation bySimplk Continuous (ok Lmekklpthdj- Overhand Suturing of All Coats, followed by Interrupted (or Continuous) Lhmbert Sutures of Outer Coats :— A, Ileum ; B. Ascending colon ; C, C, Interrupted sutures of all coats of both intestines; D. Continuous suture of outer coats. made near the end of the invaginated gut corresponding with the end of gut to- be implanted. (3) The open end of the gut which is to be implanted (usually of smaller calibre) is now brought into apposition with the incision upon the antimesenteric aspect of the gut which is to receive the implantation, at about 5 cm. (2 inches) from its sutured end — and held in contact by an assistant throughout the operation. A line of continuous overhand silk sutures, carried upon a curved needle held in a needle-holder, is placed through all the coats of both pieces of the intestine, in exactly the same manner as described under the Lateral Approximation operation, the difference in the direction of apposi- tion of the two pieces of gut in the end-in-side implantation making no differ- ENTERO-ENTEROSTOMV BV CZERXVLEMBERT SUTURE. 6S5 ence in the manner of application of the sutures. Interrupted sutures may be used instead of the continuous. The margins of the end-opening in one piece of intestine and the lateral openings in the other are thus brought together throughout. (4) A continuous or interrupted Lembert suture is now carried through the serous and muscular (and probably into the submucous) coats of the two pieces of intestine, in such a manner as to surround the first line of through-and-through suture in a somewhat elliptical fashion. (5) The mesen- teric borders are sutured in such a manner as to leave no opening through which coils of intestine may pass. (See Fig. 383.) Note. — (I) The same ultimate method of union may be accomplished in a somewhat different order. The .serous surface near the free margins of the smaller gut may be attached, by Lembert sutures, to the serous surface of the invaginated gut, in such a position as to correspond with the future opening — the attachment being first along the posterior aspect, as in Lateral Appro.xima- tion. An opening is then made by incision into the invaginated end corre- sponding with the partly attached free end of intestine. The free edges of the opening are then united throughout by continuous silk suture — after which the continuous or interrupted Lembert suture of the serous surfaces is carried around the anterior aspect of the openirrg — thus completing the union. (2) The process of union may be mechanically aided by using Senn's rubber band as a temporary ring within the segment of intestine to be implanted — where it is held for a time by gut sutures — and is afterward liberated and passed down the canal. ENTERO-ENTEROSTOMY BY THE CZERNY-LEHBERT INTERRUPTED SUTURE. Description. — The edges of the mucous coat are brought together by the interrupted Czerny suture, which passes through this coat alone — followed by the ordinary interrupted Lembert suture through the serous, muscular, and part of the submucous coats. The method of application is the same as that described under " Enterorrhaphy by the Czerny- Lembert interrupted suture" (page 666). Preparation — Position — Landmarks — Incision. — .As for median ab- dominal section. End-to-end Approximation — (i) The ends of the intestines are held in convenient apposition — as described in the same operation by the last method. The suture consists uf silk or gut, carried upon a curved needle held in a needle- holder. The manner of manipulating is described under Enterorrhaphy by this method. The sutures are interrupted and are introduced and knotted from within, in the Czerny fashion. When the circular enterorrhaphy is almost completed, the last suture or two are somewhat more difficult to place, owing to the tendency of the knot to remain upon the outer aspect — which may be allowed, as tWs tier will be subsequently buried in — or, better, maybe in- vaginated within the lumen of the gut bv a probe. (See Fig. 384, B.) (2) Having completed the first or mucous tier of sutures, the second or outer tier of interrupted Lemberts is carried through the serous, muscular, and part of the submucous coats — and consists of silk or gut carried upon a straight needle held in the fingers — and is introduced in every respect as the interrupted Lemberts are introduced in the method just described. (See Fig. 384. A.) Lateral Approximation — Lateral Anastomosis — End-in-side Implan- tation. — The methofls of holding the segments of intestines in contact and the general princi])les of com])leting the entero-enterostomy are the same as in the 686 OI'KRATIONS UI'ON THE ABDOMINO-PELVIC KliGION. correspond inij ojierations by the overhand continuous suture of all the coats,, followed l>y the interrupted or continuous I.emberl suturing of the outer coats Fig- 3S4— Enteku-enterostomv by thk Czkrnv-Lembert Interrupted bLTUKE ; — B,. Czeiiiy iiUerrupled sulure passing through mucous and part of submucous coats— appHed from within; A, Lembert interrupted suture passing through serous, muscular, and part of submucous coats — applied from without. — with the exception that the first tier of suturing, in the present method, is of the mucous coat alone, and the second tier of the outer coats. Note. — The Czerny suture should include some of the submucous coat, to hold well. ENTERO-ENTEROSTOMY BY HALSTED'S METHOD OF INTERRUPTED MATTRESS SUTURES. Description. — The opposite intestinal walls are brought and held in con- tact by a single tier of the characteristic Halsted mattress or quilt interrupted suture, pa.ssing through the serous, muscular, and part of the submucous coats. The general method of application of this form of suturing to circular enteror- rhaphy is identical with the method described under "Enterorrhaphy by Halste'd's interrupted mattress suture" (page 667). In the end to-end ap- proximation, six " presection sutures " are used additionally. Preparation — Position — Landmarks — Incision. — .\s for median ab- dominal sctlion. End-to-end Approximation, — The details of the application of the Halsted sutures in performing entero-enterostomy without artificial aids are precisely the same as employed in the Halsted operation of entero-enterostomy by means of an inflatable rubber cylinder (page 710). The technic of the op- eration, therefore, will be found under the latter head — and may be u.sed here, omitting the use of the cylinder, and accomplishing the junction of the seg- ments of intestine by end-to-end approximation by means of simple suturing. The ends of intestine to be approximated are, in this case, simply held in con- venient contact by an assistant— the steps are otherwise the same as in the more elaborate operation. Lateral Approximation. — (1) Having excised the re(|uired portion of in- testine, the free ends of both pieces of gut are closed by a single row of the Hal- EXTERO-ENTEROSTOMV BY HALSTED SUTURE. 687 sted interrupted mattress sutures, introduced in the Halsted manner (see Fig. 305). (2) The antimesenteric aspects of the two pieces of intestine are then held in contact at about 5 cm. (2 inches) from their free ends. A posterior row of interrupted Halsted sutures is now placed along the line which is to form the posterior boundary of the intestinal junction, generally being about eight in number. At either end of this line two additional sutures are placed, coming slightly more forward, in continuation of the posterior longitudinal line in a for- ward curve. All of these sutures are first placed before any are tied — and then all are tied before placing the final ones. (See Fig. 385.) The anterior row of interrupted sutures is now similarly placed before any are tied — and so planned as to form an elliptical figure surrounded by sutures. (3) The sutures forming the anterior row are now drawn apart in the center (without drawing any -of them entirely out), and a longitudinal opening is made in each gut, midway between the two lines of sutures and not extending quite to the ends (so as to be Fig. 385.— Lateral ing poslerior line of sut cisioii into intestine, co closed by same kind of s Intestinal Approximation by Halsted's Qiilt Sutures:— A. Show res. and end sutures l)egiiining to outline an ellipse; B, t-ine of future in- responding to similar line on opposite intestine,- C, C, Ends of intestines llures. (.Modified fumi Halsted.) well included within the envelo[)ing line of sutures). (See Fig. 386.) (4) The sutures forming the anterior line are now knotted — thus completely apposing the site of union and enclosing the common opening between pro.ximal and distal segnu'iUs. (5) The edges of the mesentery are treated as indicated. Lateral Anastomosis, — The operation is here performed in every respect e.xactly as in Lateral Approximation, except that no excision of intestinal tract is done — and, consequently, no invagination of free ends of intestine is re- quired. Two convenient antimesenteric aspects of intestine are brought to- gether and the union made at once by the method of suturing just described. End-in-side Implantation. — If this somewhat unusual operation be called for, it is accomplished in the following manner; — the free end of the bowel to be implanted is brought into contact with the antimesenteric aspect of the portion of bowel to receive the implantation (the free end of wliich has been closed as 688 OPERATIONS UPON THE ABDOMINO-PEIATC REGION. in Lateral Approximation) — while held in this relation, the interrupted Hal- sted sutures are placed, passing from just beyond the edge of the opening in the latter piece of bowel, to just bevond the free edge of the former piece, and back to the latter jiiece — thus drawing, by means of the loop, the inverted edge of the Fig. 3R6.— Lateral Intestinal Approximation by Halsted's Interrupted Quilt Sutures ; — Showing all the posterior and half the end sutures tied— and the anterior sutures in position to be tied. The two corresponding intestinal incisions are seen. iModified from Halsted.) free end of the bowel above, down upon the inverted edge forming the incised opening in the bowel below — approximating serous surfaces entirely around the opening by the tying of the knots. ENTERO-ENTEROSTOMY BY MAUNSELL'S INVAGINATION METHOD. Description. — In intestinal joinings made by this special method of simple suturing a temporary window is cut in the intestinal tract, near one of the two sites to be united (always in the larger piece of gut) — and through this opening the two ends of intestine are temporarily invaginated by means of traction- sutures. The free edges of gut, brought concentrically through the window, are now united by interrupted sutures — after which they are drawn back into tlieir normal position and the window is closed by suturing — thus completing the operation. Preparation— Position — Landmarks Incision — .\s for median ab- dominal section. End-to-end Approximation. — (i) Having brought the coil of intestine into the field of o[ieration, excise the indicated portion, together with the cor- responding V-shaped part of the mesentery — and bring together the edges of the mesentery with gut sutures. (2) Two horsehair sutures (or silk) are now introduced, which are tem])orarily left long and serve, primarily, as traction- sutures — after which they arc cut short and serve as two of the permanent ENTERO-ENTEROSTOMV BV MAUXSELL'S METHOD. 689 sutures. The first is placed at the antimesenteric aspect — the needle being made to penetrate all the coats of the pro.ximal intestine, near its free border, from within outward — then all the coats of the distal segment of gut at a cor- responding point, but now from without inward. (See Fig. 387.) This suture is then knotted upon the inner side, one thread being cut short, the other left temporarily long as a traction-suture. The second suture, somewhat more complicated, is placed at the mesenteric aspect — beginning with that segment of gut of larger calibre (which becomes the intussuscipiens). the needle passes from within the lumen of intestine outward, penetrating the intestine near its free border and entering the triangular space where the two lamina- of the mesentery separate to embrace the barrel of the intestine — then going through the corresponding lamina of that side of the intestine, is carried across to the opposite segment of gut (which is to become the intussusceptum), there pene- trating, from without inward, the lamina of the mesentery of the same side — and, passing onward, pierces the corresponding wall of intestine, emerging upon its inner aspect — crosses thence to the opposite side of the same segment of gut — pierces its wall from within outward, passing through the correspond- Fig. 387.— Entero-enterostomy BY Maunsell's Invagination Method— Preparatorv to Invagination : — A, Window in antimesenteric aspect of intussuscipiens ; E, Manner of placing the antimesenteric traction-suture ; C, Manner of placing the mesenteric traction-suture. ing lamina of mesentery of that side — thence across to the opposite segment of gut — where it pierces, from without inward, the lamina of the mesentery of the same side — passing thence onward and emerging in the lumen of that segment of gut at which the suture was started. This important suture is now drawn tight, thus appro.ximating, by the peculiar manner of its passage, the laminae of the mesentery closely to the barrel of the two segments of intestine at their most unprotected sites. Its knot having been tied on the inner side, one thread is cut short and one left temporarily long as a traction-suture. (3) A tempo- rary window is now made in the segment of intestine of larger cahbre, inde- pendently of its being pro.ximal or distal. If both pieces are of the .same size, the window is generally made in the proximal portion. The opening is made upon the antimesenteric aspect of the intestine, in the form of a longitudinal slit of about 4 cm. (ij inches) in length, beginning about 2.5 cm. (i inch) from the divided end of the gut and extending in the opposite direction. This slit is often made by pinching up a fold of intestine longitudinally, between the left thumb and index, passing a knife through it and cutting upward — but as this is very uncertain and inaccurate, it is best to have an assistant .-o hold the 690 OPERATIONS UPON THE ABUOMINOPELVIC REGION. intestine as to separate its walls and then make the slit by a controlled stab-like incision with a sharp, narrow bistoury, increasing its dimensions with the same instrument or with a pair of scissors — or, even better still, carefully catch the antiniesenteric aspect of the intestine with two forceps, about 1.3 cm. (^ inch) apart, raising a transverse ridge, which is cut with scissors in the long a.\is of the bowel, after which one blade of the scissors is intro- duced and the opening enlarged. (4) A pair of forceps is introduced through the window and grasps first one and then the other of the traction- sutures, drawing them out through the opening. While the intestines are steadied in the left hand, the traction-sutures are drawn upon, until the free end of the .segment of gut further from the window is drawn into the lumen of the gut containing the window — the free edge of the latter being turned inward and invaginated by the opposite segment as it enters — the process of invagination continuing until the free ends of both emerge at the window as two concentric Fi>;. 3&S. — E.NTERO-HNTEROSTOMY BV MaUNSELL'S INVAGINATION METHOD— THE 1n\-AGINA. TION Accomplished ; — A. Window in intussuscipiens ; B, Concentric ends of two pieces oi inlesline ofeqnalsize; C. Antiniesenteric traction-suture; D, Mesenteric traction-suture; H, Edges of niesen- lerv sutured. circles, which are drawn sufficienllv far out througii the window for sujjsequent manipulations. Both peritoneal surfaces will thus be in contact. (See Fig. 388.) (5) While the ends of th* intestines are held upward and away from the opening bv the traction-sutures in the hands of an assistant, a long needle threaded with horsehair (or silk) is [)assed straight across the concentric circles about midway between the two traction-sutures, passing through all the coats of the four thicknes.ses of intestines at about 5 mm. (^\ inch) from the free borders. After the passage of the needle, leaving a long piece of suture at either side, the suture is caught with forceps at the center of the opening of the concentric guts and drawn upward and outward a short distance and cut. Each suture is then tied over the free borders of the two thicknesses of gut embraced by it. Thus about twenty (or more if needed) sutures are placed at equidistant .sites by the pas.sage of ten lengths of horsehair (or .silk) — and are tied and cut. The two long ends of the traction sutures are now cut short. ENTERO-ENTEROSTOMV BV MAUXSELL'S METHOD. 691 (If they have been placed at inconvenient sites, in relation with the other sutures, they may be cut out and removed.) (6) By gentle traction in the reverse direction the invagination is reduced — the intestines now forming one continuous length. (7) The window is then closed by continuous (or inter- rupted) Lembert sutures (see Fig. 389), thus completing the operation. Comment — (i) The above method is an imitation of nature's successful manner of performing enterorrhaphy, namely, by invagination and sloughing. (2) Maunsell used horsehair — others have used silk and silkworm-gut. (3) By suturing the edges of the excised mesentery before rather than after uniting the intestines there is less danger of further separating the lamina? of the mesen- tery. (4) At the end of the operation the serous surfaces should be in contact — and all of the knots at the end of the intestines should be within the gut. "In thin-walled guts there is a tendency for the knots and threads not to be so well buried as in the thicker walls. (5) The sutures may be passed through the walls of the concentric guts in the ordinarv manner and tied one bv one, in- stead of in the above manner. (6) The sutures should not be tied too tightly. Fig. 389. — Entero-enterostomy by Maunsell's Invaginatio.v Method — the I.vvagi- NATio.N' Reduced: — A, External view of suture-line; B, Closing the window with interrupted Lemberts. (7) This is an instance of using a single layer of through-and-through sutures in intestinal work — but practical e.xperience has proved the method a good one. To avoid the possibility of drainage-infection of the peritoneum by the sutures which pass through all the coats, some surgeons place additional interrupted Lembert sutures outside of the regular row. Fine gut may be thus used. Where Segments of Intestines of Unequal Size are to be United End- to-end. — (I) The traction-.suture through the mesenteric borders is introduced in the above manner. .\ second traction-suture is introduced in precisely the same manner as the antimesenteric traction-suture above, but so placed as to pass through the edge of the upper part of the smaller gut and through the edge of the larger gut on its side, at a distance from its mesenteric attachment about equal to the diameter of the smaller gut. A third traction-suture is passed through the antimesenteric border of the larger gut alone (see Fig. 390). (2) The window is now made in the larger gut — and the invagination accom- plished as in the above case. The two free ends of the gut will not now be con- centric, as in the above instance, owing to the difference in size and to the fact 6q2 operations upon THE ABDOMINO-PELVIC REGION. that the circumference of the smaller gut is fixed to the circumference of the larger in two places by suture. (3) The suturing of the borders of these two non-concentric circles can be best accomplished by the passage of a needle through only the two walls in contact at a time — instead, of simultaneously through these two and the opposite two, as in suturing coils of similar calibre. Each suture is at once tied. The first and second traction-sutures become per- manent — the third (through the larger gut alone) is removed. It is well to put the sutures in alternately on the two sides, proceeding from the mesenteric to- ward the antimesenteric border, until the edges of the small intestine have been sutured to those of the larger. When near the antimesenteric aspect of the smaller gut, the redundancy of the larger gut will be apparent. This redun- dancy, if at all marked, is best disposed of by cutting, with scissors, a V-shaped piece out of the antimesenteric aspect of the larger gut, of a size calculated for the individual case. This V is now carefully sutured by approximation of its margins by an overhand stitch, from its apex toward the antimesenteric aspect Fig. 390. — Entero-enterostomy by Mal^nsell's Invagination Method in Intestinal Coils OF Unequal Size— Preparatory TO Invagination: — .A, Window in intussuscipiens ; B, Mesenteric traclion-suture ; C, Traction-suture which is antimesenteric for llie smaller and lateral for the larger gut ; D, Traction-suture which is antimesenteric (or the larger gut. of the smaller gut, being especially careful to approximate the edges of the larger intestine, at the base of the V, with the edges of the antimesenteric border of the smaller gut. (See Fig. 391.) (4) The invagination is reduced by gently drawing upon the intestines — and the window is closed as in the regular ope- ration. While an elbow, marking the excess of the larger over the smaller intestine, will be present, the union will be secure. (See Fig. 392.) Lateral Approximation. — (1) Excision of the intestine and corresponding me.sentery is done, the clamps having been placed e.specially well away from the site of operation. (2) The two ends of intestine are overlapped upon their free, antimesenteric borders, and a continuous Lembert suture (leaving the end of beginning long, after knotting) is run along what will be the posterior aspect of the junction, extending at either end slightly beyond the line of future union around the common opening — and left long and threaded. (See Fig. 393.) (3) Two corresponding incisions in the long axis of both guts are made. (4) The posterior edges of the wounds are sutured together by an overhand, con- tinuous suture of all the coats, leaving the end of beginning long, after knotting. ENTERO-ENTEROSTOMV BY MAUXSELL'S METHOD. 693 and also the end of endins; long and threaded. (5) Forceps are protruded through the opening and out either free end of the intestine, catching up the Fig. 3qi.— Entero-enterostomy by Maunsell's Invagination Method in Intesti.nal Coils OF Unequal Size— the Invagination Accomplished: — A, Window in intussuscipiens; B. Non-con- centric ends of two pieces ol" intestine of unequal size; C. Mesenteric traction-suture; D, Traction- suture which is antimesenteric for the small and lateral for the large gut ; E, Traction-suture which is antimesenteric for the large gut ; F. One of the sutures uniting the opposite edges of the redundant portion of the large gut. Fig. 3^.;.— Em tKo-ENTEKOSTo.MV uv Mal-nskll's Invagination Methud in Inikstinal Coils of Unequal Size— the Invagination Reduced :— A, External view of portion of suture-line representing the end of the small intestine; B. External view of portion of suture-line represented by the redundancy of the large intestine; C, Closing the window with interrupted Lemberts ; D. In- terrupted sutures approximating the edges of the cut i free end in their grasp and drawing (invaginating) it into the lumen and through the opening. A circular silk ligature is then tied around either free Fig. 393.— Lateral Intestinal Approximation bv Maunsell's Invagination Method :- A, End of inlestine iiivagiiialed through window and circular ligature placed arouTid it ; B, Traction- ligatures grasped bv forceps in act of invaginating opposite end of intestine; C, Continuous overhand suture of all coats ; D, Continuous Lenibert suture ol outer coats. Figs. 3<>4aiid 395. — Lateral Intestinai- Anastomosis bv Maunsem —A, Intussusceptum drawn through window ; B, Intussuscipiens. with v. aspect; C, Diagram showing manner of placing traction-sutures. 694 ENTERO ENTEROS rOMV BY MAUNSELL'S METHOD. 69 s end and they are dropped into their respective lumina. (6) The needle at- tached to one end of the "whipping over" suture then continues the process until the corresponding edges of the entire circumference are brought together and the long ends tied. (7) Then the needle upon the serous suture is taken up and the continuous Lamberts through the serous and muscular coats are con- tinued around the anterior aspect of the wound, burying in the first layer. The edsres of the mesenterv are sutured as indicated. Figs. 396 and 397.— End-in-sidk Intestinal Implantation bv Mai'nsell's Invagination Method :— A. Colon ; B. Ileum ; C, Free edge of lateral window in colon ; D, Free edge of end of ileum ; E, Free, open end of colon ; F. Traction-sutures invaginating free end of ileum and lateral opening of colon through open end of colon ; G, Diagram showing manner of placing traction-sutures. Comment. — The circularly ligated ends of intestine may be reinforced witii interrupted or continuous Lemberts. Lateral Anastomosis. — Two knuckles of intestine are apposed along their antimesenteric borders — two corresponding axial incisions are made — a window is then cut about 2.5 cm. (1 inch) above — four traction-sutures are ap[)lied to the cut margins and knotted within — a pair of forceps, passed through the window, catches the four traction-sutures and draws them back through the opening — by means of these traction-sutures the lateral aspects of the two pieces of intestine are invaginated through the windovi' — sutures are applied to their margins, as in the end-to-end appro.ximation — the invagination 696 OPERATIONS UPON THE ABUOMINO-PELVIC REGION. is reduced — and the window closed bv interrupted or continuous Lembert sutures. The hne of anastomosis may be reinforced by Lemberts, if con- sidered necessary. (See Figs. 394 and 395.) End-in-side Implantation. — Excise the portion of intestine, with the corresponding part of mesentery — bring the free end of the smaller gut to the antimesenteric aspect of the larger gut, near its end — about 2.5 cm. ( I inch) from the free margin of the latter, upon its antimesenteric aspect, make an axial incision, corresponding in length to the diameter of the free end to be implanted — place four traction-sutures, knotting them within — draw these traction-sutures out through the free end of the gut in which the lateral opening was made, by means of forceps — suture together the margins of the free end and the lateral opening of the larger gut, as in end- to-end approximation — reduce the invagination — close the free end of the gut with the lateral opening first by continuous, overhand silk sutures, which are then buried by interrupted gut sutures of the Lembert type — thus com- pleting the operation. The edges of the mesentery are so sutured as to close all openings. The site of implantation may be reinforced by Lembert suturing, if considered necessary. (See Figs. 396 and 397.) Note. — In all the operations by the Maunsell method, the traction-sutures may be dispensed with — the invagination being accomplished by forceps introduced through the windows, as in Ullmann's modification of Maunsell's operation (page 699). (B) ENTERO-ENTEROSTOMY BY MEANS OF ABSORB ALE ME- CHANICAL DEVICES LEFT WITHIN THE INTESTINE. Description. — (i) The mechanical devices, which are made of .some absorbable material and are inserted into the intestinal tract to serve as distending frameworks over which the suturing may be conveniently applied, are bobbins, buttons, cylinders, plates, etc. They are left within the lumen of the intestinal tract, either to be entirely absorbed, or to be partially ab- sorbed and the residue passed by nature. While possessing, in common with non-absorbable devices, the property of aiding in the approximation of the parts, they possess the additional advantage of becoming absorbed after having accomplished their purpose — with the concomitant disadvantage of possibly sometimes becoming absorbed before having done their work completely. (2) The bobbins are in the form of two cones united at their apices, which is their smallest part. Their shape has a greater tendency to approximate the intestinal surfaces than has the button, or reel. The buttons are very much like ordinary buttons, or possibly more like reels. The size of the barrel is everywhere equal between the flanges, \arious forms of plates are used, of which the best known are probably Senn's bone- plates. Some forms of cylinders are used. The terms designating these devices are sometimes usecl interchangeably. (3) These devices are made of various materials — the most usual being decalcified bone, or some form of vegetable (such as potato, carrot, turnip, etc.). In some, the bulk of the device is made of entirely absorbable material, and a small part of the center, where the pressure is to be borne, is made of more imperfectly absorbable or of non-absorbable material. (4) These devices are always used in con- nection with some form of suturing — never alone. (5) As to their range of applicability — their chief field of usefulness is in end-t(j-end a])proximation — ENTERO-EXTEROSTOMV BV ABSORBABLE BOBBIN'S. 697 and only to a limited extent in lateral approximation, lateral anastomosis, end-in-side implantation, gastro-enterostomy, and cholecystenterostomy. Some are used only in lateral methods of entero-enterostomy (as the Senn bone-plates). ENTERO-ENTEROSTOMY BY MEANS OF ABSORBABLE BOBBINS. Description. — The .-Mlingham partially decalcified bone bobbin will be taken as representing this type — the steps of the operations being the same whether the bobbin be of this or vegetable material. In .\llingham's bobbin the bone is decalcified to within 3 mm. (y\ inch) of its very center, which is left firm to resist pressure made by the suture. The two portions of the intestinal tract are approximated over the center of the bobbin by running sutures inserted, in purse-string fashion, in the free end of each piece of intestine. Preparation — Position — Landmarks — Incision. — .\s for median ab- dominal section. ^'^H' 3yS. — END-10-t.su I.NltSTI.NAL AfPKUXlMATloN BY AN ABSORBABLE BOBBI.N ;— Posiliull bobbin is shown p.irlly in outline; A. Purse-string suture in position ready to be tightened; B, Pur string suture tightened .-tnd tied ; C, Interrupted Lembert suture in position to be lied. End-to-end Approximation. — (i) Having completed the steps of a preiiminarv entercctoniv, place a running, overhand purse-string suture of silk in the ends of each piece of intestine, passing through all their coats, the thread entering and coming out at the antimesenteric borders — leaving both free ends long. (See Fig. .398.) While less simple, a more satisfactory form of purse-string suture (owing to the manner in which it approximates the lamina; of the mesentery) is the one used in connection with the operation of entero-enterostomy by means of the Murphy button (page 703 ) — and this suture is etjually applicable here. (2) Insert one end of the bobbin into the pro.ximal, or distal, end of the intestine — and, having made the double turn of the friction-knot, draw the purse-string rather tightly down upon the intestine over the center of the bobbin — but do not tie the final knot. Insert the opposite end of the bobbin into the end of the opposite piece of 6q8 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. intestine and similarly tie it. (3) When both segments of intestine are moulded well into position, so that the serous surfaces are well appro.ximated, each suture is tightened with moderate firmness and the final knot in each tied — thus securely bringing and fastening the ends of the intestines at the center of the bobbin, and holding in contact rather e.xtensive serous surfaces for union. (4) The serous surfaces may be scarified with a needle for about I cm. (f inch) around the line of suture, to cause e.xudation of lymph and firmer union. (5) .A. few interrupted Lemberts of fine gut may be applied around the line of union, further appro.ximating the serous surfaces, if thought necessary. (6) The mesentery is treated as in other operaticns of entero- enterostomy. Comment. — While especially applicable to end-to-end approximation, the method may also be used for lateral approximation, lateral anastomosis and end-in-side implantation — applying the same general principles men- tioned in the preceding descriptions of those operations. As the junction in the last three operations mentioned is not so perfect as in end to-end approximation, additional Lembert sutures should always be u.sed to rein force the line of union. ENTERO-ENTEROSTOMY BY MEANS OF ABSORBABLE BUTTONS. Description.— The Landerer potato button will be taken as representa- tive of this type of mechanical device. .\ purse-string suture is inserted into each end of the intestinal opening— these are tightened over the barrel of the button, or reel, thus relatively appro.ximating the ends of the intestine. Pig. 399.— End-to-end Intestinal Approximation by an Absorbable Button:— Positii button is shown in ouUine ; A, Forceps everting lips of intestine to aid suturing ; B, Continuous si of mucous coat ; C. Interrupted Lembert sutures of serous and muscular coats. But as the barrel of the button or reel is of the same dimension for some distance, there is not the same tendency for the approximated ends of the intestine to be held in close contact as is the case in the bobbin, where there is the narrowest part of the barrel at the center, into which the segments ULLMANN'S MODIFICATION OF MAUNSELL'S OPERATION. 699 may be readily tied. An overlying line of interrupted or continuous Lembert sutures is, therefore, placed over the ends appro.ximated by the purse-strings — and thus securely apposes serous surfaces. Preparation — Position — Landmarks — Incision. — As for median ab- dominal section. End-to-end Approximation. — (i) Having completed the steps of a preliminary enterectoniy, a purse-string suture of silk or of chromic gut is inserted into the end of each piece of intestine — in the same manner, prefer- ably, as in Alurphy's button-operation (page 703). (2) Each end of the intestine is drawn over the tlange of the button on to the barrel — the purse- string is then moderately tightened and cut short, thus bringing the two ends of the intestine into contact. (The narrower the barrel of the button, the closer will be the contact at this stage.) (3) The circumferential margins of the intestines are united with a line of interrupted cr continue us Lembert sutures of the serous and muscular coats. (4) The mesentery is repaired as in other operations of entero-enterostomy. Comment. — The comment made under '" Entero-enterostomy by means of Absorbable Bobbins" is equally apjilicable here. Union may also be accom- phshed by an inner tier of continuous suture of the mucous coat, and an ■outer interrupted tier of Lemberls through serous and muscular coats. (See Fig. 399-) ENTERO-ENTEROSTOMY BY MEANS OF ULLMANN'S MODIFICATION OF MAUNSELL'S OPERATION. Description. — Up to the ap])lication of the Ullmann modification, which is applied after the invagination of the ends of the intestines through the window in one of the pieces of gut, the steps of the operation are identical with those de.scribed under the Maunscll method (page 688). The two ends of intestine having been brought through the window, a carrot (or other vegetable, or decalcified bone) bobbin is inserted within their con- centric lumina, so that its groove is grasped by their walls, which are then tied over the groove in a circular manner, with gut or silk. The invagina- tion is then reduced — and the longitudinal wounfi, forming the window, closed. Preparation -Position — Landmarks — Incision. — .\s for median ab- dominal section. End-to-end Approximation. — (i) The operation, up to the point of invaginatiiin, is precisely the .same as in Maunsell's operation (page 688). (2) The invagination is now accomplished by passing two catch-forceps through the window — one catching the mesenteric and the other the anti- mesenteric aspects of the end of the pro.ximal gut (the gut in which the window usually is) — and draws these out simultaneously through the window. The mesenteric and antimesenteric aspects of the edges of the distal gut are similarly caught by two catch-forceps introduced through the window — which are also drawn out simultaneously through the opening. These last two forceps are removed from the distal gut and made to grasp the edges of both guts at their sides. The fir.st two are then also removed from the first gut and made to grasp the edges of both guts at the same site each was grasped bv a single forceps. Thus the concentric ends of the two intestines are readilv held open by the four pairs of forceps equidistantly placed. These forceps are given to an assistant, who hoHs them with one hand, while holding the bobbin with the other. (See Fig. 400.) (3) The bobbin is now introduced into the concentric openings of the intestines — the walls of the two guts are 70D OPERATIONS UPON THE ABDOMINO-PELVIC REGION. then tied down into the groove of the bobbin with thick catgut or silk (which will not likely cut through). (4) The forceps are rela.xed — the invaginated intestines are reduced — the window is closed by interrupted or continuous Fig. 400.— ENTERO-ENrtKOSTOMV BY UlLMANN'S MODIFICATION OF MAUNSKI.L'S INVAGI- NATION Method ;— A, Window in intussuscipiens ; B. Concentric ends of intestines drawn through window ; C, C, Traction-forceps drawing ends of intestines through window ; D, Absorbable bobbin within concentric ends of intestines ; E, Ligature binding ends of both pieces of intestine to groove of bobbin. Fig. 401. — Enteko-enterostomy by Ullmann's Modification of Mal'nsell's Invagi- nation Method ;— Showing the reduction of the invagination and closure of the window— bobbin and ends of intestine being shown in outline. Lembert sutures — the mesentery is repaired — and the operation concluded. (See Fig. 401.) Comment. — .Mthough more applicable to end-to-end approximation, the ENTERO-ENTEROSrOMY BY COFFEY'S METHOD. yot Ullmann modification of the Maunsell method may be appHed to lateral approximation, lateral anastomosis, and end-in-side implantation. ENTERO-ENTEROSTOMY BY COFFEY'S METHOD. Description. — The free ends of intestine, after having been first united at their mesenteric aspects by two or three Connell sutures, are drawn over a vegetable tube (made of potato, carrot or turnip, preferably the first) and made to meet and overlap at its center by means of two long needles passed through tube and intestines transversely, at right angles to each other — after which any form of suture desired is applied — the pins then withdrawn — and the potato-tube pushed on down and crushed. Preparation — Position — Landmarks — Incision. — As for median ab- dominal section. Fig. 402.— End-to-end Entero-hnterostomv bv Coffev's Method: — I, Ends of intestine brought together and their mesenteric aspect united by three Connell sutures— preparatory to insert- ing hollow potato-tube shown above. (Modified from Coffey.) Operation. — (i) Having completed, one mav suppose, the steps cf an excision of a portion of the intestines, the free ends are brought into contact and, while thus held by an assistant, three Connell sutures placed at the mesenteric aspect, the central one embracing both laminse of the mesentery of both ends of the intestine — each suture passing from within the lumen of one end outward through its own wall, and from withi;ut inward through the corresponding site of the opposite end — then from within outward from the lumen of the opposite end, and from without inward through the cor- responding site of the original end, back into the lumen of the original end — where the free ends of the suture are tied within the first piece of intestine. (Fig. 402.) (2) One end of the united pieces of intestine is then drawn over the potato-tube up to the center of the tube — and is held there until the opposite end of the intestine is similarlv drawn over the opposite end 702 OPERATIONS I'PON THE ABUOMINO-PELVIC REGION. of the tube tn meet it, and also held in position. (3) Two long needles (or hat-pins, knitting-needles, probes, or toothpicks) are now passed transversely through the potato-tube and through the ends of the intestine, at right angles to each other — one entering near the mesenteric, and one at the mid-lateral aspect. As these needles enter and emerge, they are made to pierce the overlapped edges of intestine — and thus hold them in four places — over- lapped where the needles penetrate, and overlapped or in comparatively close contact throughout the rest of the quadrants (Fig. 403). (4) While the ends of intestine are thus held, anv form of suture desired mav be placed — interrupted Lemberts — continuous Lembert — the Halsted (juilt suture — or a double line of sutures. (5) Having completed the suturing, the pins are Fig. 403.— End-to-end Eni ero-enterostomy by Coffey's Method: — II, Two ends of intes- tiiie drawn over tube and held in reUition with e,ich other by long needles thrust through the potato- tube at right .-angles to each other and piercing the overlapped edges ot intestine. While thus held interrupted Lembert (or otheri sutures are applied— after which, needles are withdrawn— and potato- tube may be crushed. ( Modified from Cofley. ) withdrawn. In the ca.se of interrupted sutures, those stitches which were placed while the needles were in situ can now be more satisfactorily drawn together after the removal of the needles. The potato-tube is carefully pressed away from the site of operation, distally to it — and is then crushed into comparativelv small pieces. (6) The abdomen is closed in the usual manner. (C) ENTERO-ENTEROSTOMY BY MEANS OF NON-ABSORB- ABLE MECHANICAL DEVICES LEFT WITHIN THE INTESTINAL CANAL. IN GENERAL Description. — These devices, usually made of metal, serve, as in the case of absorbable devices, as frameworks over which the intestinal joinings are ENTERO-EXTEROSTOMV HV MEANS OF MURPHY BUTTON. 703 made — but are left within the intestinal tract to be passed out at the anus by the efforts of nature. The Murphy button may be taken as the most generally used representative of this class. ENTERO-ENTEROSTOMY BY MEANS OF THE MURPHY BUTTON. Description. — The junction between the intestinal coils is accomplished by inserting one half of an ingenious button into the free end of each portion of intestine — these half-buttons are held in place by specially applied su- tures — and the two halves of the button are then appro.ximated. The opposite surfaces of the two cups of the button, aided by a spring in one of the cups, keep up a constant pressure upon the opposed surfaces of intes tine, thus holding their approximated serous surfaces in contact. Union Fig. 404. — Cross-section of Intestine, Showing Manner of Placing the Purse-string Si'TC RE :— A. Serosa ; B, Muscularis ; C, Submucosa ; D, Mucosa ; E, E, Laminae of mesenterj' : F". Mesenteric vessel and connective tissue; G. Beginning of suture; H, Crossing of suture, approxi- mating laminae to eacli other and to barrel of intestine; 1, End of suture, ready to be knotted with opposite end. takes place between the .surfaces thus held together, especially along their circumferential aspects — while the buttons are freed by pressure-necrosis and are generally ])asscd by bowel. Preparation— Position — Landmarks — Incision. — .\s for median ab- dominal section. End-to-end Approximation. — (i) Having opened the abdominal cavity, complete the partial enterectomy in the usual manner. (2) Preparatory to the insertion of half of the button into each free end of the gut, a silk suture is applied in a special manner. (See Fig. 404.) A long, straight needle is 704 OPERATIONS UPON THE AliDOMINO-PELVIC REGION. threaded upon a piece of silk about 30 cm. (12 inches) long — this suture begins just to the right of the center of the antimesenteric border, entering about 3 mm. (J inch) below the free edge, and passing from without directly inward — thence, following the right-hand margin, in an overhand stitch, over (not through) the border of the intestine to the outer side — thence through the wall from without inward — and so on, until the lamina of the mesentery belonging to that side is reached. As the suture passes from within the lumen, over the wall outward for the last time on that side, it also passes obliquelv over the lamina of the mesenterv of the opposite side. The suture is then carried through both lamin;e of the mesentery as a reversed stitch — emerging at the outer aspect of the opposite lamina. It is now obliquely carried over the lamina of the original side (and across the first limb of the suture that was carried over the opposite lamina) into the lumen of the intes- tine, toward its opposite wall — and passes through this wall of the intestine from within outward. The order is now reversed, and (to get out of the Fig. 405.— End-to-knd Intestinal Approximation by Mtrphy's Bi'tton :— Showing manner of introducing button into lumen of intestine, — male button on left, with purse-string ready to be tightened ;— female button on right, w ith suture tightened. lumen on the left side) the thread is always carried through the free border of the intestine from within outward — thence passes over (not through) the wall from without inward into the lumen — and so on, until it enters the lumen for the last time, at the antimesenteric border — here, at a distance of about 5 mm. (^ inch) from its point of entrance, and on the same level, the needle passes through the intestinal wall from within outward. Thus a "puckering" or "draw-string" is formed, so applied that when drawn about the button, it will appro.ximate the leaves of the mesentery closely about the ill-protected triangle at its base — and the two threads emerging side by side upon the outer aspect are ready to be tied about the button. Although these sutures pass through all the coats of the intestine, thev are within the spring, or pressure-cup, of the button. Similar sutures are inserted into the free ends of the opposite piece of intestine. (See Fig. 405.) (3) Each cup, or button, is now grasped by its stem (not, as so often shown in pictures, by the cup itself) by the tip of a pair of special or pointed forceps (forceps ENTEROENTEROSTOMV BV MEANS OF MLRPHV BUTTON. 705 with rounded or squarish points would tend to bend the perfectly circular opening of the stems). Both are now ready for introduction. (4) The male button (one with smaller stem) is always introduced into the end of the pro.ximal gut (because when its stem has slipped into the stem of the female button, a slight elbow or projection is formed where its free margin ends — which is harmless while in the direction of the intestinal current, but might cause obstruction by particles of sohd food lodging against it, if in the opposite direction). This male half of the button is introduced into the proximal gut just far enough for the free end of the gut to come well around the stem. The suture is then drawn moderately tight and tied with a double knot (the first being a friction-knot) around the stem — evenly distributing the puck- ered gut with a probe as the thread is tightened. An assistant takes Ihe forceps and so holds them that the stem of the button does not slip within the intestine. (5) The female button (one with larger stem) is simi- larly introduced into the distal end of the gut. The suture is similarly placed and tightened about it — and the forceps given to an assistant to hold in the Fig. 406. — End-to-end Intesti.nal Appro.ximation b\ Murphy's Bvtton : — The hali-biiitons appro .\i mated and pressed home. Two loose, interrupted Lembert sutures are shown in the position which a tier of these sutures would occupy, if used. same manner as with the male button. (6) The assistant holding the buttons, so crosses the handles of the ft)rceps as to present the buttons to the surgeon in their right relation for immediate appro.ximation. (See Fig. 405.) The surgeon now grasps a button in the thumb and first two fingers of each hand, with the hollows of the buttons looking toward each other. The as- sistant then simultaneously releases the hold of the two forceps upon the stems of each half-button. .■Xt the moment of release the surgeon guards the buttons lest they slip out of reach into the inte.stines (by pressing them against the binding sutures). The surgeon now appro.ximates the two half- buttons, one held in the fingers of each hand — calculating, in their slow and dehberate approximation, that the intervening intestinal walls will be so dis- posed as to make an even layer over the cups of the buttons — adjusting the deficiency or e.xcess of the puckered intestine with a probe, as indicated — and finally pressing the two halves home as far as his judgment deems neces- sary to secure good apposition without too great compression. (See Fig. 406.) 45 7o5 OPERATIONS Ul'ON THE ABDOMINO-PELVIC REGION. (7) The edges of the mesenter\' are sutured and the intestine dropped back into the abdomen. Comment. — (i) Segments of intestine of unequal size may be thus united by end-to-end approximation with the Murphy button — care being exercised in tying the button into the end of the larger gut, and especially in the act of approximating the two buttons, to see that the puckered excess of the intestinal tissue, particularly in the case of the larger gut, is evenly distributed around the stem of the buttons — and that when the halves of the buttons are finally pressed home the serous surfaces everywhere come together. (2) A line of interrupted or continuous Lemberts is used by some surgeons to reinforce the margins where the buttons meet, after their appo- sition. While not generally necessary, such a line of reinforcing sutures may be used where considered indicated. (See Fig. 406.) (3) See that Fig. 407.— LaTKRAL l.NTESTINAL APPROXIMATION BY TF placing tlie purse-string suture is shown upon the lower inte with suture tightened, is seen within the upper intestine. the purse-string sutures are, after knotting, cut close, and that their ends are not held by the cups of the buttons — thus retarding the escape of the button, and possibly serving as infectors of the peritoneal cavity. (4) All buttons used should be of a size that will not press upon the intestinal walls, else sloughing mav occur. Lateral Approximation. — (1) Having cxci.sed the portion of intestine, the free ends of the two pieces of gut are first closed by overhand, continuous suture of all the coats — followed by a second tier of interrupted or continuous Lemberts burying in the first row. (2) Purse-string sutures are now placed. (See Fig. 407.) These consist of silk and are carried by an extra long, straight needle (such as Keith's abdominal needle). The site for the insertion of the half-button into each segment of gut having been chosen, which will ENTERO-EiNTEROSTOMV BV MEANS OF MURPllV BLTTOX. 707 be upon the antimesenteric aspect of the guts, beginning about 2.5 or 5 cm. (i to 2 inches) from their ends, it is necessary to calculate the length of the incision to be made, as its length will regulate the length and position of the purse-string suture. If the oblong button be used, the length of the incision will be a little less than the transverse diameter of the button, — and if the round button, a little less than the diameter — in order that when the button is insinuated through an opening requiring slight distention for its entrance, it will close about it sufficiently to slightly grasp it. The sutures should be put in so that their looped end is toward the free end of the gut. The suturing passes through all the coats. Conceiving an imaginary straight line, running longitudinally, upon the center of the antimesenteric aspect of the bowel to mark the site for the future incision for the reception of the button, the needle is made to enter the wall of the gut about 6 mm. (| inch) above (or below, as the case may be) this imaginary line, and about 3 mm. (^ inch) to one side — passing through all the coats into the lumen — again passing outward (always traveling in a straight line parallel with and about 3 mm. [^ inch] from the imaginary line) and emerging about 6 mm. (J inch) from the point of entrance — and so on, until it emerges finally about 6 mm. (^ inch) beyond the opposite end of the imaginary line — here the loop is formed, the needle crossing over and entering the intestinal wall at a point corresponding with its last emergence, but on the opposite side of the imaginary line — and travels down this side in the reverse direction, but in the same manner as on the opposite side — finally emerging at a point corresponding with the entrance on the original side. Both ends of the suture are left long and the loop loose. (3) An assistant now so holds the bowel (which has been clamped at some distance from the free ends) as to separate its walls — while the surgeon, by a quick, controlled stab of a narrow, sharp bistoury, incises the gut midway between the two parallel lines of the purse- string suture, and makes an opening a little less in length than the diameter of the button to go through it — and especially considerably less in length than the length of the surrounding purse-string. Care is taken that the mucous membrane is not simply pushed ahead of the knife, in.stead of being cut, and that the lumen is well opened up. (4) The button, grasped by forceps, as in the ordinary end-to-end operation, is now insinuated into the opening, placing the male button in the proximal gut. The purse-string is drawn tightly enough to appro.ximate the walls of the gut to the stem of the button and tied — evenly distributing the puckered intestine around the stem. The forceps holding the button is then given to an assistant, who holds it as in the end-to-end operation. (5) The opposite end of the intestine is similarly treated and the female button inserted. (6) The surgeon, grasping a button in the fingers of each hand, with their stems facing (as they have been directed by the crossing of the forceps), signals to the assistant to release the buttons by relaxing the forceps — and then pushes home the two halves — using the same precautions as in the end-to-end approximation, for the even distribution of the intestinal walls. (See Fig. 408.) (7) The management of the mesentery w-ill here differ from its management in the end-to-end opera- tion, as the continuity of the intestinal canal will not be continued in one straight line. It is better (unless otherwise indicated) not to excise a V-shaped portion of mesentery, but simply to fold over and suture in contact with each other, and with neighboring mesentery, the layers of the redundant fold of mesentery. If a V-shaped portion be excised, the two free borders of the mesentery left should be so sutured down to adjacent mesentery as to leave no openings for hernia. yoS OPERATIONS UPON THE ABDOMINO-PEI.VIC REGION. Comment. — (i) See the general comments under the end-to-end ap- proximation. (2) Care should be used that in appro.ximating the two ends of the intestines the direction of the intestinal flow should be maintained. (3) The button used may be of the oblong type, which is better for this purpose — or of the ordinary round type. (4) The operation of lateral appro.ximation after closure of the ends of the resected gut is but rarely indi- cated — the usual method of junction following e.xci.sion being by end-to-end approximation. (5) Instead of using the purse-string suture to hold the button-halves in place, Carle appro.ximates the borders of the intestinal opening by one or two interrupted Lembert sutures placed at either end of the incision, thus les.sening its length and grasping the button. But the regular method is ])robably better. Lateral Anastomosis. — In this operation the two buttons are inserted Fig. 408. — Lateral Intestinal Appro.\imation by the Murphy Button: — The two hall- buttons are shown approximated. Interrupted or continuous Lembert sutures may reinforce the con- tiguous surfaces, if considered necessary. into the antimesenteric aspects of the two indicated coils of intestine — the method of insertion being identical with that used in Lateral Approximation by the button. No excision of intestine takes place. The oblong button is to be preferred. Reinforcing Lemlicrts may be used. The Carle method of tving in the buttons, just mentioned, niav l)e used. Lateral Anastomosis with Weir's Modification of Murphy's Button, Introduced by Gallet's Method. — The male half of the original button is so modified, by being shar])ened and beveled, that it can be made to penetrate the walls of the intestine. Both buttons are introduced, by means of special forceps, through a common opening in a knuckle of intestine — each being carried down a separate limb of the gut — and are then ajijiroximated — fol- lowed by the closure of the incision in the knuckle. Following are the steps ENTERO-ENTEROSTOMV BV MEANS OF MLKPHV BUTTON. 709 of the operation; (i) The sites of the anastomosis must be in such positions upon the antimesenteric aspects of the intestine that, when the length of the intestine is doubled u]K)n itself, the site to be occupied by each button will not be beyond the reach of the special forceps to be introduced through an opening at the knuckle formed by bending the intestine upon itself. (2J .^n incision in the longitudinal a.\is of the gut is now made at this knuckle. A button held in the grasp of the special forceps is then introduced through the opening down one limb of the gut — the male button in the proximal limb. The female button, similarly held, is then introduced down the oppo- site limb. (3) By pressure upon the forceps holding the male button, its .stem is made to pierce the walls of its own side and the opposite gut — and is then directed into the stem of the female button. (4) The buttons are then pressed home — the adjacent surfaces of intestine being held in contact without any form of suturing. (5) The treatment of the opening in the knuckle of gut is as indicated. In the cases where the operation is simply a lateral anastomosis, the incision in the knuckle would be closed by inter- rupted or continuous Lembert sutures of gut or silk. In the majority of cases where this operation is done, however, it is performed in connection with a gastro-jejunostomy, for the purpose of aiding in the prevention of bile and intestinal regurgitation from the duodenum into the stomach — so that as soon as the intestinal anastomosis has been accomplished, the opening in the knuckle of intestine is sutured to a corresponding opening in the anterior wall of the stomach, thus comjjleting the gastro-jejunostomy. (See Fig. 466.) Note. — The ordinary ^lurphy button may be used in practically the same manner. After opening the knuckle of gut, one half of the button may be dropped into each limb of the intestine — these are caught and held by the fingers of an assistant at corresponding positions within the two pieces of gut, with the free portion of their stems held against the antimesenteric aspect of the gut. While the intestinal wall is thus drawn tightly over the hollow stems, a limited crucial incision is made in the center of the stems, just sufficiently large for the stems to be pressed through, with the walls of the intestine clinging closely around them — immediately following which the two halves are pressed together, bringing the antimesenteric aspects of the two portions of gut into accurate apposition — no reinforcing suture being necessary. The opening in the knuckle of gut is closed as usual. (See Figs. 467 and 46.S.) Multiple Lateral Intestinal Anastomosis (Jaboulay-Braun's Opera- tion). — In addition to the single lateral intestinal anastomosis formed after gastro-enterostomy, as above described (Braun's operation), sometimes a second, or even a third, lateral intestinal anastomosis may be made — for the purpose of further avoiding the likelihood of intestinal regurgitation by furnishing as direct and easy a descent from the stomach to the anus as possible. Supposing, therefore, that a gastro-jejunostomy has been per- formed, a lateral jejuno-jejunostomy may be done by Gallet's method of using Weir's modification of the Murphy button, at the time the intestine was opened to unite it to the stomach — and then another jejuno-jejunostomv, or a jejuno-ileostomy, could be performed lower down bv the ordinarv lateral anastomosis method, thus short-circuiting by two routes the contents of the intestines. Note. — Multiijle intestinal anastomosis can, of course, be performed bv simple .suturing, as well as liy other methods. End-in-side Implantation. — Supposing the ca'cum to have been excised and the mesentery ligated, the male Murphy button is introduced into the 7IO UPKRATIONS UPOX THE ABDoMIXU-PELVIC REcnOX. free end of the ileum and tied in place, as in the ordinary end-to-end ap- jjroximation. The edges cf the free end of the csecum are then united by overhand continuous silk sutures through all the coats — and these are buried in by the interrupted or continuous Lemberts of gut or silk. An opening is then made 2.5 to 5 cm. (i to 2 inches) from the sutured end of the c^cum, upon its antimesenteric aspect, and the female button tied into place, just as in lateral intestinal anastomosis. The two buttons are now brought together in the usual fashion. The line of union should be here reinforced by a tier of interrupted Lembert sutures. The borders of the mesentery should be sutured as indicated. (D) ENTERO-ENTEROSTOMY BY MECHANICAL MEANS TEM- PORARILY USED FOR APPROXIMATING THE INTES- TINAL EDGES DURING SUTURING. IN GENERAL. Description. — \'arious more or less ingenious forms cf devices have been introduced for the purp(;se of holding in contact the opposite margins of the intestines during the act of suturing — to be withdrawn just prior to the completion of the suturing. !Many of these, at the same time, distend the otherwise flaccid gut, and render the application of sutures easier. The following instruments, and the description of their applicati(;n, will rejiresent this class of work. ENTERO-ENTEROSTOMY BY MEANS OF HALSTED'S INFLATABLE RUBBER CYLINDER. Description. — Halsted's instrument consists of an inflatable rubber cylinder, attached, by means of a rubber tube, to a syringe with a two-way stopcock. The segments of intestine are first united by five or six fixation- sutures, those toward the mesentery being tied, those toward the antimesen- teric aspect being left temporarily untied. Between these latter sutures the collapsed cylinder is inserted — it is then inflated by pumping air into it until of the desired size — and over this the Halsted mattress sutures are applied — all being placed, and most being tied, before the cylinder is withdrawn Between the last few untied sutures the exhausted cylinder is removed — and these last sutures tied. The method is of ccnsiderable aid in the suturing of the flaccid intestine and in the approximation cf segments of unequal fize — serving, at the same time, to keep the intestinal contents away from the line of suturing. The method is applicable to end-to-end approximation only. Preparation — Position — Landmarks — Incision. — .\s in median ab- dominal secti n. End-to-end Approximation. — (1) Having opened the abdomen and ex- posed the site of excision, clamp off the region with rubber bands wound in a ligure-of-eight fashion over some object (such as a sterile, round, wooden toothpick) carried through the mesentery close to the barrel of the intestine (see Fig. 371, D), so planning the excision that the blood-supply will come up to the verv edges of the ends of the gut. Ligate the mesenteric vessels prior to excising the mesentery. (2) Before excising the gut, five or six "presection" sutures, of the Halsted type, are placed, just beyond the line ENTERO-ENTEROSTflMV BV llALSTED'S .METH(.)D. 1-ig. 40C).— En — Halstkd's Me of the ENTEROSTOMY, EnE>-TO-END. A :— Showing the hue of excision presection sutures." (Modified from Halsted., L'BBER Cylinder . and the position Fig. 410.— Entero-enterustomv by Halsteu's Method :— All the presectioir sutures tied ex- cept one pair, through the interval left by which the rubber cylinder is being introduced within the lumen oi the gut b\ means of forceps. (Modified from Halsted.) 712 OPERATIONS L'l'oX THK ABDi )MIXO-I>ELVIC REGION. of future excision — t\v4— KND-io-h upon a coil of intestine into the ends of iiilestiii fied from Lee.) -KNTEKOSTOMV BY LEE'S INTI-STINAI. HoLDKR:— A. A, a portion has been excised ; H. iTilestlnal holder being extended ; C. C, The two ends of the mesenteric sutuie. ENTERO-ENTEROSTOMY BY MEANS OF LEE'S INTESTINAL HOLDER. Description. — The instrument, though simiile in principle and con- structicin. is ilitlicuh to describe clearly — but its mani[)ulation is easy. The holder is introduced into the approximated ends of the intestine closed — is then opened — and serves as a framework upon which suturing is done — and is then finally closed and withdrawn. A single instrument fits anv part of the intestinal tract — and any suture may be used in conjunction with it. Lee uses a modification of the Connell stitch. The method is only applicable to end-to-end approximation. EXTERO-ENTEROSTdMV WITH LEE'S IXTESTIXAL HOI.DE;<. T15 Preparation — Position — Landmarks — Incision. — As for meilian ab- dominal section. End-to-end Approximation. — (1) Open the abdomen — clamp off the site — and excise a portion of the intestine, ^vith or without a part of its mesen- Fig. 415.— Entero-enterostomv bv Lek's InteStin \i Hi •! oKk —A. A, Mesenteric s and ends passed out of intestine ; B, B, Showing, first, maimer of t\ing mesenteric suture- ondly, manner of passing ends of suture out of intestine. (Modified from Lee.) Fig. 416. — Entero-enterostomv ky Lee's Intestinal I iiig the right-angled continuous sutures upon the aspect of tht (Modified from Lee.) tery. (See Fig. 414.) (2) The mesenteric suture is passed — e.vactly as the mesenteric traction suture is passed in ilaunsell's operation (page 688). Both ends of the silk are left long and are knotted within the lumen of the 7i6 OPERATIONS UPON THE ABDOMINO PELVIC REGKJN. gut — thus approximating the mesenteric aspects of both guts and both laminje of the mesentery to the barrel of the gut (Fig. 415). Each end of the threads Fig. 4ifi. — Entero-k.nt t- Kos n >M drawn from intestine ; B, Ends of thi testine ; C, Loop introduced upon lie: of till* ninin suture are cauglit and wil KK'S INTKSTINAL Hoi.DKR :— A , Holder closed ! itures emerging from the same side and within the i •die through suture-line at D, under which loop the eiK at D. iModifieil from I,ee.) ENTERO-EXTIiROSTOMV WITH LEE'S INTESTINAL HOLDER. 717 is then needled — and the needles are made to pass out of the gut near the knot and the threads are drawn after. (3) The intestinal holder is now introduced and opened — distending each gut flatwise — the distal arms being against the mesenteric border and the pro.ximal arms against the antimesen- teric border — the free borders of intestine lying in parallel contact — there being no marked tension anywhere. (4) The half of the intestine nearer the surgeon is now sutured with right-angled continuous suture (Fig. 416), passing through all the coats, tightening the thread after each stitch. When the site of the emergence of the stem of the instrument is reached, the final stitch is made on the side opposite to the one on which the preceding stitch was made — and this final stitch is only a half-stitch, passing from without and ending on the interior of the gut (Fig. 416). (5) The instrument is Fi>5. 419. — Entero-enthrostomy by Lee's Intestinal I outside — which, upon cutting the threads, recedes within the now so turned as to present the opposite side (Fig. 417) — which is sutured in a similar manner — the final half-stitch ending on the same end of gut as the last half-stitch of the first side, and on the interior of the gut. (6) The in.strument is now folded and withdrawn (Fig. 418) — leaving two free ends of silk ready to be tied. (7) To enable the ends to be knotted on the interior, a threaded needle is insinuated between the stitches of the opposite side, the eye first — and is pushed upward until the threaded eye protrudes through the opening formerly occupied bv the handle of the in.strument. The thread of the needle is then loosened into a loop, under which the free ends of the two sutures are passed — and by means of which these free ends are drawn out when the needle is withdrawn through the line of suturing, at the jioint where the head of the needle was pushed through. (8) These 7l8 OPERATIONS LTOX THE ABDO.MIXO-l'ELVIC REGION. sutures are then knotted, during which process the bowel is flattened and its mucous membrane near the final half-knots is approximated to the site where the sutures are being tied — the sutures are then cut short — and the knots slip into place and the intestine regains its form by a little manipulation (Fig. 419). Comment. — .\ny other less intricate form of suturing may be used. Rein- forcing Lemberts mav be used if thought necessary. ENTERO-ENTEROSTOMY BY LAPLACE'S INTESTINAL ANASTOMOSIS FORCEPS. Description. — The complete instrument consists of two pairs of forceps, each blade ending in a half-ellipse. When the parts are clamped together two concentric and parallel ellipses are formed, which may be approximated and separated by means of the handles. In joining parts of the gastro- intestinal tract, a blade is passed into each opening — and when the blades are approximated, the walls of the free ends of each piece of intestine are held in position, serosa to serosa — while any desired form of suturing is apphed around the circumferential border of the approximated intestines. The forceps are then unlocked and withdrawn, piece by piece — a few sutures being applied where the handles entered. Five sizes of the forceps are made, including one for cholecystenterostomy and uretero-enterostomy. The method is applicable to end-to-end and lateral approximation, lateral ana.sto- mosis, and end-inside implantatiun. Preparation — Position— Landmarks — Incision. — .\s in median ab- dominal .sectiiin. End-to-end Approximation. — (1) Having opened the abdomen and clamped off the region invt)lved, the portion of intestine is excised, with or without its mesentery corresponding. (2) Four fixation sutures are in- serted into the free margins of the gut — i-ne, including both lamina' of the mesentery, at the mesenteric border — one at the antimesenteric border — and one on each side. (See Fig. 420.) (3) The forceps are introduced closed between a lateral and an antimesenteric suture — one blade being opened into the lumen of one gut — and the other into that of the opposite. As the blades open the intestinal walls are pushed inward cr inverted — so that when the blades are closed the serous surfaces are pressed against serous surfaces. If this inversion does not readily occur, it may be aided by the fingers or an instrument, or by a string passed circularly between the blades of the forceps just before closing, and withdrawn as they close. (See Figs. 421 and 422.) (4) Interrupted Lemberts, or other form of suture, are now applied around the clamped surfaces, except where the forceps emerge — approximating serous and muscular coats of one gut to those of the other. During these steps the parts are conveniently manipulated by the handles of the forceps. (5) The forceps are now undamped and carefully removed — and the opening through which they are withdrawn is closed liy two or three Lemberts. (See Fig. 423.) (6) The mesentery is then sutured and the gut returned to the abdnmen. Lateral Approximation. — Having completed the excision of the indicated portion of the inte>tine, the end of each piece of intestine is seized with La- place's invagination forceps (a long and slender instrument) and invaginated into the lumen of the gut, jircliminarily to making the approximation. \\'hile the end of the intestine is thus held invaginated, the serous surfaces are ENTEROENTEKOSTOMV WITH LAPLACE'S FORCEPS. 719 Fig. 420.— End-to-end Entero-enterostomv by Means of Laplace's Lntestinai. Anas TOMosis Forceps;— Manner of placing the four preliminary fixalion-sutures. (Modifu-d fron Laplace.) Figs. 421 and 422.— End-to-end Entero-enterostomv bs- Mkans of Laplace's Intestinal Anastomosis Forceps :— Showing the anastomosis forceps, with its special clamp for holding the blades together,— and the manner in which it approximates the ends of the intestine. A line of con- tinuous Lembcrt suturing unites the coils. (.Modified from Laplace.) 720 OPERATIONS UPON THE ABDOMINO-l'ELVIC REGION. brought together by interrupted or continuous Lembert sutures — the forceps being withdrawn just before the last two or three stitches are tied — immedi- ately following the withdrawal of which the opening left by their withdrawal is similarly closed. The invagination of both ends having been accomplished, appro.ximate the two antimesenteric aspects to be united — make two corre- sponding axial incisions about the length of the diameter of the rings to be used — place four fixation-sutures, one at each angle and one on each side — insert the closed blades between two of the approximation sutures — open one blade into the lumen of one and the other into that of the other intestine Fig. 423. — End-to-end ENTERO-ENTERosTOM^ nv Laplace's Intestinal Anastomosis For- ceps :— Showing the manner of withdrawing the blades before tightening the last few sutures. (Modified from Lapla — the walls of the intestines being inverted over the blades as they open (as in the end-to-end method) — then close the blades so as to press serosa against serosa — and suture as in the end-to-end form — after which the forceps are undamped and withdrawn — the opening through which they are withdrawn being closed by two or three Lemberts. Lateral Anastomosis. — The junction is accomplished as in lateral approximation — omitting the resection. EXCISION OF THE ILEO-CiECUM. Description. — Consists in the removal of the caecum, together with more or less of the adjoining portions of the ileum and ascending colon — followed by .some form of entero-enterostomy between the small and large intestines. The operation is generally resorted to for malignant or tubercular disease of this region, or for intu.ssusception of this portion. EXCISION OF THE ILEO-C.BCUM. 721 Preparation — Position— Landmarks. — As for Appendicectomv (page 722). Incision. — About 13 cm. (5 inches) long, beginning in the anterior axillary line (a vertical line from the anterior border of the axilla), midway between the lower margin of the costal cartilages and the iliac crest — passing downward to within about 4 cm. {i\ inches) of the anterior superior iliac spine — and thence obHquely downward and forward, parallel with the cuter half of Poupart's ligament, ending to the outer side of the position of the external iliac artery. Operation. — (i) Divide the skin, fascia, external oblique, internal ob- lique, transversalis, transversaUs fascia, subperitoneal connective tissue, and peritoneum. The size and condition of the parts generally necessitates an operation of a magnitude too great for the intramuscular method of opening the abdomen — but in so far as this method can be adopted, it should be carried out. Both the muscular and aponeurotic portions of the external oblique can ordinarily be separated in the cleavage Hne. The abdominal vessels and nerves should be preserved as far as possible. Having e.\po.sed the abdominal cavity, retract the hps of the wound well and deeply. (2) If adherent omentum be encountered, ligate off with gut and divide. (3) Separate the caecum from the ihopsoas fascia upon which it lies. This is accomplished by displacing the CiTcum and colon inward and cutting through the peritoneum along the outer aspect of the cscum and colon where it binds those structures to the posterior abdominal wall, ligating where necessary with gut. These structures are then displaced outward and the peritoneum divided along the inner side — but on this side the coUc vessels are encountered as they diverge to supply the bowel — so that this region is ligated off in sections and divided. This inner line will cross the ileum where it joins the colon. The mesentery of this small intestine is ligated in sections, as far as may be necessary, and divided. (4) Having thus freed the caecum and several inches of both colon and ileum, the contents of the bowel are pushed away, the intestines clamped, the neighboring regions protected with gauze packing, and the intestines divided at a right angle to their axis. (5) Having excised the ileo-cascal region, an entero-enterostomy is accomplished in one of the following ways (previously described in detail) : — (a) End-to-end appro.xima- tion by simple suturing, by Murphy's button, or by Maunsell's invagination method — the first or second probably being preferable; (b) Invaginate the ends of both guts by overhand followed by Lembert sutures, and then make a lateral anastomosis between the ileum and colon by simple suture, or bv a Murphy button (or by one of the other methods already described) ; (c) Divide the ileum obliquely, to give a larger opening, and unite it to the trans- versely divided colon by simple suturing — (often the ileum has been dis- tended so long, by obstruction below, that it has become the same size as the colon); (d) Close the end of the colon by invagination, bv a doulile row of sutures, and then implant the end of the ileum upon the lateral aspect of the colon (resembling nature's junction of the small and large intestines). (6) Drop the parts back into the abdomen, and close the abdomen, with or without drainage, as indicated, as in abdominal section. Comment. — Remove all diseased glandular tissue. 4O ]22 OPERATIONS UPON THE ABDOMIXO-PELVIC REGION. Fig. 424.— Appendicectomy :— A. Crecum ; B. Ileum; C. Appc inesenler\ oi the appendix APPENDICECTOMY BY McBURNEY'S l\ TK AMI'SCILAK OTERATION. Description. — Appendicectomy consists in the removal of the appendix vermiformis. The feature of McBurney's operation is based upon the exposure of the appendix through a successive separation, in the cleavage line, of the overlying abdominal muscles and aponeuroses. The fibers of the muscles and aponeuroses are not cut but are separated. The appendix is exposed and is treated by one of several methods. This form of the opera- tion is chiefly applicable to the "interval period" of appendicitis — but is sometimes used in acute cases anil in ]ius ca.scs. Preparation — Position — Landmarks — Incision. — Given under .Ab- dominal Section by McBurney's Intramuscular Incision (page 637). Operation. — (1) Having opened the abdomen in the manner described under the above operation, the right index-finger is inserted within the abdominal cavity and the appendix sought. The caput coli, or some part of the ascending colon, is generally encountered at once — and may even bulge into the wound. Sometimes the appendix itself presents at once — though exceptionally. If the appendix is not at once manifest, its base is sought in its usual position — that is, upon the internal and posterior aspect of the c;ecum, about 1.7 cm. (\\ inch) below the ileo-ca^cal valve. If the appendix is not readily found by this manoeuvre, draw out the first part of the ascending colon encountered, and then follow it down tn the lapul coli — the anterior of the three longitudinal bands of the colon will lead to the base of the appendix. The appendix is now drawn out of the wound, and its treatment will depend upon the nature of the appendix and the indi- vidual views of the operator. (See Fig. 424.) (2) .\s soon as the appendix has been delivered without the abdominal cavity, it is well to pass a .silk ligature, upon an aneurism-needle, around the appendix, about 2 cm. (J APPENDICECTOMV. 723 inch) from its base, piercing its mesentery. This ligature mav be tightened at once or later — it is only a temporary traction-ligature. The mesentery of the appendix should be ligated off with chromic gut, carried in a laterally curved aneurism-needle, proceeding from apex to base, or in the opposite direction if more convenient — and tied in sections — the mesentery being then divided between appendix and ligatures. If bound down by adhesions, these should be separated by blunt di.ssection, or ligated and cut. Often the mesen- tery of the appendix must be ligated off within the wound, before the appendix can be delivered. (3) The appendix is now treated in one of several ways — in all of which, however, the patulousness of the lumen must be determined, in advance, by the passage of a probe through its canal into the ca?cum, that drainage into the main intestine mav be assured. The following methods Fig. 425-— APPENDICECTOMV ; — A, Edges of the tnesenteriolum sutured together; B. B, Hurse-slring suture placed, the loop being grasped by forceps and the ends free. of closing the appendix may be used; — (a) Dawbarn's Purse-string Method; a continuous, silk, purse-string suture, carried upon a straight needle, is pa.ssed through the serous and muscular coats of the ctecum in a circle, about 6 mm. (i inch) from the base of the appendix, but not at first tied. (See Fig. 425.) The looyj opposite the free ends of this purse-string suture is grasped by forceps held by an assistant, to steady the appendix against the counter-pull of the operator who holds the free ends. The appendix is then divided transversely about 1.2 cm. (5 inch) from its base — the canal of the stump may be dilated with special fine forceps (to aid in invagination) — and sometimes sterilized by the actual cautery point — the free end of the stump is then seized with the same forceps and invaginated into the caecum. (See Fig. 426.) While the stump of the appendix is held invaginated into the caecum, the operator draws upon the free ends of the purse-string suture (which ha\e been loosely knotted with a friction-knot) until the slack of the loop held by the assistant is taken up — the assistant, letting go his grip Fig. 426. — Appendilkctumv :^Uilatation of caiiai of appendix by means ot forceps, prtpaiatory 10 invagination. Fig. 427.— Appendic, ;— The stump ot the appendix heiiij; invaKHialcd in the giasp t and the puibe-string about to be tightened. 724 APrKNDICECTriMY. 725 of the loop with the forceps, takes the two free ends of the suture — tightening the friction-knot accurately at the very moment the operator quickly with- draws the invaginating forceps. A second knot is tied and the ends cut short. (See Fig. 427.) If considered nece-ssary, two or three interrupted gut Lemberts may be used to further bury in the stump. (See Fig. 428.) This method of closure is especially applicable to appendices whose walls are of more or less natural thickness and softness — capable, in other words, of invagination, (b) Divide circularly the peritoneal coat of the appendix about 6 mm. (j inch) from the ctecum — peel back this serous ccat toward the ca?cum — and, on a level with the turned-back serosa, divide the middle and internal coats of the appendi.x very near the caecum. (See Fig. 42Q.) See that the lumen of the stump is patulous by means of a probe, and cauterize the interior of the stum]) with a line Paquelin point. The edges of the stump are then brought together either by fine silk sutures, or by circular ligature. Fig. 428. — Appendicectomy: — A, The free ends, after knotting, of the purse-stnng which has invaginated the stump of the appendi.x into the caecum ; B. Position whicli reinforcing Lemberts would occupj-. if used ; C, The sutured edge of the mesenteriolum. This short stump it.self is then depressed (rather than invaginated) into the caecum (see Fig. 430) — and. after suturing the serosa over the stump, the surrounding area of the ciecum, to the extent of 3 mm. (5 inch) from the base of the appendix, is invaginated by means of a purse-string suture which had been previously placed in the same manner as in the last method. (See Fig. 431.) Additional interrupted gut Lemberts may bring the edges of the furrow together, if considered necessary. This method is particularly appli- cable to thick, hard, narrow-calibred appendices, (c) The peritoneal coat may be peeled back — the middle and internal coats divided transversely — and the peritoneal coat sutured oxer the cut middle and internal coats with Lemberts. (d) The mucous coat may be excised with tine, curved, sharp- pointed scissors, or burnt out with the actual cautery — and the serous and muscular coats sutured over it. (e) The same .steps may be carried out as in "b,"' except that the stump may be simply depressed into the caecum and the walls of the cscum brought together with Lembert sutures in a 726 Ol'ERATIONS UPON THE Al'.lH )MlNii PELVIC REGION. Straight line. (4) The appendi.x having been removed and its stump sutured, the bowel is returned to the abdominal cavity — and the wound closed as Fig. 429.— Appendicectomy;— A Method of Dealing with Thick Appe.ndices. by Liga i ion AND Depression into C^eci'm : — A, Clamping off appendix from caecum : B, Cuff of serosa turned back ; C, Stump of appendix ligated ; D. Edges of mesenteriolum sutured. Fig. 430.— Appendicectomy : — A, Stump of appendix depressed into caecum ; B. liUerruplt-d I-enibert sutures closing serosa over stump ; C, Sutured edges of mesenteriolum. in McBurney's Intramuscular Abdominal Incision. Drainage is ordinarily not employed — unless specially indicated. APPENDICECTOMV. 727 "Stn^ Fig. 431. — APPENDICKCTOMV : — The depressed appendix-stump and the iiivagiiialed serosa themselves illvaginated into the caecum by a purse-string suture of the surrounding area. Comment. — If at any time during the operation more room be required, this may be i;;ained by continuing the separation either upward or downward. In the latter direction, the separation is accomplished by Weir's method (page 639). APPENDICECTOMY BV THE ORDINARY METHOD. Description. — In this operation no attempt is made to separate the muscle-fibers of the abdominal wall, which are freely cut where they cross the line of incision. The method is applicable to "interval" and to pus cases — but guards the abdominal wall from hernia less well than does the method just described. Preparation — Position. — As in the Intramuscular Operation (page 637). Landmarks. — Anterior superior iliac spine; umbilicus; outer border of right rectus muscle. • Incision. — Draw an imaginary line from the anterior superior iliac spine to the umbilicus — the incision will begin about 2.5 cm. (i inch) above this line, and will run obliquelv downward and inward, parallel with and about 1.2 cm. {\ inch) to the outer edge of the right rectus muscle. Operation. — (i) The incision divides skin and fascia — passes through the external oblique approximately parallel with its fibers — divides the internal oblique and transversalis more or less transversely, and just to the outer side of the ending of their muscular fibers. (2) All bleeding vessels are seized, and the wound well retracted. (3) Divide the fascia transversalis, subperitoneal areolar tissue, and peritoneum in the line of the original wound and with the usual precautions — especially guarding against adhe.sions. (4) Having opened the abdomen and retracted the lips of the wound well, the isolation and treatment of the appendix are carried on just as in the Intra- muscular operation of McBurney (page 637). (5) And the wound is closed as in median alxlominal section (page 635, paragraph 9). ENTEROSTOMY IN GENERAL. Description. — (i) Enterostomy consists in the making of a more or less permanent opening into some part of the intestinal canal, for the purpose 728 OPERATIONS UPON THE ABDOMINO-PEI.VIC REGION. of relieving obstruction or of furnishing nourishment — the opening thus made communicating with the external abdominal surface. This opening may be a Jejunostomy, Ileostomy, or Colostomy. When not specially designated. Enterostomy is generally understood to mean an opening of the small intes- tine, in which sense it will be here used. (Enterotomy has been incorrectly used to designate this operation.) If the opening be made high up in the small intestine, it may serve as an artificial mouth for nourishment {e. g., jejunostomy, near the stomach). If the opening be low down in the small intestine (e. g., an ileostomy, low down), or anywhere in the large intestine {e. g., colostomy), it will serve the role of artificial anus. In the last category of cases it is generally performed for some more or less permanent obstruction, the opening being, of course, above the seat of obstruction. (2) The manner of performing enterostomy will differ — as to whether a temporary opening is sought, which will, of its own accord, tend to close, — namely, a fecal fistula, which is generally done in some form of removable obstruction, — or whether a permanent opening is desired, which will, through a spur-like formation, tend to remain patulous — namely, an artificial anus, which is generally done in some form of irremovable obstruction. The technic of enterostomy, whether for artificial mouth, temporary fecal fistula, or permanent artificial anus, is practically the same as that for colostomy performed for temporary fecal fistula or permanent artificial anus — the chief difference being in the site of the operation. (3) Enterostomy (of the small intestine) is generally done upon the right side, and as near the ciecum as possible. Where the operation is done fot obstruction, the site is, naturally, always above the obstruction. The operation may be done in the median line or upon the left side. Frequently, especially in desperate and weak cases, the first coil of distended gut is opened. A permanent artificial anus is generally made, where possible, in the course of the descending colon, a description of which is given under colostomy. (4) The cause ha\ing been remo\ed, for which the fecal fistula or artificial anus has been made, it is indicated to close the opening by operation if nature does not do so. (5) The site of choice for opening the intestine for temporary fecal fistula, or permanent artificial anus, is in the colon. (See Colostomy, page 731.) RIGHT INGUINAL ENTEROSTOMY (OR ILEOSTOMY), FOR THE ESTABLISHMENT OF A TEMPORARY FECAL FISTULA. Description. — .\n incision having been made in the right inguinal region, the first di.stended coil of intestine above the caecum is drawn out and attached to the aV)dominal wall, on a level with, or but slightly projecting above, its surface. While the operation, as originally devised by Nelaton, did not follow the intramuscular lines, it should do so where possible. No attempt is ordinarilv made to remove the cause of the obstruction. The opening is meant to be but temporary, and if it does not close spontaneously it is closed hv operation subsequently. Preparation. — .\s for median abdominal section. Position. — Patient supine, with right side near edge of table. Surgeon on side of operation — assistant opposite. Landmarks. — Outer portion of Poupart's ligament; deep epigastric arterv. Incision. — .\bout 5 to 7.5 cm. (2 to 3 inches) (according to the thickness of the abdominal wall) — placed about 4 cm. (i j inches) above and parallel RIGHT INGUINAL ENTEKOSrOMV FOR TP:MPURARV FISTULA. 729 with the outer part of Poupart's ligament, and external to the deep epigastric artery. Operation. — (i) Having followed the steps of the intramuscular incisic;n of the abdominal wall (page 6^7) and retracted the lips of the wound, the ca;cum is sought with the finger and located as a rallying-point. The site of the obstruction is then located if possible, and, if so, the first distended coil of intestine above the obstruction is caught and brought into the wound. Where the source of obstruction cannot be found, any distended coil of intestine is taken and brought forward (which will probably be a portion of the lower ileum). In bringing the gut forward into the wound, its normal relations and direction should be maintained, as far as possible — and only its conve.x, antimesenteric aspect should project from the wound, but this aspect should well fill the portion of the wound to be left open, and any excess of intestine from above should be returned to the cavity, that the upper part may not sag down upon the lower. (2) The e.xcess of length of the wound is now closed from either end, either by through-and-through suturing of all layers with silkworm-gut or silk, or by layer-suturing with chromic gut. When shortened to the desired extent, in cases where the length has been excessive — or from and beginning with the first suture at either end, where the length has only been moderate — the serous and muscular coats of the intestine are included in the suture at either end of the wound, thus fixing the gut to the abdominal wall at the same time the lips c)f the ends of the wound are approximated. If necessary, two fixation-sutures may be applied laterally, passing through serosa and musculosa of the intestine and all the layers of the abdominal wound. (3) An elliptical area of the presenting gut is now sutured to the parietal peritoneum by a continuous or interrupted fine silk suture, passing through serous and muscular coats of the intestine, on the one hand, and peritoneum and transversalis fascia, on the other. A second row of continuous or interrupted silk or gut sutures may then be placed, uniting the skin of the abdominal wound to the .serous and muscular coats of the intestine, including the free margin of the parietal peritoneum external to the elliptical suture in the presenting gut. Or the second row of sutures may simply unite the edge of the abdominal skin to the free margin of the parietal peritoneum. A union considered firmer bv some may be secured by first suturing the parietal peritoneum to the skin all around the permanent opening — and then suturing the intestine to this. (4) If haste be necessary, an opening is at once made into the lumen of the gut, by a quick, controlled stab with a narrow, sharp knife and increased to the desired e.xtent with blunt scissors (having ascertained that all the coats of the intestine have been pierced before inserting the blade of the scis- sors). If no haste be necessary, a delay of two or three davs for union of the serous surfaces and exclusion of the abdominal cavity is preferable ("operation in two stages"). The intestinal contents are allowed to escape of their own accord. Comment. — (1) The operation may be performed through a median or other incision — or the obstruction may be located through a median incisiim and enterostomy done through a lateral incision — thus giving greater room for diagnosis and possibly for correcting the cause of trouble — the excess in length being closed in at either end before attaching the intestine. Left inguinal enterostomy may also be done. (2) Avoid wounding the deep epi- gastric artery and twisting the gut. (3) .\s small an opening as consistent with efficient emptying should be made, to make the subsequent closing easier. 730 OPERATIONS UPON THE AHDOMIXO-PELVIC REGION. RIGHT INGUINAL ENTEROSTOMY (OR ILEOSTOMY) FOR THE ESTABLISHMENT OF A PERMANENT ARTIFICIAL ANUS. Description. — Enterostnmy for the establishment of a permanent arti- ficial anus ditTers from enterostomy for temporary fecal fistula, in that the former is performed in cases where the obstruction is irremovable, and also where it is sought to prevent the passage of intestinal contents into the limb of the bowel below the opening. The typical operation of enterostomy for the establishment of a permanent artificial anus is seen in the operation of Colostomy (as performed for inoperable obstruction of the rectum, q. v.). The operation to be here considered is simply an application of those princi- ples to cases of the small intestine where, upon opening the small bowel above the seat of obstruction, it is found the opening must be more or less permanent. It is even of greater importance that a permanent artificial anus of the small intestine should be lower down than a temporary fecal fistula. It is well to follow the intramuscular manner of abdominal incision, where possible — both as a guard against hernia and for gaining something of a sphincteric control of the intestinal opening. The only practical differ- ence between this and the preceding operation is in the manner of attaching the knuckle of intestine to the abdominal wound. Preparation — Position — Landmarks — Incision. — .As for Right In- guinal Enterostomv for Fecal Fistula. Operation. — (i) The early steps of the operation are the same as when a temporary fecal fistula is to be made (page 728). (3) When the knuckle of bowel to be drawn into the wound is isolated, it is important and necessary to determine which is the proximal part of the coil. This having been done, and the knuckle having been drawn into the wound, the e.xcess of intestinal length which tends to sag down into and out of the upper angle of the wound is taken up and passed on down through the lower angle of the wound (so as to do away with the likelihood of future hernia of the proximal limb of the intestine through the wound). (3) The desired knuckle of intestine having been isolated and retained within reach by a temporary loop of silk passing through the antimesenteric aspect of its outer coats, the two ends of the wound are closed toward the center, as far as thought necessary, by tier suture or by through-and-through suture. (4) The parietal peritoneum is drawn out and sutured to the abdominal skin, or as nearly in contact with it as possible all around the wound. (5) The knuckle of intestine is now drawn entirelv out of the wound, until the mesenteric attachment is on a level with the skin. Care is taken that the intestine is not twisted and that the normal relations are maintained, as nearly as possible. Care is, also especially taken that the proximal limb of the loop is identified and kept uppermost in the wound, is given plenty of room in the opening, and that it is made to compress the distal limb against the lower angle of the wound (to prevent the passage of intestinal contents from the proximal into the distal limb). While held in this position, the knuckle of intestine is sutured into permanent position — by continuous or interrupted silk sutures passing through the serous and muscular, and part of the submucous, coats of the intestine, on the one hand, and the parietal peritoneum (which has been already attached to the skin) on the other. (6) If no haste exist, the opening of the intestine is deferred for two or three days, until serous arlhesions have occurred. If haste be necessary, the oj)ening may be made at once, by cutting out transversely, with scissors, a triangular piece of the whole thickness of the COLOSTOMY IN GENERAL. 73 1 intestine, with its base at the free border and its apex at the mesenteric attach- ment. Comment. — (i) This, as well as the operation for fecal fistula, may be made in the median or left lateral regions, but it is even more important than in temporary fecal fistula that the opening be as low as possible, to prevent starvation. (2) .A. somewhat smaller opening in the peritoneum is generallv made than in fecal fistula. (3) A glass rod may be run through the mesenterv, as is sometimes done in colostomy — to hold the coil of intestine in place. (4) It is well to put a few interrupted Lembert sutures along the lateral aspect of the two limbs of the knuckle, where they come in contact. (5) Where the intestine must be opened at once, only a limited opening is then made — the permanent opening being made after adhesions form. COLOSTOMY IN GENERAL. Description. — Colostomy signilies the establishment of an artificial open- ing, either temporary (fecal fi.stula), or permanent (artificial anus), in some part of the Colon. While a similar opening of the ciecum is termed ca?cos- tomv, and of the sigmoid colon, sigmoidostomy, both operations are generally, though less specifically, included under the term colostomy. The descending colon is the site generally chosen — the cause usually being obstruction, or some condition, distal to the site of operation. Chief Varieties of Colostomy. — (i) Inguinal Colostomy (Iliac Colos- tomv, .\nterior Colostomy, operation of Littre) signifies the opening of the sigmoid lle.xure of the colon in the left iliac region, through the peritoneal cavity. The ascending colon is much less frequently opened. (2) Lumbar Colo.stomv (Posterior Colostomy, operation of Amussat) .signifies the opening of the ascending or descending colon, preferably the latter, through the loin, extra|)eritoneallv. In Favor of Inguinal Colostomy. — The artificial anus is more conve- niently placed; — the operation is both easier and quicker; — the position for anesthesia is better; — the wound is not so deep; — there is no chance of failing because of the presence of a mesentery (which sometimes interferes, by its presence, with the operation posteriorly); — the exploration of the abdomen is possible; — the shallower wound makes the formation of a spur, or any other indicated step, easier. In Favor of Lumbar Colostomy. — The peritoneum is generally not opened; — where the sigmoid colon is bound down, and therefore not easily accessible by the anterior operation; — prolapse (hernia) is not so likely. Observations. — (i) Left Inguinal Colostomy is the operation of choice. Lumbar colostomy is now rarely performed. (2) The ascending colon has a mesentery in 26 per cent. — and the descending colon in 36 per cent, of cases (Treves). This means that in those cases where a mesentery is en- countered, in operating posteriorly, the operation cannot be completed extra- peritoneally unless the leaves of the mesentery can be separated and the mesenteric aspect of the colon thus approached. (3) The positions of the ascending and descending colons are represented, in the loins, by vertical lines drawn upward from a point 1.3 cm. (J inch) posterior to the center of the crest of the ilium (that is, a point 1.3 cm., or ^ inch, posterior to a point midway between the anterior and posterior superior iliac spines). (4) If a temporary fecal fistula be sought, no spur should be formed in suturing the knuckle into position. If a permanent artificial anus be sought, a spur 732 OPERATIONS UPON THE ABDOMIXO-PELVIC REOION. should be made in the knuckle, to prevent the flow of contents of the proximal into the distal gut. (5) By operating in the intramuscular manner, hernia is less apt to follow — and, additionally, greater sphincteric control is secured. (6) Where a temporary opening is sought, the bowel is opened longitudi- nally — and transversely where a permanent opening is planned. LEFT INGUINAL COLOSTOMY. Description. — Left Inguinal (Iliac or Anterinr) Colostomy consists in making a more or less permanent opening in the sigmoid flexure of the colon, in the left iliac region, through the peritoneal cavity. The manner of suturing the intestine to the abdominal wall will differ, dependent upon whether a temporary fecal fistula or a permanent artificial anus be sought. Also the final steps of the operation will differ, dependent upon whether the bowel is to be opened at once, or whether the operation is to be performed in two stages and the bowel opened in three or four days, after adhesions have formed and the peritoneal cavity is shut off — and also as to whether the opening is to be temporary or permanent. The operation is generally done upon the left side — though it may be done upon the right — the steps being the same in either case. The operation is generally done for some obstruction (u.suallv cancer of the rectum), or other condition, distal to the site of the colostomy. Preparation — Position. — .\s for median abdominal section. Landmarks. — Umbilicus; left anterior superior iliac spine; Poupart's ligament. Incision. — About 5 to 6.5 cm. (2 to 2^ inches) long — crossing, at right angles, an imaginary line from the umbilicus to the left anterior superior iliac spine, at a point about 4 cm. (li inches) internal to the iliac spine, the center of incision being upon this imaginary line. The incision will, there- fore, be about parallel with Poupart's ligament and with the fibers of the external oblique. This incision corresponds with JSIcBurney's incision for appendicectomy, except that it is upon the left (see Fig. 355). Operation. — Up to the opening into the peritoneal cavity, the ste]« are practically the .same as in ^IcBurney's intramuscular operation for the re- moval of the appendix (page 637). (i) Incise the skin and fascia in the above line, clamping the bleeding vessels. (2) Separate and retract the fibers of the aponeurosis of the external oblique in the line of their cleavage. (3) Separate and retract the fibers of the internal oblique in their cleavage. (4) Similarly separate and retract, intramuscularly, the fibers of the trans- versalis. (5) Divide the transversalis fascia and subperitoneal connective tissue in the line of separation of the transversalis muscle, for about 4 to 5 cm. (i^ to 2 inches). (6) While holding the parts apart, replace the re- tractors which have retracted the several tissues in their cleavage line by two retractors — drawing the lips of the wound asunder in the two most con- venient directions. (7) Introduce the right index-finger into the jieritoneal cavity toward the left iliac fossa — entering at the outer angle and passing downward and toward the median line, with the finger held in a hook-like fashion — hooking up the sigmoid fle.xure of the colon and bringing it out into the wound — recognizing it by its appendices epiploica?, its sacculations, and its longitudinal bands. .After drawing the loop well out, return into the lower angle of the wound all the excess drawn out of the upper angle, until checked by the mesocolon — thus assuring that there will be no downward LEFT INGUINAL COLOSTOMY. 733 sagging of the intestine from above, with consequent tendency to hernia of the proximal gut through the artificial opening. The steps of the operation from this point on will be determined by. (a) the object sought, as to per- manency of opening — and, (b) as to whether the intestine must be opened at once, (a) Where a temporary fecal fistula is intended : — In this case the presenting conxcxity alone (representing from one-half to three-fourths of the circumference of the intestinal tube) is sutured into the wound, the convexity of the gut being held, during suturing, into contact with the wound by two silk traction-sutures passed through the serous and muscular coats, preferably through the superior longitudinal band of the colon — (or this aspect of the intestine may be gently grasped with forceps). (See Fig. 432.) : Fig. 432. — Left Inguinal Colostomy— for Temporary Fecal Fisti'la : — A, A. Tcniporary ligalures drawing sigmoid flexure of coioii into wound ; B, B, Sutures uniting peritoneum and lower part of muscular wall of wound, to serous and muscular coats of intestine ; C, C. Sutures pass- ing through peritoneum and lower part of muscular wall, on one side ; serous and muscular coats of intestine, in center ; and peritoneum and lower part of muscular wall, on opposite side ; D. D, Sutures passing through entire thickness of muscular wall. Position of future axial incision in colon is shown bv dotted lines. Continuous or interrupted silk or chromic gut sutures are now passed through the serous and muscular coats of the intestine, on the one hand, and the peritoneum and muscle tissue of the abdominal wound, on the other — passing sufficiently far from the free edge of the peritoneum so that some width of peritoneum will be approximated to gut — thus bringing serous surfaces into contact. Preferably the lower line of sutures is passed through the lower longitudinal band — and the upper line, near the mesenten.-. Any excess of abdominal wound is first closed from either end by interrupted sutures passed as in abdominal section. If haste is unnecessary', the opening is made in two or three days, when the serous surfaces have united. An incision of about 2 cm. (J inch) is made into the long axis of the gut — and 734 OPERATION'S UPON THE ABDOMIXO PELVIC REGION. the edges of the intestinal wnund (all of the coats) are sutured to the skin of the abdominal wound. If haste is necessary, the above is done at (jnce. (b) Where a permanent artificial anus is intended: — The knuckle of intestine is drawn well out of the wound, exposing its mesentery. Incise the mesentery, in a line with its vessels, and near the bowel — and insert a short glass rod, or similar object, through this opening — the ends of the glass rod resting on either side of the edges of the wound. If the slit through the mesentery be excessive, the excess is gut-sutured. The two limbs of the knuckle above and below the rod are sutured to each other by gut sutures passing through serous and muscular coats and appro.ximating their mesen- teric aspects, thus forming a spur of the walls so brought into apposition. F'K 433— Left Inguinal Coi-osTOMV— FOR Permanent Artificial A traction-ligatures drawing sigmoid flexure of colon into wound ; B, B, Sutures lower part of muscular wall of wound, to serou ing through peritoneum and lower part of must intestine, in center; and peritoneum and lower passing through entire thickness of muscular w colon is shown by dotted line. 5 : — A. A. Temporary iting peritoneum and uscular coats of intestine ; C. C. Sutures pass- 11, on one side ; serous and muscular coats of nuscularwall, on opposite side ; D. D. Sutures isition of future excision of triangular piece of (See Fig. 4,33.) Having first closed in any excess of alxiominal wound from either end, lay sutures applied as in abdominal section, the protruded knuckle is then sutured into the wound by silk or chromic gut sutures passing through serous and muscular coats of the intestine, on the one hand, and through peritoneum and mu,scle tissue of the abdominal wound, on the other. If haste be not necessary — wait two or three days until the serous surfaces have united and the peritoneum has been shut off — then seize, with rat- tooth forceps, the prominent knuckle of intestine and cut out transversely, in a line with the rod, a V-shaped segment of gut, with scissors — excising the entire, or nearlv the entire, diameter of gut, with the apex of the excised portion ending where the limbs have been sutured together. Let the distal LEFT INGUIXAI, COLOSTOMY. 735 end (if the intestine retract. Suture the margins of the pro.ximal end to the skin of the abdomen. Remove the glass rod in about seven days — and the sutures in about ten. If haste be necessary — the above is done at once. Comment. — (i) Slight variations occur in the operation as done by Maydl; — the knuckle of intestine is drawn out — the glass rod passed through the mesentery — the limbs of the loop sutured together as above, — following which the steps will differ as to the object sought; — (a) If the intestine is to be opened at once — it is stitched to the parietal peritoneum, as described above; — (b) If the intestine is not to be opened at once — it is not stitched, but simply gauze is packed around and under the glass rod; — (c) If the opening is to be permanent — the bowel is to be divided transversely in from four to si.x days, through one-third of its diameter — an irrigating tube is then inserted and the intestines washed out — and in two or three weeks later the transverse division is completed — the edges of the pro.ximal gut are sutured to the margins of the skin and the distal end left unsutured — and the rod is then withdrawn; — (d) If the opening is to be temporary — the intestine is incised in its long axis — and, when the opening is ready to be dispensed with, the rod is withdrawn and the knuckle of intestine allowed to retract (no suturing to the skin having taken place) — the opening often closing of its own accord. (2) As small an abdominal incision as possible should be made, in order to lessen the chance of hernia. The higher up the abdominal wall the opening is made, the less the chance of hernia. Some surgeons make the incision parallel with the outer third of Poupart's hgament. (3) If the small intestine, mesentery, or omentum present during operation, they are pushed back into the abdomen. (4) If the sigmoid fle.xure cannot be located readily, it can be found lay injecting water through the rectum, while the finger in the wound feels for the enlarging bowel. (5) The use of the rod, or other object, to pierce the mesentery is not absolutely necessarv. The mesocolon can be sutured to the edges of the abdominal wound instead. (6) In stitching the intestine into the wound, the stitching is so done as to give the pro.ximal part of the loop ample room, and, at the same time, make pressure upon the distal part, to prevent the passage of intestinal contents into it. (7) Sometimes the parietal peritoneum is drawn sufficientlv out to be sutured to the margin of the skin around the wound, the muscle lavers not being included — and the intestine is then sutured to this parietal perito- neum. But firmer union is probably secured by the principal method de- scribed above. (8) Sometimes (though hardly to be recommended) instead of making a spur, which is often inefficient, the bowel is cut through above the obstruction (when performed for that purpose) and the lower end is closed by inverting the edges of the distal end by a double row of sutures, the outer row, an overhand, continuous suture; the second, a row of Lem- berts; and this end is dropped into the abdominal cavitv. The edges of the proximal gut are then sutured into the abdominal wound bv two tiers of .sutures; the lower, of chromic gut, through the serous and muscular coats of the gut (a short distance from the edge), and peritoneum and muscles of the abdominal wound; the marginal, of silk, through all the coats of the gut, and the skin. The method, however, is not indicated when it is ilesirable to keep the upper end of the distal gut patulous, where drainage below is difficult. Note. — Right Inguinal Colostomy, or Cafcostomv, is but rarelv done. The contents of the ascending colon (from the nearness of the small intestine) are more liquid and less easily controlled through such a fistula or anus. The absence, or shortness, of the mesentery also makes the attachment to 736 OI'ERATl(.)\S UI'dX THE ABDOMIXO-PELVIC REGIC1N. the abdi.minal wall more diffieult. The operation is, practically, done onlv when the site of the trouble is uncertain, the c;ecum at the same time being distended, — or when, in doing a Left Inguinal Colostomy, it is impossible to find the sigmoid colon. When the operation is done at all, it is generally only a temporary fistula which is made, as, when this site is selected, it is usually an operation of emergency only. A Transverse Colostomy is even rarer. LEFT LUMBAR COLOSTOMY. Description. — Left Lumbar (Posterior) Colostomy consists in making an opening posteriorly through the loin, over the descending colon — extra- peritoneally. Rarely the opening is made over the ascending colon, in the right loin. Preparation — Position. — .\s for median abdominal section. Position. — Patient lies upon opposite side and near edge of table, with a hard pillow, or support, under the opposite loin, to render prominent the site of operation, — Surgeon on side of operation, — .Assistant opposite. Landmarks. — Position of descending colon — namely, a line extending vertically upward from a point about 1.2 cm. (^ inch) posterior to the center of the iliac crest to the twelfth rib — which line will about correspond with the outer border of the quadratus lumborum. Incision. — .\bout 7.5 to 10 cm. (3 to 4 inches) long — placed obliquely between the twelfth rib and the crest of the ilium, with its center over the center of the vertical line representing the course of the descending colon — which incision will run in the direction of a line extending from the anterior superior iliac spine to the angle formed b}' the twelfth rib and the outer border of the erector spinas muscle, the incision beginning at about the outer border of this muscle. (See Fig. 434.) Operation. — (1) Divide the skin and the thick subcutaneous fatty fascia, clam[)ing all \essels. (2) Divide the latissimus dorsi and its aponeurosis in the posterior part of the wound — and the posterior part of the external oblique in the anterior part. (3) Divide the internal oblique, exposing the lumbar fascia postericrlv. (4) Recognize and protect the twelfth dorsal nerve and accompanying branch of the lumbar artery. (5) Dixide the lumbar fascia and the transversalis muscle, exposing the anterior margin of the quadratus lumborum (which rarely requires division) in the posterior angle of the wound, and the transver.salis fascia. (6) Divide the transversalis fascia, from the quadratus lumborum to the anterior angle cf the wound, e.xposing the subperitoneal tissue — avoiding the twelfth nerve on its way from the quadratus lumborum to the transversalis muscle. (7) -A distended colon may now protrude through the subperitoneal connective tissue into the wound — this areolar fatty tissue, often very thick and fatty, lying around the kidney, being separated by the fingers and forceps, or by a blunt dissector. If the colon does not thus protrude, insert an index-finger through this subperi- toneal areolar tissue, while the parts are well retracted behind the lumbar fascia — following, with the back of the finger toward the patient's back, along the anterior surface of the quadratus lumborum, aiming for the angle between the quadratus lumborum and the psoas, toward which angle the posterior surface of the colon presents, lying anterior to the plane of the kidney, the lower portion of which (kidney) is generally felt. The finger which has passed through the subperitoneal areolar tissue and is carefully working behind the peritoneum is aided in its .search by rolling the body LEFT LUMBAR CULOSTOMV. 737 over toward the side of operation, while the assistant presses the anterior abdominal wall firmly, so as to aid the colon, by gravity and pressure, to fall, as it were, into the curved index-finger. The colon is generally recog- nized by the thickness of its wall, by the absence of the peritoneal coat, and sometimes by the posterior longitudinal band. (8) Grasp the non-mes;nteric aspect of the colon with the fingers, or special forceps, and bring it out to a level with the surface — no loop being here drawn out of the wound as in the anterior operation. The colon is held in place with forceps, or traction- sutures, or temporarily allowed to fall back into place — while the excess of the abdominal wound is closed from either end — by layer suturing with chromic gut, or bv mass-.suturing with chromic gut, silk, or silkworm-gut, leaving just space enough for the emergence of the gut. (9) The convex dome of the gut is sutured into the lips of wound — by interrupted sutures Fig. 434. — Left Lumbar Colosto.my -. -.A. TweUlli rib; B, Iliac crest; C. Latissimus dorsi muscle; D. External oblique muscle ; E, Left kidney; F. Descending colon; G, Line of incision for left lumbar colostumv. of silk passing through the fibrous and muscular coats of the intestine, vn the one hand, and the skin of the abdomen, or as near it as possible, on the other. (10) If haste be unnecessary — several days are allowed to pass, for union of intestine to abdominal wound to occur, and then the intestine is inci.sed and the lips of the intestinal wound sutured to the lips of the ab- dominal wound — by interrupted sutures of silk, or silkworm-gut, passing through all the coats of the bowel, and through the skin of the abdomen, or as near it as possible — the sutures being passed from the skin into the gut (making infection less likely). (11) If haste be necessary — the above incision is made at once. (12) If a temporary fecal fistula be intended — the gut is incised in its longitudinal axis. (13) If a permanent artificial anus be intended — the gut is drawn as far into the wound as possible (which is never as far as in the anterior operation) and divided nearly through — the object being to form a spur as in the anterior operation. 47 738 OPERATIONS LTOX THE ABDOMINO-PELVIC REGION. Comment. — (i) The outer border of the erector spinae is the superficial muscular guide to the colon. The outer border of the quadratus lumborum may be cut to expose the colon if necessary. (2) The operation is difficult in very thick loins — thorough retraction aids the steps. (3) It is important to recognize and open up the transversalis fascia — and not mistake it for the peritoneum. The bulging peritoneum has been mistaken for the colon. The duodenum has been mistaken for the ascending colon in operating on the right side — and the stomach for the descending colon in operating on the left side. The kidneys and small intestines have been mistaken for the colon. The small intestines, when encountered, lie external to the colon. The colon is generallv distinguished by its longitudinal bands, anterior, posterior (at the mesocolon, when the mesentery is present), and one internal, — by its greater fi.xity, — and by its sacculations (often filled with scybala). The descending colon is sometimes congenitally absent. The large intestine may be distended with air or water to aid its recognition. The empty colon is often hard to detect. If all means of detection fail, do a median abdominal Psoas magnu Fig. 435.— Transverse Sectio-n of the Posterior Region; — A, Erector spinae muscle; B, Quadratus lumborutn ; dorsi ; E. External oblique ; F, Internal oblique; G, Transversalis ; H, The descending colon shown in its usual position, and without a mesentery, as usual ; I, The ascending colon shown with a mes- entery (an exceptional occurrence). (Motiified from Gray.) section — find the bowel — and then complete the lumbar operation. (4) If the peritoneum be accidentallv opened, clcse it bv gut suture if possible. If this cannot be done, no harm is generally done by accidentally opening the peritoneum in this locality. Draw the inte.stine into the wound and fix it there. (5) If the mesocolon be present, the abdominal cavity must be opened, unless the lamina; of the mesentery can be .split — which can generally be done. (See Fig. 435.) A branch of the inferior mesenteric artery may guide to a separation of the laminoe. (6) The non-peritoneal surface of the colon is generally thickly covered with fatty areolar tissue — which also inter- venes between the colon, in front, and kidney, diaphragmatic crura, and quadratus lumborum, behind. (7) The empty descending colon is apt to tend further toward the median line, behind the border of the quadratus lumborum, than a distended one — so that, in such cases, the normal site of the distended colon is more apt to be occupied by peritoneum, which is consequently, under these circumstances, more apt to be opened. (8) OPERATION FOR FKCAl. FISTULA AND ARTIFICIAL ANUS. 739 Owing to the fixity of the colon, it is often hard to get enough of it into the wound to form a spur, in the operation for artificial anus — though enough for a fecal fistula is generally to be gotten. If difficulty be e.xperienced in causing sufficient bowel to protrude, a Paul tube may be tied into the gut, the balance of the wound being closed about it. (9) Right lumbar colostomy may be, but rarely is, performed. OPERATION FOR THE CLOSURE OF FECAL FISTULA AND ARTIFiaAL ANUS. Description. — Sometimes occurring alone, and sometimes as a result of the o]ierations just described for the formation of fecal fistula and artificial anus, a more or less permanent fistulous tract between the intestinal canal and the abdominal wall is left. The simplest forms of such fistulous tracts tend to close of their own accord, but the more com plicated generally require some operation for their closure. These fistula; lead- ing to some part of the large or small intestine are generally one of three kinds: — (•) The gut is not bent ujjon itself to any extent; there is no spur; but little of the intestinal wall is involved; the open- ing is small; the skin and intestinal mucous mem- brane are connected by a sinus-like communication (see Fig. 436, A);-(2) The gut is bent somewhat more upon itself; an in- complete spur is present; more of the intestinal wall has been lost; the opening is larger; the intestinal mucous membrane and the abdominal skin are more nearly in contact (see Fig. 436, B); (3) The gut is more acutely bent on itself; a marked spur is present, forming an obstruction to the intestinal passage; the amount of intestinal wall lost may be variable; the condition present generally being an exaggeration of (2) (.see Fig. 436, C). The procedure for the closure of the fistulous tract will be modified, therefore, by the various degrees of fistula found and bv the extent of the adjacent adhesions. Preparation. — Neighboring skin should be gotten as healthy as possible preliminarily. Evacuation of intestinal canal; kical irrigation; vicinity of fistula shaved. Just preceding operation, sinus is to be gently scraped and again irrigated — after which it is packed with a small sponge, or with gauze, attached to a piece of silk, the end of which is left out — and the lips of the fistula are then tightly and deeply sutured and the long ends of the Fig. 43h.— Forms of Fecai. Fisxn./F. Ani : — A, F"irst form, intestine connected \vi like communication ; B, Second form, intesti (iirectly in contact and gut slightly bent on form, showing formation of marked spur. ,h skin bv sinus- le and skin more itself; C, Third 74° OPKKATIOXS LTOX THE ABDnMIXOrKI.VK' RECIOX. sutures, after tying, are knotted, or grasped by c'lamp~force])s, and drawf upward. Position. — Patient supine on edge of tal)le nearer ti.stula; Surgeon on .side of tistula; .\ssistant opposite. Landmarks. — Site of fistula and known rekition of neighboring |)arts. I. Cases in which the operation involves the peritoneal cavity — no e.xten.sive adhesions e.xisting — or where it is desired to free existing adhe- sions before excising the fistuUi : Incision. — .-Vn elliptical incision is made around the fistulous opening — its long axis will generally be vertical in operating upon fistula; of the small intestine, and will usually correspond with the long a.xis of the large gut in operating upon parts of the colon — and the length and breadth of the Fig- 437.— Operation for Cure of Fecal Fistula or Artificial Anus:— A, Skin opening of fistula closed by sutures used as traction-sutures ; B. Ellipse of abdominal wall to be removed, with its center occupied by external opening of fistula ; C, Ellipse of intestine to be removed, including neck of fistulous tract; D, Position of some of the Lembert sutures which will close in entire elliptical opening in intestine after excision of fistulous tract. ellipse will be planned, as far as passible, to extend beyond the adhesions probably surrounding the sinus. Operation. — (i) Having sutured the fistulous opening and using the sutures as traction-loops, this incision is carefully deepened on each side — clamping bleeding vessels — and guarding against opening the peritoneum prematurelv, or cutting into an adherent coil of intestine. (See Fig. 437.) (2) In passing through the thickness of the abdominal wall, the course of the incision is directed by the sensation and form of the distended fistula and by the left index-finger within the wound. In difficult cases, and espe- cially in devious fistula\ it may be necessary to introduce a sound, or bougie, through the sinus as a palpable guide. (3) Having deepened the incision, all around, down to the peritoneum, the abdominal cavitv is now carefully OPERA HON" FiiR FECAL FISTULA AND ARTIFICIAL ANUS. 741 opened in the line of the original ellipse. If the ellipse lie without the site of adhesions, no great difficulty will be experienced. If it lie in part over adhesions, a linger introduced through the site leading into the free peritoneal cavity and swept around the sinus will serve for e.xploration and as a guide to the separation or incision of the adherent portion. If the ellipse lie wholly over adhesions and come down upon these all around, great care is required to recognize the plane (i adhesions when reached, and greater care still in separating or dividing them in the line of the ellipse. (4) Having thus reached the intestines, an isolated oval island of tissues (included in the original ellipse and in deepening the elhpse to the intestinal wall) will be e\'ident — free above and continuous with the intestine below — through the center of which the sinus extends. The intestine is carefully freed and .drawn out into the abdominal wound, with the oval island of tissues still adherent — and the neighboring parts packed off with gauze. (S) Ha\ing pressed away the intestinal contents and clamped the gut above and below the site of the sinus, a small elliptical incision is made in the gut, circumscribing the con- nection of the sinus with the gut, and having its long a.xis coincident with that of the gut — and the incision is deepened through the wall of the gut, thus excising an elliptical piece of the intestinal wall, representing the intes- tinal end of the sinus. The escape of intestinal contents is especially guarded during this excision. (6) The wound of the intestine is at once closed by a double row of sutures — a continuous overhand suture of all the coats, thus bringing together the free edges — followed by interrupted Lemberts of the outer coats. (7) The abdominal wound is closei.1 in the usual manner. II. Cases in which the operation does not involve the peritoneal cavity — extensive adhesions extending around the sinus, and it being possible to excise the fistula and close the intestinal wound without passing beyond the adhesions: Incision. — Same in fcrm as above, but less extensive. Operation. — (i) The operation is conducted as above, except that care is e.xercised to avoid entering the abdominal cavity, which can be done" only when more or less extensive and strong adhesions e.xist. The sinus is fol- lowed down to its intestinal end by cutting directly through all intervening tissues to the intestinal wall, which is then incised in such a wav as to ellipti- cally excise the intestinal end of the fistula — guarding against injury to neigh- boring coils of intestines and viscera. (2) Ha\ing excised the sinus without entering the peritoneal canty, the borders of the wound on a plane with the u])per wall of the intestine are inverted and sutured together bv inter- rupted chromic gut or silk sutures, applied after the manner of Lembert's approximating surfaces, which, while not peritoneal, have been left raw from the excision of the sinus-. The sinus is closed throughout the rest of its extent by deeply buried chromic gut sutures. III. In other cases : — In cases where large and obstinate spurs exist, or where there has been much loss of intestinal wall — which may be found to be the case after having exposed the parts as in the first category of cases mentioned above, a partial enterectomy may be done, followed by one of the methods of entero-enteros- torny. Or the necessary calibre of intestine may be gotten by some form of '• elbowing, " without excision. Or junction of the involved coil of intestine with a neighboring coil may be secured by lateral anastomosis without partial excision of the intestine, after having ch.sed the wound in the intestine left 742 OPERATIONS UPOX THE ABDOMINO-PELVIC REGION. by excision of the intestinal end of the sinus. Or, where a moderate spur exists, attempts may be made to remove the spur by means of a piece of rubber tubing introduced into the lumen of the gut and held against the spur. Formerly the use of an enterotome, whereby the spur was crushed, was much resorted to. ENTEROPLASTY. Description. — Bv enteroplasty is generally understood a plastic operation carried out for the purpose of increasing the calibre of the intestinal lumen in the case of a strictured gut — without resection of the bowel. The technic of the operation is exactly similar to that of pyloroplasty — an axial incision is made through the strictured portion of the gut and this incision is then sutured in a transverse direction. For description and illustration of the principle, see Pyloroplasty, page 789, and Fig. 473. Note. — Other methods of increasing the calibre of the narrowed portion of intestine are employed in connection with operations of resection: — Jeannel, after partial enterectomy, cuts the ends of both pieces of intestine obliquely from above downward (the right-hand piece from right to left, and the left- hand piece from left to right) — and then unites their edges by suturing — forming an "elbow," as in the junction of pieces of stove-pipe. Chaput, after performing partial enterectomy, united the ends of the bowels by circular suturing — then made a longitudinal incisicn through the walls of the united intestines opposite the mesentery and sutured this longitudinal division trans- versely — employing, in the latter part of the operation, the principle of the usual enteroplastic operation. Chaput, by another method, completely divides the bowel obliquely, from above downward and from side to side — forming two oblique ellipses of the same size, but in opposite directions, at the ends of the intestines — followed by union of the intestinal margins. COLOPEXY. BRV.\N"fS METHOD. Description. — In this operation some part of the colon is elevated and attached to the abdominal wall by suturing. Colope.xy of the transverse colon to the anterior abdominal wall is done in some cases of Enteroptosis. Colope.xy of the sigmoid flexure of the colon to the antero-lateral abdominal wall is sometimes done for Prolapsus Recti. This latter operation will be here considered. Preparation — Position. — .\s for median abdominal .section. Landmarks. — Outer part of Poupart's ligament. Incision. — .About 7.5 cm. (3 inches) — parallel with and about 2.5 cm. (i inch) above the outer part of Poupart's ligament — being extended upward if more room be necessary. Operation. — (1) The above incision is carried down to and through the peritoneum — clamping and tying all bleeding vessels as encountered. (2) After having opened the abdominal cavity, the parietal peritoneum is .separated from the edges of the abdominal wound for about 2.5 cm. (i inch) on each side, the width of separation being somewhat greater above than below — the separated peritoneum thus forming two flaps. (3) The rectum is now pulled well upward, reducing all prolapse — and. at the .same time, any adjacent laxity of the colon is pulled down. While the rectum is being drawn firmly RECTOPEXY. 743 upward, the parietal peritoneal flaps are sutured to the .serous and muscular coats of the rectum by quilting and continuous silk, sutures. (4) About half a dozen silk sutures are then passed in the following order — through all the layers of the edges of the abdominal wound — through the peritoneal flap of that side — then through the serous and muscular coats of the intestine, passing behind the longitudinal liand — out through the peritoneal flap of the opposite side — and then through all the tissues of the corre.sponding edge of the ab- dominal wound. The.se deep .sutures are then drawn tight and tied — thus bringing the longitudinal band and a part of the intestinal wall into contact with the abdominal wall — and approximating the borders of the wound so that they grasp the longitudinal band and part of the wall of the gut — and, at the same time, closing the abdominal wound. RECTOPEXY. \'EKXra'lL'S METHOD. Description. — Rectope.xy, or Proctopexy, consists in the suturing of the prolapsed rectum back to its posterior bed. Preparation. — Bowels emptied; perineum shaved; prolapse replaced. Position. — Patient in lithotomy position; Surgeon seated in front of perineum; Assistant to one side. Landmarks. — Anus; tip of coccyx; ischial tuberosities. Incision. — Two straight incisions of about 2.5 cm. (i inch) in length are made directly outward from the mid-lateral aspect of the anal orifice (at right angles to the median perineal line). Two other incisions are, later, made from tiie tip of the coccyx to the outer ends of the two lateral incisions. Operation. — (i) Deepen the lateral incisions through the skin and ex- ternal sphincter. (2) Deepen the posterior incisions through skin, fascia, and external sphincter, raising a triangular flap attached at its base to the tissues of the posterior aspect of the anal orifice — and displace this flap for- ward, and hold it out of the way by retractors or skin sutures. (3) Detach the posterior wall of the rectum, by blunt dissection, from the anus to the tip of the coccyx, and for the width of 5 to 6.5 cm. (2 to 2^ inches). (4) Pass four rather stout silk sutures transversely through the posterior wall of the rectum, going through its outer coats, for as nearly the whole width of the posterior aspect of the rectum as possible, leaving both ends of the sutures free. The.se sutures are parallel, the highest being opposite the tip of the coccyx, the lowest about 1.5 cm. (f inch) from the anus, and the others equidistant between. (5) Pass a Reverdin needle (or other needle with eye at point) from the skin without to the denuded surface within — the punc- tures being made about 4 cm. (i^ inches) from the median line on each side, and above the particular thread to be drawn through — the uppermost sutures coming out through the skin en a level with the sacro-coccygeal articulation, and the lowermost opposite the tip of the coccyx. Each end of each suture is' then threaded through the eye of the needle, in turn, and thus drawn through the thickness of the posterior pelvic wall. (6) The free ends of these sutures are then tied together over a firm pad of gauze (to avoid burying into and cutting the skin) — either the opposite ends of each suture being tied trans- versely together — or the ends of the first and second, and of the third and fourth, tied together in a vertical line on either side. Rather strong traction is made during suturing — to appro.ximate and retain the posterior aspect of the denurled rectum in contact with the anterior aspect of the denuded pelvic 74t OPERATIONS UPON TllK AIJIKJMINU-PEIAIC REGION. wall. (7) Suture the triangular flap back into place— narrowing, at the same time, the anus, by suturing the inner ends of the lateral incisions somewhat further inward than normal — freshening the margins of the anus sufficiently for the purpose (the original incisions may be planned with reference to narrowing the anus). Comment. — The same object may be accomplished by Tuttle's somewhat similar operation; — and also by Peter's operation of opening the abdomen, narrowing the barrel of the rectum by invaginating a vertical strip of its anterior wall by Lemberts, and then stitching the rectum to the abdominal wall ; — as well as by other procedures. INTERNAL RECTOTOMY. Description. — Rectotomy, or Proctotomy, consists in the division of the rectum for constriction, obstruction, or the removal of a foreign body. In Internal Rectotomy the rectum is divided from within — and is generally done f. r stricture of its lower part. Preparation. — Bowels emptied; anal region sha\ed; anim])le venous ].)iles of medium size. Preparation — Position — Landmarks. — As in the ligature method. Operation. — (i) Having dilated the anus, each pile in turn, or a cluster of ])iles, is seized with toothed forceps and drawn downward and away from its attachment. (2) Divide the muco-cutaneous border, if there be one, with blunt-pointed scissors or knife (that nerve-tilaments may not be included in the grasp of the clamp). (3) Apply the clamp, with the pile stilt under gentle traction, to the base of the tumor, and in the a.xis of the gut — the clamp resting in the cut groove at the muco-cutaneous border, if the pile Ije one having a cutaneous part. The blades are then screwed together sufficiently firmly to thoroughly compress the parts. (4) With a pair of curved scissors, cut away the excess of hemorrhoid which projects above the clamp. Then, with a Paquelin or other cautery at red heat, slowly and thoroughly cauterize the stump of the ]jile. As the clamp is loosened, follow down the escaping pile-.stump with the point of the cautery — seeing that all hemorrhage is controlled. If neces.sary to make the hemostasis complete, the stump mav be again clamped and again cauterized. This process is repeated until all the piles or clusters have been cauterized. Comment. — Where the piles are in the form of a more or less complete circle surrounding the anus, they should be divided into segments or groups by incision of the mucous membrane prior to clamping and cauterizing. .\void burning the skin — or detaching the eschars, thereby favoring hemor- rhaaie. OPERATION FOR THE CURE OF FISTULA-IN-ANO BY INQSION. Description. — Consists in the laying open of the fistulous tract upon a grooved director — followed by the curettage of the sinus-walls — and light gauze packing of the raw bed to promote healing from the bottom and ob- literation of the fistula, — or excision of tract with suture of its bed. Preparation. — Purgation; rectal irrigation; shaving of circumanal re- gion; dilatation of the .sphincter just before operation, in the more compli- cated cases. Position. — Patient in the lithotomy position, with nates over the end of the table; surgeon sitting opposite the perineum. Landmarks. — .-Vnus; rectum; course of fistula and position of openings determined in advance, if jxissible. Operation. — (i) .\ grooved director is passed through the sinus. fn)m its skin opening — made to traverse its length and emerge through its internal opening within the bowel — and the end of the director is then caused to project through the anus by directing its tip with the left inde.x-finger within the rectum, while its handle is depressed with the right hand. The external and internal openings of the fistula are then in plain \iew — with the grooved director pissing through its entire lengtli. (See Fig. 451, ..\.) (2) Upon the grooved director a narrow, pointed knife is passed (or a probe pointed bis- toury may be u.sed) with its cutting-edge directed outward — thus incising the fistula throughout its entire course — freeing the grooved director and allowing the fjarts to recede into their normal positions. (3) The lips of the wound and of the sinus are then separated by the operator's left thumb and index — and. while thus exposed, the entire extent of the fistula should be scraped with a curette, so as to remove its old wall — and then lightly [jacked with gauze and allowed to heal from the bottom. .A T-bandage <5S OPERATIONS L'I'ON THE ABDOMIXO-PELVIC REGION. keeps the dressing in place. The bowels are usually kept constipated for a few days. Comment. — (i) Fistul:e-in-ano are generally one of three types; — "Com- plete" — "Incomplete Internal" — "Incomplete External." In addition, fis- tula may have several openings; — and they may have irregular forms, as, for example, the "horseshoe" type. (See Figs. 447 to 450.) (2) If the grooved director does not pass readily, a probe may first find the way — and the director passed along this — and the ]jrobe then withdrawn. (3) If the grooved director, or probe, cannot be made to tind an internal communication with the bowel, but nevertheless comes very near the mucous membrane, it ma\- be forced the remaining distance, provided this distance be short. (4) If the end of the director cannot be brought out through the anus, a narrow, probe-pointed bistour\- ma\- lie passed along it and the director Figs. 447-450. — Forms of FistiXvE-in-ano :~A. Reclum in vertical section; a, Iiicomple fistula ; A. Incojnplete internal fistula ; c. Complete fistula ; rf. Irregular complete fistula. \ie\v of fistulous tracts, showing various irregular forms of fistula and diverticula— thei openings being marked by a star. withdrawn — and then the end of the probe-pointed bistoury is pressed against the surgeon's left index-finger (or a special piece of wood) introduced w-ithin the rectum — and finger and knife simultaneously withdrawn — the knife cutting the intervening soft parts through in its withdrawal. Or one blade of a pair of scissors may be passed along the director and the sinus thus laid open. (5) In incomplete internal fistuUe, the internal opening is found through a speculum — a bent probe passed along the sinus — and an external opening made where thus indicated — after which the operation is completed as in a complete fistula. (6) In incomplete external fistula, if the inner end be very near the mucous membrane, a director is protruded through the sinus into the bowel, forcing its way through the thin barrier — after which the operation is completed as in the complete fistula. If, on the other hand, the inner OPERATION FOR FISTULA-IX-ANI ) BY IXCISIOX. (59 opening be not connected with or near the bowel, the entire tract must be laid open from without. (7) If the tistula extend high up along the bowel, judgment must be exercised as to what extent cutting is necessary, and to what extent dilatation and scraping will suffice. (8) In "horseshoe" fistuloe (an external opening on each side of the anus leading to a single internal opening, generally upon the posterior rectal wall) the bowel function is less Fig. 451.— Operation for Cl're of Fistula-in-ano by Incision and Excision :— A, Bistoury in act of dividing fistula upon grooved director ; B. Fistulous tract being excised by curved scissors, while steadied with forceps ; C. Suturing of bed of sinus after its excision ; D. Ligature attached to gauze tampon in rectum, to control cOlUents. apt to be interfered with if the sphincter be cut on one side only (and at right angles to the anal orifice) and the opposite part of the fistula be dilated, scraped, and drained from the first side. (9) Search should always be made for secondary fistuke running oft" from the main one, and these likewise laid open and curetted — or dilated and scraped. (10) The internal sphincter should not be divided if it can be helped. If it be necessary to incise the 760 OPERATIU.NS UPOX THE ABDOMIXO-PELVIC REGIUX. internal sphincter, tiie division should be at right angles to its fibers at the site of section (that repair may be more complete, and subsequent functioning). And it is preferable not to divide the internal sphincter in more than one place at a time (for the same reasons). (11) Whatever hemorrhage occurs, which is generally slight, is ordinarily controlled by gauze packing — but gut- ligaturing may be used where necessary. (12) In appropriate ca.ses the entire fistulous tract may be dissected out — and the raw edges thus left be brought together by superficial and deep chromic gut sutures — thus at once obliterating the site of sinus and inviting primary union. This method is preferable to simple incision where\er applicable. (See Fig. 451, B and C.) VI. THE STOMACH. SURGICAL ANATOMY. Description. — Lies in epigastric and left hyi)()chondriac regions — being about live-sixths to left and one-sixth to right of median line; — bing under the liver and diaphragm, — above the jejunum, ileum, and transverse colon (also upon the transverse mesocolon, which intervenes between it and pan- creas, abdominal ve.ssels and solar ])lexus), — and between gall-bladder on right and spleen on left. Relations. — Anteriorly and superiorly: diaphragm; thoracic wall (an- terior portions seventh, eighth, and ninth rilis); left and cjuadrate lobes of liver; anterior abdominal wall; lesser omentum. Posteriorly and infe- riorly : diaphragm ; crura of diaphragm ; aorta and inferior \ ena cava ; first lumbar vertebra; cceliac axis; lesser peritoneal sac; splenic flexure of colon; transverse colon; transverse mesocolon (superior layer); s])leen (gastric surface) ; left kidney and suprarenal capsule ; jiancreas ; splenic vessels ; duo- denum fourth, or ascending portion); solar plexus. Right end : transverse colon; inferior surface (if li\er. Left end : spleen; diaphragm. Position of Cardiac End (Fundus). — Reaches up to the left sixth chon- dro-sternal articulation, or fifth rib in mammary line, and to cuijola of dia- phragm; — slightly above and behind the heart ii]:ex\ — and 3 to 5 cm. (i;^ to 2 inches) higher than the cardiac orifice of the stomach. Position of Cardiac Orifice. — (^pjjosite left seventh chondro-sternal articulation, aljout 2.5 cm. (i inch) from sternum: — also on level with ninth dorsal spine (left side of eleventh dorsal vertebra). Lies from 2 to 3 cm. (J to i{ inches) below the esophageal opening, and about 7.5 cm. (3 inches) from the left extremity of the stomach. — and 11 cm. (4j inches) from the anterior abdominal wall. Position of Pylorus. — On level with bony ends cf .seventh ribs (wiiich ere 5 to 7.5 cm., or 2 to 3 inches, below the sterno-xiphoid joint), lying to right of median line and nearer the surface than the cardiac end; — also on level with twelfth dorsal spine (upper border of first lumbar vertebra). Fixation Points and Ligaments of Stomach. — Bound to diajihragm by esophagus; — bound to \ertebral column by duodenum; — ligamentum phrenico- gastricum connects cardia to diaphragm; — gastro-hepatic omentum (lesser omentum) connects lesser curvature to liver; — ligamentum hepato-duodenale connects pylorus and duodenum to liver; — gastro-splenic omentum binds greater end of stomach to spleen; — great omentum binds the stomach only when itself is bound. SLRGICAF. CiXSIIiKRAriOXS IX SKiMACll ( il'KKATH iNS. 761 Peritoneal Coverings. — Everywhere — except along the u|)per and lower curvatures, and upon the triangular areas at either end. Arteries. — Gastric; pyloric and right gastro-epiploic branches of hepatic; left gastro-epiploic and vasa brevia of splenic. Veins. — Coronary and pyloric, emptying into portal vein; right gastro- epiploic, emptving into superior mesenteric; left gastro-epiploic, emptying into s])lenic. Nerves. — Right vagus (posterior surface) ; left vagus (anterior surface) ; solar plexus of sympathetic svstem. Lymphatic Glands. — Along greater and lesser curvatures — and at pvloric and cardiac ends. SURFACE FORM AND LANDMARKS. Stomach when empty — lies far back in the abdominal cavity, beneath left lobe of liver and in front of pancreas. In moderate distention — Cardiac end lies beneath left seventh chondro- sternal articulation, about 2.5 cm. (i inch) beyond the sternum. Pyloric end lies opposite a point near end of eighth right chondro-costal articulation. Borders (curvatures) of stomach are represented appro.ximately by curves of the characteristic contour between the points just given — the greater curvature reaching at first to the left, then downward to the infracostal line. The les.ser curvature crosses the vertebral column on a level with the first lumbar vertebra. The greater curvature crosses the epigastrium on a line connecting the ninth and tenth costal cartilages — which is about two finger- breadths above the umbilicus. Gastric fossa — a triangular area of about 40 square centimeters (15^ inches) of the anterior wall of the stomach where it lies in direct contact with the abdominal wall — bounded, below, by the transverse colon; above and to left, by seventh, eighth, and ninth costal cartilages; and above and to right, bv the anterior border of the liver. GENERAL SURGICAL CONSIDERATIONS IN OPERATIONS UPON THE STOIVIACH. Stomach may be recognized by it^ relation to ihe inferior surface of the liver — bv its continuity with the anterior laver of the gastro-hepatic omentum — by its thick and stiff wall, as determined by pinching it up between the fingers — by the direction of its vessels — and by its pinkish-white color and absolute opacity. The stomach and transverse colon have been mistaken for each other. The transverse colon .should be displaced downward and the liver upward — revealing the stomach between them. If not otherwise recognizable, follow back the under surface of the liver to the portal fissure, with the index- finger — thence downward along the gastro-hepatic omentum to the stomach. .\nterior gastric wall lies in the greater peritoneal cavity — and its posterior wall in the lesser cavity. Superior wall of the transverse colon lies in the lesser peritoneal cavity — and its inferior wall in the greater cavity. Mesentery de.scends downward and forward from under the back part i>f the transverse mesocolon. The omentum major descends from the greater curvature of the stomach and inferior aspect of the transverse colon — and 762 OPERATIONS UPON THE ABDOMINO-PELVIC RECIION. mav contain a cavity and be continuous with the nmentum minor above the transverse colon — but its component layers are more generally united. The omentum can be more convenientlv displaced ujnvard and to the left. Note. — Other general surgical considerations will be mentioned under special classes of gastric operations. INSTRUMENTS. Scalpels; straight and blunt-pointed bistouries; scissors, curved and straight; dissecting and toothed forcejis; tenacula; artery-clamp forceps; various retractors; large gauze pads; broad spatuke; intestinal clamps; stomach clamps; ^lurphy button; sponge- holders; volsella; stomach-tube; rubber tubing (for gastrostomies); needles, curved and straight; needle-holders; sutures, silk and gut; ligatures, silk and gut; ligature-carrier, wound-hooks. INTRODUCTION OF STOMACH-TUBE. Description. — The passage of a hollow tube down the esophagus and into the stomach — for the purpose of removing fluid from, or injecting fluid into, the stomach. Position. — Patient sits upright in chair or in bed — head thrown backward (preferably steadied by an assistant) — mouth gagged (preferably, but not necessarily) — napkin placed over tongue to enable it to be more easily grasped; — Surgeon stands in front. Operation. — The surgeon depresses the base of the tongue with the left indexTinger, and, at the same time, draws it forward — this finger thus also guarding the larynx. The tube, previously warmed and lubricated, and held in the fingers of the right hand, is guided along until it impinges upon the posterior wall of the pharynx, when it is directed downward. The esopha- gus once entered, the tube is gently pressed further downward, aided by the act of swallowing, until it has entered the stomacli. Comment. — In the average adult, the distance from the up])er incisor teeth to the superior end of the esophagus is given as 14 cm. (5^ inches); — from the same point to the arch of the aorta, as 23 cm. (9 inches) ; — and from the same point to the diaphragmatic opening, as 37 cm. (14^ inches). Pouches and diverticula of the esophagus are to be avoided. GASTROTOMY liV MKDIAX IXCISION. Description. — Consists in the temporary opening of the stomach by incision, followed by its closure at the same ojjeration. Generally resorted to for removal of foreign bodies, for exploration, or for treatment of surgical conditions of the stomach, pylorus, or esophagus (such as gastric ulcer, dilatation of the esophageal or pyloric orifice, dilatation of the esophagus, etc.). The opening may be made in the median line, or below and parallel with the left costal arch. .\s far as possible, transver.-e dixision of muscles and iniurv to nerves should be avoided. Preparation. — Stomach washed out. Position. — Patient supine; Surgeon to patient's right, cutting from aljove downward; .Vssistant opposite. GASTRDTO.MV. 763 Landmarks. — Linea alba; xiphoid cartilage: umbilicus. Incision. — In the median line — its center being about opposite the space between the eighth and ninth costal cartilages — and extending to or toward the tip of the xiphoid cartilage above, and to or toward the umljilicus below. as far as the circumstances of the case require — generally being from 5 to to cm. (2 to 4 inches) long. (Fig. 452. A.) Operation. — (1) The steps of the operation, up to entering the peri- toneal cavity, are exactly similar to those for median abdominal section (see page 631). (2) The edges of the abdominal wound are now well retracted and the stomach sought — the steps for its recognition being given under Gen- eral Surgical Considerations. While searching for the stomach, which is often not easily located, temporar)- silk sutures, or traction-ligatures, may be utured into lower part of lips of abdc"' — ' — ' ■ and lower plane of abdominal "* ^ D, Tube about to be buried in st D. Sulurt-'S through toneum is sutured to the skin before the stomach-wall is attached to the edi^es of the al:)d()minal incision. Preparation— Position. — See General Surgical Considerations. Landmarks. ^As in Witzel's operation. MARWEDEL'S GASTKOSTf^MY. 773 Incision. — Oblique incision about 6 to 7.5 cm. (2^ to 3 inches) in length — made over the left rectus muscle — beginning near the median line and passing downward and outward somewhat more vertically than horizontally, though approximately parallel with and about 2.5 cm. to 4 cm. (i to li inches) from the left costal arch. Operation. — (i) Incise skin and fascia — clamp bleeding vessels — and retract the lips of the wound. (2) E.xpose the rectus muscle — divide the anterior layer of the rectal sheath vertically, nearer its outer part — separate the fibers of the rectus vertically in their line of cleavage, by blunt dissection — divide the posterior layer of the rectal sheath vertically — and the transversalis fascia, sub.serous areolar tissue, and peritoneum in the same line. (3) The parietal peritoneum is now drawn out and sutured with interrupted gut to the skin at the margin of the abdominal wound. (See Comment.) (4) The anterior N H.ACKEKS MI.Tllnl>. Description. — In this operation some part of the small intestine as near as possible to the stomach (generally the upper part of the jejunum) is carried through an artificial opening made for the purpose in the transverse meso- colon, and anastomosed with the posterior wall of the stomach. (Fig. 463, B.) Preparation — Position — Landmarks. — .\> in the anterior operation. Incision. — In the median hne — beginning about 5 cm. (2 inches) below the ensiform cartilage and e.xtending below the umbilicus. Operation. — (i) Expose the peritoneal cavity, as in median abdominal section. (2) Lift the great omentum upward and to the left, and the trans- verse colon upward and to the right, displacing them over the stomach. (3) Isolate and draw out the beginning of the jejunum, as described in anterior gastro-enterostomy. (4) An assistant, standing above the stomach and to one side, so grasps the stomach that both his thumbs press its anterior and his fingers its posterior surface — then by pronating his forearms, the posterior surface is protruded downward and forward prominently toward the surgeon, the transverse mesocolon intervening. (5) .Separate the fibers of the transverse mesocolon by blunt dissection in the direction of its vessels, and opposite the site of the future anastomosis — thus opening into the cavity of the lesser omentum. (Fig. 468.) (6) The assistant, continuing to press upon the stomach as above, causes its posterior wall to bulge through the artificial slit in the transverse mesocolon — until it presents in the cavity of the great omentum. The edges of this slit in the mesocolon are immediately sutured to the stomach, leaving an oval area of posterior stomach-wall of sufficient size, the sutures passing through the entire thickness of transverse mesocolon and through serous and muscular coats of the stomach. (7) A convenient coil of jejunum, so selected as to avoid tension and kinking, is now approximated to the posterior gastric wall — its contents having been pushed awav for several inches on either side and the gut clamped — the 784 OPERATIONS UPON' THE AUDOMINO-PELVIC REGION. assistant holding the stomach likewise keeping its contents away from the site as far as possible. The coil of jejunum should be so appro.ximated to the stomach as to make the flow of contents from the latter correspond with that in the intestine. While the need of giving it a half-turn is not so pressingly necessary as in the anterior gastro-enterostomy, because of the more favorable relations of the parts at the site of the posterior operation, it is, however, generally best to resort to this manoeuvre. (8) While the jejunum is held in Fig. 468.— Posterior Gastro-enterostomy:— A and B. Great omentum and transvcise colon turned upward ; C, Transverse mesocolon with edges of its incised wall sutured to posterior stumacli- wall ; D, Posterior stomach-wall with a half-button inserted ; E. Coil of jejunum, with a half-button inserted; F, F, Forceps holding buttons; G, Coil of jejunum, just beyond ligament of Treitz, given a half-turn; H.Mesemer\- of jejunum; 1, Entero-enterostomy by simple suturiiij,'; J. Intes- tinal clamps. contact with the posterior stomach-wall (both being drawn as far out of the abdominal cavity as feasible) the surfaces are sutured together exactly as in the anterior gastro-enterostomy — first the hne of continuous chromic gut suturing is applied posteriorly, extending about 1.2 cm. (^ inch) bevond the ends of the incisions, slightly eUiptically — carried by a long, straight needle — following the directions given in section 5 of Wolfler's Anterior Gastro-enter- ostomy. Sections (9), (10), (11), and (12) of the Posterior Gastro-enterostomy GASrR(_)(_;ASTROSTO.MV. 785 are perfurmcd exactly as are the corresponding steps in the Anterior Gastro- enterostomy — where they are found described under sections 6, 7, 8, and 9. (13) The viscera are now returned to the abdominal cavity and the wound closed as usual. Comment. — (i) In the posterior operation, the opening in the stomach is made with a slight obliquity from left to right and from above downward — the intestine being incised in its long axis, as in the anterior operation. (2) The suturing of the split transverse mesocolon to the stomach lessens the chance of the intestine slipping through the opening — and also lessens traction of the transverse mesocolon on the small intestine. (3) The application of the sutures is somewhat more difficult in the posterior operation. In placing the continuous suture, it is well to tie it at intervals, without interrup>ting its continuity — to prevent its acting as a draw-string. There is also probably greater danger of twisting of the intestines subsecjuentl}' — owing to the passage through the slit in the mesocolon. (4) While a single intestinal anastomosis is generally advisable, some surgeons perform multiple intestinal anastomoses — to further prevent regurgitation of intestinal contents. Some surgeons also narrow the calibre of the proximal portion of the small intestine, by Lemberts through the serous and muscular coats transversely, thus infolding the walls as a rosette. (5) The various disadvantages of the anterior operation are. however, largely overcome — and some of them entirely overcome. The direction of the flow and the position of the parts are more natural. POSTERIOR GASTRO-ENTEROSTOMY 1!V THE MURPHY BUTTON. Description. — Consists in anastomosing the jejunum to the posteri(;r stomach-wall by means of the Murphy button — the manner of exposing the parts being the same as in Von Hacker's Posterior Gastro-enterostomy — and the manner of applying the button being identical with its application in the operation of Anterior Gastro-enterostomy In- the Murphy button. See pages 783 and 781. (Also see Fig. 468.) Where a single or multiple intestinal anastomosis is done in connection with the operation of Gastro-enterostomy, it may be performed in one of the several manners mentioned upon page 782. Note. — There are several other methods of performing both Anterior and Posterior Gastro-enterostomy — but those above described are considered among the best modern methods. GASTROGASTROSTOMY BY WULl-'LERS OPHR.ATION. Description. — The operation of Gastrogastrostomy consists in the anasto- mosis of the two pouches of an hour-glass contraction of the stomach, for the purpose of making a common cavity. Wolfler"s method of operating is probably more applicable to a symmetrically deformed hour-glass contrac- tion, where the two pouches are approximately of the same size and the inter- vening connection fairly large. Preparation — Position. — Gastrostomy in General, page 76.'). Landmarks. — As for median abdominal section. Incision. — In the median line — from the tip of the xiphoid cartilage to about 7.5 cm. (3 inches) below the umbilicus. 50 786 OPERATIONS UPON THE AHUOMIN'O-PELVIC REGION. Operation. — (i) Havini; exposed the abdominal ca.'itv, the deformed stomach is brought as well into the wound as possible — the portion inter- vening between the two pouches being apt to be bound doivn to the pancreas and gastro-hepatic ligament. (2) Having packed off the adjacent regions with gauze, the assistant holds first one and then the other gastric pouch conveniently to the surgeon. (3) Oval incisions (thus e.xcising elliptical por- tions) are made upon those aspects of the two pouches which face each other — near their lower borders, so as to re-establish a greater curvature. (Figs. 469 and 470.) These openings are about 7 cm. (aj inches) long and pass through all the coats of the stomach. Bleeding vessels are clamped and gut-ligatured. The pouches are so held as to minimize the escape of intestinal contents. (4) An assistant now approximates the two openings while the Wolfler (which are practically the same as the Czerny-Lembert) sutures are Figs. 469aiKi 470.— Gastrogastrostomv (Woi.fler's Operation* :— I. A. A. Iiicisioi two pouclies of an hour-glass contraction of the stomach. II. Manner of appl\ing sulur Wolfler's sutures through the mucous coat ; C, C. Sutures through the outer coats. applied — along the posterior aspects first (Fig. 384). Along the posterior borders the sutures are first passed through the serous and muscular coats, each knot being turned outward as tied, being pushed outward with a probe if necessary (so as not to serve as a capillary drain from the stomach). Then the mucous membrane is sutured along the posterior aspect — and then on around both sides and front — all knots iieing turned inward toward the lumen. Then the outlying line of sutures through the serous and muscular coats, which had been applied posteriorly only, is now continued on around the sides and in front — thus completing the double line of .suturing. (5) The stomach is now returned to its position and the abdomen closed. Comment. — (1) The openings are so calculated that thev will correspond with the greater curvature of the stomach — and increase this when the two GASTROPLRAIIUX. 787 halves of the stomach are united. (2) In some cases of non-symmetrical hour-glass contraction of the stomach, the pyloric pouch is bent over upon a vertical axis and sutured along an elliptical outline to the cardiac pouch — an opening is then made in the pyloric pouch, and through this an incision is made through the two walls which have been sutured together and w-hich now intervene between the two pouches — the margins of this incision through the double walls is then whipped over with a button-hole stitch — and then the original incision in the pyloric pouch is closed by sutures — and the abdo- men, which has been opened bv an incision from the tip of the xiphoid carti- lage down the median line two-thirds of the way to the umbilicus, and thence rounding outward and upward to the left costal arch, is closed — constituting Watson's operation. GASTROPLICATION. WEIR'S MODU- II'.ATION r)F BIRCHER'S OPER.ATION. Description. — Gastroplication consists in the reduction of the .size of a chronically dilated stomach by invaginating a fold of the stomach-wall into ^'.^5. 471 and 472. — Gastroplication (Wkir's Modificatio.n of Bir A. Sound infolding anterior slomach-wall ; B, B. First tier of Lenibert sutu Second tier of .sutures ready to bury in sound for second time, wlien latter 11. Sectional view of stomach after the two tiers have been lied. HKR's Operation); — I. s burying in sound ; C, jjlaced upon first tier. the lumen of the stomach, with suturing together of the walls portion. .)f the infolded 788 OPERATIONS Ul'OX THE AliDOMIXi Kl'ELVIC RKUIO.N. Preparation — Position— Landmarks. — As for median abdominal sec- tion. Incision. — In the median line — from below tlie ensiform cartilage, nearh' or (juite to the umbilicus. Operation. — (i) E.xpose the abdominal cavity by the usual steps of the median abdominal section — control hemorrhage — retract the edges of the wound — well e.xpose the anterior surface of the stomach and lift it as far forward into the wound as possible, separating by blunt dis^ection all minor adhesions. (2) In a direction parallel with the long axis of the stomach, and midway between the greater and lesser curvatures, depression of the anterior surface of the stomach is made with a sound, causing parallel longi- tudinal ridges to form on either side of the sound. (Figs. 471 and 472.) (3) These ridges of anterior stomach-wall are now united with interrupted silk sutures, passing through serous and muscular coats of each ridge, and extending for 15 to 20 cm. (6 to 8 inches). (4) The sound is now withdrawn and reapplied over the first line of sutures, and parallel with it — similarly depressing them — and similarly causing two secondary parallel longitudinal folds of anterior .stomach-wall to rise up on each side of the sound. These secondary folds are similarly sutured. \\"hether a third tier is placed, will depend upon the size of the stomach — the process being continued, in some cases, until the greater and lesser curvatures meet. (5) The stomach is then allowed to recede into position — and the abdomen is closed. Conunent. — Bircher did not suture the two walls of the fold together, but left a dead space — Weir's suturing of these folds into apposition con- stitutes his modification. Chromic gut mav be substituted for silk. GASTROPEXY. Description. — Consists in the suturing of a prolapsed or displaced stomach to some fixed point of support. The condition of the stomach is termed gastroptosis — and as this condition is frequently associated with a general enteroptosis (Glenard's disease) of the abdominal viscera, suturing into a more fixed position of other viscera than simply the stomach is generally indicated. The viscera usually sutured to the anterior abdominal wall are the stomach, liver, and transverse colon. Preparation — Position — Landmarks. — As for median abdominal sec- tion. Incision. — In the median line, from just below the xiphoid cartilage to or below the umbilicus. Operation. — (1) Expose the abdominal cavity — control hemorrhage — retract margins of wound — isolate the stomach and other displaced organs. (2) The following steps have been resorted to: — (a) Treves, in whose case the liver was also involved, passed three stout silk sutures — one through the edge of the liver to the round ligament — and two from the falciform ligament and round ligament to the fibrous tissue of the al)dominal parietes near the ensiform cartilage, (b) Buret passed a continuous suture through the serous and muscular coats of the anterior wall of the stomach, on the one hand, and through the undivided parietal peritoneum on a level with the fold around the round ligament of the li\er, on the other, (c) Rovsing placed three silk ligatures between the anterior wall of the .stomach and the parietal peritoneum, (d) Davis, in one case, sutured, with silk, the lesser curvature of the stomach to the parietal peritoneum near the xiphoid cartilage. PVLOUOI'LASTY. 789 In another case, he did the same operation, together with gastroplication. (e) Beyea shortened the gastro-hepatic omentum witli eight or ten inter- rupted sutures, (f) Depage operated by lessening the capacity of the ab- dominal cavity by removing a T-shaped segment of the abdominal wall. GASTROLYSIS. Description. — Consists in division of gastric peritoneal adhesions from neighboring structures. The adhesions are met incidentally, in the course of other operations. The region of adhesions having been well e.xposed in the course of some primary operation, the adhesions are dealt with according to their nature; — (1) Slight, flat adhesions may be separated by finger or blunt dissection; — (2) Cord-like or ribbon-like adhesions are divided between double ligatures; — (3) E.xtensive, firm adhesions often require partial excision of the wall of the stomach, or that of the neighboring organ — with repair of the denuded surface, or excised area, by suturing, omental grafting, etc. Note. — See the section upon Peritoneal .\dhesions, page 649. GASTROPLASTY. Description. — .\n operation ftir widening the opening between the two pouches of an hour-glass contraction of the stomach — similar in principle and application to Pyloroplasty. The stomach is exposed bv median abdominal section — after which the narrowed portion between the two pouches is brought into the field — and the same operation is there done which will be described below under Pyloro- plasty. PYLOROPLASTY. THE HEIXKKK-MIKII.ICZ OPFR.\TIOX. Description. — Consists in an increasing of the caliber of the pyloric orifice of the stomach, by means of a horizontal incision through its anterior wall, corresponding with the site of stricture, followed by a vertical suturing of the wound. Chieily resorted to in non-malignant stricture of the pylorus. Preparation— Position. — .\s for Gastrostomy. Landmarks. — Linea alba — for median incision ; — right rectus — for in- cision through rectus. Incision. — (i) Incision is generallv made in the median line, beginning a short distance below the xiphoid cartilage and extending nearly to, or beyond, the umbilicus. (2) .\ better approach to the site itself, though with more injury to the abdomin.il wall, is accomplished by a vertical incision through the outer third of the right rectus muscle. The median incision will be used in the operation which follows. Operation. — (i) The abdominal cavity having been opened — hemor- rhage is controlled — and the edges of the wound, especially on the right side, are well rctracleti. C2) The pylorus is i.solated (any slight adhesions being separated by blunt dissection) and brought into the abdominal wound as well as possible. Xeighboring regions are well guarded by gauze packing. (3) Incise longitudinally through the anterior wall of the pylorus, beginning over the ga.stric aspect and ending over the duodenal aspect of the pylorus. 79° OPERATIONS II'ON THE ABDOMIXi i TELVIC REGION. and extending along midway between the superior and inferior borders of the pylorus — through all the coats. (Fig. 473.) The incision, at first, is about 2 cm. (| inch) long. The right index-finger is then inserted through this opening and passed on into the pylorus, to determine the degree of con- striction and the thickness of the wall, by palpation between the internal finger and external thumb. The incision is now continued through the strictured portion on into the healthy duodenum and stomach — and is gener- ally about 5 cm. (2 inches) long. (4) By means of wound-hooks, or silk Fig. 475. — P%LOROPi-ASTV : — I. Longitudinal incision in anterior aspect of coiistricled p\ lorus — which is shown clamped off proxinially and distally. Figs. 474 and 475.— Pvloropi astv :— II. I,, by suturing ; A, Tier of sutures through all coals III. Showing the site sutured. retractor>. inserted at the center of either side of each lip, draw upon the margins until the longitudinal wound first becomes diamond-shaped, and then transverse — and while held in this last position the sutures are applied. (5) The mucous membrane may be first sutured with continuous silk suturing, or sutures may pa.ss through all the coats. (Figs. 474 and 475.) Interrupted silk Lembert sutures are then introduced through serous and muscular coats. If indicated, a third continuous Lembert suture may be applied. (6) The PVLORECTOMV, IX GEXEKAL. 791 parts are then thoroughly cleaned and dropped back into ])osition — and the abdomen closed in the usual manner. Comment. — (i) In a very dense, thick wall, a small diamond-shaped excision may be made — to aid in the approximation of the two edges. (2) Suturing may be done as above, but over an absorbable tube. (3) The site of operation should be clamped on both sides. DIVULSION OF PYLORIC ORIFICE OF STOMACH. LORET.\S OPERATIlJ.V. Description. — The cavity of the stomach having been entered by gastro- tomv, the constricted pyloric orifice is dilated either bv finger or instrument. Chiefly resorted to in non-malignant >tricturc. Preparation — Position — Landmarks — Incision. — .As for Gastroiomy bv median incision. Operation. — (i) Median abdominal section is done — and the abdominal walls retracted. (2) The pylorus is isolated and brought as well into the wound as possible — exactly as in Pyloroplasty. The region is well packed off with gauze. (3) Incise the anterior stomach-wall vertically, at a distance of about 5 cm. (2 inches) from the pylorus, and midway between the upper and lower curvatures — at first, to an extent only sufficient to admit the index- finger snugly. (4) The right index-finger is immediately inserted through the opening and is made to slowly work its way through the pyloric stricture — while the region is steadied from without by the left hand. Should the stricture be found too tight for the tip of the finger, a dilating instrument may be used first — to be followed by the finger. When the stricture is en- larged sufficiently to accommodate one finger, the stomach wound is enlarged with a blunt bistoury, without withdrawing the first finger, and the middle finger introduced alongside of it. The fingers in the stomach wound prevent any con.siderable hemorrhage — the vertical direction of the gastric incision also aiding in this respect. Even a third finger may be introduced. (5) The object having been accomplished — the fingers are withdrawn — and the hemorrhage from the stomach wound is controlled by clamping and twi.sting, or by gut-ligaturing. (6) The wound in the stomach is then sutured in the ordinary manner — or as in Pyloroplasty. (7) The abdominal wound is closed in the usual fashion. Comment. — (i) Incision into the stomach may be parallel with its length and just to the left of the pylorus — as in Pyloroplasty. (2) Loreta inserted both index-fingers and stretched in opposite directions. (3) In Hahn's operation, no opening is made into the stomach — the neighboring stomach- wall is simplv invaginated into the [ivlorus upon the end of the finger. DILATATION OF CARDIAC ORIFICE OF STOMACH. See under Retrograde Dilatation of Esophagus, page 562. PYLORECTOMY IN GENERAL. Pylorectomy consists in the excision of the pylorus, together with as much of the stomach and duodenum as may be necessary. Generally resorted to in cases of malignant growth of the pyloric end of the stomach. The operation 792 OPERATIONS UPOX TUH Ani)( JMIM )-PELVlC KEcaON. is sometimes called partial g;;strectomy, es]ieciall\- where a ci)nsi(lcral)le jiortion of the stomach is removed. After all pvlorectomies an additional operation is always necessary, uniting the lower intestinal tract with the stomach. The cut end of the duodenum is the part generally united to some part of the stomach — though the cut end of the duodenum may be closed by suture and the jejunum united. The anastomosis may be by simple .suturing or by some form of mechanical device. PYLORECTOMY FOLLOWED BY POSTERIOR GASTRO- DUODENOSTOMY. I'.V KOCHER'S METHOD. Description. — This operation con.sists in the e.xcision of the pylorus, with as much of the adjacent stomach and duodenum as indicated — followed Fig.476.— PVI-ORKCTO.MY. FOLLOWED BY Po.STERlOR GaSTRO-DUODENOSTOMV (KoCHER'S OPKR- ATiON) :— A, Pylorus. wiUi involved malignant growth to be removed ; B, Lesser omemuni ligated off ■ C. r.realer omentum ligated off ; D. D, Clamps placed on citlier side of line of future incision through stomach ; K, K. Clamps similarly placed upon duodenum. I Modilieteri(ir part, fo>sa for vena cava. Transverse fissure : — Transmits hepatic artery, portal vein, hepatic duct, nerves, lymphatics, and connective tissue. Lobes. — Right, Left, (Quadrate, Caudate, S])igelian. Ligaments and Fixations of Liver. — (i) Coronary: — from posterior surface of Hver to diaijhragm. Formed of two layers of reflected parietal peritoneum. (3) Right lateral ligament : — from right lobe of hver to hack of diaphragm. Lateral continuation of coronary ligament. (3) Left lateral ligament : — from left lolje of li\-er to diaphragm anterior to esophagus. Lat- eral continuation of coronary ligament. Note: — Middle portion of coronary ligament has its anterior layer furnished by greater peritoneal sac, its po.sterior layer by lesser sac; Right lateral ligament has both layers from greater sac; Left lateral ligament has both layers from greater sac. (4) Longitudinal (broad or suspensory) ligament : — Passes antero-posteriorly upon upper and anterior portion of liver. Posteriorly and superiorly it is connected with the coronary ligament, .\nteriorly and superiorly it is connected with the posterior sheath of the right rectus muscle, up to the umbilicus — and thence to under .surface of diaphragm, diverging to either side. Free anterior margin extends from interlobular notch to transverse fissure — containing round liga- ment (remains of fetal umbilical vein). Interiorly it extends along the superior surface of the liver, from before backward. Formed l)v portions of peritoneum covering superior surface of liver — one layer passing over left lobe, the other over right, and meeting at longitudinal ligament. (5) Round ligament : — Remains of umbilical vein — in free margin of longitudinal ligament, extending from left longitudinal fissure to umbilicus. (6) Lesser omentum (Gastro- hepatic omentum) : — may be considered a ligament of liver, consisting of following jxirts; — (a) Lig. Hepatogastricum — from borders of transverse fissure to upper curvature of stomach; — (b) Lig. Hepato-duodenale — that part embracing superior curvature of duodenum, and enclosing following structures; common bile-duct, portal vein, hepatic artery, lymphatics and nerves; — (c) Lig. Hepato-colicum — that part passing over duodenum to transverse colon; — (d) Lig. Hepato-renale — that part from inferior surface of right lobe of liver (near gall-bladder and vena cava, and posterior to foramen of W'inslow), to upper surface of right kidney; — (e) Lig. Cystico-duodenale — that part from gall-bladder to duodenum. Xole: — Fusion of upper surface of liver to dia- phragm forms a strong fixation of liver. Peritoneal Covering. — Only portions of liver uncovered by peritoneum are; transverse fissure, fossa of gall-bladder, and postero-superior aspect of right lobe (where fused to diaphragm). Relations. — (i) Antero-posteriorly: — diaphragm (whole of right arch and part of left — which separates li\-er from right and left lungs and peri- cardium); abrlominal wall; six or seven lower right ribs (.seventh to eleventh, according to Morris) ; fifth to ninth right costal cartilages (sixth to ninth, ac- cording to Morris). (2) Inferiorly : — stomach (cardiac and pyloric ends, ie.sser curvature, and part of anterior surface); duodenum (superior cur\e and descending parts); gall-bladder and cystic dud; jiortal vessels; right kidney and capsule; colon (hepatic flexion). (3) Posteriorly: — diaphragm and crura; tenth and eleventh dorsal vertebrae; tenth and ele\enth ril)s; esophagus; aorta; vena cava; right suprarenal capsule; thoracic duct. Vessels of Liver. — Hepatic artery (of coeliac axis), artery of supply; 8o2 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. Portal vein, bringing hliKxi from stomach, intestines, pancreas, and spleen; Hepatic veins, emptying blood of li\-er into vena ca\a; He|jatic duct, formed at tran>verse fissure. Lymphatics. — Deep set; accompany portal vein, hei)atic artery, and duct and join superticial set. Superficial set; empty into (a) mediastinal glands; (b) sometimes into thoracic duct; (c) glands of small omentum; (d) lumbar glands; (e) glands of esophagus and lesser curvature of stomach. Nerves. — From left pneuniogastric and co-liac plexus. Structures at Transverse Fissure. — (a) Hepatic artery, portal vein, anc numerous nerves enter : — (b) Hepatic duct and some lym])hatics leave : — Note: the hepatic veins do not emerge here, but jiass backward into the vena cava. Order of Structures at Transverse Fissure. — From l)efore liackward; hepatic ihu t, liepatic artcrv, portal vein. Order of Structures in Gastro-hepatic Omentum. — Common bile-duct, to right; hepatic artery, to left; ])ortal vein, behind and between other two. SURFACE FORM AND LANDMARKS. The liver occupies parts of right hypochondriac, epigastric, and left hypo- chondriac regions — filling all of right and part of left diaphragmatic arches — the diaphragm forming dome of cavity in which liver rests and passing down laterallv between ribs and liver. Upper limit of right lobe — is along line from right fifth chondro-sternal articulation e.xtending horizontally outward to a point about 2.5 cm. (i inch) below the right nipple — thence downward to seventh rib at lateral aspect of chest. Upper limit of left lobe — along line from riglnt lifth ( hondro-sternal artic- ulation extending across sternum .slighth' downward to a point about 5 cm. (2 inches) to left of gladiolus, on a level with left sixth costal cartilage. Lower limit of right margin — corresponds with line pa.ssing from behind forward about 1.2 cm. (^ inch) below the lower margin of the right thorax to right ninth costal cartilage — thence obliquely across the subcostal angle to left eighth costal cartilage. Lower limit of left margin — represented l)v a curved line, with outward con- vexity, from left eighth costal cartilage to a point 5 cm. (2 inches) to left of gladiolus and on a level with left sixth costal cartilage. Lower border of liver in middle line — about half-wa}' between xiphoid cartilage and umbilicus. Convex surface of liver, on right side — corresponds with seventh to eleventh ribs, inclusi\-e — and, in front, with ensiform cartilage and sixth to ninth co.stal cartilages, inclusive. Heart descends to left fifth interspaie. Right lung descends to superior margin of sixth rib, in the nipple-line. Xole. — -Authorities differ considerably upon the relations of the liver to the thoracic wall. GENERAL SURGICAL CONSIDERATIONS. The liver may be approached either through the aljdominal cavity, the more usual route — constituting a transperitoneal operation; — or through the thoracic cavity — in which latter case the operation may be either transpleural or subpleural, while, at the same time, intrathoracic. While desirable that all incisions should be in intramuscular cleavage lines THE LIVER— GENERAL SL'RGICAL COXSIDERATIONS. 803 as far as possible, 3-et, as hernia of the upper abdominal wall is less frequent than of the lower, incisions about the liver and gall-bladder, thereft)re, often violate this desirable rule. The two most general methods of transperitoneal approach are the follow- ing: — (a) By incision parallel with and about 1.2 to 2 cm. (^ to | inches) below the right costal arch, with its center over the indicated site; — (b) By incision in the right linea semilunaris (which runs down from the ninth rib to the pubic spine) — or further outward, from the tenth costal cartilage — passing from the lower border of the right costal arch as far down as necessary. Oblique subcostal incision: — gives better api)roach to the subhepatic space — and especially to the right end of the liver. It may be extended upward or downward obliquely, parallel with the costal arch. It will cross the e.xternal oblique and transversalis at a right angle, and about coincide with the fibers of the internal oblique. It affords a somewhat better chance to preserve some of the abdominal nerves. Anterior vertical incision: — gives best access to gall-bladder and ducts — together with a very good exposure of the hver. A vertical incision in the right linea semilunaris — or more externally, from the tenth costal cartilage — can be increased directly downward to give room. Its lower end may also be ex- tended transversely, or obliquely, toward the median line — giving an angular flap. A continuation of tiie original incision gives a very extensive approach to the abdominal cavity — and even the pelvis. The sim|.)le vertical incision will cross the external and internal oblique muscles obliquely, and the trans- versalis at a right angle — and will cross the abdominal nerves at a right angle. In operating to expose the liver, it will often be found, when the liver is reached, that its serous surface is adherent to the parietal peritoneum — and, therefore, that its substance can be entered without involving the general peritoneal cavity. .•\s adjuncts to the satisfactory exposure of these sites, the following man- oeuvres are helpful: — (a) the reversed Trendelenburg position — (b) firm up- ward traction upon the liver and right costal arch — (c) passage of the left index through the foramen of Winslow and the left thumb over the lesser omentum, thus embracing that structure between the digits. When the round ligament is encountered descending to the umbilicus and is severed, it should be sutured at the end of the operation. Standing, the lower border of the liver is about 1.2 to 2.3 cm. (J to ^ inch) below the costal cartilages; — reclining, the lower border recedes until about 2.5 cm. (i inch) above the lower costal cartilages. This change in position, and change during respiration, must, therefore, be allowed for in suturing the liver to the parietes. Anteriorly, the gastro-diaphragmatic sinus (between the lower edge of the pleura and the diaphragm) makes it possible to reach and pierce the diaphragm more easily and without involving the pleura, in operating intrathoracicaliy, — therefore the subpleural operation is more generally done anteriorly or antero- laterally. Tliis sinus is at)sent posteriorly, and an incision here would pass through the pleura (if that structure were not raised from the course of in- cision Iiy blunt separation) — hence the posterior operation is generally trans- pleural. In the transpleural operation, where the two layers of jileura' cannot be sutured in situ — the parietal ])leura is incised — its edges are gras])ed with for- ceps, or traction-sutures (to keep them from receding out of the way) — then the visceral peritoneum is incised — and the edges of the parietal and visceral peritoneum are whipped together by an overhand stitch. 8o4 orEKATIONS UPON THE AIIDOMINO-PEI.VIC REGION. INSTRUMENTS USED IN OPERATIONS UPON LIVER AND GALL-BLADDER. Scalpels; bistouries; scissors, curved and straight; forceps, dissecting and toothed; artery-clamp forceps; clamp-forceps for adhesions; retractors, various; broad spatuht; grooved director; tenaculum; costotome; blunt dissector; in- testinal clamps; forceps for removing calculi; forceps for crushing calculi; Halsted's hammer; lithotomy scoop (small); lithotomy forceps (small); needles for needling stones; cholelithotomy forceps and scoop; sponge-holders; gauze pads viith tails; intestinal and other needles; silk, gut, and silkworm-gut; drain- age-tubing, glass-drains, gauze-drains; exploratory cannula and trocar, or exploratory needle; intestinal instruments; Murphy button (special) ; probe. EXPLORATORY PUNCTURE OF LIVER. Description. — Resorted to for withdrawal of iluid for diagnostic pur- poses — generallv pus or hydatid. An operation inxohing some danger. The site of puncture is generally determined by some phy.sical sign, such as tumor or other indication — and the puncture is made by the safest and most direct route into the .site. Preparation. — .Site asepticized. Position. — Such as to best e.xpose the region. Landmarks. — .Anatomical outline of liver; physical signs. Fig. 4S1. — Rri.ativk R TAL ARt:H <5 cm., or 2 nach; B, Liver; C, Sjik Riidinger.) Operation. — The exploration is usually made with the needle of an ex- liloratory syringe. The depth of puncture is to be guarded by the right index on the barrel of the needle — and to be largely determined in advance by the estimated thickness of the abdominal or thoracic wall and intervening liver substance at the site to be punctured. If no physical sign guiding to the seat of exploration exist, puncture may be made in several sites: — (1) Laterally, HKPAIOTU.MV IN GENERAL. 805 in the ninth, tenth, or eleventh intercostal space, in the mid-axillary line — the most general position — and the tenth space being the one most frequently used; — (2) Anteriorly, in the subcostal angle, over the known region of the liver (on anatomical grounds) — in the space bounded, above, by the costal arches, and, below, by a hne from the right ninth costal cartilage to the left eighth costal cartilage. In abnormal ca.ses, the liver may, of course, be looked for considerably lower than usual; — (3) Posteriorly, in the tenth intercostal space on the right. The liver is in relation, posteriorly, with the tenth and eleventh ribs — and the pleura comes down to the twelfth, or lo\\er — hence the pleura would be pierced if not displaced; — (4) Transthoracic — preferably subpleural — rarelv transpleural. See subpleural and transpleural hepatotomy, pages 810 and 812; — (5) Below the free border of the ribs — where thejiver dulness e.vtends below; — (6) ,\t any point from which liver substance can be reached with minimum risk and danger — the guides being anatomical and physical. Upon the withdrawal of the needle the puncture-wound is generally sealed with sterile gauze and collodion. (See Fig. 481.) Comment. — (i) Wounding of the lung should be avoided — and also piercing of the pleura or diaphragm, unless specially indicated. (2) The dia- phragm would be penetrated by any puncture above the lower border of the ribs or costal arch. The pleura would be penetrated by any puncture above the eighth right rib in the nipple-line — the ninth right rib in the mid-a.xillary line — (the tenth left rib in the same line) — and the twelfth right rib in the pos- terior scapular line. The lung would be penetrated by any puncture above the sixth costo-sternal articulation in front — the .sixth right rib in the nipple-line — the eighth right rib at the mid-axillary line — and the right twelfth rib in the .scapular line. HEPATOTOMY IN GENERAL. (I) Hepatotomy consists in an incision of the liver — and is generally re- sorted to for abscess, hydatid cyst, or other tumor. The site of the incision is usually determined in advance — by the presence of a tumor, or as a result of an exploratory puncture. (2) The liver may be e.xposed by the transperito- neal, subpleural, or transpleural routes — and each of these routes mav be fol- lowed from the anterior, lateral, or posterior aspects of the thoracico-abdom- inal wall — though each method of approach usuallv has a site of preference. (3) The selection of the site and method of operation will depend upon the location of the abscess, or other condition — as to its accessibility, importance of contiguous organs, and possibility of drainage. (4) The choice of incision for approaching the liver transperitoneally will generally He between the oblique subcostal and vertical subcostal incisions — each having its advantages (see General Surgical Considerations). It is to be remembered that abscesses, hydatids, tumors, etc., often project downward considerably below the ribs. It is also to be remembered that, after incision of such sacs and emptying of their contents, there is a tendency for the portion of involved liver to regain its normal position — and that, therefore, in calculating to suture such parts to the abdominal wall for drainage, calculation must be made that the stitching will not draw the part too far out of its natural position. (5) Where no guide exists, the anterior or antero-lateral subcostal transperitoneal route is generally chosen, as, in abscess, pus is usually in the more anterior part of the right lobe. But after exposure of the liver, if, by exploratory syringe, or otherwise, pus be found in a localitv more convenientlv reached and drained from another ex- ternal incision, the first incision may be closed and a second made in the in- 8o6 Ol'KRATIi INS UI'OX THE AHDOMINO-I'ELVIC REGION. dicated j)ositi(in. (6) The different incisions described in the following pages are given to cover the various sites in which the liver may be exposed — and apply as much to the exposure of the liver for other purposes as for incision of that viscus. In the case of pus or hydatids the site of operation will generally have been indicated by a preliminary exploratory puncture. (7) The operation of exposure of the liver may be done in one or in two stages. In operating in one stage, the liver is exposed and the organ is cut into at once — after safeguarding the general peritoneal cavity by suturing the parietal perito- neum to the surface of the liver, or by gauze packing, — or, in transthoracic operations, after protecting the pleural cavity on the same principles. In operating in two stages, the liver is first exposed and the wound then packed with gauze for two or three days, until the peritoneal surface of the liver adheres to the wound (the union being reinforced and aided by sutures, in some cases) — and then the organ is incised. (8) In o[)erating transthoracically, if the pleura be wounded, it should be immediately sutured — with a purse-string suture, if possible, thus drawing the edges together. (9) The subpleural method is generally impossible if adhesions exist — but then, also, the pleural cavity is apt to be shut off — so that it is not opened up even if one passes through its layers, (lo) The posterior superior aspect of the right lobe of the liver is fused to the diaphragm (there being no peritoneum here) — hence the diaphragm may be immediately incised in this locality, without waiting for adhesions. .-Vn abscess here would be subphrenic and extraperitoneal, (ii) If the transpleural method of approaching the liver be adopted, the same prin- ciples should be adhered to as in operating transperitoneally — either suture the two op[)osed pleura.' together and incise through them at once — or press the two pleural surfaces into contact with gauze packing for two or three days, until adhesions occur — and then incise through them. (12) It is preferable to pass beneath the pleura rather than through it — and if they must be incised at once, it is preferable to suture the parietal and visceral layers together pre- paratory to going through them. The operation of suturing the pleura^, how- ever, is quite difficult — and the suturing is apt to tear awa}' — or allow of leak- age. (13) In cutting into the liver the incisions should be made in straight lines radiating from the direction of the center toward the periphery. (14) Bleeding from deep incisions may be controlled by ligature en masse, with in- terlocked stitches — as described under partial excision of the lixcr. ANTERIOR SUBCOSTAL TRANSPERITONEAL HEPATOTOMY V.\ .WTHKIOR OF,I,IOI-F. INCISUIN r.\K.\ l.lj;i, Willi COSTAI. ARCH. Description. — The liver is exposed along the right costal arch, by an in- cision which parallels that arch and is placed 1.3 to 2 cm. i\ to f inch) below it. Resorted to where the more central portion of the anterior aspect of the li\cr and gall-bladder region is to be exposed. Preparation — Position. — As for abdominal section. Landmarks. — Right costal arch. Incision. — Parallel with and from 1.3 to 2 cm. {\ to f inch) below the right costal arch — beginning near the right linea semilunaris (which runs downward from the ninth rib to the spine of the pubis) — and extends as far downward and outward, below the costal arch, as considered necessary — even to the extent of 12.5 to 15 cm. (j to 6 inches). (Fig. 452, F.) Operation. — (1) Incise skin — fascia — external oblique (transversely) — internal oblique (in cleavage line). Superior epigastric artery may be cut at ANTERIOR SUBCOSTAL TRANSPERITONEAL HEPATOTOMV. 807 inner end of incision, if the inner end reaches the outer border of the rectal sheath — if so, it is ligated. The abdominal nerves lie between the internal oblique and transversalis, crossing the line of incision, and an attempt should be made to draw them aside if encountered. The transversahs muscle is then divided obliquely to its fibers. In long incisions, much division of muscles and nerves must occur. In short incisions, much displacement in intramuscular cleavage lines and saving of nerves may he accomplished (Fig. 482). (2) Divide the transversahs fascia, subperitoneal areolar tissue, and peritoneum in the original hne — and retract the v.ound well. (3) Adhesions are looked for as soon as the abdomen is opened. If encountered, intervening between the seat of pus, or hydatid fluid, and the abdominal wall, they are carefully pre- served — that they may serve as a protection to the general peritoneal cavit-y in opening these collections of fluid. If the object be the exposure of the liver Fly. 4.S2. — Exposure of Liver, and Hepatotomy, by A.nterior Obliqi-e Slbcostal In- cision ; — A, External oblique; B, Internal oblique; C, Transversalis; D. Outer border of right rectus incised, showing superior epigastric vessels between muscle and posterior sheath ; E, Transversalis fascia and subserous areolar tissue; F, Peritoneum; G, Surface of liver; H. Suture through lip of liver wound, peritoneum, transversalis fascia, subserous areolar tissue, and transversalis ; I. Same tightened, approximating lip of liver wound to lower plane of abdominal wound. on Other grounds, the adhesions are separated by blunt dissection, or are divided between ligatures. (4) The liver having been e.xposed, the operation may be concluded in a single stage, or in two stages: — (A) In One Stage; — Where (in pus and hydatid cases) adhesions of parietal peritoneum to hepatic peritoneum have occurred, the incision may be made directly into the liver substance. Where no such adhesions exi.st, one of two courses mav be pur- sued; — (a) The lips of the abdominal wound may be applied to and pressed around the site of the liver to be opened, by the fingers of an assistant and by packing — the tensity of the abscess wall is then lessened (to avoid a gush of pus) by the withdrawal of some of its contents with a .svringe — a narrow bistourv is inserted into the aijscess and its walls incised — the contents are directed out without escaping into the abdomen — and as .soon as the cavity is partly emptv, SoS opp:rati(j.\s urox the aiidomixo-pklvic region. the edges of the abscess wall, including Glisson's capsule, are seized with special forceps and drawn up into the wound and everted, while the balance of its contents is emptied — the borders of the abscess cavity are then stitched to the edges of the abdominal wound at its lower plane (that is, to the parietal ])eritoneum, subserous areolar tissue, transversalis fascia, and possibl}' into the edge of the muscle tissue) with continuous or interrupted silk or chromic gut sutures — closing in either end of the abdominal wound in the usual way — leaving room for the exit of tube or gauze drain. Or, pursuing a second course — (b) Before opening the peritoneum, and after recognizing that the parietal and hepatic peritoneal surfaces are not adherent, the parietal peri- toneum (by slight outward separation of the e.xtraperitoneal parts of both lips of the wound) may be stitched, with curved needle, to the hepatic surface over an elliptical area, with continuous silk or chromic gut — surrounding and further protecting the area liy gauze packing — and then incision is made simultane- ously through parietal and visceral peritoneum into the liver — drainage being established and the wound treated as in (a). (B) In Two Stages; — This method is practised only where no adlicsions are found — and when no haste exists. The parietal peritoneum is united to the serous surface of the liver in one of the two above way.s — the gauze packing being preferable to the stitching (or both may be used together) — the wound being packed with gauze, pressing the serous surfaces together for two or three days — after which the incision is made and the operation completed as in (a) above. Comment. — \\'here the abscess, or other cavity, is incised before the ab- dominal wall is sutured to the liver, the suturing of the margin of the cavity to the abdominal wound is aided by inserting the left index-finger into the cavity and hooking it forward — thus holding it in contact with the abdominal wall while the sutures are being placed and tied. EXPOSURE OF LIVER BY ANTERIOR SUBCOSTAL TRANS- PERITONEAL ROUTE BY .\N'TERU)R \'ERTirAL IXCISIoN IIIKol (.11 KK.IIT L1N'E.\ SKMILTNARIS. Description. — A free exposure is thus given — which may be lengthened so as to ii'wx- access to both peritoneal and ]3eivic cavities. See General Sur- gical Considerations. The incision mav also be placed to the outer side of the right semilunar line. Preparation — Position. — As for abdominal section. Landmarks. — Right Linea Semilunaris (which extends from the ninth right costal cartilage to the pubic .spine, passing within 7.5 cm. [3 inches] of the umbilicus); right costal arch. Incision. — Vertically downward in the right semilunar line, beginning at the right ninth costal cartilage and extending as far as necessary (Fig. 452, G). Operation. — Incise skin — fascia — external oblique (obliquely) — internal olilique (obliquely) — abdominal nerves between internal oblique and trans- versalis are almost necessarilv divided (except in very short incisions they may sometimes be displaced) — transversalis muscles (transversely) — transversalis fascia, subserous areolar tissue and peritoneum — entering the abdomen in the original line. .\11 hemorrhage is controlled — the lips of the wound retracted — and the liver exposed. INTERCOSTAL SLTSPLECRAL EXPOSURE OF LIVER. 809 EXPOSURE OF LIVER BY LATERAL SUBCOSTAL TRANS- PERITONEAL ROUTE BV I.AIKKAI, HORIZO.NTALLV CURVED INXISIOX RKLOW RKIHT TWELFTH RIB. Description. — The general features of the operation are the same as by the anterior oblique subcostal incision — the steps of the operation differing only in SI) far as determined by anatomical circumstances. Chiefly applicable where the lower lateral aspect of the liver is to be exposed. Preparation. — .\s for abdominal section. Position. — Patient rests upon opposite side, with cushion under the sound side to round out the involved side; Surgeon may stand behind or in front of patient; .\ssistant ojiposite. Landmarks. —Right twelfth rib, in the mid-a.xillary region. Incision. — Parallel with and about 1.3 to 2 cm. (5 to | inch) below the right twelfth rib, with its center about opposite the mid-axillary line. Operation. — Incise skin — fascia — external oblique (obliquely) — latis- simus dorsi (transver.sely, if the incision extend that far backward) — internal oblique (obliquely) — the nerves between the internal oblique and transversalis being guarded as well as pos.sible — transversalis muscle (in cleavage line) — transversalis fascia, subserous areolar tissue, and peritoneum in the original line. .•Ml hemorrhage is controlled — the wound retracted — and the liver Ijrought into the field. Comment. — Unless the liver be enlarged, hut small part of its lower 1. order is accessible through this incision — except by the strong upward retraction of the twelfth rib, and the downward retraction of the lower lip of the wound. EXPOSURE OF LIVER BY INTERCOSTAL SUBPLEURAL ROUTE r.\ l\TEKCOST.\[. IN'CISI(.)X BELOW LEVEL OF PLEURA. Description. — This incision, which is made in an intercostal space below the level of the pleura, rarely gives sufficient room — and is indicated only in cases where absce.ss or fluid point here and adhesions have, in all probability, protected surrounding regions. In the following description the operation site will be supposed to be in the right tenth interspace, in the mid-axillary line. Preparation — Position. — .\s for intercostal thoracotomv (see page 601). Landmarks. — Right tenth and eleventh ribs, in the mid-a.\illarv line. Incision. — Midway between lower border of the right tenth and the upper border of the right eleventh rib — in the mid~axillar}' region. Operation. — The steps of the operation are the same, practically, as those for Intercostal Thoracotomy (q. 7'.. page 601) — with the exception that in the present instance the incision is made below the level of the pleura. As an operation, owing to the small amount of room which it affords, it is indicated only in those cases in which the liver is supposed to be adherent to the dia- phragm opposite the site of incision (either naturally or by pathological pro- cess). If during operation it be found that the liver be not adherent to the diaphragm, parts of one or two ribs should be excised — and the operation be completed as given in the following description. Comment. — The operation is distinctly inferior to the following method. OPERATIOXS UPON THE ABDOMINO-PELVIC REGION. Fig. 4S3.— Exposure of Liver by Subplelral RoirrE, by Partial Excision of a Rib bki.ow Level of Pleira :— A. A, Thoracic muscles ; B. B, .Anterior and posterior layers of rib periosteum retracted after excising pan of rib. both divided longitudinally, and eudothoracic fascia seen upon under surface of latter; C, Diaphragm being sutured to conve.\- surface of liver and incised within area elliptically sutured. EXPOSURE OF LIVER BY SUBPLEURAL ROUTE BY PARTLVL H.XCISIOX OF (_)NE OR .MORE RIBS BELOW THE LEVEL OF PLEl'RA. Description. — The liver is here approached transthoracically, but the inci.sion beina; placed below the normal level of the pleura, the pleura is not, ordinarily, brought into the field of operation. In the following account, part of the right eleventh rib in the mid-axillary line will be removed. Preparation — Position. — As for Thoracotomy by the partial excision of a rib. Landmarks. — The special rib nearest the site to be exposed. Incision — Operation. — As for the Partial Subperiosteal E.xcision of a Rib (see page 447) — up to the point of the removal of the rib. The posterior layer of jjeriosteum, forming the bed in which the rib has lain, is then incised in its center, in its long axis. If more room be required than furnished by the partial excision of one rib, two or more ribs are excised in part (see page 603). Having passed through the thoracic wall, the diaphragm is exposed and in- cised — in a line corresponding with the direction of its muscle-fibers at the site incised. The edges of the diaphragmatic wound are sutured to the convex surface of the liver, if not already adherent. If adhesions be present, or if haste be necessary, the liver is incised at once. If haste be unnecessary, and no adhesions be present, the wound, after the above suturing, is packed with 'Tauze for two or three days, until adhesions form — and the organ then in- ci.sed (Fig. 483). EXPOSURE OF LIVER BY SUBPLEURAL ROUTE BY PARTEM- EXCISION' OF ( IXE ok MOKIC kll'.S OPPOSITE THE PLEURA. Description. — Parts of one or more ribs are excised .subperiosteally above the level of the pleura — the pleura is exposed but not opened — and is carefully EXPOSURE OK LIVER 1!V SUBPLEURAL ROUTE. Sll separated from the thoracic wall and diaphragm and displaced upward — the diaphragm being thus exposed and the liver entered through its substance. In the following account, parts of the seventh and eighth right ribs in the antero- lateral aspect of the che-st will be removed. Preparation — Position. — .\s for Thoracotomy. Landmarks. — The rib or ribs overlying the involved site. Incision — Operation. — (i) The operation is conducted as a Partial Sub- periosteal E.xcision of one or more Ribs (see page 447) — up to the removal of the rib. The Subperiosteal bed of the rib is very carefully incised in the center of its long axis — cautiously recognizing but not incising the costal pleura — which is to be preserved with the greatest care from the smallest cut or tear (on account of the respiratory complications often arising from the entrance of air into the pleura, with the possible collapse of the lung, and the possiljle infection Fig. 4S4. — Exposure of Liver by Subplecral Roctk. bs- Partial E.xcision of Parts of Two Ribs Opposite the Pleura ; — A, A, Upper layer of periosteum and thoracic muscles retracted : B, B, Lower layer of periosteum and intercostal muscles retracted ; C. Pleura detached and retracted upward: D, Diaphragm incised; E, Incised margin of parietal pleura: F, Convex surface of liver; G. Sutures uniting edges of diaphragm and parietal peritoneum to surface of li\or. of the pleura). (2) The costal pleura is carefully detached by blunt dis.section, largely aided by the back of the surgeon's fingers — first detaching it from the ribs, until its lowe.st thin edge is reached — then from the upper surface of the diaphragm — and finally displacing it upward and retaining it there by blunt, rounded retractor, or gauze packing. Thus the upper .surface of the diaphragm, as far inward as necessary, is freely e.xposed — with the upper convex .surface of the liver immediately below it (Fig. 484). (3) The operation is now com- pleted in one or in two stages: — (a) In One Stage; — The diaphragm is incised over the site of fluid — the edges of the diaphragmatic wound are slightly sepa- rated — and these edges are sutured with chromic gut (by means of a curved needle in a holder) to the upper surface of the liver, in the form of an ellipse. If adhesions be present between liver and diajihragm, this suturing is unneces- sary. In addition (to either suturing or ndhesionsi, eau/c is packed around 8l2 OPERATIONS UPON THE ABDO.MINO-PELVIC REGION. the region, further guarding against infection. To reheve the tension part of the contents of the cavity is first aspirated. The liver is then incised and drained. The wound is closed up to the .site of drainage — so suturing the parts that the thoracic cavity is shut oft" and the pleura prevented from coming into the region of the wound, (b) In Two Stages; — The diaphragm is sutured as above to the hver and the wound packed — and. after two or three days, when adhesions have occurred, the liver is incised and drained — and the wound treated with the same precautions as just given. Comment. — (i) Parts of at least two ribs should generall}- be e.xcised — to give the necessary room to meet the difficulties which are apt to arise in the progress of the operation. (2) \\ here, from the position of the opening it is possible to do so, it is well to unite the edges of the diaphragm to the edges of the thoracic wound — thus giving freer drainage and better protection of the neighboring parts from infection. EXPOSURE OF LIVER BY TRANSPLEURAL ROUTE BV PAKIIAL F.\( ISloX (11- llXi; ( IR MciRK RIBS OPPOSITE THE PLEURA. Description. — Following the subperiosteal e.xcision of parts of one or more ribs, no attemjit is made to avoid the pleura, but care is taken not to open it prematurely. .After entering the thoracic cavity, in the same manner as in the last operation, the costal and diaphragmatic pleura? are recognized — their surfaces are then sutured together in the form of a circle or an ellipse — and an opening is made through their united surfaces — at once if necessary, — after two or three days if haste be unnecessary. Thus an attempt is made to pre- vent the invasion and infection of their cavity. The operation is inferior to the subpleural method, which should always be practised if possible — reserving the method just described for those cases in which the pleura cannot be thus sepa- rated and pushed above the seat of operation. In the following account parts of the seventh and eighth right ribs will be excised in the anterolateral aspect of the chest. Preparation — Position — Landmarks -Incision. — .As in the operation last described. Operation. — Same as in the above operation — except that when the pleura is exposed, instead of detaching and displacing it upward, the costal and dia- phragmatic pleura; are sutured together in an elliptical or circular outline, with continuous suture of silk or fine chromic gut carried upon a curved needle in a holder — carefully guarding against opening the pleural cavity in the pro- cess of mani[)ulation — it being very difficult to prevent the tearing out of the pleural stitches. The operation may now be concluded in one or in two stages: — (a) In One Stage; — Through the center of the area thus sutured, the two pleura; are incised — through this incision the diaphragm is exposed — the margins of the pleurae are now sutured as one layer to the diaphragm, over an elliptical area, with continuous suture of silk or fine chromic gut, carried upon a fully curved needle in a holder — the surrounding area is packed off with gauze, in addition — the diaphragm is incised — and the edges of the diaphragm are stitched, in turn, to the liver with chromic gut — after which, the tension of the abscess is partly relieved by aspiration — the liver then being incised — drain- age established and the wound partly closed, (b) In Two Stages; — Same as in the single-stage method — except that after suturing the double layer of pleura together, and, at the same time, to the diaphragm, in the form of a circle or ellipse — the area is packed with gauze for two or three days — after which the HEPATORRHArHV. 813 operation is completed as above. In such cases, the diaphragm will u,>ually be found adherent to the liver (when the operation falls over the peritoneal aspect of the liver). If, however, upon exposing the hver through the diaphragm, no adhesions are found, the margins of the diaphragmatic wound can be stitched to the liver surface — the wound packed and two or three days longer waited, if haste be unnecessary. Comment. — (i) If the two pleurse cannot be sutured, and time be avail- able, incise the parietal ])leura — pack the wound for a few days, until the two pleur;e have united around the margins — then incise the visceral pleura and diaphragm — similarly .stitching the diaphragm to the liver for a few days, if desired. (2) If the situation of the wound make it possible, it is well to suture the edges of the diaphragmatic and thoracic wounds together. EXPOSURE OF LIVER BY CHONDRO-PLASTIC RESECTION OF RIGHT COSTAL ARCH BV .\NTF.RIOR OBLIQUE SUBCOSTAL INCISION. Description. — Where the operation site is encumbered by the bony or cartilaginous thoracic wall, the area may be more satisfactorily exposed by temporarily resecting the right costal cartilage forming the costo-chondral arch — turning it outward — and back into place at the end of the operation. The amount of costal arch to be temporarily resected will depend upon the needs of the .special case. E.specially is this step sometimes called for in gall- duct surgery. Preparation — Position — Landmarks — Incision. — As for exposure of liver by anterior oblique subcostal incision. Operation. — If, in the course of exposure of the liver by the anterior ob- lique subcostal incision, insufficient room is afforded, the upper margin of the wound is retracted — after extending the original incision in either or both directions, as indicated — and dissected backward sufficiently far to expose the right costal arch — which is then divided with a costotome, above and below, in- cluding an extent of from 5 to 10 cm. (2 to 4 inches) — and partially bent, par- tially broken isackward upon itself — thus more freely exposing the liver. At the end of the operation, the costo-chondral margin is then turned back into place — and sutured at either end. if necessary. HEPATORRHAPHY. Description. — Suturing of the liver .substance. Generally done in the case of wounds of the liver — and in the approximation of the cut surfaces after partial excisions. The liver may be exposed by any of the above operations, according to the circumstances of the case — preference being given to the simplest route. Preparation — Position— Landmarks — Incision. — .\s for Hepatotomy (page 806) . Operation. — Having exposed the liver in one of the usual methods — and an assi.stant having brought the involved region of the organ well into the field — interrupted chromic gut sutures, carried upon a large, fully-curved Hagedorn, or other, needle, are carried through the opposed edges of the wound. Two tiers of .sutures are, ordinarily, indicated — coarser gut carried more deeply and further from the edges — and finer gut more superficially and 8i4 OPERATIONS UPON THE AliDUMINO-PliLVIC REGION. nearer the edges. The deeper sutures are first tied — then the superficial,- after which the Hver is dropped back into place — and the abdomen closed- unless special cause for drainage e.xist. (See Fig. 485.) Fi.s;. 4S5.— Partial Hkpatectomy, foli.o liqiie, iiilernal ubli.iui;. ,iml liaiisversalis ; B, Ii retracted from liver; D (Iowlt D), Gauze pad excision of wedyc ; F, Supcriicial sutures throi; haph^' : — A, Incised e.xtcriKil ob of rectal sheatli ; C, Costal arcl : E. Borders of liver-woinul afte D (upper D), Deep sutures. HEPATOPEXY. Description. — Ojieration of suturing the li\'er, in whole or in part, to the abdominal wall, or neighboring structures. Resorteti to for jjartiai or com- plete hepato])tosis. Preparation — Position — Landmarks — Incision. — A> for Hepatotomy bv anterior oblique subcostal incision. Operation. — The prolapsed liver having been exposed, the jiart in\-olved in the prolap.'ie. or the whole liver, if involved in its entirety, is brought into its normal position — and is then .sutured with coarse chromic gut, kangaroo- tendon, or silk, to the posterior surface of the anterior abdominal wall. It may also be sutured to the round ligament — to the cartilages of the ribs — or to the general abdominal wall. The sutures are carried deeply into the livei substance with a large, fullv curved needle. Description. erallv done in the removal of growths. PARTIAL HEPATECTOMY. xcision of a limited portion of the liver substance. Gen- SURGICAL ANATOMY OF THE GALL-BLADDKR. 815 Preparation — Position — Landmarks — Incision. — As for Hepatotomy bv line of the Iransperitoneal routes — and preferably by an incision [jarallcl with and just below the ribs. Operation. — (i) The abdomen is o])ened — and the involved portion of the liver is brought as far forward into the wound as possible. (2) Circum- scribe the growth, or part to be removed, by an elliptical incision — the elliptical outline representing the base of a wedge, the sides of which come together within the liver beyond the part to be removed. The ellipse, where possible, is made with its long a.xis radiating from the center of the liver toward the per iphery, and so placed as to avoid the chief hepatic vessels. This area is e.x- cised by cutting down along the outline of the incision, the knife traveling at a right angle to the surface — hemorrhage being controlled by pressure and" by ligature with chromic gut. (.\lso see Comment.) (3) The sides of the wound are then brought together by deep and superficial chromic gut sutures — placed and tied as described under Hepatorrhaphy (page 813). (4) Unless drainage be specially indicated, the liver is dropped back into place and the abdomen closed — particularly if the surfaces of the wound be satisfactorily approximated and hemorrhage be entirely controlled (Fig. 485). Comment. — (i) If the area to be excised is first surrounded by a deejjly placed, interlocking chromic gut ligature, hemorrhage is more thoroughh- con- trolled. These ligatures are then drawn tightly enough to cut through the liver substance and bind the vessels before these are cut. (2) .Also a heavy ligature may be placed through the liver, surrounding the part to be removed, which is thus tied off in sections — the ligatures being tightened and the part removed with the knife or cauterv. VIII. THE GALL-BLADDER. SURGICAL ANATOMY. Description and Position. — Bound to fossa of gall-bladder, upon under surface of liver, by connective tissue and vessels, lying between the right and quadrate lobes — its fundus reaching the abdominal wall anteriorly — and its neck extending to the transverse fissure posteriorly. Its fundus and inferior and lateral aspects are covered with peritoneum reflected from the liver. It sometimes has a mesentery. Its neck points backward and upward, toward the transverse fissure of liver, — its fundus points downward and forward toward the anterior border of liver. Its length is from 7 to 10 cm. (2^ to 4 inches) — the width of its fundus is from 2.5 to 3 cm. (i to iy\ inches) — and it holds about 20 c.c. Relations. — Superiorly; — fossa of gall-bladder;— Inferiorly; — duode- num (first and second ])arts); pyloric end of stomach (sometimes); colon (hepatic flexion and commencement of transverse portion); — Anteriorly; — abdominal wall; ninth costal cartilage. Arteries. — Cystic, from right branch of hepatic. Veins. — Cystic (two) emptying into right branch of vena port;e; others emptving into liver. Lymphatics. — Run into a gland at its neck. Nerves. — Supulied by cieliac plexus. Fixations. — Connective tissue; vessels; peritoneum reflected over under surface of liver; cysto-duodenal ligament (a fold of peritoneum extending from neck of gall-bladder to duodenum). 8lO UFEKATIOXS UTON THK AUDOMINO-l'KI.VIC KKcaoN. SURFACE FORM AND LANDMARKS. The fundus of the gall-bladder projects outward be\ond the anterior border of the liver, in the incisura vesicalis — generally resting upon the transverse colon — and coming into contact with the anterior abdominal wall close to the outer border of the right rectus muscle. Authorities differ as to the exact point of contact with the abdominal wall, in relation with the costochondral struc- tures; — according to Morris, the fundus lies opposite the cartilage of the right ninth or tenth rib; — according to Gray, opposite the inferior border of the right ninth costal cartilage; — and according to Treves, below the inner end of the right tenth costal cartilage. GENERAL SURGICAL CONSIDERATIONS. (I) The gall-bladder is in relation with the first and second portions of the duodenum, with the he])atic flexure and commencement of the transverse colon, and sometimes with the i)ylorus. Therefore the gall-bladder could generally be united with either duodenum or colon — but if united to the colon, the func- tion of the bile in the small intestines would be lost — hence the duodenum is the usual site of anastomosis. (2) In e.xamining the gall-bladder and ducts, first pass the left index over these structures, to gain an idea of their size and contents — then let the left index slip through the foramen of Winslow — in which position the left thum.b will grasp the ligamentum hepato-duodenale (the right margin of the gastro-hepatic omentum) and press it against the left index — and thus the ducts can be jialpated between thumb and index, up- ward and downward. (3) By drawing upon the gall-bladder, the gall-ducts are rendered more tense and evident. (4) The pedicle of the gall-bladder consists of cv.stic duct, arterv, and veins. INSTRUMENTS USED IN GALL-BLADDER OPERATIONS. Mentioned under Instruments used in operations upon the Liver (page 804). CHOLECYSTOTOMY KV Olil.Iljri: Sl'KCOST.M. iN-nsioN. Description. — Incision of gall-bladder for removal of its contents — fol- lowed bv closure at same operation. Usually resorted to for removal of gall- stones in healthy gall-bladder and with unolastructed ducts. The gall-blad- der may be exposed by an oblique or vertical subcostal incision — the former generallv being accomplished with less damage to the abdominal wall. Landmarks. — Site of fundus of gall-bladder (ojiposite lower border of right ninth costal cartilage). Preparation — Position — Incision— Operation. — Same as for the ex- posure of the liver by the anterior oblique incision parallel with the costal arch. The gall-bladder is'brought into the tield— and incised with a sharp knife or scLssors — the apex of the fundus (that portion normally in contact with the anterior abdominal wall) being ojjened in the long axis of the body. Having accomplished the object of the operation, which is generally the freeing of fluid or removal of gall-stones, the bladder is to be closed by two tiers of sutures, introduced with a cur\ed needle held in a holder- the first tier consisting of CHOLECVSTOSTOMV. 817 fine interru[)ted gut sutures passing through mucosa and muscularis — and these buried in by a second row of interrupted Lemberts of tine gut (chromic) passing through serosa and muscularis. The gall-bladder is then dropped into place and the abdomen closed — unless it be indicated to temporaril_v drain from the sutured gall-l)ladder to the outer wound. CHOLECYSTOSTOMY I'.V OBLIQUE OR NEKTICAI, SLBCOSTAL INCISION. Description. — Incision of gall-bladder, followed by suturing of the opened bladder into the abdominal wound for a shorter or longer time. Generally resorted to in cases of gall-stones, or in suppuration. The operation may be done in one or in two stages — in the former case, the gall-bladder is opened at once — in the latter, it is first sutured to the abdominal wall and not opened until after adhesions have formed. Preparation. — As for median abdominal .section. Position. — As for median abdominal section — or, better, the rexersed Trendelenburg position. Landmarks. — Lower border of ti]) of right ninth costal cartilage; costal arch; right linea semilunaris. Fig. 4S6.— CiioLECvsTosro.viv Bv OBLigcE Subcostal Incisio.n' :— A. External oblique: B, In ternal oblique; C. Traiisversalis ; D. Subserous areolar tissue and transversalis fascia; E. Peri- toneum ; F, Gall-bladder, its fundus being drawn out of abdominal wound ; G, Sutures through trans- versalis and subserous fascise, ;ind through serous and muscular coats of gall-bladder. Incision. — Oblique or vertical subcostal incision, as for exposure of the liver (see pages 806 and 808, and also General Surgical Considerations in Operations upon the Liver, page. 802). Operation. — Having opened the abdomen by the chosen incision, hem- orrhage is controlled, the wound is retracted, and the gall-bladder located. If any adhesions are found, these are .separated by blunt dis.section, or tied off — and the bladder brought as far out into the abdominal wound as possible (Fig. 486). If much intravesical tension exist, this should be lessened pre- hminarily by the aspiration of part of the fluid. The operation may now be concluded in one or in two stages; — (A) In One Stage: — (a) Having partially emptied the gall-bladder by aspiration, and after having packed otT the vicinity 52 8l8 OPERATIONS UPON THE ABDOMIXO-PELVIC REGION. with gauze, the bladder is seized with special forceps, a pair in each hand of an assistant — or by two traction-loops passing through the serous and muscular coats — and while thus held as far out of the wound as possible, the fundus of the bladder is incised vertically between the forceps or traction-loops, pro- vision being made for the catching of the fluid, (b) Having opened the gall- bladder, and while holding the lips of the bladder wound apart, insert a finger, or special instrument, and pass it down to the cystic duct to examine the con- tents — removing with special forceps or scoop any calculi found — followed by irrigation or cleansing of the bladder, (c) The cystic, hepatic, and common ducts are then carefully palpated, (d) In completing the operation, the pack- ing is removed and the e.xcess of abdominal wound is closed in from either end toward the center, in the ordinary manner, leaving a sufficient opening mid- way between the ends, or in the most convenient site for approximating the bladder. The margins of the gall-bladder are now sutured into the lower edge of the abdominal wound left after the partial closure of the ends of the abdominal incision — in such a way that all the coats of the gall-bladder are sutured to the lower layers of the abdominal wound with fine interrupted chromic gut — so that serous surfaces are approximated, but so that the edges of the gall-bladder wound do not reach to the skin. Or, where sufficient room for manipulatiiin exi>ts, it is better to use two tiers of sutures — the first row of fine gut sutures passing through serous and part of muscular coats of the gall- bladder, on the one hand, and through the parietal peritoneum, on the other, — followed by a second tier suturing all the coats of the gall-bladder to the apo- neurotic layer of the abdominal wound, (e) A drainage-tube is then generally conducted through the abdominal wound down to tiie cystic duct. (B) In Two Stages; — (a) Having closed in the excess of abdominal wound from either end, the fundus of the gall-bladder is sutured into the remaining opened portion of the abdominal wound by interrupted silk or fine chromic gut sutures — pass- ing through the serous and muscular coats of the gall-bladder, on the one hand, and through the parietal peritoneum and the lower layers of the abdominal wound, on the other, (b) When adhesions have formed in two or three days, the fundus is incised — as in the single-stage operation. Comment. — (A) In Operating in One Stage; — (a) The gall-bladder may be tied with a purse-string around a glass flanged tube, which is then brought out of the abdominal wound. Or a Murphy button-tube, with long cylinder, may be used. The tube or button tied in sloughs out in a few days, by which time adhesions have shut ot'f the cavit\-. (b) Where the gall-bladder is small and contracted, so as not to reach the abdominal wound, the parietal perito- neum may be peeled back from the edges of the abdominal wound and sutured around the wound in the fundus of the gall-bladder. (B) In General; — (a) It may be possible, by the oblique .subcostal incision, to expose the gall-bladder through an intermuscular .separation of the external oblique, internal oblique, and transver.salis muscles, in the triangular space bounded by the eighth nerve running along the costal arch, the ninth nerve running transversely inward from the level of the lower border of the ninth costal cartilage, and the linea semilunaris, (b) Adhesions may have to be separated before the gall-bladder can be brought forward, (c) Avoid stitching the gall-bladder to the skin, as such fistula? are hard to cure, (d) Sometimes stones discovered in the ducts can be milked back into the gall-bladder and thence removed, (e) In the two-stage operation, the examination of the interior of the bladder and of the ducts is not so satisfactory as in the single-stage ojjeration — nor the removal of stones, if found, so easy. CHOLECYSTENTEROSTOMY. 819 CHOLECYSTENDYSIS P.V OBLIQUE OR VERTICAL SUBCOSTAL IXCISION. Description. — This operation consists in doing, first, an ordinary Chole- cystotomv, after which the steps of the procedure in view are carried out — followed by the closure of the gall-l)ladder by suture — after which the fundus of the gall-bladder is anchored by suture to the abdominal incision, which is closed over it. Indicated in cases where no obstruction in the ducts exists, and where the opening into the gall-bladder is small and the parts healthy. The operation throughout is that of a Cholecystotomy — with the addition that, in the act of closing the abdominal wound, the fundus of the gall-bladder, at the site of the incision into the bladder, is sutured in contact with the intra- abdominal aspect of the abdominal wound — in such a position that should it become necessary to open the wound for drainage, or other purpose, the ab- dominal wound and the bladder wound would lie in the same line. Comment. — Some drop the gall-bladder back into the abdomen without attachment to the abdominal wall — which would constitute the operation a Cholecystotomy, — while others .sometimes do not entirely close the abdominal wound immediately — which would constitute a temporary Cholecystostomy. In suturing the gall-bladder fine gut is preferable, especially where the sutures enter the cavity of the bladder, thus avoiding the retention of unabsorbable sutures, which might become foci of calculous formation. CHOLECYSTENTEROSTOMY PV THE MURPHV BUTTOX. Description. — By Cholecystenterostomy is meant the establishment of a communicatiijn between the gall-bladfler and the small or the large intestine. Preferably the union is made with the duodenum (Cholecy.sto-duodenostomy), — next, with the upper jejunum (Cholecysto-jejunostomy), — and if these be not easily brought into apposition (because of adhesions, or other conditions), the junction is made with the hepatic flexure of the colon (Cholecysto-col- ostomy). Union may be accomplished by some mechanical device, of which Murphy's .special gall-bladder button is probably the best — or it may be ac- complished by simple .suturing. The operation is indicated in unremovable obstruction of the cystic or common ducts, in chronic cholecystitis, and in persistent fistuL-e following cholecystostomy. Preparation— Position — Landmarks. — As for Cholecystotomy. Incision. — .\ vertical subcostal ineisinn is generallv to be preferred. If a tumor exist, the incision is placed over it — if not, it is placed in the right semi- lunar line, or just to the outer side of it. Operation. — The steps of the operation are not essentially ditTerent from Entero-enterostomy by the Murphy button. (1) The abdomen having been opened, the gall-bladder and duodenum are exposed — and trial is made to as- certain that both structures can be brought into the field and approximated without too great tension. The field is then packed off with gauze. If the bladder be very much distended, the distention is lessened by partial aspira- tion, that the contents may not be thrown out over the neighboring parts on incising the viscus. (2) The regular purse-string suture (see Fig. 487) is then in- troduced through all the coats of the gall-bladder, calculating to so place it upon the prominent fundus, or the inferior surface of the gall-bladder, as to make the best approximation with the duodenum^ without tension. The bladder- 820 OPERATIONS UPON THE ABUOMINO-PELVIC REGION. wall is then incised between the lines of the pursc-strinj; suture for a distance equal to two-thirds of the diameter of the special button. The male button, grasped in the usual manner, is insinuated into the opening in the gall-bladder and the walls of that viscus drawn about the cyhnder of the button and tied. (3) The female button is similarly introduced into the free aspect of the duo- denum and tied. (4) The halves of the button are pressed together — thus completing the cholecysto-duodenostomy. If reinforcing Lembert sutures are considered necessary, thev are applied. (5) Unless special cause for drainage exists, the abdomen is closed as after ordinary abdominal section. klV BV THE Ml Bltton :— a, Male button « ithiii gall Comment. — (1) Union of the gall-bladder to portion."; of the intestine be- tween the usual site of anastomosis (duodenum, or upper part of jejunum) and the hepatic tle.xure of the colon, is more apt to be followed by volvulus. (2) Prior to completing the ana.stomosis, the interior of the gall-bladder should be examined for calculi, and the ducts palpated. (3) The contents of the duo- denum should be pressed away from the site of anastomosis and controlled by double clamps during the operation. (4) If more convenient, the smaller iemale button may be placed in the gall-bladder. CHOLECYSTENTEROSTOMY EV SI.MPLE SUTURI.N'C Description. — The operation is the same as Cholecystenterostomy by the Murphy button, except that no artificial device is used in accomplishing the union other than simple suturing. CHOLECYSTECTOMY. 821 Preparation — Position — Landmarks — Incision— Operation. — Are, in the main, the same as those just described. Having brought the gall-bladder and intestine (preferably the duodenum) into convenient position for manipula- tion, the two viscera are united in e.xactly the same manner as in Entero-enter- ostomy by lateral anastomosis (see Fig. 683). A posterior row of continuous Lembert sutures is introduced through the .serous and muscular coats of the two viscera, along their posterior aspects, leaving the threads long at both ends. The two organs are then incised — and the lips of the incision whipped together by an overhand continuous suture of all the coats — after which, the line of con- tinuous Lembert suturing is carried around the anterior aspect of the wound. The opening made in the gall-bladder and intestine is from 1.2 to 2 cm. (5 to J inch) long. The parts are returned to the abdomen, which is closed in the usual manner. Comment. — (i) The above method of suturing is simpler than to first make the incision and suture together the mucous coats alone — followed by suturing of muscular and serous coats. (2) Sometimes, though rarely, union by simple suturing is done in two, or even in three stages; — (a) In Two Stages; — The gall-bladder and intestine are sutured together by continuous sutures of serous and muscular coats, appro.ximating an area of each equal to about 2.5 by 3.7 cm, (i by li inches). These viscera are then sutured to the bottom of the abdominal wound and the wound packed for several days. An incision is then made through the intestine — and through this an incision is made through the adherent walls of gall-bladder and intestine. The incised wound in the intestine is then closed — and the abdominal wound also closed, (b) In Three Stages; — The gall-bladder and intestine are sutured together, as in the above. The gall-bladder is then incised and its edges sutured into the abdominal wound (after closing the excess of abdominal wound from the ends). After several days the adherent wall between gall-bladder and intestine is incised through the fistula — which fistula is then allowed to close, or is closed by a plastic operation. CHOLECYSTO-LITHOTRITY. Description. — Consists in the exposure of the gall-bladder and crushing of the calculi from the outside, as they lie within the gall-bladder — bv means of the fingers or special forceps with protected blades — and manipulating the fragments on into the cystic duct. The operation is sometimes applicable in cases of soft and friable stones. Fragments of hard stones are apt to wound the gall-bladder. Small stones may .sometimes be pushed or worked on out of the gall-bladder into the cystic and common duct without being broken. The steps of the operation are the same as those for Cholecystotomy, up to the point of exposing the gall-bladder — after which it is a process of palpation and manipulation with the fingers, or special protected forceps. CHOLECYSTECTOMY. Description. — The total excision of the gall-bladder. Indicated when the gall-bladder or the cystic duct is considerably changed bv disease, or where contracted and deep-lying, making difficult the approximation of the gall- bladder to the abdominal wall (cholecystotomy) ; and where the hepatic and common bile-ducts are patulous. Preparation — Position — Landmarks — Incision. -.\s for Cholecvsto- tomv bv vertical subcostal incision. 822 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. Operation. — (i) Having exposed the subhepatic region by thorough re- traction, aided by the reversed Trendelenburg position, and packed jff the neighboring vicinity with gauze, the gall-bladder is isolated (Fig. 488). (2) The peritoneum binding the gall-bladder to its fossa is incised over the pro- minent inferior surface of the gall-bladder — either in one straight line in the long axis of the bladder, from fundus to cystic duct — or in the form of an ellipse (especially where the bladder is large), the two limbs meeting at the fundus and cystic duct. (3) This incision having passed simply through the serous covering into the underlying connective tissue, the peritoneum is sepa- rated from the gall-bladder by blunt dissection, from fundus to neck, and Fig. 48S.— Cholecystectomy by Vertical Subcostal Incision : — A, Li\-er displaced upward, exposing fossa of gall-bladder; B, Gauze pad protecting neighboring structures; C, Longitudinally incised peritoneum OYer gall-bladder being separated from the bladder by blunt dissection ; D, Liga- ture placed around pedicle of gall-bladder. throughout its width, and retracted to either side. Having dissected and peeled back the peritoneal covering, the gall-bladder itself is then dissected, or shelled out, by blunt dissection from its fossa and freed to its pedicle — working with curved blunt scissors and a blunt dissector, and keeping strictly in the connective-tis.sue plane. The pedicle, formed by the cystic duct and vessels, is well isolated, doubly ligated with chromic gut, and divided between the Hgatures, the adjacent'structures having been protected with gauze packing. The end of the divided duct may be immediately cauterized. (4) The divided peritoneum, which has been separated and retracted in the form of two flaps, THE GALL-DUCTS— GENERAL SURGICAL CONSIDERATIONS. 823 is now sutured with gut over the fossa of the gall-bladder. (5) The abdomen is closed — generally without drainage. Comment. — (i) It may be necessary to separate adhesions by blunt dis- section, or by division between ligature. (2) If much distended, the gall- bladder should be first partially emptied by aspiration through a fine needle — the needle wound being subsequently puckered together with a purse-.^tring ligature before manipulating the bladder. (3) Avoid the inclusion of the hepatic and common ducts. (4) The abdominal wound may be clo.sed in part only, leaving a temporary drain. IX. THE GALL-DUCTS. SURGICAL ANATOMY. Hepatic Duct. — Formed by right and left bile-ducts uniting generally at their emergence from the liver. Length from 3 to 5 cm. (ij to 2 inches). Diameter, about 4 mm. (nearly y\ inch). Passes downward in right border of gastro-hepatic omentum, having vena cava behind and hepatic artery to left. Unites with cystic duct to form common bile-duct. Cystic Duct. — Begins at neck of gall-bladder — is directed slightly to left — and ends at its junction with hepatic duct at an acute angle, to form common bile-duct. Length, 2.5 to 4 cm. (i to i^ inches). Passes downward, back- ward, and to left in gastro-hepatic omentum — having hepatic artery to left and portal vein behind. Common Bile-duct. — Formed by union of hepatic and cystic ducts. Length, about 7.5 cm. (3 inches), dependent upon site of union of cystic and hepatic ducts. Diameter, about 6 mm. (nearly ^ inch). Its course and re- lations are the following; — continuing the direction of hepatic duct, it passes downward and backward in hepato-duodenal portion of gastro-hepatic liga- ment, having hepatic arter\' and its gastro-duodenal branch to left, and portal vein behind and between — enters right pancreatico-gastric fold behind first portion of duodenum (superior curve), then passes between second ])ortion of duodenum (descending part) and head of pancreas — and ends by entering posterior and inner wall of descending portion of duodenum (being crossed on the way by the pancreatico-duodenal artery), running obliquely for about 2 cm. (I inch) through its walls and opening u[)on a papilla of mucous membrane about 10 cm. (4 inches) from the pylorus. The pancreatic duct joins the com- mon bile-duct just before its termination. SURFACE FORM AND LANDMARKS. INSTRUMENTS. See these headings under the Liver and Gall-bladder. GENERAL SURGICAL CONSIDERATIONS. The common bile-duct lies in the hepato-duodenal ligament, near its right free margin — in the free border which constitutes the fold at the entrance of the foramen of Winslow — the hepatic artery lying nearby to its left — and the vena porta behind and between the common duct and hepatic artery — owing to which important relations, the ducts should be fully exposed before being opened. (See Fig. 489.) 824 orERATIONS UPON THE ABDOMINO-PELVIC REGION. Where more than usual room is required, resection of the right costal arch may be performed. No suture should be used which will come within the lumen of any of the ducts — for fear of forming the nucleus of calcuU. The exact nature of the operation to be done is frequently not known until the gall-bladder and ducts are exposed and examined Fig. 4Sq.— HepATO-DI ODPNAl LlGAMhS hepato-duodenale; B. Common bile-duct; G, Arrow within foramen of Winslow. iND CoNTAiNFL Stri LTi RES : — A . Liganien' na porlae ; D, Hepatic artery; E. Gall-bladder CHOLEDOCHOTOMY. Description. — Incision of common bile-duct for removal of gall-stone. Often less correctly used in connection with incision of the other biliary ducts. Preparation — Position — Landmarks. — As for exposure of liver or gall- bladder l)y an oblique or vertical subcostal incision. Incision. — The site of operation is often reached in the course of some other operation about the liver or g^ll-passages. \Miere especially planned for the removal of a stone in the common duct, a vertical incision may be made along the outer border of the right rectus, ending about 5 cm. (2 inches) above the level of the umbilicus. A curved incision may also be used — from just below the outer aspect of the ensiform cartilage, thence parallel with and about 1.2 cm. (i ir.^h) from the costal arch to a point about 1.2 cm. (J inch) above the end of the eleventh rib. In either of these incisions only the ninth nerve need be divided. Fenger gives a vertical incision, combined, if necessary, with a transverse addition. Operation. — (1) The abdomen having been opened — the liver retracted well upward — the intestines depressed (or having fallen away in the reversed Trendelenburg position) — the gall-bladder is exposed. (2) The bladder is then first palpated for calculi — and the cystic and hepatic ducts are followed down until the common duct is reached — manipulating in the manner de- scribed below. (3) All adhesions present should be broken down by blunt dissection, or divided between chromic gut ligatures. These adhesions are apt to be found between gall-bladder, stomach, transverse colon, great omentum, and duodenum. The entire area should be packed off with gauze. (4) After tracing down the cystic duct, expose the anterior surface of the hepato-duo- CHOLEDOCHOTOMV. 8-\S denal ligament down to the duodenum — demonstrate the free border of the iigamentum hepato-duodenale to the right — insert the left index-finger into the foramen of Winslow (with pulp of finger forward) and left thumb upon the anterior surface of this ligament — follow its structure downward to the duo- denum, having, between the fingers, the common duct to the right, the hepatic artery to the left, and the vena porta? on a plane posterior to and between the other two. (5) Having located the stone by the above method of palpation, especially guard against its slipping into the hepatic duct from between the thumb and index — by pressing it forward against the anterior wall of the duct and steadying it in that position. (6) Incise the duct in its long axis, directly over the stone, for a distance of from i to 3 cm. (^ to ij inches) as indicated (Fig. 490). The escape of bile is caught in gauze — and the presenting calculus FiK- 400. — Choledochoiomy and Choledochorrhaphv. by Vertical Subcostal Incision IS Kn;nr Linea Si-:mii.vnaris : — A. Foramen of Winslow, leading behind hepalo-duodenal liga- ment; B. Dislended common, bile-duct incised over a calculus. Lembert interrupted sutures are shown placed ready to be tied after extraction of stone ; C, Position of Yena porta; ; D, Position of hepatic artery. removed with special forceps or scoop. Having removed the stone, the com- mon duct should be examined for other stones — by means of the finger or probe — and from the duodenum to and into the cystic and hepatic ducts. (7) Having extracted the stone, the wound in the duct is to be closed — either by sim])le suturing — or by suturing aided by some such mechanical de\ice as one of HaLsted's hammers (which are of various sizes), (a) Closure Aided by Hal.sted"s Hammer; — Preliminary to the incision, two traction-sutures are inserted on either side of the line of the future incision, through the outer coats of the duct — for the purpose of aiding the manipulation. Having evacuated the duct and examined its cavity for other calculi, Halsted's hammer is in- troduced l)v insinuating its longer arm into the incised wound — the hammer 826 OPERATIONS UPON' THE ABDOMINO-PELVIC REGION. portion distending the duct and rendering it easier to suture its walls over the round, iirm form — which also obstructs the i\o\v of bile during the operation. (Fig. 491.) The opening is finally closed either b\' Halsted's mattress sutures passed through the outer coats of the duct, — or two rows of ordinary sutures may be used — an inner row of interrupted gut sutures through the muscular and external coats, without penetrating the mucous membrane — and an outer row of interrupted silk sutures through the serous surfaces. The peritoneum covering the anterior aspect of the hepato-duodenal ligament is included in the suturing, (b) Closure by Simple Suturing; — Having incised the duct over the stone, before the stone is removed the first row of sutures, inserted upon a small, fully curved needle through the muscular and e.xternal coats, is passed while the stone is still hi situ (using the stone as a di.stender of the gut) — these stitches are then held apart and the stone is withdrawn between them — after which the first row is tied and an outer row of interrupted silk sutures is passed through the serous surfaces, as above described (Fig. 490). (8) In completing the operation, a rubber drainage- tube may be carried down to the wound in the duct, and this sur- rounded by gauze — the abdominal wound being closed except where the drainage comes out. Comment. — (i) If distended, the gall-bladder or duct should first be partly aspirated. (2) Where choledochotomy with suture of the duct is done, cholecystostomy is fre- quentlv done at the same time, to relieve the tension upon the stitches and as a drain. (3) It is easier to suture a thickened duct, and harder to suture a thin one. If it be im- possible to suture the duct, insert a small rubber drainage-tube into the opened duct and pack around it with gauze. (4) If the stone can be shifted, it is better to shift it nearer the duodenum before incising the duct — as there is less danger of wounding the vena portoe. (5) After incising the duct, it may be necessary to crush the stone in situ by inserting special crushing forceps through the wound in the duct and then removing the debris with scoop or forceps. (6) If possible, ascertain with the probe whether duct into the duodenum is patulous. Fig. 491.— Cho H.^LSTED's Hammer: — The hammei situ during placing of sutures — and prior to tightening last of the sutures CHOLELITHOTRITY. Description. — Exposure of the gall-ducts (cy.stic, hepatic, or common) — the crushing of the contained calculi /;; situ, without opening the duct — and the pressing onward of the fragments toward the duodenum. Instead of crushing, the calculi may be broken up by a needle inserted through the walls of the duct (Tait's method of "needling"). As a])plied to the common duct, the operation is called choledocho-lithotrity — in which duct the calculus is found more fre- quently than in cystic or hepatic ducts. Cholelithotrity is understood to refer to the operation in its application to any of the three ducts. SURGICAL ANATOMY OF THE SPLEEN. 827 Preparation — Position — Landmarks — Incision. — As for Choledochot- omy. Operation. — The region of operation is exposed exactly as in the de- scription immediately preceding. The gall-bladder and ducts, especially the common duct, are palpated by the same process of manipulation as there de- scribed. When the calculus is located, an attempt is made to crush it with the fingers, or special protected forceps, and then to manipulate the fragments on- ward into the duodenum — pushing them on if possible — crushing them only if absolutely necessary. Guard against the escape of the stone from the cystic into the hepatic duct, and thence into the right or left hepatic ducts out of reach. The abdomen is closed without drainage if no great harm is thought to have been done in the manipulation — otherwise temporary drainage is used. X. THE SPLEEN. SURGICAL ANATOMY. Description and Situation. — Situated chief!}- in left hypochondriac region — King above left kidney and splenic flexure of colon — between con- cavity of diaphragm to left and behind, and fundus of stomach to right and in front — corresponding, in axillary line, with ninth, tenth, and eleventh left ribs. It lies obliquely from above downward and from within outward. Its length is about 12 cm. (4! inches) — breadth, 8 cm. (3 J inches) — thickness, 3 cm. (ij inches). The peritoneum entirely surrounds the spleen except at its hilum — which is at the center of the internal surface (between the renal and gastric portions of internal surface) through which the arteries and nerves enter and the veins and lymphatics emerge. Its pedicle is formed by the reflection of peritoneum over the vessels at the hilum. The diaphragm separates all parts of the normal spleen from the parietes. The spleen may be absent, or there may be from one to twenty more or less rudimentary spleens present. Surfaces and Borders. — Phrenic surface; lies beneath left ninth, tenth, and eleventh ribs — peritoneum, diaphragm, portions of left pleura and lung, the costo-phrenic sinus (and sometimes left lobe of liver) intervening. Renal part of internal surface; touches superior and external part of left kidney, and generally the suprarenal capsule. Gastric part of internal surface; in contact with posterior wall of a filled stomach. Basal surface (lower outer end); in contact with splenic flexure of colon and phreno-colic ligament (and often with tail of pancreas). Anterior margin; situated between diaphragm and stomach. Posterior border; between diaphragm and left kidney. Superior end; on le\el with tenth dorsal vertebra, approaching within 2 to 3 cm. (I to ij inches) of spinal column. Reaches to level of ninth dorsal spine. Inferior end; limited anteriorly by costo-clavicular line (connecting left sterno-clavicular articulation with anterior end of eleventh rib). Reaches to level of first lumbar spine. Relations. — Externally and Superiorly; peritoneum; diaphragm; left ninth, tenth, and elex'enth ribs; costo-phrenic sinus; left lung and pleura; pos- terior thoracic muscles. Inferiorly; splenic flexure of colon; phreno-colic ligament; tail of pancreas (sometimes). Internally; stomach (posterior sur- face of fundus) ; left kidney and capsule; tail of pancreas; spinal column (some- times). Relations of Spleen to Thoracic Cavity. — Upper third of spleen is 828 OPERATIONS UPON THE Al;DOMlNO-PEL\ TO REGION. covered b}' left lung, — middle third is in contact with left costo-phrenic sinus, — lower third passes below lower pleural limit and costal origin of diaphragm. Ligaments and Fixations of Spleen. — Gastro-splenic omentum — from hilum to fundus of stomach. Phreiio-splenic hgament — from upper end of spleen to diaphragm. Spleno-renal ligament — formed partly by greater and lesser peritoneal sacs — contains the splenic vessels. Phreno-colic ligament — atTords support, though not connected with spleen. Pancreatico-splenic liga- ment — present when tail of pancreas does not reach spleen. Spleno-colic liga- ment — from basal aspect of spleen to colon (sometimes present). Arteries. — Splenic. Veins. — Splenic. Lymphatics. — Empty into glands at hilum. Nerves. — From coeliac plexus and right ])neumogastric. SURFACE FORM AND LANDMARKS. Upper end of spleen lies opposite level of ninth dorsal spine — lower end opposite level of first lumbar spine. The inner border comes within 3.8 to 5 cm. (i^ to 2 inches) of the median plane of the body. The outer border lies just posterior to the mid-a.xillary line — not coming further forward than a line joining the left sterno-clavicular articulation and the anterior end of the eleventh rib. The spleen corresponds with the ninth, tenth, and eleventh left ribs — separated from them by the diaphragm and, in its upper part, also by the lung. Its long axis about corresponds with the line of the left tenth rib. It slightly overlaps the outer border of the left kidney below. GENERAL SURGICAL CONSIDERATIONS. The spleen may be exposed in several ways — by oblique subcostal incision parallel with costal arch; by vertical incision in left linea semilunaris; by ver- tical incision to left of left linea semilunaris; by median abdominal incision; by intercostal incision; by partial excision of one or more ribs, followed by sub- pleural or transpleural exposure of spleen. If more room be needed, any of the vertical incisions may be increased by a transverse or curved incision extending toward flank or median line, from the lower part of the \ertical incision. Where an abdominal incision is first made for pure exploratory purposes, the median abdominal incision is probably best. There is general similarity in the technic of hepatic and splenic operations. INSTRUMENTS. See those used in operating upon the Liver. EXPLORATORY PUNCTURE OF SPLEEN. Exploratorv puncture of the spleen is made in the same general manner, and with the same general precautions, as is exploratory puncture of the liver (see page 804). As in the case of the liver, exploratory puncture of the spleen is rarely warrantable, owing to the risks of sepsis and hemorrhage — and should not be used except in the case of tumors, which are almost certainly adherent to the abdominal wall, thus shutting off the general peritoneal cavity — and EXPOSURE OF SPLEEN' BV SLBPLELRAL ROUTE. 829 especially in those projecting below the ribs. The site of the tumor and the general relations given under Surgical Anatomy wiU serve as the guide for the site of puncture — the puncture itself being made exactly as it is in the case of the liver. SPLENOTOMY BY OBLIgUE SUBCOSTAL INXISION. Description. — Incision of the spleen — by an incision just below and paral- lel with the left costal arch. The spleen may be e.xposed by any of the incisions mentioned under General Surgical Considerations — one of the tirst three being [ireferablc. The operation may be done in on(; stage — or in two stages (after adhesions have formed). Preparation — Position. — As for Median Abdominal Section. Landmarks. — Lower border of left costal arch; left linea .semilunaris; position (.>f lumor, if anv. Incision. — ( !)i)lique incision parallel with and about 1.5 cm. (^ inch) below left costal arch, with its center over the site of spleen (the imier border of which comes to within 4 to 5 cm. [i^ to 2 inches] of the median plane — and whose outer border extends just posteriorly to the mid-axillary line). Operation. — (i) Having opened the abdomen in the same manner as in Hepatotomy by the same incision, the .spleen is isolated and brought into the wound as far as possible and the neighboring field packed otT with gauze. In dealing with fluid collections within the spleen substance, the tension should be lessened by partial aspiration of the contents preliminarily to incision of the viscus, after the organ is brought into the wound. (2) The operation may be completed in one or in two stages; — (a) In One Stage: — Having been brought as near the surface of the wound as possible, and after packing off the vicinity as securely as po.ssible, the spleen is incised in the same general manner and with the same precautions as in the case of the liver (see page 806). In the case of a fluid collection, the edges of the pus or cyst cavity are then .seized and brought forward and sutured into the lower plane of the abdominal wound (which is closed in from either end for a part of the distance) — the sutures passing through spleen substance and capsule at some distance from the wound in the viscus, on the one hand, and through parietal peritoneum and part of the thickness of the lower plane of the lips of the abdominal wound, on the other — thus approximating the peritoneum of the spleen and the perito- neum of the abdominal wall all around, (b) In Two Stages; — The spleen is brought into the wound and the parietal peritoneum and edges of the abdo- minal wound are stitched in an elliptical manner to the serous surface and to the substance of the spleen — the wound of the alidomen, which is partly closed from one or both ends, is then packed with gauze and two or three days given for union — after which the spleen is incised. .\11 incisions into spleen sub- stance are planned so as to avoid, as far as pos.sible, the large vessels of the viscus. (3) Where the spleen has been incised for exploration .simply, and nothing has been found, splenorrhaphv is done and the abdomen closed. EXPOSURE OF SPLEEN BY SUBPLEURAL ROUTE V,\ PARPIAI. EXCISION' OF ONE OR TWO RIBS. Description.- -For the general description, see the corresponding opera- tion upon the liver. The ribs chosen are usually the tenth and eleventh 830 OPERATIONS LTOX THE ABDOMINO-PEUTC REGION. (and the former when uTily (}ne rib is excised) — the site of excision lying mid- wav between a point about 4 to 5 cm. (i^ to 2 inches) from the median plane, and a point just posterior to the mid-axillary line. The steps of the operation are the same as those for the subpleural exposure of the liver by the partial ex- cision of one or more ribs (see page 810). SPLENORRHAPHY. Description. — Suturing of the spleen. Generally resorted to for incised and lacerated wounds, and for approximating surfaces after partial splenec- toniv. The route of approach is often determined by a pre-existing wound or operation — if not, the oblique subcostal incision parallel with the left costal arch gives the best exposure. For the method of approaching the spleen, therefore, see Partial Splenectomy by Oblique Subcostal Incision parallel with the Ribs, page 831. For the details of the operation, after exposing the organ, see Hepatorrhaphy, page 813, the technic being practically the same. SPLENOPEXY. Description. — By Splenopexy is meant the fixation, generally by means i)f Mituring, of a displaced spleen back to its original site, or to another site. Indicated in wandering" spleen (Splenoptosis). Preparation — Position — Landmarks. — As for Partial or Total Splen- ectoniv, according to the incision adopted. Incision. — The organ may be approached by a vertical incision in the left linea semilunaris; by an obhque subcostal incision; or by a median vertical incision. The first incision given provides the most convenient approach to the parts involved. The median incision has been used by Rydygier, who in- trofluced the operation. Operation. — Having opened the abdomen, isolated and exposed the dis- placed spleen, its position, its environments, and the laxity of its ligaments are studied, and a site for its fixation decided upon, (a) Rydygier, having opened the abdomen in the median line, elevated the spleen to a proper height — then detached from the parietes sufficient peritoneum to form a pocket — dividing the parietal peritoneum with a transverse upward convexity, detaching it down- ward from the abdominal wall. The lower half of the spleen was then placed in this pocket — the parietal peritoneum was sutured to the underlying tissues along the lowest line of separation (to prevent further separation) — and the free border of the parietal peritoneum was attached to the gastro-splenic omentum above, (b) Bardenhauer entered the abdominal cavity by a some- what rectangular incision, made by a vertical incision extending from the ribs to the superior iliac crest, the upper line of which was extended transversely forward along the inferior border of the tenth rib. The flap thus included was detached downward to but not through the peritoneum and turned inward — the peritoneum w-as then incised sufliciently to enable the spleen to be drawn through edgewise. A strong purse-string suture of silk, previously placed around the margin of the peritoneal opening, was then drawn so as to pucker it around the pedicle but not constrict it. A suspensory silk suture was passed under the end of the spleen and over the tenth rib as a sling. Other sutures were passed where indicated. The .spleen was thus practically extraperito- neally placed. The abdomen is closed without drainage. TOTAL SPLENECTOMY. 831 PARTIAL SPLENECTOMY BY SUBCOSTAL INCISION PARALLEL WITH RIBS. Description. — E.xcision of part of spleen. Generally done for removal of tumor invohing a portion of the organ. Preparation — Position. — .\s for median abdominal section. Landmarks. — Lower border of left costal arch — or modified by the position if a tumor, if one be present. Incision. — Obliquely curved incision parallel with and about 1.2 cm. (h inch) below the left costal arch, with its center over the site of the spleen (whose inner border e.xtends to w-ithin 4 or 5 cm. [i^ or 2 inches] of the median plane, and whose outer border extends just posteriorly to the mid-a.xillary Une), — or, if a tumor be present, directly over the tumor. Operation. — (i) Having incised the skin and fascia; the external oblique transversely; separated the internal oblique in the cleavage line; retracted what nerves could be spared; divided the transversalis obhquely; and the trans- versalis fascia, subserous areolar tissue, and peritoneum in the hne of the original wound, the abdominal cavity is opened. (2) Having retracted the wound and brought the spleen as far into the opening as possible, the area of the spleen to be removed, including the tumor, if any, is now to be surrounded in sections by interlocking silk or chromic gut ligatures and tightened — or other form of ligature which will compress the entire area to be circumscribed and removed. When the entire portion to be removed has been thus circum- scribed by a compressing ligature, the tied-off area is excised with curved scissors, or by the actual cautery — further ligating any portions requiring lig- ature. Where the area to be removed has anv ligamentous attachments corre- sponding to it, or adhesions connected with it, these are first tied off and divided between ligatures. (3) Where possible, the surfaces left by the partial ex- cision should be approximated by deeply placed sutures. See Splenorrhaphy, page 830. The spleen is then dropped back into place — and the abdomen generally closed without drainage. Comment. — \\'here the tumor or tumors are small, small wedge-shaped masses mav be removed and the edges approximated by deeplv placed sutures, which both coapt the surfaces and control the hemorrhage — thus obviating any previous ligation of the spleen substance. TOTAL SPLENECTOMY BY \ERTICAL INCISION IN LEFT LINEA SEMILrNARIS. Description. — Excisions of entire spleen. Resorted to in some cases of movable sjik-cn, injurv of the organ, simple hvpertrophy and in some tumors. Preparation. — .\s for Median Abdominal Section. Position. — .\s for Median .\bdominal Section — the position of the surgeon to the right of the patient giving better access to and control of the pedicle. Landmarks. — Left linea semilunaris. Incision. — \'ertical incision in left linea sem_ilunaris. beginning near the left costal arch and extending downward as far as necessary. (Such an incision will divide the ninth nerve transverselv on a line with the lower border of the ninth rib.) The spleen may also be exposed by one of the incisions given under General Surgical Considerations. Operation. — (1) Having incised abdominal wall and o[)ened the peritoneal cavity and retracted the lips of the wound, the spleen is located and brought as 83^ Ul'KKATIOKS UPON THE AI!DOMIi\0-PEL\IC REGION. prominently forward as possible. If any adhesions be found between the spleen and neighboring viscera, or the abdominal wall, these are separated by blunt dissection, or divided between double ligatures — carefully a\oiding in- jury to the spleen. (2) Freeing Splenic attachments (ligaments) and Enu- cleation of the Spleen; — The phreno-splenic ligament is best reached and freed, as suggested by Jonnesco, by covering the spleen with a square of gauze, to avoid slipping of fingers, and then depressing the spleen downward and to the right, while an assistant draws the left lower edge of the abdominal wound to the left — thus exposing the bed of the spleen and vault of the diaphragm and the phreno-splenic ligament, which latter is divided between double ligatures. (3) Following this, the remaining Hgaments and attachments of the spleen to its bed are freed, commencing at its lower aspect. The spleen is then enu- cleated and delivered through the abdominal wound. The gastro-splenic ligament is the omentum surrounding the pedicle, and therefore a part of the pedicle — and is treated in ligating the pedicle. (4) Ligation and Di\ision of the Pedicle; — The spleen having been delivered, is then turned toward its left and made to rest upon its conve.xity, thus e.xposing its pedicle. The con- stituent vessels of the pedicle, beginning with the most important, should all be separated and each doubly ligated and divided between the two ligatures, which should be of strong silk. This is the most important step of the opera- tion. Separate ligation is better than ligation cii masse, or in two or three divisions or groups of vessels — though the latter may be done in cases of haste or other need. Traction upon the constituents of the pedicle, which are easily ruptured, is to be avoided. Adherence of the splenic artery and vein to the tail of the pancreas often adds to the difficulty of isolation and separate liga- ture of these vessels. (5) Hemostasis of the Splenic Bed; — Having removed the spleen, its bed is carefully examined — and every bleeding point ligated with chromic gut. Especially examine the pillar of the diaphragm, where the phreno-splenic ligament has been divided — after drawing the stomach and intestines to the right. Limited bleeding surfaces may be controlled by su- turing peritoneum over them, where possible. (6) The abdominal wound is closed — unless drainage be specially indicated, or there should be uncertainty as to the hemostasis. Full elastic dressings are applied so as to compress the region formerly occupied by the spleen. Comment. — («) It is better to ligate the pedicle at once — than to clamp first and then ligate. (2) Some surgeons, especially in very large spleens, pre- fer to ligate the pedicle fir.st, with the spleen in situ — then draw the spleen down and tie oft' the gastro-splenic omentum — then deliver the spleen. (3) The vessels are often enormously enlarged — and the veins are often especially thin. (4) Tie the arteries first — then the veins — as less blood is thus lo.st. (5) See that ligatures, in tying off the pedicle, pass between rather than through the vessels — passing through connective tissue between the vessels. (6) Srme surgeons advise first clamping and separating the gastro-splenic ligament — in order to enable the spleen to be lifted up and the pedicle better exposed (J. Wesley Bovee — but adds that this is often impossible in marked hypertrophy — in which cases the vessels are ligated in the order encountered). (7) Some surgeons, in dealing with less accessible pedicles, transfix the entire splenic omentum with double ligature, tying each half separately — then subsequently surround the entire pedicle with another .single ligature. (8) After exposing the spleen, the hand should be passed between it and the diaphragm and its surface examined — as well as its other aspects, as far as possible. Very ex- tensive and firm adhesions would contraindicate the continuance of the opera- tion. There mav be visceral, parietal, and omental adhesions. If much SURGICAL ANATOMY OF THE PANCREAS. 833 damage be done in separating adhesions, temporary drainage is indicated. (9) Practise no traction upon the pedicle, both because of the friable vessels and because of the general bad symptoms which are apt to supervene from pressure upon the splenic ple.xus (from the solar plexus). Relax the pedicle before tightening each ligature. (10) Treatment of the pedicle comes first in importance and treatment of adhesion second. Hemorrhage is the chief dan- ger. (II) If secondary hemorrhage be feared, suture the pedicle to the abdo- minal wall. XI. THE PANCREAS. SURGICAL ANATOMY. Description. — The pancreas lies transversely across the po.sterior abdo- minal wall, the large vessels intervening between it and the wall — being on a level with the second lumbar vertebra (and sometimes with the first or third) — lying in the epigastric and left hypochondriac regions — fiaving the stomach in front, duodenum to the right, and spleen to the left — and the aorta, vena cava, coeliac plexus, thoracic duct, and diaphragmatic crura behind. It lies behind the posterior wall of the lesser omental cavity and is between the lamina; of the mesocolon of the transverse colon. The head of the pancreas is surrounded by the loop of the duodenum. The tail of the pancreas is in contact with the interno-inferior aspect of the spleen. Peritoneum covers the pancreas except upon its posterior surface. The viscus is 15 to 16 cm. (about 6 inches) in length — 3 to 4 cm. (i^ to i^ inches) in width — and 15 to 18 mm. (about h inch) in thickness. Relations. — Anteriorly; Upper layer of transverse mesocolon; lesser peritoneal sac; transverse colon; gastro-duodenal and pancreatico-duodenal arteries; stomach (posterior surface). Posteriorly; second (sometimes third •or first) lumbar vertebra; crura of diaphragm; aorta and right and left renai arteries and superior mesenteric artery; inferior vena cava, superior and inferior mesenteric, splenic, and right and left renal veins; vena portse; coeliac plexus: thoracic duct (origin); ductus communis choledochus and pancreatic duct; left kidney (and sometimes its capsule). Superiorly; Duodenum (first part); liver; hepatic and splenic arteries and coeliac axis; solar plexus. Interiorly; Duodenum, third (preaortic) and fourth (ascending) parts; duodenojejunal angle; jejunum; transverse colon; transverse mesocolon (inferior layer); superior mesenteric artery and vein; inferior mesenteric vein; mesentery. Right end ; Loop of duodenum. Left end ; Interno-inferior aspect of spleen. Fixations. — Held in place by its peritoneal investment and by adjacent viscera and structures to which attached. Pancreatic Duct (Canal of Wirsung). — Begins at left end, or tail, of pancreas — runs thence toward the head of the organ, passing nearer its pos- terior than anterior aspects — after passing the neck, it turns downward, back- ward, and to right, in the head of the viscus, and runs to the left side of the common bile-duct — entering the duodenal wall together and parallel with the ductus communis choledochus — uniting with the latter while running ob- liquely in the walls of the duodenum — and emptying by a common opening with it upon a papilla of mucous membrane about 10 cm. (4 inches) from the pylo- rus — the opening being covered by a fold of mucous membrane from above. The pancreatic duct is recognized by its white color and its relation to the pancreatica magna artery. Its diameter, near its termination, is between ? and 3 mm. (about ^ inch). The Duct of the Lesser Pancreas (Duct of San 5.5 834 OPERATIONS UPON THE ABDOMIXO-PELVIC REGU)N. torini) may join the Canal of Wirsung near its termination — or may empty into the duodenum by a separate mouth. Arteries. — Pancreaticas parvae and pancreatica magna from splenic artery; pancreatico-duodenalis superior from gastro-duodenalis of hepatic; pancre- atico-duodenalis inferior from superior mesenteric. Veins. — .Accompany the above arteries, emptying into s])lenic and superior mesenteric veins. Lymphatics. — End in two glands upon superior mesenteric artery. Nerves. — From solar ple.xus. SURFACE FORM AND LANDMARKS. The pancreas lies obliquely behind the stt)mach — crossing the spine op- posite the second (or sometimes the first or third) lumbar vertebra. Anteriorly, it lies transversely about 7.5 cm. (3 inches) above the umbilicus. GENERAL SURGICAL CONSIDERATIONS. General Considerations. — (i) Surgery of the Pancreas is limited to op- erations lor cysts (which is the most frequent operation done upon theviscus), remo\al of small tumors, abscess, hemorrhage, localized necrosis, calculi, "annular pancreas," and for the removal of parts of the organ. (2) Anato- mically, complete pancreatectomy is very difficult. (3) Surgically, complete removal with subsequent life has been proved with animals — but not with man. Rapidlv fatal diabetes follows complete removal of the organ. (4) Cysts may be incised or e.xcised. In incision, the cyst-wall should be sutured to the abdo- minal wall (marsupialization) — for drainage, and to prevent pancreatic juice from getting into the abdominal cavity. (5) Pancreatic juice in the abdominal cavitv is apt to e.xcite peritonitis. (6) If the pancreatic opening into the duo- denum be cut otT, a new route must be made, or a pancreatic fistula must be established. (7) Suturing material .should not be left in the pancreatic ducts, as such material mayform the nuclei of calculi. (8) Wounds of the pancreatic canals should be closed by suture. (9) Always ligate before excising a portion of the pancreas — in order to prevent the escape of pancreatic juice into the peritoneal cavity. (10) Extirpation of the tail and part of the body, cr of limited portions of the head, may be done. The tail of the organ is the part most safelv operated upon. In operating upon the head, it is necessary to spare the canal of \\'ir.sung, or the duct of Santorini. In removing the whole head of the fiancreas, there is no way to restore the flow of pancreatic juice into the intestines. Routes of Approaching the Pancreas. — (i) Gastrocolic; — by incising the anterior layers of the gastrocolic omentum between the greater curvature of the stomach and the transverse colon, and thus entering the lesser omental cavitv. This is the route to be preferred — and is made by a transperitoneal median incision above the umbilicus. (2) Transmesocolic ; — by incising the inferior laver of the mesocolon. This route may be used when the tumor lies between the lamina; of the mesocolon — and is made by a transperitoneal median incision above the umbilicus. (3) Epigastric ; — Isy cutting through the gastrohepatic omentum. This approach may l)e used when the tumor presents above the lower curvature of the stomach, as less frequently happens — and is made by transperitoneal median incision above the umbilicus. (4) pancrp:atotomy. 83 s Lumbar; — by incising as for exposure of the kidney. Sometimes done for tumors of the tail of the pancreas — and is made by an extraperitoneal incision as for exposure of the left kidney — or below and along the twelfth rib. (See Fig. 492.) Methods of Drainage of Pancreatic Cavities. — (1) If pus have col- lected in the bursa umcntalis, incise in the median line, from the ensiform car- tilage downward, and cut through the gastrohepatic omentum — after, if possi- ble, first suturing that omentum to the abdom- inal wall. (2) If pus be in the bursa omentalis and extend along the pancreas, resort to Leith's lumbar drainage mentioned below. (3) Lumbar drainage is sometimes necessary where anterior drainage cannot be secured — in such cases Leith suggests a lumbar in- cision made under the left twelfth rib. Through this the finger is inserted by the upper border of the quadratus lumborum, lo- cating the left kidney and its vessels. The tail of the pancreas and the posterior and external wall of the bursa omentalis are placed above and just internal to the renal vessels. The lesser peritoneal cavity can be here entered either through the mesocolon or through the posterior layer of the peritoneum. (4) If pus be retroperitoneal — make a lumbar in- cision as for e.xposure of the left kidney and reach the site extraperitoneally. Fig. 492. — Illustrating Routes of Approach to Pan- creas: — A. Gastro-colic ; B, Trans-mesocolic ; C. Trans-gas- trohep.ltico-omental (epigastric); D, Lumbar; E, Pancreas. (Modified from Gray.) INSTRUMENTS. See those given under the Liver (page S04). PANCREATOTOMY BV G.ASTROCCII.IC ROUTE. Description. — Incision of the pancreas. Generally resorted to for cyst or abscess of that organ. The method of approach is generally one of the first three given under General Surgical Considerations — and is usually the one above mentioned. In the case of a cyst of the pancreas, its walls may be excised, or, as is more generally done, sutured to the abdominal wall and drained. Preparation — Position — Landmarks. — .\s for Median Abdominal Sec- tion. S^b OPERATIONS Ul'ON THE ABI )()MIN(i PKI.VIC REOIdN. Incision. — In median line, with its center opposite the lower border of the stomach — which is about 4 cm. (i^ inches) above the umbilicus. Where a tumor is evident, the incision is usually placed directly over it. Operation. — (i) Having opened the abdomen as in median section, the gastrocolic omentum is exposed. (2) Having displaced the stomach upward and the transverse colon downward, the gastrocolic omentum is in- cised vertically, between the lower border of the stomach and the upper border of the colon — thus reaching the lesser peritoneal cavity. (3) Having controlled all hemorrhage, the pancreas is reached through the opening in the omentum and drawn forward into the wound — packing oti" the vicinity with gauze. (4) If haste be necessary, the operation is completed in one stage, the cyst being incised and its edges sutured into the lower plane of the abdominal wound, having been brought through the rent in the gastrocolic omentum, which is sutured ? round the opening in the pancreas as well as ])ossible. (5) If haste be unnecessary, the operation is concluded in two stages — the first step being similar to the one just described — the second step, the incision of the viscus, being performed two or three days later, after adhesions have formed and the general peritoneal cavity has been shut off. (6) In any event, therefore, drainage is temporarily provided for through the abdominal incision, which is usually accomplished by drainage-tube and gauze packing. Comment. — (i) Adhesions are apt to be found in such cases, and should be separated by blunt dissection, or divided between chromic ligatures, before attempting to expose the pancreas in the wound. (2) In distended cysts or abscesses, partial aspiration should first be done to lessen tension. (3) In some cases adhesions are found walling off the general peritoneal cavity — so that it is possible to incise directly through the abdominal wall and gastrocolic omentum into the pus or fluid cavity. (4) In exceptional cases cysts may be excised in the same manner as small tumors. PARTIAL PANCREATECTOMY BY GASTROCOLIC ROUTE. Description. — Excision of part of the pancreas. Generally |)erformed in connection with removal of a tumor involving a portion of the organ. Preparation — Position — Landmarks — Incision. — As for Pancreatot- omy. Operation. — The pancreas is exposed in precisely the same manner as for Pancreatotomy. The tumor in the organ is sought and brought as well forward as possible. Chromic gut ligatures are then placed deeply around the mass to be removed, so as to completely circumscribe it — thus preventing both hemorrhage and the escape of pancreatic fiuid. This having been done, the tumor is excised with curved, blunt-pointed scissors, aided by blunt dissection. If a marked cavity is left, and it is possible to do so, the walls of the cavity are approximated by deep chromic gut sutures. Drainage is then established between the site of the operation and the abdominal wound — and the remainder of the abdominal incision closed. SURGICAL ANATOMY OF THE KIDXEVS. 837 XII. THE KIDNEYS. SURGICAL ANATOMY. Description. — Each kidney lies partly in ihc hypochondriac, lumbar, epigastric, and umljilical regions — abutting upon the confines of each — resting upon the lower part of the diaphragm and areolar fatty tissue covering the quadratus lumborum and psoas magnus — and placed behind the peri- toneum. They lie embedded in abundant fatty areolar tissue, more abundant posteriorly than anteriorly — constituting the fatty areolar capsule. The right kidney generally (though not always) lies about 7 mm. to 1.3 cm. (^ to ^ inch) lower than the left (owing to the presence of the liver upon the right). Vertically, the kidneys correspond to the space between the uysjier border of the twelfth dorsal and the first and second (and sometimes the upper half of the third) lumbar vertebrae — and to the eleventh and twelfth ribs and transverse processes of the first and second lumbar vertebrie — the left kidney generally reaching to the upper border of the eleventh rib — and the right kidney generally reaching to the lower border of the eleventh rib. Outer borders of the kidneys he from g to 10 cm. (3^ to 4 inches) e.xternal to the lumbar spines. The superior poles of the kidneys lie about 5 cm. (2 inches), and the inferior poles from 6.3 to 7.6 cm. (2^ to 3 inches), from the median line. Inner border of right kidney lies close to the vena cava — the inner border of the left kidney lies within 2.5 cm. or more (i inch or more) of the aorta. The kidneys average 10 to 12 cm. (4 to 4f inches) in length — 2.8 cm. (i| inches) in thickne.ss — 6.3 cm. (2^ inches) in breadth — and weigh about 4^ ounces. There may be an irregularity from the normal in the form, size, number, po>ition, and mobility of the kidneys. Peritoneal Relations of the Kidneys. — Posterior surfaces of both kidneys are uncovered by peritoneum. Upon the anterior surface of the right kidney — the hepatic and mesocolic areas are peritoneal — and the areas of the duodenum and transverse colon are non- ])eritoneal. Upon the anterior surface of the left kidnev — the gastric area is peritoneal — the pancreatic area is non-peritoneal — the outer part of the colic area is non-peritoneal, and the inner part of the colic area is peritoneal. Fixations. — (i) Fatty areolar tissue, or capsule — in which the kidneys are embedded — derived from parietal subperitoneal fascia — and separates them from the diaphragm and from the anterior lamella of the lumbar fascia covering the quadratus lumborum and psoas muscles. (2) \'essels, nerves, and connective tissue form the pedicle. (3) Partial covering of peritoneum upon their anterior surfaces and borders. Relations. — Anterior Surface — (a) Right Kidney; — Liver (right lobe) — peritoneum interx'ening; ascending colon and lie[)atic flexure; duodenum (descending part); suprarenal capsule (to slight extent), (b) Left Kidney; — Stomach (fundus) — peritoneum of lesser sac intervening; pancreas (tail); splenic artery and vein; splenic flexure of colon and upper part of descending colon; duodenum (ascending part); suprarenal capsule (to slight extent). Posterior Surface— (Both Kidneys) — .\reolar fatty tissue, separating the kidneys from diaphragm and quadratus lumborum and psoas muscles; pos- terior abdominal wall, corresponding to eleventh and twelfth ribs and trans- verse processes of first and second lumbar vertebra?; diaphragm (areolar tissue intervening); anterior layer of posterior aponeurosis of transversalis (i. e., anterior layer of lumbar fascia), separating kidney from quadratus lumborum; psoas; diaphragmatic, transversalis and iliac fascia lining dia- 8T.& OPERATIONS UPON THE ABDOMINO-PELVIC REGION. [jhragm, transversalis and iliacus; twelfth dorsal, ilio-hypogastric and ilio- inguinal nerves; anterior divisions of tirst and second lumbar arteries and veins. The nerves and vessels just mentioned all pass downward and out- ward anteriorly to the quadratus lumborum and pierce the transversalis beyond the external border of the quadratus. Ahtte. — The left kidney is in contact with a larger area of diaphragm than the right — and the amount of diaphragm in contact may be increased on both sides when the arcuate liga- ments are attached to the tips of the transverse processes of the second lumbar vertebra. External border — (a) Right Kidney; hver (upper two-thirds); a.scending colon (lower third), (b) Left Kidney; spleen (above); descending colon (below). Internal border — (a) Right Kidney; near vena cava; struc- tures of hilum {q. ■?'.). (b) Left Kidney; 2.5 cm. or more (i inch or more) from aorta; structures of hilum (q. v.). Superior extremity— (Both Kid- neys) — Suprarenal capsule — which encroaches also upon the anterior and in- ternal border and is bound to the kidney by the connective tissue of the sub- peritoneal fascia. Inferiorly — (Both Kidneys) — come within about 5 cm. (2 inches) of the crest of the ilium. Relations of the Pleurae. — The pleura- are in j)r<).\imity to, but not in relation with, the kidneys. The lower limit of the pleura extends nearly FlK 4Q^— H0R170NT^I ^h I scendiiig tolon C Splueii D \b oblique H Internal oblique I rrans\ers-llii ] Piois niagim-. Erector spniae M Latissimus dorsi (Modified from Esmarch ) horizontally outward from the lower margin of the twelfth dorsal vertebra — crossing the twelfth rib close to its neck — and crossing the eleventh rib about 5 cm. (2 inches) beyond (external to) its neck. Relation of Structures within the Sinus of the Kidney.— (A) Struc- tures; — Branches forming renal artery; branches forming renal vein; lymph- atic vessels and glands; plexus of nerves; ureter; areolar fatty tissue. (B) Order of Structures from Before Backward;— (a) Right Kidney— vein, artery, ureter: — (b) Left Kidney — vein, artery, ureter. (C) Order of Structures from Above Downward; — (a) Right Kidney — vein, artery, ureter: — (b) Left Kidney — artery, vein, ureter. Arteries. — Renal, suprarenal, spermatic, and lumbar — all from aorta. Veins. — Renal. Right vein empties directly into vena cava. Left vein receives left spermatic (or left ovarian), left inferior phrenic, and sometimes left suprarenal before emptying into vena cava. Nerves. — From solar and aortic plexuses, semilunar ganglia, splanchnics, and yineumogastrics. Lymphatics. — Superior and deep sets — emptying into lumbar glands. SURFACE FORM A\U LANDMARKS OF THE KIDNEYS. 839 Description of Lumbar Fascia. — Consists of three layers, which en- sheathe erector spina; and quadratus lumborum muscles, (i) Posterior or superficial layer : — Layer through which latissimus dorsi, and serratus pos- ticus inferior beneath it, are connected to the vertebral spines (same thing as aponeurosis of those muscles). Latissimus dorsi is connected with it most posteriorly — serratus posticus inferior, lying beneath latissimus dorsi, is con- nected with its upper part anteriorly to latissimus dorsi — and beyond the line along which these two muscles are connected with it (/. c, after these two muscles are free of it) it gives origin to the posterior part of the internal ob- lique — and then passes on (after internal oblique is free of it) to merge with middle layer — thus binding down posterior aspect of erector spins. It is con- tinuous with the vertebral aponeurosis. (2) Middle layer : — Arises from tips of lumbar transverse processes — runs outward between quadratus lum- borum in front and erector spinas behind, to fleshy part of transversalis muscle — forming posterior aponeurosis of transversalis. It is joined at outer border of erector spinae by posterior layer — and at outer border of quadratus lum- borum by anterior layer. It is attached, above, to lower margin of last rib — and, below, to ilio-lumbar ligament and adjacent iliac crest. (3) Anterior layer : — attached to front of lumbar transverse proces.ses at inner border of quadratus lumborum — covering anterior surface of quadratus lumborum to its outer border, where it becomes united with middle layer and becomes the trans- versalis fascia. Attached above (forming ligamentum arcuatum externum) to front of transverse processes of first (or second) lumbar vertebra and apex of last rib, and, below, to ilio-lumbar ligament and iliac crest (Fig. 493). SURFACE FORM AND LANDMARKS. (I) A horizontal line through the umbilicus will be below the lower border of each kidney — about 2.5 cm. (i inch) below the right kidney, and 4 cm. (ij inches) below the left (Quain). According to Treves, such a line will in- tersect the lower portion of the right kidney, and pass below the left. (2) A vertical line from the middle of Poupart's ligament upward to the costal arch will have one-third of the kidney to its outer, and two-thirds of the kidney to its inner side. (3) Posteriorly, the kidney lies within a parallelogram in- cluded within the four following lines: (a) Line parallel with and 2.5 cm. (i inch) external to the spine, from the lower border of the tip of the eleventh dorsal spine to the center of the tip of the third lumbar spine, — (b) Line drawn outward for 7 cm. (2 J inches) at a right angle to, and from the upper end of line "a," — (c) Line drawn outward for 7 cm. (2J inches) at a right angle to, and from the lower end of line "a," — (d) Line parallel with line "a," between the outer ends of lines "b" and "c." (4) The right kidney is generally from 1.3 to 2 cm. (^ to J inch) lower than the left, — and will lie that far below the measurements given in (3) above. (5) The upper border of the kidney lies upon a level with the eleventh intercostal space and with the eleventh or twelfth dorsal spine — the right kidney lying somewhat lower. (6) The twelfth ribs divide the kidneys, approximately, into a superior and an inferior half. (7) The lower border of the kidney about corresponds with the center of the spinous process of the third lumbar vertebra. (8) The kidneys are accessible to pressure in the triangle formed by the lower border of the twelfth rib above, and the outer border of the erector spina- internally. (9) The axes of the kid- neys are oblique — from above and within, downward and outward. (10) The superior pole of the kidney is about 5 cm. (2 inches) from the median plane, (ii) The hilum of the kidney lies about 5 cm. (2 inches) from the 840 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. median plane, im a level with the first or second lumbar spine, or opposite the interval between them. (12) The inferior pole of the kidney lies about 6.3 to 7.5 cm. (2^ to 3 inches) from the middle line. (13) The inner border of the upper part of the kidne)' lies about 2.5 cm. ( i inch) external to the middle line of the body. The inner border lies upon the e.xternal border of the psoas — the rest of the kidney lying upon the lumbar fascia covering the quadratus lum- borum. (14) The outer border of the lower part of the kidneys is about 9.5 cm. (3! inches) from the middle line. The external border lies from 2 to 3 cm. (J to I J inches) to the outer side of the external border of the quadratus lum- Fig. 494. — Rhlations of Kidneys —A. A, Latissimus dorsi ; B, B. Erector spin Imetual oblique: F, Transversalis ; G, Low the descending on the left. (Modified from Ribs, Pleur.«, AND Overlying Muscles: C, C. Quadratus lumborum ; D, External oblique ; E, imit of pleura. .Vscending coK.n is seen on the right, V, and from Esniarch and Kowalzig. I borum muscle. (15) The ureter expands into the pelvis of the kidney op- posite the lower half of the kidney. (16) Both kidneys rest upon the lower portion of the arch of the diaphragm (as it comes downward between the kid- neys and the twelfth ribs), quadratus lumborum, anterior layer of lumbar fascia, and psoas muscle. {17) The external border of the erector .i^pinK is the superficial guide to the kidney — and the quadratus lumborum the deep guide, — the former muscle marking the twelfth rib about 6.3 cm. (2^ inches) from the median line — and the latter being attached to the inner half of the twelfth rib (Fig. 494). RETROPERITONEAL EXPOSURE OF THE KIDNEY. 841 GENERAL SURGICAL CONSIDERATIONS. Preparation. — Bowels and bladder emptied — part shaved. Position. — In operating e.xtraperitoneally, the patient lies upon the sound side, near the edge of the table, with a firm cushion or support under the op- posite loin, to round out and make prominent the side of the operation and in- crease the interval between the twelfth rib and the iliac crest. The surgeon stands at the patient's back, cutting from above downward on the right side, and in the reverse, or in the same direction, on the left. The assistant stands opposite. In operating transperitoneally, the position is the same as for median abdominal section. Approach to the kidney may be by the extraperitoneal or transperitoneal route — preferably the former. .\lways ascertain that the opposite kidney is present before removing a kidney. An incision to expose the kidney may go, with safety, to the lower border of the twelfth rib. If the eleventh be the last rib, the pleura would be endangered if that rib were taken for the twelfth. If the thirteenth rib be present, the operation area would be contracted. Do not take for granted that the last rib is the twelfth rib — else the pleura may be wounded. Always count the ribs from above. The pleune may reach lower where the arcuate ligaments are attached to the second lumbar vertebra. If necessary to better expose the kidney, the twelfth rib may be excised subperiosteally, in whole or in part. Hemorrhage in kidney operations is often great. It may be controlled: — by compression of the pedicle by the fingers, or a special forceps temporarily applied, — by gauze pressure of the bleeding surface, — by hot douching. Su- turing of bleeding surfaces in contact also controls hemorrhage. In bisection of the healthy kidney, pressure of the pedicle is necessary. Di.seased kidney bleeds less than healthy kidney substance. The right renal vein is generally much shorter than the left — a fact to be remembered in handling the pedicle of the right kidney. Gut is preferable to silk throughout in kidney surgery — as being absorb- able — and less apt to form the nuclei of calculi. INSTRUMENTS. Scalpels; bistouries; scissors, various; forceps, dissecting, toothed, and dressing; blunt dissector; probe; sound; grooved director; tenacula; e.xploratory syringe and needle; needle in handle, for exploration; periosteotomes; costo- tome; pedicle forceps; special stone scoops and forceps; stone-searcher; an- eurism-needles; artery-damp forceps; dilators; ureteral buttons; needle-holder; needles, straight and curved; sutures and ligatures, of chromic and plain gut, kangaroo tendon, and silk; ligature-carriers; long tenotome; drainage-tubes; gauze; l)lunt hooks; clamps, various; retractors. RETROPERITONEAL EXPOSURE OF THE KIDNEY l>,V Olil.IOUE Ll'MP.AK INXISION, Description. — The most generally applicable method of exposing the kidney, for whatever, purpose indicated. The incision arlmits of being ex- 842 OPERATIONS UI'ON THE ABDOMIXO-PEI.VIC REGION". tended upward over the twelfth or eleventh rib, exposing them for partial excision, if necessary — as well as downward toward the anterior superior iliac spine, and onward and downward just above and parallel with Poupart's liga- ment, exposing, if need be, the entire length of the ureter — the parts being ex- posed throughout, extra])eritoneally. Preparation — Position. — See General Surgical Considerations. Landmarks. — Twelfth rib; outer border of erector spina'; iliac crest; Poupart's ligament. Incision. — Begins in the triangle made by the lower border of the twelfth rib and the outer border of the erector spina; — at a point about 1.3 cm. (^ inch) below the twelfth rib, and just to the outer border of the erector spins (which crosses the twelfth rib about 6.3 cm. [2^ inches] from the median line) — passes thence obliquely downward and forward in the direction of the anterior superior :';■ ,----w.-' ,'-;aSk- X~^'-'- ---. — ■ il III \i.-''iJAKA'-^- Fig. 495. — Incision for Exposure of Kidneys by the Lv.mbar Route :— A. Retroperitoneal exposure hy oblique lumbar incision ; B, Continuation of this incision where additional room is required; C, Retroperitoneal exposure by Koenig's angular lumbo-abdominal incision; D, Incision in Edebohls's operation of nephropexy. iliac spine, generally at first for 7.5 to 10 cm. (3 to 4 inches) — and may be subse- quently extended both upward and downward as mentioned. When so con- tinued downward, it passes to within 2 to 2.5 cm. (f to i inch) of the anterior superior iliac spine, and thence turns downward and inward parallel with and about the same distance above Poupart's ligament (Fig. 495, A and B, and Fig. 4q6). Operation. — (1) Incise skin and superficial fascia, exposing the posterior layer of the lumbar fascia, the anterior part of the latissimus dorsi and the posterior part of the external oblique. Continuing the incision in the original line, the anterior portion of the latissimus dorsi will be incised transversely to its fibers. The upper part of the serratus posticus inferior will be incised transversely beneath it. The po.sterior border of the external oblique will be RETROPERITOXEAL EXPOSURE OF THE KIDNEY. 843 divided, and, if the incision be continued far toward the iliac crest, the knife will pass into the intermuscular cleavage line of this muscle (Fig. 497). (2) The outer border of the erector spinae is exposed, but its sheath is not opened. The internal oblique is incised nearly at a right angle to its course. The pos- terior ay)oneurosis of the transversalis muscle (fascia lumborum) is divided also to the full length of the wound. Between the internal oblicjue and trans- versalis, branches of the last dorsal nerve and last intercostal artery may be encountered passing downward and forward near the twelfth rib — and branches of the first lumbar nerve and last lumbar artery near the iliac crest. The nerves are retracted wherever possible. The arteries are ligated with gut. All the parts are retracted as divided. (3) The outer border of the cjuadratus lumborum muscle and the anterior layer of the fascia lumborum are now-en- countered. The latter is incised to the limit of the wound. The outer border of the former is retracted — or may be incised if necessary. This divided layer is also retracted. (4) The fas- cia transversalis is thus ex- fll\;^ posed, and is similarly divided M|^%\ — when the entire depth of the wound is well retracted on each side. (5) The fatty areolar capsule of the kidney is now exposed, retroperitoneally — and is opened up, partly by careful incision, and partly by blunt dissection of the perirenal tis- sue — while an assistant, by pressure upon the abdominal wall, thrusts the kidney into the lumbar wound — thus exposing the surface of the organ. (6) The special object of the ojiera- tion is now accomplished — and the wound treated as indicated. Comment. — (1) There is more chance to separate, rather than divide, some of the mus- cle-fibers in this incision, if it become necessary to extend it, than in most of the other incisions. (2) In exploratory incisions, and in limited operations upon the kidney, it is generally only necessary to divide the skin, superficial fascia, lumbar fascia, latissimus dorsi, and serratus posticus inferior over a distance between the anterior border of the erector spinoe and the posterior edges of the external and internal olilique muscles. (3) In thick loins, longer incisions are necessary. (4) Where the kidney does not extend down as far as usual, the incision may be extended well over the twelfth rib (but see Surgical .\natomy). (5) Guard against opening the pleura, which is only separated by a comparatively thin layer of fibrous tissue from the renal fatty tissue at the costo-lumbar hiatus of the diaphragm. (6) Proximity of the kidney is sometimes noticed, in approaching from behind, by the finer texture of the fatty areolar tissue near it. (7) .-Xvoid the colon, which sometimes pushes its way into the wound. (8) If, in the course of operation, more room be needed, the incision may be extended in one of three directions; — (a) back- ward, dividing, if necessary, the anterior border of the erector spin;c: — (b) uj)- Fig. 496.— Oblique Lumbo-abdominai. Inc exposure of kidney and ureter. 844 OPERATIONS UrON THE AliDOMINO-PELVIC REGION. ward and backward over the twelfth rib, which maybe partially excised: — (c) downward and forward toward the anterior superior iliac spine, and thence parallel with and about 2.5 cm. (i inch) above Poupart's ligament. (9) If it be desired to examine the opposite kidney during operation (which should al- ways be done before removing a kidney, except where that ground has been preliminarilv covered by vesical catheterization of the opposite ureter). Kocher re.sorts to the following technic; — he divides the transversalis muscle sufficiently Fin- 4<)7.— Retroperitoneal Exposure of Kidney by Oblique Lvmbar Incision:— A, I.atissimus . (Fig. 495, D.) Operation. — (1) Incise skin and fascia. Recognize the latissimus dorsi and separate its fibers in their cleavage line — beginning the separation over the outer aspect of the erector .spina^ and continuing it upward and outward. The sheath of the erector .spina? is not opened. (2) Divide the transversalis fascia, NEPHROPEXY. 853 exposing the perirenal fatty areolar tissue. If the ilio-hypogastric nerve can- not be retracted to one side, it is cut and subsequently sutured with gut, after the kidney has been sutured into place. (3) The sheath of the quadratus luniborum is incised from the twelfth rib to the ihac crest, along the anterior surface of its lateral border — exposing, by the retraction of its incised edges, considerable raw muscle. (4) The kidney is now freed by blunt dissection, aided by clips of curved, blunt scissors, if necessary — and is delivered upon the back, surrounded by its fatty capsule — which delivery is aided by rolling the patient up and down upon the air-pillow. The size of the opening in the abdominal parietes may be increased, if need be. (5) Dissect away the entire fatty capsule from the proper fibrous capsule of the kidney. (6) Any explora- tion of the kidney by palpation, .v-raying, or instrumental means may now be done — and any measure carried out that may be indicated. (7) At this stage, Kig. 501. — Nephropkxn' — I-Mt-boiiIs's Operation kitliie\' is sliowii delivered llirough lumbar wound- way — and the four fixation sutures passed through ri aiui not penetrating kidney substance. (Modified fn -I, Placing fixation or suspension sutures — the he proper capsule split and stripped back half- iected and attached portions of proper capsule, n Edebohls.) if the removal of the appendix vermiformis be indicated — which the author of the operation considers to be so in a certain percentage of cases — the perito- neum is opened external to the kidney, and to the outer side of the ascending colon — part of the ascending colon is drawn out and one of its longitudinal bands is followed down to the ca-cum and the ajjpendix thus located at the termination of the muscular band — after which the appendix is delivered into the wound (the kidney having been temiKirarily replaced) — and is either in- verted entire into the cascum, after ligating the meso-appendix, or excised and the stump treated according to the operator's individual ideas. (8) Following the replacing of the intestines, the author of the operation — who considers that there is an association, in a certain percentage of cases, betvv-een nephroptosis and disease of the bile-passages — explores, by jjalpation, the gall-bladder, ^54 OPERATIONS UPON THE ABDOMINO-PEI.VIC REGION. cystic and common ducts, inferior aspect of liver, and the pyloric end of the stomach, through the lumbar wound. (9) The peritoneal wound is then closed and the kidney again dehvered through the lumbar wound, in prepara- tion for anchorage. Where the peritoneum has not been opened, the kidney remains delivered, as described under (4), from the time of its first exposure. (10) Incise the proper capsule of the kidney at the center of its convex border, carefully avoiding entering the kidney substance. Pass a grooved director be- •^ween the fibrous capsule and kidney proper, first toward the upper pole, and -hen toward the lower pole, to and half-way around both poles. The fibrous capsule is then separated from the kidney by blunt dissection, from the line of incision, peeling it off (as the skin from an orange) on both sides toward the pelvis — until practically one-half of the kidney is denuded — the detached por- Fig. 502.— Nhphropexy — Fldehohls's Operati —the skin wound is shown retracted, and the k A. A. Two upper huried fixation sutures, untied, buried suture uniting lips of lumbar wound in cle; are tied. (Modified from Edebohls. ) II :— II, Anchoring kidney and closing lumbar wound dney has been returned within abdominal wound. The two lower fixation sutures are tied. B. Untied vage line of latissimus dorsi. Similar sutures below tion remaining continuous with the undetached portion, and turned back upon the latter as the lapel of a coat. If the proper capsule appear excessive, a por- tion may be excised (Fig. 501). (") Four forty-day chromic gut fixation or suspension sutures are now introduced through both that portion of the proper cap.sule which has been detached and reflected, and through the still adherent portion — the passage of the sutures occurring near the line of reflection and being accomplished as shown in Fig. 501, — two being placed upon the anterior and two upon the posterior aspect of the kidney, at the center of the upper and lower halves on each side. A straight Hagedorn needle is used — the suture is carried from within outward entirely through the reflected proper capsule, near the line of reflection — travels transversely to the axis of the kidney and enters the attached portion of the proper capsule (directly opposite its point of emer- NEPHROPEXY. 8SS gence from the detached portion) and pierces it from without inward, just be- yond the line of reflection — thence the Hagedorn needle travels, flatwise, en- tirely between the proper capsule and the kidney substance, parallel with and just below the line of reflection, for 2 or 3 cm. (f Ui i\ inches) — thence emerges through the attached capsule from within outward — and, traveUng transversely to the a.xis of the kidney, passes through the reflected proper capsule from without inward, parallel with the companion limb of the suture. (12) Having placed all four sutures, the kidney, with the eight suture ends hang- ing free, is returned within the body. Each suture is now passed through the entire lumbar wall, from within outward — either bv threading a needle upon each and penetrating the wall from within outward, or by passing a Reverdin needle through the abdominal parietes from without and drawing the sutures through from with- in. The four inner sutures will thus pierce the lumbar wall on the inner side of the incision, and at a dis- tance from each other equivalent to the distances apart at which they pene- trate the proper capsule — and will pass through the retracted sheath of the quadratus lumborum near its edge, through the quad- ratus muscle, and through the erector spina\ The four outer sutures will pierce the lumbar wall on the outer side of the inci- sion, at the same distance from each other as those of the opposite side, and each at a distance from its companion suture of the opposite side equivalent to the antero-posterior thick- ness of the kidney — and will pass through the transversalis fascia and the latissimus dorsi muscle. The highest sutures pass through immediately below the last rib. These eight sutures are, at first, left untied. (13) The incision in the lumbar wall is now closed, in the cleavage line of the latissimus dorsi, by from four to si.x . deeply buried interrupted sutures of forty-day chromic gut, in such a manner as to turn the raw surface of the quadratus lumborum muscle toward the kidney. This is accomplished by suturing the latissimus dorsi and lumbar fascia, composing the external margin of the wound — to the latissimus dorsi, the sheath of the erector spina?, and the external margin of the incised sheath of the quadratus lumborum, composing the inner margin of the wound (Fig. 502). (14) The eight free suspension or fixation sutures are now drawn taut, thus snugly approximating the decapsulated convex surface of the kidnev into contact with the raw substance of the quadratus lumborum. from rib to ilium Fig, 50J. — Xi iHKOi H \v - Edebohls's Operalion : — III, Cross-sectidfi of region of operation. A. Psoas inagtius ; B, Erector spinse ; C. Quadratus lumborum ; D, Latissimus dorsi ; E, Rectus abdominis; F. External oblique; G, Internal ob- lique; H, Transversalis; I. Lumbar incision exposing kid- ne>- ; J. The decapsulated con\-exity of kidney is shown ap- proximated to raw substance of quadratus lumborum by the fixation-sutures seen passing through both the detached and adlierent portions of proper kidney capsule. ( Modified from S56 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. — and are then tied (Fig. 503). (15) The skin and fascia are then closed in the line of the original incision, with a subcuticular suture — and a broad lum- bar dressing applied. NEPHROPEXY BV SUTURING SPLIT PROPER CAPSULE AND PARENCHYMA OF KIDNEY TO LUMBAR WALL, BY OBLIQUE LUMBAR INCISION— TUFFIER'S OPERATION. Description. — Anchoring of an abnormally movable kidney into its own or another adjacent site — by suturing of the parenchyma and partially stripped fibrous cap.sule to the lumbar wall or lower ribs. The kidney may be exposed through anv of the posterior incisions recently described — but is generally ex- posed through the oblicjue lumbar incision. Preparation — Position — Landmarks — Incision. — .As for exposure of the kidney by an olilique lumbar incision. Operation. — (i) Having exposed the kidney and brought it well into the wound, partly bv pressure from the abdomen, and partly by drawing the organ downward and backward from under the rib (or simplv backward, where already much dis- placed and loosened from its natural position), the fatty areolar capsule is divided and partly turned backward, exposing the kidney and its proper fibrous capsule. (2) Trim away any excess of fatty capsule. Incise the proper fi- brous capsule of the kidney along its mid-pos terior aspect, in the long a.xis of the kidney and for its entire length — adding a cross-cut, at right angles, at either end of the vertical inci- sion, of about 2.5 cm. (i inch) in length, half of its length being on either side of the vertical cut. Peel back the fibrous capsule thus liberated for about 1.3 cm. (^ inch) on either side of the median incision. Pass from four to six chromic gut or kangaroo tendon sutures, in a curved needle, held in a holder, so as to include, on one side, the deeper structures in one lip of the lum- bar wound (but not the entire thickness of the lumbar wound), the transversalis fascia, fatt}' capsule, reflected portion of fibrous capsule, part of unreflected portion of tibrous capsule, and about 1.3 cm. (i inch) of kidney substance, — emerging from the kidney substance on the opposite side, it takes up, in reverse order, part of the unreflected portion of the kidney capsule, reflected portion of the proper capsule, fatty capsule, transversalis fascia and deeper structures in the opposite lip of the lumbar wound (Fig. 504). These are tied as buried sutures, simultaneously drawing the kidney up to the lumbar fascia, posterior abdominal wall, and borders of the wound, and, at the same time, approximating the deeper parts of the lips of the wound. Care is taken to draw the kidnev up to and under the lips of the wound and in contact with as much raw surface as possible — but not into and between the wound. It is also essential to see that the reflected most, to of the proper capsule remains spread out with its raw surface upper portion add to the extent of raw surface for adhesion. (3) The upper depth and Fig. 504.— Nephrope-XV by Sc- TVRE OF Split Capsule .and Kid- ney Parenchyma : — Sutures are seen penetrating kidney substance and split t:apsule. which latter has been turned back on either side. The outer limbs of the sutures are ready to be carried througli site of abdominal wall, or other site, to which kidney will be approximated by tightening the sutures. Tuf- fier's method. XEPHROPEXV. 857 skin margins of the wound are then closed with interrupted sutures of silk or chromic gut. Comment. — (i) This may be regarded as one of the best methods of Nephropexy — granulations of the raw surface of the kidney and capsule form stronger adhesions than when the kidney is not partly stripped. .\nd stronger union is formed than when the stripped capsule alone is sutured into the wound (instead of the stripped capsule and kidney substance). (2) The split fibrous capsule is sometimes also sutured to the periosteum of the twelfth rib. (3) In some cases gauze packing is used down to the kidney in the center of th' wound, to strengthen adhesion by granulation. (4) .\void including nerves in suturing of the kidney to the lumbar wall. (5) Deep drainage may be temporarily used — but is generally not indicated. NEPHROPEXY BV SIMPLE SUTURING. Description. — Here neither the fatty nor the fibrous capsule of the kidney is split — one or both of these structures being sutured to some neighboring structure. .See, further, "Description" of the last operation. The kidnev may be exposed by any of the incisions given — the oblique lumbar incision being preferable Preparation — Position — Landmarks — Incision. — As for exposure of kidne\- by oljlique lumbar incision. Fig. 505.— Nephropexy bv Slmple Sutiring :—A, Sutures passing through lower portion of lips of wound, perirenal fatty areolar tissue, and kidney substance, ready to bind kidney to and into lower plane of wound ; B, Sutures passing through skin and upper portion of lips of wound. The structures are the same as those einimerated in Fig. 497. Operation. — Having exposed the kidney as in the last operation, the dis- placed organ may be treated in one of several ways; (a) By Suturing of th Unopened Fatty Capsule; — E.xcess of fatty areolar cap.sule is trimmed away, and the remaining shortened capsule is stitched into the lower plane of the lumbar wound by four to six interrupted chromic gut or kangaroo tendon sutures — the upper layers of the lumbar wound licing closed as in the last oper- ation (Fig. 505). (b) By Suturing of the Parenchyma, together with the un- 858 OFERATIO^:S tPUN THE AUDUMINei-l'ELVIC KEGIOX. stripped Fatty and Fibrous Capsules; — Having shortened the excess of fatty capsule, if necessary (by excising a jwrtion), three or four kangaroo tendon or chromic gut sutures are passed, with fully curved needle, dipping about i .3 cm. (^ inch) into the kidney substance, and taking up about 2 cm. (f inch) in width of the kidney, into the posterior aspect of the kidne}', in a horizontal direction — the sutures passing through the muscles of the wound, transversalis fascia, fattv capsule, fibrous capsule, and the above amount of kidney. These are buried sutures. The upper layers of the wound are separately sutured by in- terrupted sutures. The fatty capsule is thus sutured between the lips of the wound. Comment. — (i) The above o])eration is inferior to splitting the fibrous capsule. (2) Sometimes the fatty and fibrous capsules, without including the kidney, are sutured to the lumbar wound. (3) Sometimes the fibrous capsule is exposed and sutured to the periosteum of the twelfth rib. TOTAL NEPHRECTOMY BY or.Linn: i.imi'.ak ixcision. Description. — Excision of one entire kidney. Generally indicated in tumor, extensive suppuration, tuberculosis, fistula. No kidney should be re- moved until the presence of an opposite, and, if possible, healthy one is as- certained (by vesical catheterization of its ureter — or by actual palpation by hand in the abdominal or lumbar wound). The kidney ma)' be remo\ed b_\' several routes — lumbar nephrectomy — abdominal nephrectomy. The lumbar route is to be preferred — and of the lumbar incisions, the oblique lumbar is the best, being especially capable of extension in either direction to give the neces- sary room. Preparation — Position — Landmarks — Incision. — As for exposure of kidnev bv oblique lumbar incisicm. Operation. — (i) The ])erirenal adipose tissue having been exposed and separated from the kidney by blunt dissection — the kidney being enucleated, as it were, by the finger — the kidney itself is brought well into the wound, partly by abdominal pressure from in front, and partly by traction, while the lips of the wound are drawn well apart (Fig. 506). (2) The pedicle is care- fully isolated and freed by blunt dissection — and the kidney is then delivered outside of the wound if possible — especially avoiding traction and twisting of the structures of the pedicle during delivery. (3) The pedicle should be tied with strong silk carried upon a blunt aneurism-needle. Where possible, the artery and vein should be tied separately, and, preferably, prior to their division into branches — the artery being tied first. If not easily differentiated and isolated, the artery and vein may be tied en masse — or in several bundles, re- gardless of whether arteries or veins. If possible, all the structures should be doubly ligated — and the structures forming the pedicle should be relaxed dur- ing the placing of hgatures. The ureter should always be tied separately. The pedicle is then severed between the double ligatures, or between kidney and single ligatures. (4) If healthy, the proximal end of the ureter should be cauterized and dropped back into the wound. If unhealthy, it should be at- tached into the wound and drained. (5) In healthy, clean cases the entire pedicle is dropped back into the abdomen and the wound closed. In sus- picious cases, the pedicle is anchored into the wound and drained. Comment. — (1) Guard the vena cava, which has been wounded in the operation upon the right side. (2) Sometimes the fatty capsule as well as the PARTIAL NEPHRECTOMY. *59 kidney must be removed — necessitating the removal of the entire mass from the surrounding tissues. (3) The peritoneal cavity is often opened. If the rent be small, it is closed with ordinary continuous or purse-string suture of gut. If too large to suture, it is packed with gauze. (4) The pleural ca\dty may be opened in working near the twelfth rib — and should be immediately sutured with continuous or purse-string gut suture. (5) The colon may be wounded. Fig. 506. — Total Nephrectomy by Oblique Lumbar Incision: — A, Kidney brought om of wound in grasp of vulsellum : B, Ligature of renal artery ; C. Ligature of renal vein ; D, Ligature of ureter; E, Quadratus lumborum muscle and last dorsal nerve and lumbar arter>- ; F. Erector spinas muscle; G, Serralus posticus inferior; I, External oblique • J, Internal oblique muscle, and intercostal nerve and artery ; K. Trans\'ersalis aponeurosis. Treat as wounds of intestine elsewhere. (6) Nephrectomy by morcellement (piecemeal) is sometimes done. (7) If the pedicle have not been doubly ligated, it should be clamped near the kidney before division. PARTIAL NEPHRECTOMY BV OBLlglE LUMB.AR INCISION. Description. — Removal of part of a kidney. May be done in removal of growths — or in badly lacerated wounds. Generally done by the lumbar opera- 'ion — unless occurring in the course of some other operation. Operation. — (a) In the deliberate removal of a portion of the kidney, a wedge-shaped piece should be taken out, if possible — so that the sides of the kidney wound, left after the removal of the wedge, could be brought into fairly accurate apposition and sutured by alternate deej) and superficial sutures of gut. (b) In extensive lacerations, leaving irregularities of .-surface, the raw surfaces are to be brought into contact and sutured in the best manner pos- 86o OPERATIONS UPON THE ABDOMINO-PELVIC REGION. sible — by deep and superficial gut sutures. The wound of the abdominal wall is treated upon general principles. SUBCAPSULAR NEPHRECTOMY. Description. — \\'here a dense, perirenal capsular mass surrounds the kidney and is firmly adherent to the peritoneum, colon, \ena cava, diaphragm, and other structures — so that damage to these structures would likely result in attempting to separate such a capsule, this fatty areolar capsule is incised and the incision carried also through tlie proper fibrous capsule of the kidney — which is then peeled back to, and, if possible, into the pedicle — which is then ligated or clamped, and the kidney removed. The cavity of the capsule is then curetted (where indicated) and packed — the abdominal-wall wound being closed up to the packing. The best approach in such cases is by the oblique lumbar incision. TOTAL NEPHRECTOMY BY .ANTERIOR TRAXSPERITONEAL OPERATION. Description. — Removal of an entire kidney through an anterior trans- peritoneal route — the incision being made in either the median or linea semi- lunaris region, the latter giving the more direct approach. Preparation — Position — Landmarks — Incision. — .\s for exposure of kidne\' by vertical incision in linea .semilunaris. Operation. — (i) Ha\ing opened the abdomen as in the operation above indicated, both kidneys and ureters are examined by the hand introduced into the cavity. (2) Displace the colon toward the median line and incise the outer layer of the mesocolon in a vertical direction. This division of the pos- terior peritoneum will be upon either the lateral or median aspect of the meso- colon, as determined by its position on the anterior surface of the kidney. The vessels of the colon are less interfered with if the peritoneum be divided upon the outer side of the mesocolon. (3) The fingers are now passed through this incision down upon the kidney — the perirenal fat is incised and the kidney enucleated by blunt dissection. The pedicle is first to be cleared — by stripping off the peritoneum toward the aorta. The vessels are then ligated with silk passed by means of an aneurism-needle — tving, preferably, the artery first, then the veins. If room be sufficient, double ligatures should be used, pro- viding for division between them, — if not, the pedicle may be clamped near the kidney (instead of the second ligature). (4) The pedicle is now divided be- tween the two sets of ligatures— or between the clamp and ligatures. The ureter .should be separately doubly ligatured and similarly divided. The liga- tured stump, with or without cauterization, as indicated, is returned to the abdomen. (5) The kidney is then further enucleated from its perirenal fatty areolar ti.ssue and removed. .-Ml bleeding vessels are gut-ligatured. (6) If drainage be indicated, it is established through the lumbar region by a counter- opening made upon some instrument thrust backward from within and cut upon from without. (7) The incised mesocolon is sutured with gut. (8) The abflominal wound is closed in the general manner. Comment. — (i) The kidney should be systematically exposed, after in cising the fatty capsule — first the anterior surface, then the lateral borders, the poles, and the posterior surface. (2) Where anterior drainage must be es- tablished, the edges of the incision in the posterior peritoneum are sutured to SURGICAL ANATOMY OF THE URETERS. 86l the edges of the incision in the parietal peritoneum, thus shutting off the gen- eral cavity. Posterior drainage, however, is always preferable. (3) Sus- picious ureters must be brought out into a posterior lumbar wound made as a counter-opening. (4) Avoid injury to the nutrient arteries of the inner layer of the mesocolon. (5) The operation is practically the same whether done through a vertical incision in the Hnea semilunaris or through a median incision. XIII. THE URETERS. SURGICAL ANATOMY. Description. — Fibro-elastic tubes of about 3 to 4 mm. (\ to nearly y\ inch) in diameter — flattened from before backward — with walls of about i mm. (ji inch) m thickness. They consist of outer, fibrous — middle, muscular — and inner, mucous coats. They have an average length, in the male, of about 30.5 cm. (12 inches) — e.xtremes being from 25.5 to 40.5 cm. (10 to 16 inches). They are about 7.5 cm. (3 inches) apart at their beginning — about 5 cm. (2 inches) apart near the sacro-iliac joint — about 3.2 cm. (i j inches) apart at en- trance to bladder — and about 2 to 2.5 cm. (J to i inch) apart at their bladder- mouths. The ureters begin in the funnel-shaped pelvis of the kidney, opposite the spinous process of the first lumbar vertebra — and run downward through a sort of lymph-space between the lamin;e of the subperitoneal connective tis- sue, downward and inward through the lumbar and pelvic regions — ending in the base of the bladder. The genitocrural nerve is in close relation with the ureter. There are three sites at which the ureter is narrower than else- where, — between 4 and 5 cm. (i^ and 2 inches) from the pelvis of the kidney — crossing of iliac artery — and at junction of pelvic and vesical portions. Course and Relations. — d) Abdominal portion : Male and Female : — (a) Right Ureter, — Runs downward and slight!}' inward, from [)elvis of kidney to promontory of sacrum, where it cros.ses either common or e.xternal iliac artery. Rests (posteriorly) upon psoas muscle and fascia, genitocrural nerve, common or external iliac artery. Covered (anteriorly) by peritoneum, sper- matic and colic vessels, and ileum. Internallv lies inferior vena cava, near ure- ter, (b) Left Ureter, — Runs downward and slightly inward, from pelvis of kidney to promontory of sacrum, where it crosses either common or external iliac artery (same course as right ureter). Re.sts (posteriorly) upon psoas muscle and fascia, genitocrural nerve, common or external iliac arterv (same posterior relations as right). Covered (anteriorly) by peritoneum, spermatic and colic vessels, and sigmoid colon. Internally lies abdominal aorta, being 2.5 cm. ( r inch) from ureter above, and i .3 cm. (i inch) below, near bifurcation. (2) Pelvic portion: Both sexes: Both sides; — Runs downward in front of sacro iliac joint — passes upon obturator internus and its fascia, lying inferiorly and internally to psoas — enters posterior fal.se ligament of bladder (rectovesical fold, in male — uterovesical fold, in female) below the obliterated hypogastric artery — hence its course differs in the two .sexes: — (a) Male: Both sides; — It is here crossed above and to inner side bv vas deferens, which intervenes be- tween it and bladder — and, just before entering bladder, it passes beneath the free extremity of the vesicula? .seminalcs. The two ureters are about 5 cm. (2 inches) apart at base of bladder, and about 4 cm. (ih inches) posterior to the prostate gland, (b) Female : Both sides ; — It pas.ses down parallel with the cervix uteri and upper part of vagina — lying about 5 mm. (i inch) external to cervix opposite os internum — running ])ostcriorly to uterine artery, through 862 iiPERATIONS UPON TIIK AIUmiMIXOPELVIC RKCIdX. the uterine venous plexus, and below the broad ligament — crossing the vagina opposite its upper third, to the vesicovaginal interspace, and entering the blad- der opposite the center of the vagina, (c) Intravesical portion : Both sexes : Both sides; — Entering the bladder 4 to 5 cm. (ih to 2 inches) apart, the ureters pass oblicjuely downward and inward through its wall, emerging upon the mucous membrane about 2 cm. (| inch) apart, and about the same distance posterior to the meatus urinarius internus. Arteries. — From renal, spermatic, internal ihac, and inferior vesical. Veins. — End in corresponding trunks. Lymphatics. — Empty into pelvic and lumbar glands and into receptacu- luni ch_\li. Nerves. — From spermatic, renal, and hypogastric ple.xuses. SURFACE FORM AND LANDMARKS. As the ureters are about 7.5 cm. (3 inches) apart at their commencement at the pelves of the kidneys, opposite the first lumbar spinous process, the be- ginning of each ureter will lie about 4 cm. (15 inches) external to the line of the spinous processes, on a level with the spinous process of the first lumbar verte- bra. -And they lie about 5 cm. (2 inches) apart near the sacro-iliac articulation — or abt)ut 2.5 cm. (i inch) from tlie median line. Anteriorly, the line of the ureters, from the kidneys to the brim of the pelvis, may be gotten, appro.ximately, by drawing a line vertically upward from the junction of the inner and middle thirds of Poupart's ligament. And the posi- tion of the crossing of the ureters over the brim of the pelvis may be approxi- matelv represented bv the intersection of a vertical line e.xtending u[)ward from the spine of the pubis, with a horizontal line between the anterior superior iliac spines. GENERAL SURGICAL CONSIDERATIONS. (I) The ureter is so intimatel\' atlherent to the peritoneum that when the peritoneum is stript up, the ureter is almost always reflected along with that membrane and adherent to it. (2) In all suturing about the ureter, an attempt should be made not to include the mucous membrane — though, prac- tically, this may often be done unintentionally. The fibrous and part of the muscular coats should be taken up by the stitch. (3) Fine silk is the suture material generally used — it being difificult to manipulate gut, or to get it fine enough. (4) There is a tendency to narrowing at the site of suture, especially after transverse division. (5) E.xtra-pelvic portions of the ureter should be approached retroperitoneally — except where the cause for the operation upon the ureter arises, or is discovered, during an intra-abdominal operation. (6) Intra-pelvic portion of the ureter is accessible by incision through the abdom- inal wall, bladder, rectum, vagina, perineum, or by sacral resection. (7) Longitudinal wounds of the ureter heal better than transverse ones. (8) Drainage is indicated in all cases where infection is present or suspected, or where the technic is uncertain. (9) In retroperitoneal operations, suture is not absolutelv necessarv, provided drainage be established down to the wound. (10) Whenever the ureter is opened intraperitoneallv. the peritoneum or omentum should be sutured over the wound, so as to make it extra[)eritoneal. (11) \\'here the ureter has been divided and must be transy)lanted. implanta- tion into the bladder is the most dcsiraljle. (12) \Miere the ureter has been EXPOSURE OF THE URETER. 863 completely divided transversely, it should be repaired by uretero-ureterostomy, if possible. (13) Where the division is near the kidney, and uretero-ureteros- tomy cannot be performed, it should be implanted into the pelvis of the kidney. If the division be low down, it should be implanted into the bladder. (14) If such an extent of ureter be lost that uretero-ureterostomy cannot be done — or the end cannot be implanted into the pelvis of the kidney or into the bladder, implantation into the bowel or skin should be done. (15) Longitudinal wounds of the ureter generally heal without suture, if retroperitoneal drainage be provided. (16) Where it is possible, any operation should be protected by peritoneum — in one of two ways: — (a) Lift the ureter up out of its bed, at the site of operation, into the peritoneal cavity — and draw the peritoneum around the ureter from both sides, so stitching the serous membrane as to form a tube through which the ureter runs, practically excluding it from the general peri- toneal cavity. The suturing should, however, be lightly and carefully done, forming a loose tube, so as to avoid subsequent contraction. This is probably the better method, (b) The site of operation upon the ureter may be sur- rounded by a detached piece of omentum lightly sutured to the ureter. (17) The ureter has been separated for as much as 8.3 cm. (3^ inches) from its at- tachments without gangrene — owing to the long artery which accompanies it and is intimately connected with it. (18) The ureter may be lengthened 2.5 cm. (i inch) or more, by steady, gentle traction. (19) When a gap in ureter at the lower end cannot be bridged by stretching, a vesical diverticulum can sometimes be turned up to meet the end of the ureter. (20) Uretero-ureteros- tomy is generally practicable except in the lower 2.5 cm. (i inch) in the male, and the lower 5 cm. (2 inches) in the female. (21) In .severed ureter, the best course is uretero-ureterostomy by, probably. Van Hook"s method — and the next best, uretero-cystostomy (v. i. ). (22) Normal urine is not injurious to the peritoneal cavity, but it is well not to let it come in contact if it can be helped. INSTRUMENTS. See instruments used in operating upon the Kidneys. Also the following special instruments: — Very fine needles, curved, straight, and plain cambric needles; fine silk; fine catgut; fine forceps; fine scissors; small needle-holders; ureteral sound; ureteral catheters; cystoscope; electric illumination; urine evacuator; instruments for segregation of urines. EXPOSURE OF THE URETER. Description. — The exposure of the ureter may be made deliberately — or may be done in the course of some other operation. Most of the operations for exposure of the kidney generally also admit of exposure of more or less of the ureter. .\bdominal portion of the ureter is best exposed bv the oblique lumbar in- cision used in exposing the kidney, extending from just below the twelfth rib, at the angle of junction of the lower border of the twelfth rib and the outer border of the erector spin;e muscle — and passing thence obliquely downward toward, and to within 2.5 cm. (i inch) of, the anterior superior iliac spine — and thence downward and parallel with and 2.5 cm. (i inch) above Poupart's liga- ment, to about its center. This incision will enable the upper three-fourths of the ureter to be freely e.xposed, and will allow of access to the entire ureter, from kidnev to bladder — though, of course, not so free access to the lower one-fourth. 864 OPERATIONS UPON THE ABDOMIXO-PELVIC REGION. It is a possible thing to thus expose the entire ureter extraperitoneally. This exposure should be the one of preference for the upper three-fourths of the ureter (and may be resorted to for even the entire ureter) — except when the ureter is exposed in the course of abdominal section. Pelvic portion of the ureter is readily accessible through the lower median abdominal incision — followed by retraction of the intestines (especially aided by the Trendelenburg position) — and division of the peritoneum over the course of the ureter. The intrapelvic portion may also be exposed by incision through the bladder, vagina, rectum, male perineum, or by sacral resection. Intravesical portion of the ureter may be exposed through a cystotomy vv-ound (incision of the bladder) — generally by the suprapubic route. URETEROTOMY. Description. — Incision of the ureter. Generally done for the removal of calculi — in which case the operation may be called uretero-lithotomy. Calculi may be lodged at either the upper or lower end of the ureter, or in the middle — usually at one of the two ends. Ureterotomy may be extraperitoneal or trans- peritoneal (intraperitoneal) — when the ureter is approached, respectively, behind the peritoneum, or through the abdominal cavity. Extraperitoneal ureterotomy is always preferable. Where the site of the ureterotomv is only determined in the course of an operation performed through one of the regular incisions, the ureterotomy will be extraperitoneal or intraperitoneal, according to circumstances. Even when the ureterotomy is done intraperitoneally, how- ever, the site of the ureterotomv, in concluding the operation, should be as thoroughly shut ofT (walled off) by suturing of peritoneum around the site, as pos.sible. Extraperitoneal ureterotomy is usually done through the oblique lumbar incision, extended as far forward and downward as necessary. Trans- peritoneal ureterotomv is generallv dene through a median abdominal incision, or one in the linea semilunaris. Preparation — Position — Landmarks — Incision. — .\s for exposure of the kidnev Ijv either an oblique lumbar or an anterior abdominal incision. Operation. — (a) In the Extraperitoneal Operation — the ureter — which has generally been found by tracing downward from the pelvis of the kidney — is exposed and divided longitudinally to the necessary extent — over the calculus, if the operation be done for that purpose — the ureter having been steadied and carefully inci-sed with a small, sharp knife, aided by fine forceps — after which the calculus is removed by scoop or forceps. The wound in the ureter, in favorable cases, should be closed with fine silk sutures, passing through the fibrous and muscular coats. Temporary drainage should be employed, in case of leakage — the lumbar wound being closed elsewhere, (b) In the Transperitoneal Operation — the ureter is exposed — the peritoneum divided longitudinally over it — the ureter incised in its long axis — and the object of the operation accomplished (usually the removal of a stone). The incised ureter is generally sutured, as in the extraperitoneal operation — and the peritoneum is then sutured about the wound in the ureter so as to render it as extraperito- neal as possible. Prior to suturing the peritoneum over the ureteral wound, a posterior counter-opening is made, and drainage established through this — the abdominal cavity being then closed. Comment. — Calculi lodged at the lower end of the ureter may sometimes be removed through the bladder, rectum, or vagina, with or without dilating the mouth of the ureter. LRETERU-UKETERAL ANASTOMOSIS. 865 URETERORRHAPHY. Description. — Suturing of the ureter. Generally done for repair of wound.s, or following the incision after ureterotomy for calculi. ^Nlany of the vvouiids are accidentally made by the surgeon in the course of other operations. Varieties of Wounds. — Longitudinal — Oblique, incomplete — Oblique, complete — Transverse, incomplete — Transverse, complete. Preparation — Position — Landmarks — Incision. — As for Exposure of Ureter. Operation. — Suturing is generally done with fine silk, or with very fine catgut — carried upon a fine, curved needle, held in a needle-holder. The edges of the wound are brought together by interrupted sutures, generally in- troduced in the Lembert fashion — passing through the fibrous and part of the muscular coats — but carefully avoiding the penetration of the mucous coat — union taking place by growth of the connective tissue of the apposed surfaces, which is rendered raw in e.xposing the ureter. The following summary sug- gests the appropriate methods for dealing with the various sorts of wounds of the ureter: — (i) Longitudinal wounds ; (a) Close by fine silk (or fine chro- mic gut) Lembert sutures. Reinforce, if possible, by folding or stitching over the suture-line a fold of peritoneum, or an omental graft, (b) Or excise the piece and do an end-to-end ureteral anastomosis. (2) Oblique wounds, incomplete; (a) Same as above (i). (b) Or complete the oblique division and treat as a complete oblique division (v. i.). (3) Transverse wounds, incomplete ; (a) Lembert sutures, (b) Divide the upper lip of the wound in its center longitudinally upward a short distance. Similarly divide the lower lip of the wound in its center longitudinally downward a short distance. Round off the four corners thus formed with scissors — and suture the borders as in "elbowing" the intestines, (c) Having divided and incised as just de- scribed, suture as in the operation of pyloroplasty (see Fig. 7S9). (d) Or comjjlete the transverse division and do an end-to-end anastomosis. (4) Oblique wounds, complete ; (a) Oblique end-to-end anastomosis. (5) Transverse wounds, complete; (a) Transverse end-to-end anastomosis. URETERO-URETERAL ANASTOMOSIS (URETERO-URETEROSTOMY). Description. — Junction, or "splicing," of ends of ureter — by suturing alone — or bv suturing aided by supports. Indicated in wounds accompanied by no loss, or very little loss, of substance. Preparation — Position — Landmarks — Incision. — As for exposure of ureter. Or, as is usually the case, the ureter may be exposed in the course of some other operation. Operation. — Having exposed the ureter, uretero-ureterostomy may be accom])li .Inided iireti rupled Lenibert sutuies passed Ihrou^'h llic outer coals fibrous and muscular coats only — the sutures used being alternating rectangu- lar and interrupted. The peritoneum is then so adjusted as to exclude the sutured ureter from the ])eritoneal cavity. (4) Uretero-ureterostomy by End-into-end Invagination, with Support, without Splitting (Markoe): — This method was resorted to in division of the ureter near the bladder. Two traction-sutures, each threaded upon two needles, are passed through the pro.ximal ureter near its free end, from within outward and nearly 2 mm. (about -^^ inch) apart. The needles are then made to draw the traction-sutures through the wall of the distal ureter, entering in the same relative position and at the same distance apart, passing from within outward. An ureteral catheter is then passed through the distal ureter into the bladder and out of the meatus, being caught by forceps passed ^i^^3Sff«»m»*n»YittW>^l]ttWi^H'l*\ mmmammv. Fig. 508. — CTreterorrhaphv with Scpport :— I'TVU-ral catheter is seen within the ureter, which interrupted sutures are passed through the outer coats of the ureter. through the female meatus (or might be passed from the urethra, by means of a cystoscope, in the case of a male) — the opposite end of the catheter passing into the distal ureter. Over this the proximal ureter is invaginated into the distal, by the traction-sutures — which are then tied. Reinforcing circular suturing is used at the line of Junction, passing through all the coats of the distal and through the fibrous anrl muscular coats of the ])roxinial portions. (5) Uretero-ureterostomy by End-into-end Invagination, without Support, without Splitting (Poggi) : — Dilate the distal end with special for- ceps — [ilace one {ox two) pair of traction-sutures through the proximal end — two needles upon single thread, introduced nearly 2 mm. (about -fV inch) apart, in the same horizontal plane, and about 3 mm. (J inch) from within the lower end of the proximal portion of the ureter — brought out — and the needles passed from within outwartl in the distal end, the same distance apart and about 7 mm. URETERO-L'RETERAL ANASTOMOSIS. 867 to 1.3 cm. (J to J inch) from the free end, and opposite the points of penetra- tion above. The proximal end is then invaginated into the distal by traction, and the sutures tied. This invagination is then reinforced by a continuous or interrupted suture applied around the line of union, including all the coats of the distal and the lihrnus and muscular coats of the pmximal segments. (6) Uretero-ureterostomy by End-into-end Invagination, without Support, with Splitting (Robson, Winslow) :^Slit the ujjper distal end longitudinallv — place one or two pairs of traction-sutures as aV)ove and in- vaginate in the same manner — followed by suturing the slit in the distal end over the proximal end. If necessary, reinforce with circular suturing, as a^Dove. First step. (Modified from (7) Uretero-ureterostomy by Lateral (End-into-side) Implantation (\'an Hook) : — Ligate the distal ].)art of the ureter circularly, aboul 3 to 6 mm. (5 to \ inch) from its free end, with silk or gut (Fig. 509). Commencing about 6 mm. (\ inch) below this ligature, make a longitudinal incision through all the coats of the distal ureter for a distance equal to the diameter of the ureter — with fine, narrow knife, or sharp-pointed sci.ssors. Make a longitu- dinal incision in the proximal ureter, from the margin of the free end upward for about 6 mm. (^ inch). A traction suture of fine catgut, upon two needles, is passed just as in the invagination method — about 3 mm. (J inch) from the free Fig. 510.— URETERO-fRETEROSTOMY II. Second step. (Modified fron end, and from nearly 2 mm. to 3 mm. (j'g- to | inch) apart, and upon the lateral aspect opposite to the vertical slit (Fig. 510). Pass the points of both needles through the slit into the distal ureter, and thence for about 1.3 cm. (h inch) below its lower end — thence penetrate the wall of the distal ureter outward, upon the same aspect of the ureter as the slit, and both needles held at the same horizontal level (side by side — not one over the other). Unthreading the needles, draw (invaginate) the proximal into the distal ureter, until the slit in the proximal is well within the .slit in the distal — and then tie the sutures. Complete the union by suturing the edges of the vertical im ision around the 868 OI'EKATKUNS Ll'oN THK AKDOMINO-PELVIC REGION. proximal, the sutures passing through the fibrous and muscular coats (Fig 511). Further protect the site by peritoneum folded around it, if the operation be intraperitoneal. Note — Where the pro.ximal end (from distention or other cau.se) is too large to go into the distal, it may be narrowed by placing and tying two or more sutures in its free end. Both ends of these "narrowing sutures" are then threaded — and all si.x needles passed into the slit, in pairs, as in \'an Hook's operation, and the threads tied. Comment. — (i) In the operations of invagination, instead of introducing the traction-sutures through all the coats of the proximal end, it would be better to introduce a single needle on a thread, from without through the fibrous and muscular coats alone — then, keeping the needle on the original end, thread an- other needle on the other end, and proceed as is ordinarily done. Thus no capillary thread passes into the lumen of the proximal portion — and the ap- ^ proximated outer wall of the proximal portion to the inner wall of the distal portion blocks off the wall of the distal ureter. (2) In some cases the kidney has been lowered somewhat from its original site, in order to furnish additional length for uretero-ureteral anastomosis. Comparison of Methods of Uretero-ureterostomy. — \'an Hook's Lateral Implantation method is probably the best for all-around use. End- to-end anastomosis is more apt to be followed by leakage. End-into-end anas- tomosis is less apt to be followed bv leakage and stricture. In end-into-end anastomosis about 2.5 cm. (i inch) of ureter is taken up. In end-in-side im- plantation about 4 cm. {\\ inches) of the ureter is consumed. IMPLANTATION OF URETER, IN GENERAL. After division of the ureter, or after excision of a part of the ureter (by accident or other cause), the lower end of the proximal portion of the ureter may be implanted, or "grafted," into the bladder, large intestine (caecum, sigmoid, or rectum), vagina, op|)osite ureter, pelvis of opposite kidney, upper portion of the distal end of the .same side (which is really uretero-ureterostomy), or into the skin. When a simple division has taken place, without loss of substance, a simple implantation, or ana.stomosis of the proximal into the distal end (uretero- ureterostomy), is best. Where a loss of some extent of ureter has occurred, a uretero-ureterostomy is still the best course, where it is possible to approximate the ends without too great tension. Where the loss is too great for this, an implantation into some other structure is necessary. The most usual sites (in order of preference) into which the proximal end of the ureter is implanted are — bladder, large intestine (rectum), and skin. IMPLANTATION OF URETER INTO HI. ADDER. 869 The distal end is ligated and left in situ — some surgeons first cauterizing the stump. .\s many in<,' upward from side of bladder, on each side of urachus. (2) Superior, or abdominal surface : — Entirely covered by peritoneum, from summit and obliterated hypogastric arteries to base of bladder; sigmoid flexure (in male); part of vasa deferentia (in male) ; uterus (in female) ; small intestines (in both se.xes). (3) Antero-inferior, or pubic surface : — Uncovered by perito- neum, and separated from the following .structures by the ca\'um Retzii, or prevesical space; triangular ligament; symphysis pubis; levatores ani and in- ternal obturator muscles; abiinminal wall (when distended), separated bv recto-vesical fascia. (4) Lateral surfaces : — Upper part covered by perito- neum, above and posterior to obliterated hypogastric arteries, — lower part, below and in front of obliterated hypogastric arteries, is covered by recto- vesical fascia, which separates the lateral surfaces from the levatores ani and sui-rounds the vesical vessels and nerves; obliterated hypogastric arteries, which cross lateral surfaces obliquely from below upward and forward; vasa deferentia, arching from before backward along subperitoneal aspect of lateral surfaces toward base, crossing obliterated hypogastric arteries, and passing between ureter and wall of bladder; entrance of ureter, at junction of jiosterior and lateral surfaces, about 5 cm. (2 inches) aljove the pro.state; levatores ani and obturator internus muscles. (5) Postero-inferior surface, or base : — May be subdivided into two parts; — (a) Upper, Peritoneal Portion: — Recto- vesical pouch in male, generally from 1.3 to 2.5 cm. (i to i inch) from pros- tate, up to as much as 5 cm. (2 inches) in marked bladder distention; utero- vesical cul-de-sac in female: — (b) Lower, Non-])eritoneal Triangular Por- tion: — In Male, rests upon anterior surface of .sect)nd jiart of rectum, inferior 876 ()PEKATK).\S I'POX THE ABDOMINO-PELVIC RE(;iON. part of vasa deterentia and vesicula^ seminales; — its boundaries being; Base, reflected recto-vesical fold ; Sides, diverging vasa deferentia and vesiculas seminales; Apex, summit of prostate; — In Female, adherent to anterior vi-all of cervix uteri, and to upper portion of anterior \aginal wall; — Neck of Blad- der, beginning of urethra. Ligaments. — (a) Five true ligaments: — (i) Two puboprostatic, — recto-vesical fascia and muscular tissue — from back of pubic bone to antero- inferior or pubic surface of bladder, passing over superior surface of prostate gland. (2) Two lateral, — recto-vesical fascia — from lateral aspects of pros- tate to sides of bladder and walls of pelvis. (3) Superior ligament, or urachus, — fibro-muscular structure between summit of bladder and umbilicus, (b) Five false ligaments (peritoneal folds): — (1) Two posterior, or recto-vesical folds of peritoneum (in male), — from side of rectum to side of bladder. (2) Two posterior, or utero- vesical folds of peritoneum (in female), — from sides of uterus to posterior surface and sides of bladder. (The posterior false liga- ments form the lateral walls of the recto-vesical and utero-vesical cul-de-sac, and transmit the ureters, obliterated hvpogastric arteries, with vessels and nerves.) (3) Superior ligament, — fold of peritoneum reflectefi over urachus and oblileratetl hy]i(igastric arteries, from ^ummit nf bladder to imnbilicus. Relation of Peritoneal Fold to Anterior Abdominal Wall. — The re- flection of peritoneum is carried upward as the bladder is distended. The maximum elevation of the peritoneal fold rarely exceeds 5 cm. (2 inches). Sometimes it fails to reach the upper border of the .symphysis pubis. Space of Retzius, or Prevesical Space. — Space between the reflection of peritoneum above and the symphysis pubis below, — and between the bladder posteriorly and the symphysis pubis anteriorly — and occupied by connective tissue. Trigonum Vesicae. — Triangular smooth .surface at base of bladder — bounded .it eath posterior angle by the ureteral opening — and at the antero- inferior angle by the urethral orifice. Orifices of Ureters. — Situated about 3.8 cm. (i^ inches) from base of prostate gland and l)eginning of urethra — and are a little less than 5 cm. (2 inches) apart, at either end of the base of the trigone. Internal Urinary Meatus. — Lies, in the adult male, from 2 to 2.5 cm. (f to 1 inch) posterior to the symphysis pubis, and from 5 to 6.3 cm. (2 to 2A inche.s) above the perineum. It generally lies opposite seme part of the upper half of the symphysis pubis. Arteries. — Superior, middle, and inferior vesical, and branches from the obturator and sciatic, in the male, — and the same, with additional branches from the uterine and vaginal, in the female, — all from the anterior trunk of the internal iliac. Veins. — Form plexuses around neck, sides and base, and end in internal iliac vein. Lymphatics. — .Accom])any the veins and enrl in the pel\ ic glands. Nerves. — From livpogastric ])lexus of sympathetic, and from lliird and .'ourth sacral nerves. SURFACE FORM AND LANDMARKS. In young children, the apex of the empty bladder is about 2.5 cm. (1 inch) above the level of the symphysis pubis. In the adult, the apex of the em])ty bladder is about on a level with the superifir border of the symphysis ]nibis. THE BLADDER— GENERAL SLRGUAL CONSIDEKATH i.NS. 877 In marked distention the anterior bladder-wall comes closely into contact with the abdominal parietes — without the intervention of peritoneum between the two. For the normal extremes of the peritoneal reflection, see Surgical Anatomy, page 876. For the position of the jjeritoneal reflection under surgical disten- tion, see General Surgical Considerations, below. The neck of the bladder is on a level with a line extending horizontally backward from just below the center of the symphysis pubis. Also see position of internal urinary meatus, Surgical Anatomy, page 876. The depth from the perineal skin to the pelvic floor generally averages from 5 to 7.5 cm. (2 to 3 inches) in the posterior and external part of the perineum — and somewhat less than 2.5 cm. (i inch) in the anterior part. In the lithotomy position the bladder is about 6.3 or 7.5 cm. (2^ or 3 inches) from the perineal surface. GENERAL SURGICAL CONSIDERATIONS. When both bladder and rectum are empty, the apex of the bladder and the peritoneal reflection are slightly below the superior border of the symphysis pubis. When the apex of the bladder is as much as 5 cm. (2 inches) above the symphysis and resting against the anterior abdominal wall, the peritoneal re- flection is about 2 cm. (| inch) above the upper border of the symphysis. Simple distention of the rectum alone tends to elevate the base of the blad- der without correspondingly elevating the non-peritoneal prevesical space. When the rectum is distended by a rubber bag filled with air or water, the prostatic portion of the urethra is elongated, and the bladder is thereby raised out of the pelvic cavity and the peritoneum pushed upward. The maximum elevation of the non-peritoneal prevesical space is obtained by distending the rectum first and then distending the bladder. The rectal bag is first filled with about 10 or 12 ounces of fluid — and then the bladder is filled with about 8 ounces. Thereby an additional space free of peritoneum is secured in the anterior line. The amount of space uncovered by peritoneum which is thus ordinarily secured generally amounts, altogether, to about 7.5 cm. (3 inches). The bladder, however, is often first filled — and up to 15 ounces may be used. dray states that after distending the rectum with 420 c.c. water — and then filling the bladder with 500 c.c. — the bladder will be elevated by the rectum sutHciently to make an interval between the lower peritoneal reflection and the upper border of the symphysis equal to 8.5 cm. (3 fji inches). .\s the point of reflection of peritoneum, therefore, is not fi.xed, and as it sometimes comes down to a level with the upper border, or even below, the symphysis pubis, it is never absolutely safe to plunge a trocar directly into the bladder, even immediately above the upper border of the symphvsis. It is always better to expose the bladder-wall by a limited median incision before using the trocar. Though not to be recommended, the iiladder may be punctured from the rectum, in the lower, non-peritoneal surface at the base of the bladder. No vessels of any size cross the median line of the abdomen or of the peri- neum — the two sites through which cystotomy is generally done. The artery of the bulb, especially when arising normally, i> not generally cut in perineal lithotomy. If the artery of the bulb arises from the accessory pudic it will lie more anteriorly than normal — and well out of the way. If, however, it arises from the pudic sooner than usual, it will cross the perineum more posteriorly and will be almost certainly cut. 87S iil'KKATIiiNS irnx llIK All] )i I.MIXO-PKIA IC kK(.;|(J.\. Perineal incisions made into the neck of the bladder shoukl not exceed the limits of the prostate. The prostatic plexus of veins is likely to be wounded in lateral perineal lithotomy. The ejaculatory duct is apt to be cut in the same operation if the incision be too far posterior. INSTRUMENTS. Scalpels; bistouries, straight and curved, sharp and blunt : lithotomy knives; scissors, straight and curved, blunt and sharp; forceps, dissecting and toothed; artery-clamp forceps, long and short; grooved director; special grooved directors and perineal guides; grooved lithotomy staffs, median and lateral; tenacula; probe; retractors, various; blunt dissector; sponge-holders; trac- tion-loops; Clover's crutch; rectal bag; catheters; sounds; whalebone guides; tunneled sounds; lithotomy forceps; lithotomy scoop; lithotrite; evacuator; irrigating syringe; special bladder forceps; cystoscope; special electric illumi- nator; trocar and cannula; exploratory svringe; needles, straight and curved; needle-holder; ligatures and sutures, silk and gut; drainage-tubing; gauze. INTRODUCTION OF SOUND OR CATHETER. Description. — The general method of entering the male bladder by the urethra is the same in all essentials — whether by metallic sounds, catheters, lithotrites, or cystoscopes. Soft instruments are not subject to much guiding, but generally enter the bladder by being simply protruded through the urethral canal without special effort to direct them through the anatomical curves. The passage of in>truments in the female is simple. Passage in the Male. — (i) The glans and the meatal opening are cleansed. (3) The patient lies supine, near the edge of the table — shoulders slightly elevated — thighs shghtly flexed and rotated outward by bending the knees (to relax the muscular tension). The surgeon stands on the left, just above the hips, facing the patient's side. (3) The sound, or catheter, warmed, lubri- cated, and disinfected, is held lightly in the right hand, between thumb and first two fingers — the handle at first parallel with the abdominal wall. Thus held, its point is introduced into the meatus, the lips of which are parted by the sur- geon's left index and thumb to receive it — the glans and penis being held ver- ticallv in the surgeon's left fingers. As the instrument is ])ushed onward and downward, the penis is correspondingly drawn upward and over the instrument. (4) As soon as the instrument is felt to have entered about 10 or 13 cm. (4 to 5 inches), and to be rounding toward the subpubic arch, the handle is gradually elevated until the perpendicular is reached — allowing the instrument to gravi- tate through the canal and beneath the pubic arch. (5) As this occurs, the handle is continued in its sweep forward, directing the point through the tri- angular ligament — onward through the membranous and prostatic urethra — until the end is felt to glide into the bladder — when the handle will be found pointing directly away from the bladder and slightly downward — having passed through a semicircle in the vertical plane. (6) In withdrawal, the above steps should be exactly reversed. Comment. — (1) The sound should first hug the floor of the spongy ure- thra, until the lacuna magna (on the roof. 2.5 cm. [i inch] from the meatus) is passed — and then gently hug the roof for the balance of the way through the PARACENTESIS VESIC.Ii. 879 spongy, membranous, and prostatic urethra. (2) By carrying the handle of the instrument forward and between the thighs too soon, the tip of the instru- ment is made to hug the roof of the urethra too suddenly and closely, and is apt to lodge against the upper part of the anterior aspect of the triangular ligament, and thus fail to enter the membranous urethra. (3) On the other hand, the instrument sometimes fails to pass the triangular ligament because of lodging against the lower part of the anterior aspect of the triangular hgament, the handle not being depressed enough — and, in such cases, is made to glide on by depressing the handle more — or by lifting the lodged point upward by the lelt index-finger in the rectum, or even by pre.ssure against the perineum -behind the scrotum. (4) The instrument may be at first introduced while held about parallel with the left Poupart ligament — that is, over the left groin — and then swept into the median line as it descends. (5) If the beak of the instrument revolves readilv, the sound is in the bladder. Passage of the Female Sound or Catheter. — (i) The patient lies supine, with hips and knees semiflexed, and thighs separated. (2) Separate the labia with left thumb and index. Holding the instrument between the right thumb and index, the index extending beyond the end of the instrument, pass the tip of the right index just within the vaginal orifice — withdraw the finger partly, hugging the upper wall of the vagina — and, as the finger glides out of the vagina upon the vestibule, the prominent urethral papilla is felt (about 1.3 cm., or h inch) above the junction of the vagina and vestibule — upon which is situated the meatus — into which the instrument is then introduced and protruded into the bladder. PARACENTESIS VESICA. Description. — Puncture of the bladder-wall by cannula and trocar, or bv aspiratory syringe. Indicated in retention of urine. The bladder mav be punctured immediately above the pubis, just below the symphvsis pubis, through the rectum, or through the prostate gland. The suprapubic puncture is practically the only method of puncture now resorted to — and will be here described. Preparation. — Ascertain that the bladder is well distended. Shave in the region of the median line, just above the .symphysis pubis. Position. — Patient supine, — or sitting upright, supported. Surgeon on patient's rit,'ht, facing him. Point of Puncture. — In median line, immediately above the upper border of tile svm];)h\'sis pubis. Operation. — Having outlined the distended bladder by percussion — a curved cannula and trocar (which are better than the straight) are taken in the operator's right hand, with the convexity upward, and so held, with the index- finger upon the shaft of the instrument, that the depth to which it may enter the bladder is fi.xed in advance. The bladder is steadied by the surgeon's left thumb and index placed on each side of the median line. The instrument is thrust sharply but gently into the bladder, entering in the median hne just above the symphysis pubis, and directed backward and downward — piercing skin, superficial fascia, jjassing between the inner borders of the recti and pyramidales (or through their muscular substance), prevesical space, anterior bhidder-wall, and into the bladder. The trocar is then withdrawn and the cannula left in silii until the urine has come away, chiefly of its own accord, and partly aided by gentle pressure. Upon withdrawal of the instrument, the opening is at once closed by sterilized cotton and collodion. 88o OPERATIONS UPON THE AKDOMINO-PELVTC REGION. Comment. — (i) Local anesthesia should be first used. (2) Incision of skin may be first made and then trocar introduced. This may be done either to avoid the most difficult part of the puncture mechanically, namely, the penetration of the tough skin with a comparatively dull instrument, — or it may be done, as mentioned under Surgical Considerations, ft.r tl.e purpose of first exposing the bladder before puncturing. (3) If the skin be drawn down- ward over the symphysis just before puncture, a valve-like opening will be formed. (4) In those rare cases in which the reflection of peritoneum comes very low down, to or behind the symphysis pubis, it will almost certainly be wounded — not being possible to avoid it, e.xcept, were it known in advance, by exposing the area by dissection and pushing the peritoneum upward before the puncture. Puncture of the peritoneum, however, is exceedingly rare provided the bladder be well distended, and a curved instrument be used. CYSTOTOMY IN GENERAL. By Cvstotomv is meant the incision oi the Ijladder. The less correctlv used term " lithotomy " (or "stone-cutting," literally) is equivalent to "Cystotomy for removal of calculus." Cvstotom\' is indicated in calculus, foreign bodv in the bladder, exploration, drainage, acics^ to prostate, tumors, diM'a.secl icjnditions of the mucous mem- brane, catheterization of the ureters intravesically, etc. Cystotomy may be suprapubic, median perineal, lateral perineal, bilateral perineal, medio-lateral perineal, medio-bilateral perineal, vaginal, and by ex- ternal urethrotomy. The first three of these are, practically, all which are now- done — and of these three, the suprapubic is the one which is most frequently performed. For the removal of large stones, the suprapubic route should always be chosen — while it is preferable for the removal of any calculus. For the pur- poses of drainage alone, not weighing other considerations, the perineal route is the best. SUPRAPUBIC CYSTOTOMY. Description. — Incision of the bladder above the symphysis pubis, through the prevesical space. Indicated for calcuh — especially large ones — or encysted small ones; exploration; drainage; tumors; foreign bodies; access to prostate gland. Much more frequently performed than median or lateral perineal cvstotom}'. Preparation. — Pubes shaved; rectum emptied; rectal bag in rectum, well above the sphincters, in hollow of sacrum, and filled with lo to 12 ounces of water (or with air); bladder irrigated and filled with 8 to 10 ounces of water (after the rectum has been distended); penis carefully ligated with rubber band to keep water in bladder. Position. — Patient supine. Surgeon on patient's right. Assistant oppo- site. Landmarks. — Median line; up):er border of symphysis pubis. Incision. — About 7.5 cm. (3 inches) in length — placed in the median line — beginning about 6.5 cm. (ai inches) above the symphysis pubis and ex- tending to a point about 1.3 cm. (J inch) above the symphysis. The extreme upper antl lower ends of this incision are not carried to the lowest depths of the wound — but are onlv .superficial and are to allow for retraction of the parts. SUPRAPUBIC CYSTOTOMY. 88l Operation. — (i) Divide the skin and superficial fascia, clamping, if neces- sary, any bleeding vessels. Sometimes abundant fatty areolar tissue must be traversed. The interval between the inner borders of the recti and pyramidales is sought, but is frequently not demonstrated — and, if not, the muscle tissue is divided in the line of its fibers, without further needless search — the edges of the wound being well retracted as they are deepened (Fig. 519). (2) The transversalis fascia is encountered and similarly divided in the median line — and the prevesical space reached. The areolar tissue overlying the prevesical space is cautiously divided in the median line — extreme care being here used, for the purpose of recognizing the lower reflection of peritoneum, especially if it be prolonged unusually far down. The peritoneal fold must be sought from below (near the symphysis) upward, the dis.section beginning immediately Fig. 519. — Si'PRAPUBic Cystotomy : — A, Margins of recti and pyramidales muscles; B, B, Prevesi- cal areolar tissue freed and retracted from blatlder ; C, Peritoneum retracted upward (unopened); U. D, Tenacula passed through serous and muscular coats of bladder and subsequently used to re- tract lips of bladder-wound. above the upper border of the symphysis. As soon as encountered, the peri- toneal fold is carefully pushed upward, with the left index, off the front of the bladder, so as to be out of the way of injury. All the prevesical fatty areolar tissue should be divided accurately in the middle fine, until the bladder-wall is well exposed — which is generally recognized by its pink muscular appearance, convex contour, fluctuation, and elasticity. The lips of the wound should be well retracted — and any bleeding from the prevesical veins controlled. (3) The bladder is steadied by two tenacula passed transversely across the median line through the outer coats, at the extreme upper and lower limits of its exposed surface, and held in the two hands of the assistant. When all is in readiness, the operator, with sharp, narrow knife, by a quick, controlled thrust, stabs through the bladder-wall just below the upper tenaculum (in- 882 OPERATIONS UPON THE ABDO.MINn-PEl.VIC REGION. suring, by this method, the penetration of all coats of the bladder — and not the protrusion of the muscular coat ahead of the knife-point, as sometimes happens in a slowly made incision) and cuts downward in the middle line toward the lower tenaculum, increasing the extent of the incision as he draws the knife out. The contained fluid immediately escapes — but, owing to the holding up of the bladder, but a small amount enters the prevesical wound. Two silk retraction- sutures are now placed through the center of each lip of the bladder-wound — and the tenacula withdrawn. Some surgeons, instead of using the tenacula as above, originally place these traction-sutures, with a curved needle, passing through the outer coats of the bladder, parallel with the future incision, and about 1.3 cm. (5 inch) apart. Hemorrhage from the edges of the bladder- wound may occur at lirst, but generally is esa^iW controlled. The ligature about the penis is now relaxed and the bladder emptied. (4) The assistant who held the tenacula now holds the bladder-lips apart by traction-sutures. The opening into the bladder is enlarged to the desired extent in the median line, upward and downward — carefully guarding the peritoneum above, which especially tends to prolapse when the bladder is empty. A finger is introduced and the cavity of the bladder examined — and the special object of the operation accompHshed. If it be a calculus to be removed, special forceps, guided by the introduced finger, grasps the stone and withdraws it. The rectal bag may be emptied and withdrawn as soon as the bladder is entered — or, if not distended before, may be then distended to bring the fundus of the bladder more into the wound. (5) Where indicated — in healthy condition of the parts and where no great traumatism has been done — the bladder-wound may be closed at once. In suturing, retract the upper and lower angles of the bladder-wound by wound- hooks, thus approximating and paralleling the margins of the vesical woimd. Withdraw the silk traction-sutures as soon as the wound-hooks are in place. The margins of the bladder are then neatly and closely brought together with fine chromic gut, upon a curved needle — placed interruptedly and passing through all the coats except the mucous membrane. It is probably well to reinforce this Hne of suturing with a second tier of interrupted Lemberts of silk or fine gut — the roughened connective-tissue coat of the bladder, being ap- proximated in tlie Lcmbert fashion, uniting. Some surgeons use a first layer of sutures through the mucous membrane — and a second layer through the outer coats. Still others use a row of Lemberts through the outer coats only. (6) The superficial wound is now closed — except to a small extent immediately over the center of the bladder-wound — where temporary drainage is established for thirty-six or forty-eight hours, in case of leakage. Two tiers of sutures are used in the superficial wound — a buried chromic gut interrupted or con- tinuous tier, uniting the divided muscle tissue, — and a superficial silkworm- gut, or silk, placed interruptedly through the skin and fascia. The sutures opposite the site of drainage may have been placed — and simply tightened upon the withdrawal of the drain. Comment. — (1) The incision, superficial and deep, especially where done for exploration, mav be less extensive than the above. (2) If in doubt about the position of the bladder, use an exploratory .syringe. (3) Avoid detaching the anterior bladder-wall from the posterior surface of the symphysis. (4) If the peritoneum be accidentally wounded, immediately close it with fine gut sutures of the Lembert type. (5) Special forms of hooked gorgets have been made to hold up the bladder while exploring or operating upon its cavity. (6) Use round needles in suturing the bladder. (7) In some cases, for drainage, or other reason, the .suprapubic wound is left open — and then the edges of the bladder are sutured with chromic gut to the deeper edges of the superficial LATERAL PERINLAL CYSTOTOMY. 883 wound. (8) Some surgeons leave a catheter in the bladder for two or three days — to avoid overdistention and pressure upon the sutures. (9) In children, the bladder is naturally higher in the abdomen. LATERAL PERINEAL CYSTOTOMY FOR REMOVAL OK VliBICAL CALCULL'S. Description. — Incision of bladder through left lateral region of perineum — generally performed for the removal of calculi. The operation is sometimes less correctly called I.ateral Lithotomy. It is always performed upon the left side because the manipulations upon that side are more convenient to the surgeon. The operation, as here carried out, is applicable to any purpose for which it is indicated to approach and open the bladder by this route — but it is generally done for stone, although less frequently now than formerly. Calculi of moderate, but not the largest, size may be removed by this route. The special instruments required are: — a left dorso-laterally grooved lithotomy staff; probe-pointed knife (if preferred to straight-pointed); stout bistoury with cutting edge of about 5 cm. (2 inches); Clover's crutch, or .some provision for maintaining the lithotomy position; wristlets and anklets (mav be used). I cystotomy ; B. Median Preparation. — Rectum empty and irrigated. Perineum shaved. Rec- ognition of calculus bv sound. Position. — Patient rests upon back, and, in this position, is brought down to end of table, so that buttocks come well oxer the edge of the table. While steadied in this position, the syjecial staff is jiassed into the bladder and gixen into the charge of an assistant, who, henceforth, holds it steadily and unvary- ingly in the middle line. Clover's crutch (and anklets and wristlets, if de- sired) are then adjusted, and the thighs flexed back upon the abdomen — or an assistant on each side may hold a limb in the above position, without the use of the crutch — and the patient remains in the characteristic lithotomv position throughout the operation. The surgeon sits at the end of the table, facing the patient's perineum. The assistant, standing on the left, who holds the staff in his right hand, holds up the penis and scrotum with his left. Up to the en- trance of the knife into the groo\e of the staff, the staff" is held so that its handle 884 OPERATIONS UPON THE ABDOMINO-PEIATC REGION. is nearly parallel with the abdominal wall, so that its convexity causes the membranous urethra to round out more prominently and nearer to the peri- neum, making it more accessible to the operator. When once the knife has entered the groove and the deeper part of the incision is being made, the staff is held with its handle perpendicular and its concavity up against the pubic arch and its point v^'ell in the bladder. When all is ready for the incision, and the staff is in position, the surgeon should examine, by rectum, for staff, prostate and ischial tuberosities — and then change gloves. Landmarks. — Central tendinous point of perineum; median raphe; anus; ischial tuberosities. Incision. — From a point about 8 mm. (^ inch) to left of median raphe and just posterior to the central tendinous point of the perineum (which is 3.2 to 3.8 cm., or i^ to i^ inches, anterior to the adult anus) — to a point between the ischial tuberosity and the posterior portion of the anus, and one-third nearer the Fig.52i.-Si'RrACK ViK are seen on right, and deep c perineal cystotomy; C, Bulb seminalis, and base of bladd) I, Hemorrhoidal vessels and : — Superficial structures 1 left. A, Incision for lateral perineal cystotomy ; B, Incision for median D, Membranous urethra ; E, Prostate gland ; F, Vas deferens, vesicula r ; G, Internal pudic arterv ; H , Superficial perineal vessels and nerves ; lerves ; J, Anus. (Modified from Gray.) tuberositv than the anus (according to others, midwav between the tuberosity and the anus) — making a total incision of from 5 to 7.5 cm. (2 to 3 inches). (Sec Fig. 520, A, and Fig. 521, A.) Operation. — (i) With the staff in the first of the positions indicated above, the superficial incision is made in the form of a thrust — the operator steadying the perineal tissues with his left fingers — and directing the point of his knife at a right angle to the perineum, with its back upi:)ermost, enters its point at the upper limit of the above incision — and aims directly for the groove upon the lateral asjject of the staff, but does not attempt to actually reach it, though he may do so and enter it at once. The incision is made as the knife is withdrawn, following the above line of incision — is about 7.5 cm. (3 inches) in length, and grows less deep as it passes backward and outward. The structures cut in the superficial incision are, in order — integument; superficial and deep layers of LATERAL PERINEAL CVSTOTOMV. 885 superficial fascia; transversus perinasi muscle; transverse perineal artery, veins, and nerves; lower margin of superficial layer of triangular ligament; hemor- rhoidal vessels and nerves. (2) With the staff now in the second one of the positions indicated above, the left index is introduced into the upper angle of the wound and feels for the staff — and, with this finger held in position as a guide, with the nail turned so that it enters the groove, or is directly over it, the knife is passed, with the back of the blade uppermost, along the back of the forefinger and nail straight into the groove — either the knife with which the superficial incision was made, or a special probe-pointed lithotomy knife. The point of the knife having been well engaged in the groove of the staff, the second or deep incision is now made — by pushing the knife down- ward and backward, depressing the handle as the knife goes forward to pre- vent its leaving the groove, the point kept constantly in the groove, and the Fig. 522.— Sectional View of Perineal and Pelvic Regions :— The knife is ■ tlirougli the perineal structures, and incising the membranous urethra between the bulb, the prostate gland, behind. (Modified from Gray.) sides of the knife parallel with the edges of the now deep wound, and inclined to the left— until the lower end of the knife passes through the prostate gland and neck of the bladder — as evidenced by a gush of urine. The deep opening into the bladder is then enlarged to the extent considered necessary by bearing gently upon the cutting end as the knife is withdrawn — and ceasing to use pres- sure, and, therefore, cutting force, as the knife reaches the more superficial planes of the wound. The structures cut in the deep incision, are, in order — membranous and prostatic jtarts of the urethra; superior or deep layer of tri- angular ligament; compressor urethra- muscle; anterior portion of levator ani muscle; left lateral lobe of prostate gland. The incision through the urethra and prostate will be from near the median line obliquely backward and out- ward (Fig. 522). (3) In the case of a stone, the lithotomy forceps are intro- 886 OPERATIONS UPON TIIK AliDOMINO-PELVIC REGION. duced closed, along the finger in the l)ladder as a guide, preceded or not by the dilatation of the bladder, as indicated — and the stone is grasped and removed, aided or not by the fingers in the bladder. (4) The interior of the bladder may be then irrigated — if debris or other cause call for it. (5) A perineal lithotomy drainage-tube is inserted — and the wound left open, or closed only at its ex treme ends by suture. Comment. — (1) Where the calculus is lodged behind an enlarged pros- tate gland, or held by the bladder-walls in some unusual position, or embed- ded, special manipulations of the lithotomy forceps is necessary. (2) Large stones may be broken by the lithoclast and removed in pieces. (3) Contra- indications to lateral perineal cystotomy for the removal of stone, are — a large stone; enlarged prostate, and deep perineum — under which circumstances a suprapubic cvstotomy would be done. (4) Hemorrhage during the steps of the operation is controlled by ligature, clamping, pressure, and hot douching. (5) Avoid cutting the bulb and its artery in front — the rectum behind — and the pudic artery laterally. (6) Inci.'^ion too far posteriorly will cut the ejaculatory ducts. (7) Draw the penis well u[) over the .staff as the deep cut is made — so as to pull the bulb up. (8) Incision through the neck of the bladder should not exceed about 2 cm. (J inch). (9) Stick to the groove in the staff, after once reaching it. (10) Some difficulties, peculiar to the smallness of the parts, are encountered in lateral lithotomy uj)on children. MEDIAN PERINEAL CYSTOTOMY FOR REMO\ AL OK \KSICA1, CALCLLl'S Description. — Incision of bladder through median perineal region — generally performed for the removal of calculi. The operation is s(a and the corpus spongiosum. Corpora Cavernosa. — Connected, side by side, in the median Une, for their anterior three-fourths — an imperfect fibrous septum intervening. Sep- arated, posteriorly, to form the crura, or roots. The crura are attached by their blunt, fibrous, posterior ends to the antero-internal aspects of the two rami of the pulses and ischia, above the tuberosities. The anterior ends of the cavernosa are received into the fossa formed by the ba.se of the glans penis, or head. The superior median groove of the corpora cavernosa lodges the dorsal vein of the penis. The inferior median groove lodges the corpus spongiosum. Corpus Spongiosum. — Encloses the urethra, which passes into the bulb nearer its superior as])ect. It is received into the inferior median groove of the corpora cavernosa. It ends, anteriorly, in the glans penis, or head of the organ. It ends, posteriorly, in the bulb of the corpus spongiosum — between the diverging crura of the corpora cavernosa, and between the deep laver of the superticial fascia and the superficial layer of the deep fascia — being covered by a fibrous process from the anterior layer of the deep perineal fascia and sur- rounfied bv the accelerator urin;e muscle. Suspensory Ligament of the Penis. — A fibrous band passing from the front of the symj)hy>is pubis to the adjacent portion of the penis, merging with its fascial sheath. Muscles of Penis. — Erector penis; accelerator urin;e; compressor ure- thra?; transversus perina;i. Arteries. — (a) Of the corpora cavernosa : — arteries of the corpora caver- nosa; dorsal arteries of the penis. All from internal pudic. (b) Of the corpus spongiosum: — artery of the bulb, from internal pudic. Veins. — Some of the veins empty into the dorsal vein, which ends in the prostatic plexus. Other veins empty directly into the prostatic plexus, pudic ple.xus, pudic veins, and obturator veins. Others empty into the cutaneous veins of the penis and scrotum. Lymphatics. — The superficial empty into the inguinal glands. The deep empty into the pelvic glands. Nerves. — From the dorsal and superficial perineal branches of the pudic and from the hypogastric plexus of the sympathetic. INSTRUMENTS. Scalpels; narrow, straight bistoury; scissors; retractors; tenacula; dissecting and toothed forceps; artery-clamp forceps; blunt dissector; periosteal elevator; 896 OPERATIONS UPON THE MALE GENITAL ORGANS. rubber tourniquet (rubber catheter); needles, straight and curved; needle- holder; ligatures and sutures, silk and gut. CIRCUMCISION. Description. — Removal of greater portion of redundant or contracted pre- puce. The amount of foreskin to be removed should be so calculated that two objects be accomplished: — first, that enough foreskin be removed to insure easy exposure of the entire glans penis, even during erection; — secondly, that enough foreskin be left to insure constant covering of the prominent corona glandis during relaxation of the organ, thereby securing retention of greater sensitiveness of the papilla; than when the corona is ^\ worn constantly bare, and, therefore, dry. Many me- chanical contrivances have been devised for aiding in circumcision — but the oper- ation can generally be more satisfactorily done with scis- sors alone — and, by this means, greater accuracy is usually obtained in provid- ing the exact amount of pre- puce which it is well to leave. Preparation. — A con- strictor, usually a rubber band, is applied around the base of the penis. Position. — Patient su- pine, near the left edge of table. .Surgenn on patient's right. Landmarks. — Positior of sulcus at junction of head and body of organ. Operation. — (i) As there will be a much greater tendency for the skin-aspect of the prepuce to retract more than for the mucous-membrane-aspect, it is well, in all methods of cir- cumcision, as a preliminary step to the actual division of preputial tissue, to take the skin and mucous surfaces of the foreskin be- tween the left index and thumb (or between the blades of a pair of toothed forceps) and so dispose the parts that the mucous membrane is drawn slightly forward and the skin pushed slightly backward — so that there will be somewhat less disparity when the section is made. (2) Taking the foreskin in the left fingers, the surgeon inserts the lower blade of a pair of straight scissors beneath the upper aspect of the foreskin, between it and the dorsum of the glans — and Fig. 528. — Circumcision :— I. glans and prepuce, cutting forest; in up to level of its removal. CIRCUMCISIOX. 897 cuts through the prepuce with one stroke, up to the height upon the dorsum which it has been calculated will leave sufficient prepuce to cover the corona during relaxation of the organ (Fig. 528). (3) The scissors are then with- drawn from the vertical incision — and the position of the hands then changes. The left fingers grasp the left flap, the one nearer the surgeon, and, holding it slightly away from the glans, the scissors are made to cut through one-half of the circumference of the organ — the guide for the cut being that it should pass about parallel with the corona glandis, crossing the median line upon the under aspect of the prepuce just in front of (distal to) the frcenum (Fig. 529). (4) The right flap is now dealt with in the same manner — completing the encircling of the organ. The incision will, therefore, slope ob- liquely from above down- ward and from behind for- ward. (5) Four primary chromic gut sutures are then applied in the mid- points — above, below and laterally — closely approxi- mating the margin of mu- cous membrane to the margin of skin. These are followed by four or eight secondary sutures evenly distributed between the primary ones (Fig. 530). (6) The dressing is so ap- plied as to leave an opening for urination. Comment. — (I) The usual error is to remove too much foreskin. A pre- puce, appearing to be suffi- cient after the completing of the operation, often gets entirely and permanently behind the corona in sub- sequent retraction — at the expense of considerable loss of sensitiveness of the papillae. (2) If any ques- tion arise, during opera- tion, as to the width of the opening being too narrow, the vertical incision may be extended upward ad- ditionally high — the lateral incisions then being sloj)ed downward so as to come just in front of the fra-num. (3) The redundancy of the mucous mem- brane is apt to be much greater than that of the skin. (4) In using all forms of circumcision-clamjjs too much or too little prepuce is apt to be cut awav. (5) If the penis is to have a preliminary constrictor applied, which would tend to draw back the foreskin into a somewhat unnatural position, greater accuracy in measurements may be obtained by first (before applving tourni- .=;7 Fig. 529.— Circumcision :— II. Division of the entire thick- ness of the prepuce transversely, at the upper limit of the median incision. While the entire redundant portion of pre- puce is being drawn downward, the left thumb and index so manipulate the parts that more of the mucous membrane than of the skin is removed. SpS OPERATIONS UPON THE MALE GENITAL ORGANS. quel) stain. marking the site at which the removal is desired with a nitrate of silver (6) Sometimes one or more vessels have to be twisted or gut-ligatured. (7) Do not leave too great an amount of tissue near the frwnum. (8) It may be necessary, before suturing, to trim the edges somewhat with scissors, especially of the mucous membrane. (9) Where there is firm adhesion between prepuce and glans, especially in children, the pre- puce must be carefully peeled otT — by means of the fingers, aided by toothed forceps and the flat portion of a probe. (10) Often, in adherent prepuces, no in- strument can be sli]jped up between the l)repuce and glans — and the opening of the prepuce is too small to allow of re- tracting the membrane far backward — in which cases the redundant portion must be put upon tension and cut off trans- \ersely, after which the .separation of ad- hesions may be more easilv accomplished. (11) In operating in adherent cases, re- adhesion is prevented by removing an excess of mucous membrane and leaving a sHght redundancy of skin. In com- pleting the operation, the skin is sutured to the very short mucous membrane — and, being quite long, is doubled upon itself, and the part in contact with the f the nature, somewhat, of mucous membrane. Fig. 530.-ClKcrMCisK.N:-III. Plac iu^ ut interrupted sutures — which approxi male the free edge of the skin (A) to thi free edge of llie mucous membrane (B). lans eventuallv becomes PARTIAL AMPUTATION OF PENIS y,\ I I. AT Ml riic )]< Description. — Consists in the amputation of more or less of the free por- tion of the penis by a long anterior and short posterior flap — the freed urethra being brought through and sutured into the anterior flap. The stump is thus covered by two bluntly rectangular flaps. Preparation. — A rubber tourniquet (usually a rubber catheter) is placed around the base of the organ. A short piece of soft catheter is passed into the urethra, down to the tourniquet, to emphasize the furrow between the corpora cavernosa and corpus spongiosum — or may be passed just l)efore the trans- fixion. Position. — Patient supine, at edge of table. Surgeon on patient's right. Assistant opposite. Landmarks. — Line of section. Furrow between cavernosa and spongio- sum. Incision. — The anterior flap will have a width of one-half the circum- ference of the penis at the liiie of division, and a length of about one diameter of the penis. The posterior flap will have the same width of base, and a length of about a half diameter of the penis. Operation. — (1) Having decided upon the line of section of the penis, an I'ARTIAL AMI'LTATKiX OF I'EXIS. 899 anterior or dorsal flap, of skin and connective tissue, is cut, having a vi^idth of half the circumference of the organ at the line of division, and a length about equal to the diameter of the organ (Fig. 531). This is raised up by dissection Fig. 532. — Partial Amputation of Penis by Flap Method : — II. Transverse section of stump ; A. Long anterior flap turned back, showing slit for urethra ; B, Short posterior flap ; C, Dorsal vein and arteries ; D, Corpora cavernosa and vessels ; E, Corpus spongiosum ; F. I'rethra dissected out, and ready to be sutured into slit of anterior flap. and turned back — the dorsal arteries being tied with gut. (2) On a level with the base of the anterior flap, the divisional groove between the corpora caver- nosa and corpus spongiosum is recognized, aided by the soft catheter in the goo OPERATIONS UPON THE MALE GENITAL ORGANS. urethra. A narrow-bladed knife, held flatwise, with back of blade backward, is thrust horizontally through the organ, between the cavernosa and spongio- sum — and cuts its way through, passing at first directly forward in the groove and then rounding abruptly downward — thus forming an inferior flap of about one-half the diameter of the penis in length, composed of corpus spongiosum, with its included urethra and skin. (3) The urethra is now dissected out from the small inferior flap, back to a line with the base of the flaps. (4) The cor- pora cavernosa are divided transversely from within outward and upward, on a line with the highest point of transfi.\ion (base of flaps) (Fig. 532). The arteries of the corpora cavernosa are tied with gut, or twisted, (s) Make a vertical incision in the center of the long anterior flap, opposite the urethra and just large enough to receive the urethra. The urethra is then drawn through this opening. If the urethra be much too long, the redundancv is cut off, leaving a protru- sion of about 7 mm. (J inch) — which is slightly slit above and below — and sutured into ihe margins of the opening in the ante- rior flap. (6) The two flaps are then united by suture, both where their free ends meet — and where in apposition laterally (Fig. 533). (7) A dressing is applied, leaving room for urination — at the same time exercising pressure of the flap against the stump of the penis. Comment. — The arteries of the corjius spongiosum and of the septa mav need ligating. F'Sff- 533- — Partial Amputation of V Method:— III. The parts sutured; A. Sutur E, Urethra sutured into slit iu long anterior flap. TOTAL AMPUTATION OF THE PENIS. Description. — In the total am])Utation the entire organ is removed, ex- cept the i)oslerior portion of the corpus spongiosum — the proximal portion of the urethra ijeing made to open in the perineum. Preparation. — Shave pubis and perineal region. Position. — Patient supine, at end of table, in lithotomy position. Surgeon between limbs. Assistant to surgeon's right. Landmarks. — Subpubic arch; scrotal and perineal raphe. Incision. — The incision circularly surrounds the ba.se of the organ, at its junction with the abdominal wall — and is then continued down the median line of the scrotum and into and along the median line of the perineum. Operation. — (i) Inci,se the scrotal tissues exactly in the median line, from the under surface of the penis, at its junction with the scrotum, to and into the perineum. Separate the two scrotal sacs by blunt dissection, until the corpus spongiosum is reached. All bleeding vessels are clamped and ligatcd as en- TOTAL AMPUTATION OF THE PENIS. goi countered. If a metallic sound be previously introduced through the urethra, the incision and subsequent dissection are made easier (Fig. 534). (2) If a sound have not been previously introduced, a large-sized metallic sound is now passed through the urethra up to the triangular ligament, to aid in defining the corpus spongiosum. The corpus spongiosum is then dissected out until free in its entire circumference. The sound is then withdrawn — and the s])ongy urethra is divided well in front of the triangular ligament — and the proximal end of the spongy urethra is then freed back to the triangular ligament. (3) Carry the upper end of the vertical incision circularly around the base of the Fig. 534. — Total Amputation of Penis : — A, A, The two halves of scrotum split and retracted outward ; B, Penis drawn downward and to one side, thus aiding separation of its crura ; C, Corpora cavernosa (crura) ; D, Ramus of ischium ; E, Periosteal elevator detaching left cms of penis from ascending ramus of ischium bj- blunt dissection ; F, Dorsal vessels of penis divided and ligated. 'rhe suspensory ligament of penis and concavity of pubic arch are seen just below ; G, I^islal end of corpus spongiosum and urethra ; H, Proximal cml of urethra dissected out and ready to be stitured into perineum. penis. Divide the suspensory ligament — and e.xpose the corpora cavernosa. (4) The corpora cavernosa are to be followed down to their attachment to the rami of the pubes and ischia^and freed from their attachment chiefly by blunt, but partly by sharp, dissection. The dorsal arteries are tied after cutting through the sus|jensory ligament, and the arteries of the corpora cavernosa generally recjuire ligation when the cavernosa are freed from the bone. Bleed- ing from the ve.sico-prostatic plexus of veins is often considerable, and is to be controlled by pressure and hot water. (5) The proximal end of the urethra is now turned downward and .sutured into the perineum — the mucous membrane of the former being sutured to the skin of the lips of the perineal wound. If necessarv, the urethra mav be split so as to enable its lips to be more readily sutured into the perineal wound. (6) The remaining perineal and all the 902 OI'ERATIUNS L'I'OX THE MALE GEXrrAI, (JRGAXS. scrotal portions of the wound and the circular area formerly occupied bv the base of the penis, at the peno-abdominal junction, are all sutured in one straight antero-posterior line with continuous silk suture. (Figs. 535 and 536.) Fig. 535. — Total Amputatio.n- oh Pknis :— Scrotun uniting scrotal sacs ; B, proximal eiitt o\ urethra sutured into perineum Fig. 536. — Same; Scrotum in normal position (patient on back); C. suture-line uniting ; sacs ; D, interrupted sutures about to be tied, converting circular incision around base of penis linear cicatrix continuous with scrotal suture-line. Comment. — (1) The urethra should be so sutured into the perineum that in the act of urination, in a sitting posture, the urine will not wet the scrotum. (2) The early passage of the metallic sound greatly aids in the splitting of the scrotum. II. THE URETHRA. SURGICAL ANATOMY. l\) yixi.v. Urethra. Description. — Extends from bladder-opening to e.xternal urinary meatus — from 20.5 to 23 cm. in length (8 to g inches). It consists of muscular, erec- tile, and mucous tissue. It is divided into prostatic, membranous, and .spongy portions. Prostatic Portion. — .About 3.2 cm. (ij inches) long. Passes through the prostatic gland, near its upper aspect, from base to apex. The following ob- jects are upon the floor of the prostatic urethra, from behind forward; — (a) verumontanum, an elevation of mucous membrane in the middle line; — (b) prostatic sinuses, one upon each side of the verumontanum, with the orifices THE UKETHKA— GENERAL SURGICAL CONSIDERATIONS. 903 of the prostatic ducts opening into them; — (c) sinus pocularis, a cul-de-sac lying in front of verumontanum and passing backward for about 1.3 cm. (j inch) into the substance of the prostate gland, beneath the central lobe; — (d) openings of the two ejaculatory ducts into the orifice of the sinus pocularis. Membranous Portion. — Portion of urethra between the two layers of the triangular ligament — about 2 cm. (f inch) long upon its anterior, and 1.3 cm. (t inch) long upon its posterior aspect. E.xtends between ape.x of pros- tate gland and posterior aspect of bulb of corpus spongiosum. Its anterior surface is about 2.5 cm. (i inch) below the pubic arch — the dorsal vessels and ner\es and some muscular fibers intervening. It pierces both Jayers of the triangular hgament, receiving an investment from each. It is sur- rounded by the compressor urethra' muscle. Spongy Portion. — .\bout 15.5 cm. (6 inches) in length. E.xtends entire length of corpus s]jongiosum, from bulb to e.xternal meatus. The portion within the bulb is sometimes called the "bulbous urethra." The ducts of Cowper's glands open upon the floor of the bulbous portion. The glands of Littre open upon the mucous membrane of the penis, especially upon the floor of the spongy portion. One of these, the lacuna magna, opens upon the roof of the fossa navicularis, about 2.5 cm. (i inch) from the external urinary meatus. The fossa navicularis is situated within the glans penis. Narrowest Portions of Urethra. — At e.xternal meatus; in the mem- branous portion; at the neck of the bladder. Vessels and Nerves. — See under '• Penis." (B) Fe.nlale Urethr.^. Description. — .\bout 3.2 to 3.8 cm. (i^ to i^ inches) in length — from neck of bladder to external urinary meatus. Its diameter is about 6 mm. (i inch), undilated. It pierces the triangular Hgament and is directed upward and backward, with concavity slightly forward. It is surrounded anteriorly and laterally by a ple.xus of veins (plexus of Santorini). It lies under the symphysis pubis — its posterior wall being closely connected with the anterior wall of the vagina. The bladder-opening lies about 2 cm. (J inch) behind the center of the symphysis pubis. The external urinary meatus is a vertical slit lying about 2.5 cm. (i inch) posterior to the clitoris, just anterior to the entrance of the vagina, and inferior to the lower edge of the symphysis pubis. The female urethra is composed of muscular, erectile, and mucous tissue — and is embraced by the compressor urethra muscle, between the layers of the triangular ligament. Vessels and Nerves. — From the same source as those of the vagina {q. v.). SURFACE FORM AND LANDMARKS. The base of the triangular ligament can be felt through a thin perineum. The membranous urethra pierces the triangular ligament about 2 cm. (J inch) below the subpubic ligament — and about 2 cm. (f inch) in front of the central tendinous point of the perineum. GENERAL SURGICAL CONSIDERATIONS. Stricture never occurs in the prostatic urethra — and is very rare in the membranous — hence one may generally count upon finding a patulous urethra 904 OPERATIONS UPON THE MALE GENITAL ORGANS. after cutting down upon that portion emerging from the apex of the prostate gland. For other general considerations, see Urethrotomy. INSTRUMENTS. Scalpels; bistouries; scissors; forceps, dissecting, toothed, and artery clamp; tenacula; grooved director; sounds; catheters; filiforms; tunneled sounds; grooved and tunneled guides; probe-pointed scalpels; sponge-holders; retractors; thread-retractors; bulbous bougies; dilating bougies; prostatic catheters; medially and laterally grooved staffs; urethrotomes; Clover's crutch, wristlets and anklets; gorget; urethral dilator; dilating urethrotome; penis syringe; female catheters; needles, straight and curved; needle-holders; ligatures and sutures, of silk and gut; silkworm-gut; drainage-tubing; gauze. INTRODUCTION OF SOUNDS AND CATHETERS. See Introduction of Sounds and Catheters into the Bladder, page 878. MEATOTOMY. Description. — Incision of external urinary meatus. Indicated in con- tracted meatus, especially in cases where it is necessary to pass a full-sized instrument. Preparation — Position. — As for Internal Urethrotomy. Operation. — The penis is taken in the fingers of the operator's left hand — the lips of the meatus are parted by the index and thumb — a probe-pointed bistoury is passed just within the canal, its cutting-edge downward — and an incision made, as far as necessary, downward along the median line of the floor of the meatus, increasing the size of the meatus to the desired dimen- sion. The lips of the wound, until healed, must be kept apart with a strip of gauze. Comment. — The operation may be done bv a meatome, a special instru- ment, which is inserted closed and the meatus is cut in the act of opening the instrument. URETHROTOMY IN GENERAL. Urethrotomy consists in the incision of the urethra, generally in its long axis. Varieties of Urethrotomy. — Internal Urethrotomy and External Urethrot- omy. Internal Urethrotomy: — division of a strictured urethra from within the canal, by means of a special in.strument, a urethrotome, introduced into the canal. Where simultaneous dilatation is indicated, a dilating urethrotome is used. Internal urethrotomy is usually confined to the penile portion of the organ, and the incision is generally made into the roof of the urethra. External Urethrotomy: — division of a strictured urethra from without inward. External Urethrotomv is indicated — (a) In impermeable strictures anywhere and evervwhere in the canal — (b) All strictures, whether permeable or not, at or posterior to the subpubic urethra. Several grades of permeabilitv of the urethra mav exist — calling for ex- IXTER.NAL URETHROTOMY. 905 ternal urethrotomies of several grades of severity. These grades of stricture, and the measures for their relief, are, in order: — (i) Grooved staff can be passed entirely through the strictured urethra, — and, upon this, the stricture is divided — constituting E.xternal Urethrotomy by Syme's Method. (2) Grooved staff cannot be passed, but a filiform guide can be introduced through the stricture into the bladder, and, over this guide, Gouley's grooved tunneled sound can be carried down to the stricture (but not through it), — and, upon this, the upper end of the stricture is exposed, and the tihform followed into the bladder and the stricture thus divided — constituting External Urethrotomy by Goulev's Method. (3) Grooved staff cannot be passed through stricture, nor can filiform be passed through, but a grooved staff can be passed down to the stricture (not through it), — and, upon this, the urethra is opened just in front of the stricture, a fine grooved director passed, and the stricture divided upon this — constituting External Urethrotomy by \Vheelhou.se's Method. (4) Neither grooved staff nor filiform can be passed through the stricture, the urethra being, practically, impassable to instruments of all kinds — therefore no attempt is made to use any form of guide — the urethra is opened, by the sense of touch and relations, posterior to the stricture and immediatelv anterior to the prostate — constituting External Perineal Ure- throtomv without a guide (Perineal Section, or Cock's Operation). The bladder is kept partly full in all urethrotomy operations, in order that entrance to it may be recognized by the escape of fluid. For the anatomy involved in the perineal operations, see the description of Median Perineal Cvstotomv. INTERNAL URETHROTOMY BY D1L.-\T1NG URETHROTOME. Description. — Division of a strictured urethra from within the urethra, bv means of a special instrument, a dilating urethrotome, introduced into the canal. If simultaneous dilatation be not indicated, a plain urethrotome mav be used. Internal urethrotomy is generally confined to the penile por- tion of the organ, and the incision is usually made from behind forward, upon the roof of the urethra. Preparation. — Locate the exact position of the stricture by a bulbous bdugic. in the following manner, — introduce the largest-sized bulbous bougie which will pass the stricture — draw it back until its shoulder is felt against the posterior end of the stricture — bend the free portion of the bougie at the external meatus — draw the instrument outward until the bulb shps through the stricture — then push it back until the tiy) of the bulb rests against the anterior end of the stricture — then again bentl the free portion of the bougie at the external meatus — and withdraw the instrument entirely- -when the portion of the handle between the two bends will repre.'^ent the extent and distance of the stricture from the meatus. .\ more accurate means of getting the desired position and extent of the stricture is accomplished by the ure- thrometer. The urethra should be irrigated with a mildly antiseptic solution before instrumentalization — and a cocain, or other anesthetic solution, thrown into tlic canal. Position.— Patient .'^upine at edge of table. Surgeon upon left, facing patient's ])enis. Landmarks. — Previous data gotten from urethrometer, or bulbous bougie. Kniiwn anatomv of urethra. go6 OI'ERAIIUXS UI'UX THE MALE GENITAL ORGANS. Operation. — The dilating urethrotome, with closed blades and concealed cutting-edge, and well lubricated with aseptic lubricant, is introduced into the urethra after the fashion of a sound, until the concealed cutting-edge has passed directly opposite the posterior aspect of the stricture, as determined by the previous measurements of the urethrometer corresponding with the measurement and distances marked on the urethrotome. The dilating blades are then put upon the stretch until the strictured urethra is tensely distended — then the cutting-edge, turned toward the roof of the urethra, is sprung by the controlling screw in the handle — and drawn through the stricture, to its anterior limit, from behind forward. (Fig. 537.) It is then caused to sink below the blades — and the dilating blades again separated. If the ^iS- 537- — Internal ^Urethrotomy.: — A dilating urethrotome is shown within the urethra — the limbs of the instrument being moderately dilated — and the knife-blade sprung so as to incise roof of spongy urethra anterior to the triangular ligament. cutting has allowed of sufficient dilatation, it is not repeated — if not, while the urethra is under dilatation, the blade is sprung a second time, and again cau.sed to sink — after which the dilating blades are again separated, to see if sufficient dilatation has been secured, as indicated by the dial upon the handle. If so, the blades are permanently closed and the instrument is withdrawn. If there should be marked bleeding, a large sound, dipped in sterile cold water, is passed into the urethra and the penis bound to it. Cominent. — The incision mav be made from before backward — but from behind forward is better. It mav also be made upon more than one site of the same stricture, but upon the roof generallv suffices, and is safer than EXTERNAL PERINEAL URETHROTOMY. 907 upon the floor. Several strictures may be divided simultaneously. If the external meatus be too small to admit the urethrotome, meatotomy should be done. The subsequent passage of sounds is necessary, until healing is complete — and, at intervals, for a considerable time afterward. EXTERNAL PERINEAL URETHROTOMY UPON GROOVED STAFF— SVME'S METHOU, Description. — A grooved staff can be passed entirely through the stric- ture — and, upon this, the stricture is divided from the perineum. Special Instruments Required. — Syme's grooved staff, or an ordinary lithotomy staff of small size, grooved medially upon its convex aspect. Gorget, or grooved director, for entering the bladder from the perineal wound. Preparation — Position. — As for median perineal cystotomy. # Fig. 538. — External Perineal Urethrotomy: — The perineum is shown incised and retracted. A Syme's shouldered, grooved staff is seen engaged witliin the membranous urethra — while the edge of a knife is shown incising the constricted urethra upon the groove of the instrument. Landmarks. — Median perineal line; position of grooved staff in urethra, and especially the position of the stricture to be divided, as ascertained by previous use of the urethrometer, and also verified by the shouldered portion of the staff corresponding with the urethrometer measurements and resting against the anterior end of the stricture. Incision. — Having introduced Syme's grooved staff, or a small, centrally grooved lithotomy staff, well lubricated, into the urethra and through the stricture — so that its shouldered projection rests against the anterior aspect QoS OPERATIONS UPON THE MALE GENITAL ORGANS. of the stricture, an incision is made in the median line of the ])erineum, so placed that the shoulder of the staff (that is, the anterior end of the stricture) will be exposed in the depth of the incision. Operation. — (i) The steps of the operation are, practically, those of median perineal cystotomy, as to structures incised and the manner of dividing them. The cut is made directly toward the .shoulder of the instrument — the groove is entered — and, with the back of the point of the knife in the groove, its cutting-edge is pushed in the direction of the neck of the bladder, until the entire stricture is felt to be divided along its floor. (Fig. 538.) (2) A gorget, or grooved director, is now passed along the grooved staff on into the bladder — and the staff is then withdrawn. (3) A soft-rubber catheter is pa.s.sed through the urethra from the meatus — its end being guided through the ])erineal wound by the operator's fingers and on into the bladder, upon the grooved director, on the proximal side of the perineal gap. (4) The perineal wound is allowed to heal by granulation around this catheter — being left oiien in whole — or sutured onlv at the ends. Comment. — (1) If the catheter cannot be constantly retained, a tube may be carried into the bladder through the perineal wound. But an instrument should be daily passed from the meatus into the bladder during heali .g, even though a full-length instrument cannot be constantly worn. (2) An ex- tensive perineal wound should be closed in part, from the ends — leaving the center open for the tube and drainage. EXTERNAL PERINEAL URETHROTOMY UPON' ,\ FII.II'OKM Gl'lDi:— COri.KV'S OPERATION'. Description. — In ca.ses in which the grooved staff cannot be passed, and only a filiform whalebone guide can be made to enter the bladder — a grooved tunneled guide is carried o\er the filiform down to the stricture (but not through it) — and, upon this tunneled guide, the upper end of the stricture is exposed — and the filiform is then followed on down into the bladder and the stricture divided. Special Instruments — iMliform whalebone guides; Gouley's (or other) grooved tunneled staff. Preparation — Position. — As for median perineal cystotomy. Landmarks. — Median raphe; scroto-perineal junction ; anus. Incision. — In median line, from base of .scrotum to a point about 1.3 cm. (^ inch) anterior to the anus. Operation. — (1) Having succeeded in getting a filiform whalebone guide into the bladder, Gouley's tunneled grooved staff is threaded upon this and carried down into the urethra upon it, with the right hand, while the left hand holds the filiform — until it is arrested at, or within, the strictured urethra. An assistant now takes the filiform and metallic .staff in his right hand, and draws up the scrotum with his left. (2) The surgeon incises directly in the median line of the perineum, beginning at the scroto-perineal junction, and ending about 1.3 cm. (i inch) in front of the anus. The incision at first passes only through skin and fascia. The lower end of the instrument in the urethra is then felt for, the surgeon's left index nail depressing the intervening structures over the groove — and all the intervening ti.ssues are now divided down to and into the groove — in the same manner and order as in median perineal cystotomy. (3) A silk traction-loop is placed in either lip of the urethral wound and the lips are then drawn apart — thus clearly demon- EXTKRXAL I'EKIXEAL URETHROTOMY. 909 strating the interior of the urethral canal, from its normal lumen above to where it disappears below into an almost imperceptible lumen. (4) The metallic staff is now partly withdrawn and steadied by an assistant, using care to retain in situ the filiform, by holding it in the perineal wound as the staff is withdrawn over it. Nothing now remains at the immediate site of the operation but the whalebone guide passing into the bladder. (5) With a probe-pointed bistoury, the filiform is carefully followed backward and the stricture thus divided throughout its length and slightly beyond. The tun- neled staff is then thrust into the bladder over the whalebone guide. (6) The filiform is then withdrawn. A grooved director or gorget is passed into, the bladder, through the perineal wound, over the grooved statT — and the staff withdrawn. (7) The remaining steps are the same as in Syme's operation (see sections (3) and (4), including " Comment," page 908). EXTERNAL PERINEAL URETHROTOMY UPON GROOVED STAFF P.\BSED DOWN' TO STRICTIRE — WHHELHOUSE'S OPER.-VTION. Description. — In these cases the grooved staff cannot be passed through the stricture — nor can a fihform be passed through — but a grooved staff can be passed down to the stricture — and, upon this, the urethra is opened just in front of the stricture and a fine grooved director is passed through it — and the stricture is divided upon this last director. The urethra is thus opened in the median line about 6 mm. (J inch) in front of the stricture — the feature of the operation being that at least this much of the sound urethra should be exposed in front of the stricture. Preparation. — Perineum shaved. Lubricated groo\-ed sound introduced down to the stricture and steadily held in the median line. Position. — Patient supine, in the lithotomy position at the end of the taljle. Surgeon seated opposite the i)erineum. Assistant on patient's left, hcil(hng staff. Landmarks. — Median line; perineo-scrotal junction; anus. Incision. — From reflection of superficial perineal fascia, at perineo- scrotal junction — to anterior border of sphincter ani. Operation. — (i) Incision is made in the median line to the above extent, and the tissues of the perineum are divided as in median perineal cy.stotomv — separating the tissues in the direction of the sound until the urethra is reached. (2) The urethra is then divided to a limited extent upon the grooved sound — especial care being taken that the urethra is opened about 6 mm. (J inch) in front of the stricture — the opening not extending down to the stricture. Looped silk traction-ligatures are then put in through the lips of the divided urethra, upon either side, and the two lips of the urethra are thus drawn apart. (3) The grooved sound is then withdrawn a short dis- tance — just far enough to free its end from the remaining 6 mm. (\ inch) of intact urethra in which it had been, up until then, engaged — the .sound is then turned through a lialf revolution upon its axis, so that its extremitv now I)oints outward — and thus hooks up upon its concavity the uj)per limit (angle) of the urethral wound. The urethral opening is thus stretched apart in a lozenge-.shaped manner, by the hooked .sound above, bv the traction-ligatures on each side, and by the attachment of the intact urethra below. (4) While thus held apart and well exposed, a fine probe-pointed grooved director, or gorget, is insinuated into and along the strictured urethra, with its groove QIO OPERATIONS UPON THE MALE GENITAL ORGANS. uppermost. Even often when the opening cannot be seen, the director will find its way toward the bladder among a mass of distorted tissue. (5) The groo\-e of the director is now turned downward — and the strictured portion of the urethra is divided upon its floor by a knife passed along the director. The knife is withdrawn and the groove of the director, still in the urethra, is turned upward — and a metallic catheter, or sound, is then passed from the meatus, and is guided through the opened urethra b\' the fingers in the perineal wound — and thence on to the groove of the director — and thus into the bladder. (6) The metallic in.strument is allowed to remain /;; situ for three or four days during granulation of the parts around the new canal — and is then passed daily until the perineal wound heals. (7) The perineal wound may be partly closfr less permanent opening of the urethra upon the perineum. Indicated where the anterior portion of the urethral canal is impermeable, as for stricture, — or in case of amputation of the penis. Preparation — Position — Landmarks. — As for median perineal cys- totomy. Incision. — Determined by the special circumstances of the case. Operation. — (a) For the establishment of Urethrostomy following ampu- tation of the penis, see section 5, under " Operation," page goi. (b) In per- forming Urethrostomy in connection with a strictured urethra: — Having expo.sed the strictured site, divide the urethra transversely, just behind the stricture, and free the proximal end of the urethra to a limited e.xtent. Slit the proximal end slightly upon its floor, or upon floor and roof — and suture the lips thus formed by slitting, into the skin of the perineum. Suture up the proximal end of the distal portion of urethra — and close the wound up to the margins of the imi)lantcd urethra. 912 Ol'EKATlONS UPON THE MALE GEMTAl. ORGANS. III. THE SCROTUM AND TESTES. SURGICAL ANATOMY. (A) The Scrotum axu CnvKKixds df Testes and Cords. Description. — The scrotum is a cutaiieo-musculo-areolar sac, investing the testes and [jart of the spermatic cords. It is composed of skin and dartos — the remaining layers mentioned below being, more ]3ro]ierly, coxerings of the testes and cords. Skin. — Of characteristic appearance. CcMiiinuous with the general integument. Marked in the middle line by a raphe, which divides the scrotum into two lateral halves superficiallv. Dartos. — Proper tunic of the scrotum — composed of reddish, elastic, and unstriped muscle tissue — continuous with the superficial and deep layers of the superficial fascia. Septum scroti — formed by the dartos — extending from the raphe to the inferior surface of the penis — dividing the scrotum into two cavities for the two testes, the left cavity being the longer. Intercolumnar or External Spermatic Fascia. — Derived from borders of pillars of external al_>dominal ring. Continiuius with superficial perineal fascia and superficial fascia (i\er the s\mphysis pubis. Loosely (Gray — closely, according to iSIorris) adherent to the dartos. Intimatel\- adherent to the cremasteric fascia. Cremasteric or Middle Spermatic Fascia. — Fibro-muscular layer de- rived from lower border of internal ciblique muscle. Infundibuliform Fascia (Fascia Propria, or Internal Spermatic Fascia). — Connective-tissue layer tericirlv than anteriorlv. Relations of Peritoneum. — Invests whole of posterior aspect of uterus, Init only up])er three-fourths of anterior aspect. Ligaments. — Three pairs peritoneal — four pairs muscular (three of latter lying between folds of broad ligament and one I'etween folds of posterior liga- ment). Two Lateral or Broad Ligaments (])eritoneal) : — duplication of peritoneum extending transversely outward from sides of uterus and vagina to sides of pelvis — the two peritonea! lavers being continuous above at free bor- der, but diverging below and laterally, and including various structures be- tween their folds (v. Broad Ligament, page g;;o). Two Anterior, or Vesico- uterine (peritoneal): — reflected from top of bladder to aniiricr wdW of uterus, at junction of sui)ra\aginal cervix. Two Posterior, or Recto-uterine (peri- toneal) : — peritoneal folds reflected backward from intraperitoneal part of cer- vix and vagina, on to second part of rectum — forming lateral boundaries of Douglas's pouch. Two Utero-sacral (muscular) : — muscular bands lying 59 Q2q g^O OPERATIONS UPON THE FEMALE GENITAL ORGANS. between folds of the posterior or recto-uterine ligaments. Extend from second and third pieces of sacrum forward and downward to sides of uterus at junc- tion of body and supravaginal cervix (opposite os internum), crossing the sides of the rectum opposite the junction of its first and second parts. Two Utero- pelvic Ligaments (muscular): — muscular expansions, extending between folds of broad ligaments, from fascia over obturator internus muscles to sides of uterus and vagina, surrounding the utcro-wiginal vessels and nerves. Two Utero-ovarian Ligaments (Ligaments of the Ovaries) (muscular); — pro- longations of uterine muscular t'lbers in the form of round cords, e.xtending between folds of broad ligaments, from upper angles of uterus to inner aspects of ovaries. Two Round or Utero-inguinal Ligaments (muscular) : — libro- muscular cords, lo to 12.5 cm. (4 to 5 inches) long, placed between folds of broad ligaments, extending from superior angles of uterus through inguinal canals to labia majora (v. Round Ligaments, page 931). Arteries. — Ovarian, of abdominal aorta — carried into broad ligament by infundibulo-pelvic ligament — divides into tubal artery and ovarian artery projjer. Uterine, of internal iliac — runs downward along pelvic wall to base of broad ligament — thence inward near floor of pelvis toward cervix, which it reaches at junction of vagina, passing in front of ureter — and runs up side of cervix and uterus between folds of broad ligament, communicating with oppo- site uterine and Ijranches of ovarian. Veins. — Correspond with arteries. \"eins from ovarian plexuses empty — right, into inferior vena cava — left, into left renal. \'eins from uterine plexuses em|it\' into internal iliac veins. Lymphatics. — Those from body empty into lumbar glands — and those from cervix into pelvic glands. Nerves. — From third and fourth sacral — and from hvpoga.stric and renal plexuses. (2) Broad I-igamext.* Description. — Duplicature of peritoneum, extending transversely from sides of uterus and vagina outward to sides of pelvic wall — the two layers being continuous superiorly at their free border — and diverging laterally and infe riorly to envelop various structures (v. i.). Relations. — Superior or free Border (mesosalpinx): — summit of dupli- cature, where it envelops fallopian tube. Extends from side of uterus toward pelvic wall, to beyond the fimbriated extremity of fallopian tube. Infundibulo- pelvic ligament — that portion of superior border of broad ligament between fimbriated extremity of fallo]3ian tube and lower attachment of broad ligament — a concave, rounded border — the ovarian vessels being conveved in this liga- ment. Inferior Border : — attached to levator ani muscle and recto-vesical fascia. Ureters, vessels, and nerves pass through the subperitoneal areolar tissue between its layers. Internal Border : — attached to lateral walls of uterus and vagina. Utero-vaginal \essels anri muscular bands pass between the two lamina?. External Border: — In contact with oliturator fascia. Transmits uterine vessels and rounrl ligament. Structures between Two Layers of Broad Ligament. — Ovary — pro- jects from posterior lamina. Ligament of ovary — from angle of uterus to lower or internal aspect of ovary. Fallopian tube — in upper free margin. Round ligament — forms a ridge beneath anterior lamina, on its way to inguinal canal. Parovarium (fetal relic) — between ovary and outer part fallopian tube. Duct of Gaertner; hydatid of Morgagni; small cysts — all fetal relics. Uterine, * Here described because involved in Hysterectomy. SURGICAL ANATOMY OK THE VAGINA. 931 ovarian, and funicular vessels; lymphatics; and uterine plexus of nerves. Sub- peritoneal fatty areolar tissue. Inxoluntary muscular fibers — from obturator fascia to sides of uterus and vaj^ina. Broad ligament divides pelvic cavity into : — Anterior part — containing bladder, urethra, and vagina; — Posterior part — containing rectum. Boundaries of Douglas's Recto-uterine Pouch. — Anteriorly; posterior wall of uterus, supravaginal ccr\i.\, ujjper fourth of vagina. Posteriori}'; rectum, sacrum. Laterally; sacro-uterine ligaments. Superiorly; small in- testines. (3) RcirXD LiG.AMEKTS.* Description. — Two flat, cord-like bundles of muscular, filirous, and areo- lar tissue, vessels and nerves, continuous with uterine fibers, attached to supe- rior angles of uterus just below and in front of fallopian tube — each passes upward, outward, and forward between layers of broad Ligaments to pelvic wall, raising the anterior layer of broad ligament into a fold — curves around deep epigastric artery on inner side of external iliac arter\ — enters internal abdominal ring — passes through inguinal canal — emerges from external ring — its fibers then becoming lost in tissues of labia majora and mons veneris. May be accompanied by an invagination of peritoneum, the canal of Nuck (analogous to pouch of peritoneum accompanying descent of testes), which may remain patulous. Receives fibers in transit through inguinal canal — and gives off few fibers to pillars of ring. Aierage length — 10 to 12.5 cm. (4 to 5 inches). Supplied by funicular branch of superior vesical of internal iliac. (4) \".AC.1NA. Note. — \'agina is here described in connection with \'aginal Hvsterectomv. Description. — Extends from orifice I)elow through an opening in tri- angular ligament, to neck of uterus above — completely surrounding the cervix. E.xtends u]>ward much further beyond posterior lip of uterus (about 2 cm., or J inch) than beyond anterior lip. Length of anterior wall, about 6.3 cm. (2^ inches), — posterior wall, about q cm. (3^ inches). Fornices, anterior and posterior — consist of angles of reflection of vaginal on to uterine mucous mem- brane. Transverse .section of vagina is H-shaped, when collapsed. Struc- ture — fibrous, muscular, and mucous coats. Relations. — Anteriorly; Base of bladder — loose subperitoneal fascia intervening. Urethra — subperitoneal areolar tissue intervening in upper one- third, but closely connected in lower two-thirds. Ureters — which enter blad- der v2 cm. (i^ inches) Ijelow level of os uteri. Posteriorly ; Rectum — Doug- las's peritoneal cul-de-.sac intervening for about 2.5 cm. (i inch) above — and subperitoneal areolar tissue intervening lower. Perineal body — below (sepa- rating vagina and rectum). Laterally: — \'aginal branch of uterine artery. Subperitoneal venous plexus at base of broad ligament. Ureters crossing upper third obliquely. Levatores ani, in relation with lower two-thirds. Arteries. — \'aginal, internal pudic, ve.sical, and uterine branches of in- ternal iliac; external pudic branches of femoral. Veins. — Correspond with arteries — but form vaginal plexuses on each .side of \agina. Lymphatics. — Empty chiefly into pehic — some into inguinal glands. Nerves. — From fourth sacral and i)udic nerves — and from hypogastric plexus. * Here described because involved in Hysterectimiy. 932 OPERATIONS UPON THE FEMALE GENITAL ORGANS. Fig' 544.— Diagram Showing Some of the Relations of the Uterl-s:— A. Uterus; B. Os uteri; C. Vagina ; D. Ovary; E. Utero-ovariaii ligament; F, Fallopian tube; G, Round ligament; H. H, Ureters; I. Ovarian artery; J. Internal iliac arter>' ; K, Uterine artery; L. L, L, Vaginal arteries; M. Infundibulo-pelvic portion of broad ligament. The position of the ligatures about the vessels and broad ligament is shown (here shown as interlocking, which is unessential) as applied in total abdominal hysterectomy. SURFACE FORMS AND LANDMARKS. Utero-vesical fold of peritoneum is about on a level with the internal o.s uteri. Utero-rectal fold of peritoneum is reflected for nearly 2.5 cm. (i inch) on t!ie posterior wall of the vagina. The cervix may be divided into three zones: — the lower third is intra- vaginal; — middle third is, anteriorh', supravaginal (united to base of bladder) — and intra vaginal posteriorly; — up])er third is supravaginal — united to blad- der anteriorlv — and in relation with peritoneum jiosteriorly. The ureters, in the case of a normal uterus, with empty bladder, lie nearly 1.3 cm. {h inch) from the cervi.x. They pass parallel with the cervi.x and nearly 1.3 cm. (i inch) away — running through the ple.xus of uterine veins and under- neath the broad ligament — and, continuing near the vagina, run between the vagina and bladder, and enter the bladder about on a level with the center of the anterior wall of the vagina. The uterine arteries run over them, ujjon their inner aspect. For further description of the female ureter, see page 903. For the course of the uterine and ovarian arteries, see page 930 (also see Fig. 544, II, H). INSTRUMENTS. See those given under .\l)doniinal .Section (page 631) — in addition to whith, may be mentioned: — vaginal retractors; broad ligament clamps; vulsella kn- ceps; pedicle clamps; pedicle needles, straight and laterally curved; aneurism- needles, straight and laterally curved; tenaculum-forceps; long artery-clamp forceps; long scalpels; long scissors, straight and curved; long forceps, toothed and dissecting; uterine sound; urethral catheters. PARTIAL ABDU.MIXAL H VSTKRECTOMV. 933 PARTIAL ABDOMINAL HYSTERECTOMY, TOGETHER WITH REMOVAL OF OVARIES AND TUBES. (PARTIAL ABDOMINAL H VSTFRO-SALPIN( .O-OOPHORECTOMV.) Description. — The supravaginal portion of the uterus, together with the ovaries and tubes, are removed through a median abdominal incision. In Partial .Abdominal Hysterectomy the supravaginal portion of the uterus only is removed, and the vagina is not opened. In Total Abdominal Hysterectomy the entire uterus, including the cervix, is removed, and the vaginal vault is opened. The ovaries may or may not be removed, in either case — thev should be left when possible. Preparation. — Bowels and l)ladder emptied. Median line and ])ul)is shaved. Position. — An upward tilt of patient's pelvis, of about 30.5 cm. (12 inches), in the Trendelenburg position aids by causing the intestines to fall awav from the uterus. Surgeon stands on jiatient's right during most or the entire opera- tion. .Assistant opposite. Landmarks. — Median line; navel; symphysis pubis; position of bladder and ureters. Incision. — In median line, extending from umbilicus downward towards symphysis pubis. It may be e.xtended above the umbilicus, passing directlv through the navel, or may pass around it to the left. It averages from 10 to 15 cm. (4 to 6 inches) in length. Operation. — (1) Median .Abdominal Section: — Perform a median abdo- minal section in the usual manner — control hemorrhage — retract the edges of the abdominal wound — displace the small intestines and the sigmoid coil of the large intestine and keep them out of the pelvis with gauze pads, aided bv the Trendelenburg po.sition. Examine the contents of the pehic cavitv and learn the condition of the organs and the presence and extent of adhesions. (2) Freeing Uterus, Tubes, and Ovaries from Adhesions: — The weakest adhesions are separated by the fingers — firmer adhesions by scissors — the most extensive are divided between double chromic gut ligatures, as near the uterus as possible. The fundus of the uterus is seized with vulsella and drawn toward the pubis, and the rectum displaced backward, while freeing the posterior aspect — then to the right, while freeing the left aspect of the uterus, ovar\-, tube, and broad ligament, — and to the left while freeing the right as]::ect of the same structures. Den.se adhesions are sometimes more easily broken uji by following down the fallopian tubes and working up under the tube and ovar\-, than from above downward. Free more closely to the organ to be removed than to the struc- tures to be left. A sound in the uterus will often aid in outlining the cleavage- lines of dense adhesions, along which separation must Ije accomplished bv dis- section with knife and forceps, or scissors. If completion of the freeing of adhesions in the usual way offers in.superable difficulties, it is sometimes best to stop and ligate the ovarian vessels and round ligament (in the manner and order described below) and divide the upper part of the broad ligament, making it possible to reach and free the tube and ovary from in front. (3) Enuclea- tion : — (a) Ligate the left ovarian vessels with silk, at the outer end of the broad ligament, beneath the sigmoid colon — either di\iding them between two silk ligatures, or between a clamp on the uterine and a ligature upon the pelvic side — cutting obliquely across the broad ligament to the round ligament, (b) The round hgament is similarly ligated with chromic gut, or clamped and ligated, and divided about 1.3 cm. (i inch) from the uterus, (c) The vesico-uterir.e 934 OPEKATIiiNS CPOX THE FEMALE GEXITAI. ORGANS. peritoneum is tletachecl from the uterus, by first incising the peritoneum along the concave line of its reflection, from left round hgament to right round liga- ment. While the uterus and adnexa are drawn up and to the opposite side, the vesical peritoneum is pushed ofT of the cervi.x with gauze or s])onge grasped in a holder — thus separating bladder from cervix and baring the latter for about 3 cm. (ij inches) and exposing the uterine vessels, (d) Grasp the cervix be- tween the left index and thumb, and verify its lower termination and the site of the uterine arteries on each side. Ligate the left uterine vessels by silk liga- ture carried under them upon a curved aneurism-needle, passing from before backward and near to the cervix — but not carried too deeply alongside of the cervix, for fear of including the ureter. Place a clamp, or a second ligature, on the uterine side, and divide between them, (e) Amputate the cervix trans- versely, just above the vaginal attachment — so as to leave the stump of the cervix cupped antero-posteriorly and laterallv. Protect the cut uterine canal with gauze from emptying its contents into the wound site. Cauterize the cervical canal — and stuff with gauze down into the vagina, (f) The uterus is drawn upward and to the opposite side — the right uterine vessels are exposed and are ligated and divided as on the left (or mav be clamped at first and tied later), (g) The uterus is still further drawn up and to the opposite side — and the round ligament ligated as on the left and di\ided (or may be first clamped, and ligated later), (h) Cut obliquely across the broad ligament to the right ovarian vessels in the infundibulo-]>elvic ligament — ligating and dividing them (or clamping first, and ligating later). The enucleation is now complete — and there is left a crescently denuded area in the pelvic cavity, broadest at its center, opposite the cervical stump, and coming to points at the brim of the pelvis, on either side, where the ovarian vessels were ligated. (4) Closure of the Cer- vical Canal: — The cujjped surface of the cervical stump is sutured with chro- mic gut in such a wav as to approximate the anterior and posterior aspects by from four to six interrupted sutures — entering the anterior lip exclusive of the vesical peritoneum, and emerging from the anterior lip anterior to the cervical canal — then passing over the cervical canal and entering the jiosterior lip just behind the cervical canal and emerging on the posterior peritoneal aspect of the cervical stump — thus closing the cervical canal, approximating the lips of the cervical stump, and controlling hemorrhage. The sutures are cut short and the stump dropped back into place. (5) Repair of the Pelvic Floor: — Having seen that all bleeding vessels are ligated (with chromic gut) — the denuded sur- faces are entirely covered in, by suturing together the peritoneal surfaces with continuous gut — uniting the edges of the anterior peritoneal layer of the broad ligament and reflected vesical peritoneum in front, to the edges of the posterior jieritoncum behind — beginning and ending at the stumps of the ovarian ve.ssels — and suturing the vesical peritoneum opposite the cervical stump to the pos- terior peritoneum which has been included in the stitches which closed in the cervical canal. (6) Closure of the Abdominal Wound : — The abdominal wound is closed as usual — without drainage, unless specially indicated. Comment. — 1* The broad ligament is everywhere divided between liga- tures. Where the ligatures for the ovarian ves.sels, round ligament, and uterine vessels, above mentioned, do not extend entirely across the broad ligament, in- tervening separate ones are placed. (2) Especially guard against injuring the ureters while ligating the uterine arteries (see Anatomy, pages 861 and 932). TOTAL VAGTNAL HYSTERECTOMY. 935 TOTAL ABDOMINAL HYSTERECTOMY. TOGETHER WITH REMOVAL OF OVARIES AND TUBES. (TOTAI, ABUOMI.NAL in'STERO-SALPINGO-OOPHORECTOMV.) Description. — The entire uterus, including the cervix, as well as the ovaries and tubes, are removed, and the vaginal vault opened — all through a median abdominal section. The ovaries should be left when possible. Preparation — Position — Landmarks — Incision. — As for Partial Abdo- minal H\>tererlomv. Operation. — The technic is so similar to that for Partial Abdominal Hysterectomy that only those points will he mentioned in which the technic of Total Alidominal Hysterectomy differs from the operation just described. (I) The lips of the cervix are closed w'ith strong silk sutures applied through the vagina, before the operation is begun — to protect the abdominal cavity from infection. The vagina is packed with gauze. (2) \Mien the peritoneal reflection has been pushed away from the supravaginal part of the uterus, and the uterine arteries tied, as described in Partial Hysterectomv (down to 3 — d, page 933) — instead of cutting through the cervi.x transversely, the upper limits of the vagina, anteriorly and posteriorly, are determined — and the vaginal vault is then opened in front, about i to 2 cm. (f to f inch) below the vaginal attachment of the uterus, by means of the thermocauter}- or scissors — aided by a vaginal sound passed into the anterior fornix, if necessarv — the incision being continued around each side until the cervix is freed. The margin of the cut vagina is ligated, pari passu, with chromic gut at a right angle to its long a.xis, using interlocking ligatures if necessary — the sutures being placed parallel with and at a short di.-^tance from its margin. The sites of the ligatures re- quired in total abdominal hysterectomy are shown in Fig. 544. All exposed areas are protected with gauze. (3) The anterior and posterior edges of peritoneum bordering the denuded area are .sutured with continuous gut in a transverse line from one pelvic brim, across the pelvic floor, to the opposite pelvic brim, thus repairing the floor of the pelvis. The peritoneal edges are clo.sed over the vaginal opening — but the opening in the vaginal vault is not sutured together — but, instead, a loose gauze pack is pushed through the opened \aginal vault up to the sutured overlying peritoneum. (4) The abdominal wound is closed in the ordinary manner. Comment. — (i) If ureteral catheters are passed into the ureters prior to the operation, the positions of the latter are made more evident during opera- tion. (2) The uterine arteries may be ligated further back in the pelvis, nearer their origin from the anterior branches of the internal iliacs — first assuring one's self of the ])osition of the ureters by picking up the uterine artery and parallel tissues between the index and thumb — and then allowing them to slip out of the grasp. If this be done, the artery is caught and drawn up and the dis- section of the connective tissue is carried on down to the uterus. (3) \'eins, large single ones, and in ple.xuses, are apt to be encountered in the broad liga- ment and on the pelvic floor. TOTAL VAGINAL HYSTERECTOMY. Description. — Removal of entire uterus through the vault of the vagina — the incision Vieing made from within the vagina. Indicated chiefly for malignant growth of the cer\ix, or for malignant disease limited to cervix and fundus. 93<^ OPERATIONS UPON THE FEMALE GENITAL ORGANS. Preparation. — Pubis, labia, and jjcrineum shaved. \'agina tlean.ecl l)v constant irrigation through a special glass tube held just above the vulva, — after opening tlie jjeritoneum, by gauze mops. (2) Catheters passed into the ureters before the operation enable the position of the ureters to be readily made out and guarded during operation. (3) If it be found, during operation, that it is desirable to remove the tubes and ovaries, ligatures are placed on the outer side of these. These ligatures are somewhat more difficult to a[)ply and tighten than the others. (4) Especially guard the ureters near the cervix and behind the uterine arteries, while working near the cervix. II. THE OVARIES. SURGICAL ANATOMY. (1) 0V.\R1ES. Description. — Placed one on each side of the pelvis — connected with the p"-terior la\er of the broad ligament, posterior and inferior to the fallopian tubes. Rests against the lateral wall of pelvis, with long axis nearly vertical in erect position of body (His). Length, about 3.8 cm. (i-j inches); — breadth, about 2 cm. (| inch); — thickness, about 1.3 cm. (i inch). Position of ovary corresponds with a point about 5 cm. (2 inches) internal to the anterior superior iliac spine. In the position and relations given by His, the fallopian tube and fimbria almost completely envelop the ovary. In structure, the ovar\- con- sists of peritoneal serous covering and stroma. Relations. — Mesial Surface ; — Is free. Fimbriated extremity of fallo- pian tube is in contact to \arious extent. Meso.salpinx is also in relation. Coils of jejunum and ileum often to inner side of right ovary. Sigmoid colon mav be to inner side of left o\ ary. Lateral Surface ; — Lies in fossa ovarii, a peritoneal depression upon the lateral pehic wall, generally just below the external iliac ves.sels — with the ureter often bounding the fossa below and be- hind. Posterior Border; — Is free. Directed toward rectum. Partly em- braced by fimbriated end of fallopian tube. Anterior Border; — Furni.shes attachment to broad ligament. Presents hilum (between two layers of broad ligament) for entrance of vessels and nerves. Fallopian tube. Upper Ex- tremity ; — Ovarian fimbria of fallopian tube are attached. Ligamentum sus- pen.'^orium ovarii (ligamentum infundibulo-pelvicum) passes from brim of pel\i> to upper extremity — conveying the ovarian ves.sels and nerves. Lower Extremity; — Ligament of ovary — from angle of uterus to lower or inner end of ovary. Arteries. — Ovarian of abdominal aorta; anastomotic branches of uterine and internal iliac. The ovarian artery, crossing brim of pelvis, enters broad ligament and runs in infundibulo-pelvic ligament — and, passing between layers of broad ligament, runs to the ovary and upper part of uterus. Veins. — Follow the arteries — and form the pampiniform ple.xus. Nerves. — From ovarian plexus; from pelvic plexus; from uterine nerves. Lymphatics. — E^mpty into prevertebral glands, in front of aorta and vena (2) F.\I.I,OPIA\ TfUF.S. Description. — .Average length, 10 to 12.5 cm. (4 to 5 inches). Begin at superior angle of uterus and extend — enclo.sed in upper free border of the 942 OPERATIONS UPON THE FEMALE GENITAL ORGANS. broad ligament — to the sides of the pelvis, ending in the fimbriated extremities, which are in relation with the corresponding ovaries. After enveloping the fallopian tubes, the layers of the broad hgament are continued down to the ovary. The tubes are made uj) of — the isthmus (inner third) — ampulla (from isthmus to neck) — neck (or ostium abdominale) — and fimbriated cMremitv. They are composed of serous, muscular, and mucous coats. Course and Relations. — Fmm the superior angles of the uterus, thev run nearly horizontally outwartl, lor about 1.3 to 2.5 cm. (^ to i inch) to the pelvic wall — thence ascend, sometimes tortuously, anteriorly to their ovaries — then cur\e backward over the ovaries, lying internal to the .suspensorv liga- ment — and end by passing downward along the inner and posterior borders of the ovaries. Ileo-jejunal convolutions are .sometimes above and to inner side of right fallopian tube. Sigmoid rectum is sometimes in the same relation to the left tube. Artery. — Tubal branch oi oxarian. OVARIECTOMY. OR OOPHORECTOMY. WITH REMOVAL OF FALLO- PIAN TUBE. lSALPlXc;0-<:)\ AKIIXTdMV, OK S.\l.l'l M .O-CH'iPIIOKIX" I ( >.M\ . I Description. — Ovariectomy (or, less correctly, Ovariotomy) consists in the removal of the ovarv through, generallv, an abdominal section. \\'hen the fallopian tube is simultaneously removed, the operation becomes Salpingo- ovariectomy, or Salpingo-oophorectomy. The ovary may be removed alone, or the tube may be renio\ed alone. In the operation here described, the following structures will be removed: — entire ovarv, entire fallopian tube, part of utero-o\arian ligament, and the arteries, veins, Ivmphatics, and nerves belonging to these structures. Preparation. — Median line and ])ubis shaved. Bowels and bladder emptied. Position. — Patient supine near edge of table at first — and subscf[uently ilevated into slight Trendelenburg position after the abdomen is opened. Sur- geon on side of operation — or always on patient's right, independentlv of ovary ('perated upon — or may prefer to cut upward, and then stands on patient's left in both cases. Assistant oppo.site. Landmarks. — As for median abdominal section (juige 631). Incision. — In median line — about 5 to to cm. (2 to 4 inches) in length — extending upward from a point about 2.5 cm. (i inch) above the symphx'^s jnibis. Operation. — (1) Perform a medium abdominal section — control hemor- rhage — and retract lips of abdominal wound. (2) Pass the first and second fingers into the wound, with the back of the hand to the abdomen — follow down the under surface of the abdominal parietes to the sym])hysis — thence down on to the bladder and uterus — and thence out laterally over the superior cornu of the uterus, with the palm of the hand still downward, to and along the broad ligament — along the posterior superior aspect of which the fallopian tube is found — and, just posterior to the tube, the ovary. These structures are drawn toward the median line, into an accessible position in the abdominal wound. (3) The ovarian artery and veins are first tied, with silk — the ligature being carried, upon a laterally curved aneurism-needle, through the clear space of the broad ligament and tied over the top of the infundibulo-pelvic ligament, outside of the fimbriated end of tb.e fallopian tube, and close to the brim of tl e OVARIECTOMY. 943 pelvis (Fig. 550). (4) The utero-ovarian ligament, lying behind the fallopian tube, is ligated with chromic gut, rather nearer the uterus, carried upon a later- ally curved aneurism-needle. (5) The inner end of the fallopian tube and the upper free part of the broad ligament are ligated with silk near the horn of the uterus — which ligature also controls the branches from the uterine arter}-. (6) The structures are now removed by cutting through the broad ligament well within the outer ligature of the ovarian vessels — and cutting through the fallo- pian tube and ovarian ligament well to the outer side of their ligatures — and t'g- 550. — Ovariectomy, with Re.moval of Fallopian Tvbe:— A. t'terus; B, .Aneurism- needle carrying ligature around ulero-o\-arian ligament; C, Ligature passing through broad liga- ment and surrounding fallopian tube and ovarian artery; D, Ligature passing through broad ligament and over top of infundibulo-pelvic ligament and surrounding ovarian arterv ; E, Round ligament; K, Bladder; G, Colon. carrying the incision through the broad ligament well below the hilum of the ovary. Any doubtful ligature is strengthened, and any bleeding point is sur- rounded by an additional gut ligature. (7) The edges of the anterior and pos- terior layers of the broad ligament, left by the removal of the above structures, are sutured together with gut. The patient is lowered to the horizontal posi- tion — and the intestines and omentum are replaced. (8) The abdomen is closed, as after median abdominal section. Comment. — (i) The main danger in the operation is from uncontrolled Q44 OPERATIONS UI'ON TIIK KKMAl.K GEXriAI. OKCAXS. hemorrhage. Where there is any danger of a Hgature sHpping, one end of the ligature may be carried through neighboring tissue and knotted to the oppo- site end. (2) The non-vascular portion of the broad ligament between the ligatures of the special structures may be left free — or, if ligated, should be so ligated as not to bind the pelvic and uterine aspects of the broad ligament together. NOTE. Other operations upon the Uterus and Ovaries, and the operations upon the Fallopian Tubes, Broad Ligaments, Round Ligaments, Labia Alajora and Minora, Clitoris, Hymen, Glands and Ducts of Bartholin, Bulbi X'estibuli, \'agina. Female Perineum, Female Bladder, Female Urethra, and Female Ischio-rectal regions — all belonging more particularly to special Gynecological Surgerv, will not be considered here. CHAPTER VIII. OPERATIONS FOR HERNIAE. I. INGUINAL HERNIA. SURGICAL ANATOMY. The structures encountered in the operations for inguinal herni;e and those in the immediate neighborhood of the site of operation, will be here brietiv described — chietlv in the order encountered, from without inward. Superficial Fascia. — Divisible into two layers, between which lie super- ficial arteries, veins, lymphatics, and nerves of the inguinal region. Superficial Layer of Superficial Fascia. — Continuous with superlicial fascia of abdomen, thigh, penis, scrotum, labia, and perineum. Superficial Arteries. — Superlicial epigastric branch of femoral. Super- ficial circumtlex iliac nf femoral. Superficial external ])udic of femoral. Superficial Veins. — Accompany arteries and end in internal saphenous vein. Superficial Lymphatics. — Superior group, along Poupart's ligament. Inferior gniup, around saphenous opening. Superficial Nerves. — Hypogastric branch of Iliohy]iogastric, Ilioinguinal. Deep Layer of Superficial Fascia (Scarpa's Fascia). — Attached to linea alba — continuous with superficial fascia over trunk — connected with fascia lata — helps form dartos — continuous with deep layer of superficial fascia of perineum. External Oblique Muscle. — Poupart's Ligament. — That portion of aponeurosis of external oblique extending from anterior su]ierior iliac spine to spine of os pubis. Gimbemat's Ligament. — That portion of aponeurosis of external oblique which is rellected from Poupart's ligament, at spine of os pubis, along the pectineal line. Triangular Ligament. — That portion of aponeurosis (if external oblique which is rellected from Gimbernat's ligament, at the pectineal line, upward and inward beneath the spermatic cord and behind the internal pillar of the ex- ternal ring and in front of the conjoint tendon, to the linea all)a, where it inter- laces with its fellow of opposite side. External or Superficial Abdominal Ring. — A triangular opening in aponeurosis of external oblique immediatelv above and just external to crest of OS pubis. Bounded, inferiorly, by crest of os pubis, — Superiorly, by inter- columnar fibers, strengthened by intercolumnar fascia. — Internally, by inner or superior pillar, — Externally, by outer or inferior [)illar. Transmits >]:er- matic cord in male, and round ligament in female. Internal Oblique Muscle. — Conjoint Tendon of Internal Oblique and Transversalis. — Inserted into crest of o> ]iubis and pectineal line, directly behind external abdominal ring. Cremaster Muscle. — Corresponds with inferior fibers of internal obli(]ue 60 945 946 OPERATIONS FOR HERXI.K. — arising from center of Poupart's ligament, where they are continuous with the interno-inferior aspect of that muscle — descend along external and anterior aspect of spermatic cord — curve around testicle — and, ascending along inner aspect of cord, are inserted into crest of os pubis and anterior surface of sheath of rectus. The fascia cremasterica increases the strength of these fibers. Transversalis Muscle.— Transversalis Fascia. — Inguinal Canal. — Transmits spermatic cord in male — and round ligament in female. E.xtends obliquely downward and inward for about 3.8 cm. (15 inches) — parallel with and slightly above Poupart's ligament — beginning at the internal abdominal ring and ending at the external abdominal ring. Anterior boundaries, — skin ; superficial fascia ; aponeurosis of external oblique (through- out) ; internal oblique (outer third). Posterior boundaries, — triangular liga- ment; conjoint tendon of internal oblique and transversalis; transversalis fascia; .subperitoneal fat; peritoneum. Superior boundaries, — curved fibers of in- ternal oblique and transversalis. Inferior boundaries, — junction of fascia transversalis and Poupart's ligament. Internal or Deep Abdominal Ring. — An oval opening lying in the trans- versalis fascia, half-way between the anterior superior iliac spine and symphy- sis pubis, and about 1.3 cm. (^ inch) above Poupart's ligament. Superior and External boundary, — curved fibers of transversalis. Inferior and Internal boundaries, — deep epigastric vessels. Transmits spermatic cord in male — and round ligament in female. Infundibuliform process of fascia transversalis slreniithens its ojiening. Subperitoneal Areolar Tissue. — Deep Epigastric Artery, of External Iliac. — For Surgical Anatomy, see page 92. Other anatomical pioints, ncK.'ssary to the thorough understanding of the Intruinal Hernia-, are given under (ieneral Surgical Considerations. GENERAL SURGICAL CONSIDERATIONS. Definition of Inguinal Hernia. — Hernia j)assing through the abdominal wall in the inguinal region. Varieties of Inguinal Hernias.— (i) E.xternal or Oblique Inguinal Hernia, — neck of sac lies external to deep epigastric artery, — follows course of spermatic cord through inguinal canal. (2) Internal or Direct Inguinal Hernia, — neck of sac lies internal to deep epigastric artery, — hernia pene- trates some portion of abdominal wall internal to deep epigastric artery. (a) Oblique or External Inguinal Hernia. — Coverings of Oblique Inguinal Hernia :— The hernia enters the external inguinal fo.ssa (v. i.)— and, passing down from the abdominal cavity, receives the following coverings, in order —(1) At Internal Abdominal Ring:— perito- neum; subserous areolar tissue; infundibuliform process of fascia transversalis; — (2) In Inguinal Canal: — (passes under curved fibers of internal oblique and transversalis, but does not receive a covering from them); cremaster muscle; — (3) .\t External Abdominal Ring: — intercolumnar fascia; — (4) In Scrotum' — superficial fascia; skin. Position of Oblique Inguinal Hernia.— This variety of Inguinal Hernia always lies to the outer side of the deep epigastric artery— and generally lies anterior to the vessels of the s]:ermalir cord— and rarely descends below the the testis (because of adhesion of the hernial coverings to the tunica vaginalis). INGUINAL IIKRNIA— GENERAL SLK(;irAL CONSIDERATIONS. 947 Seat of Stricture in Oblique Inguinal Hernia. — JVIost frequently at the internal ring, — mav occur at the external ring, — or may occur in the canal, by fibers of internal olili(|ue and trans\-er.sa)is. (b) Direct or Internal Inguinal Hernia. — .\ correct understanding of this form of hernia depends upon a knowledge of the anatomy of the lower abdominal wall: — Cord-like Structures upon Inner Aspect of Lower Abdominal Wall. — Seven cord-like structures are seen upon the inner aspect of the lower abdom- inal wall — ranging from near the median line upward: — (a) Plica Urachi — remains of fetal urachus in median line; — (b) Two Plicae Hypogastrics — obliterated hypogastric arteries on each side of median line, running upward toward the median line; — (c) Two Plica^ Epigastrica- — deep epigastric arteries running upward and toward median line; — (d) Two Poupart's Ligaments — running upward and outward. Fossae upon Inner Aspect of Lower Abdominal Wall. — Eight fossa? are formed by the |)critoncum stretched over these ])n)minL-nt cord-like structures — by the depressions between them: — (a) Two Internal Inguinal Foss:e — be- tween plica' urachi and plica- hypogastrica?; — (b) Two Middle Inguinal Fosss — between plic;E hypogastrica? and plica" epigastrica; — (c) Two Ex- ternal Inguinal Fossa — between plica hypogastrica and Poupart's ligaments; (d) Two femoral fossa — below Poupart's ligaments, to inner side of femoral vein. Relations of Hernias to Fossae upon Inner Aspect of Lower Abdom- inal Wall. — (I) Tiirough the E.xternal inguinal fossa, an oblique inguinal hernia occurs; — (3) Through either the Internal or Middle inguinal fossa, a direct inguinal hernia comes; — (3) Through the Femoral fossa, a femoral hernia occurs. Fossae within Hesselbach's Triangle through which direct Inguinal Hernia may come. — Hesselluich's Triangle is bounded — Externally; by deep epigastric artery; — Internally; by outer border of rectus muscle; — Inferiorly; by Poupart's ligament. The conjoint tendon of the internal oblicjue and trans- versalis is stretched across the inner two-thirds of Hesselbach's triangle. The remaining outer one-third has only the subperitoneal areolar tissue and trans- versalis fascia between the peritoneum and the external oblique a)3oneurosis. The plica hypogastrica divides Hesselbach's triangle into an internal inguinal fossa (which is the region of the conjoint tendon) and a middle inguinal fossa. Two forms, therefore, of direct inguinal hernia may occur — dependent upon whether the hernia escapes through the inner two-thirds or the outer one- third of Hesselbach's triangle. Commoner Form of Direct Inguinal Hernia. — In which the hernia en- ters the internal inguinal fossa, anper and lower ends in median line — and maximum sc]>aration of limbs of ellipse opposite the greatest width of the hernia, and determined by the .size of the tumor. Laterally the lines of incision generally come near the base of the tumor, .so as to remove the excess of skin. Operation. — (1) Incise, at first, through skin and fascia only. (2) Care- fully deepen the wound on one side until the abdominal aponeurosis (sheath of the recti) is reached — aiming to come down upon it a short distance to the outer side of the hernial neck. (3) Having once reached the rectal aponeuro- sis, .similarly expose this aponeurosis and the neck of the hernial sac all around the outline of the ellipse. All bleeding is controlled bv clamp and ligature. (4) The hernial sac is now incised and its contents dealt with as indicated. .'\dhesions are separated. Excess of omentum is ligated and e.xcised. .All remaining contents of the sac are returned to the abdomen — and kept in ])lace by a large, anchored gauze pad — which is removed just before closure of the abdomen. (5) The entire sac, with the umbilicus and the coverings included in the ellipse, is now excised — dividing the peritoneum in an elliptical manner g6o OPERATIONS FOR HERNI.E. about the neck of the sac. (6) The peritoneum — or the peritoneum and trans- versalis fascia together — is sutured with interrupted or continuous gut sutures. (7) The borders of the abdominal ring — formed by the sheaths and margins of the recti muscles — are freshened with curved scissors. The edges of the ring are then brought together with interrupted sutures of kangaroo tendon or chromic gut — using either the plain interrupted suture, or the mattress t_vpe. (8) The skin and fascia (unless the fascia be thick enough to require separate gut suturing) are sutured with interrupted silkworm-gut sutures. (9) The jiart is then well supported by an abdominal dressing. Comment. — Wirious forms of operation have been devised — including the transposition of portions of the recti muscles over the site of hernia. NDEX. Abbe's operation for stricture of esophagus, Abdomen, puncture of. 651 Abdominal aorta, anatomy (jf, ^8 ligation of, 80 section, anterior, through rectal sheath, 641 anterolateral, inferior, Fowler's angu- lar incision, 645 anterolateral, inferior, Meyer's hockex-- stick incision, 644 anterolateral, McBurney's intramuscu- lar incision, 637 anterolateral, superior, obliiiue sub- costal incision, 646 anterolateral. Weir's prolongation of anterolateral intramuscular inci- sion through rectal sheath, 639 lateral, Vischer's luinbo-iliac incision, 646 median, 63 1 complications during, 636 inferior, Pfannenstiel's incisions, 643 Abdomino-pelvic region, operations upon, 624 general considerations, 620 Abdomino-pelvic wall, anatomy of, 624 operations upon, 624 instruments for, 631 visceral adhesions to, o|ieration for, 650 Abscess, cerebellar, operation for, 407 cerebral, operation for, 496 Acupressure of veins, 120 Ai upuncture for radical cure of aneurism, Albert's method of gastrostomy, yfx) Alexander's method of prostatectomy, ()26 Allingham's operation for hemorrhoids, 754 Amputation. 220 about hands, general considerations, 2114 61 Amputation, adjustment and suturing of musculo-periosteal or periosteo-cap- sular covering, 255 circular, cuff method, 263 division of muscles in, 230 modified, 264 ordinary, 261 drainage in, 258 dressing of wound, 250 elliptical, 273 flap, division of muscles in, 242 equal, of skin, 270 e(|Ual, of skin and muscle, 269 single, of skin, 269 single, of skin and muscles, 267 unequal, of skin, 272 uneciual, of skin and muscles. 271 unequal rectangular, of skin and muscles, 272 freeing and retracting muscles in, 246 freeing skin and fascia in, 237 general considerations in, 229 general technic in, 232 hemorrhage in, control of, 230 incision of skin and fascia in. 234 instruments for, 229 irregular methods of, 275 ligating arteries and veins in, 253 location of limits of skin incisions in, location of line of bone-section in, 232 making musculo-periosteal, or periosteo- capsular covering, 247 methods of, 259 selection of, 275 of arm at surgical neck, 322 , general considerations, 31Q in general, 319 lower third, 320 together with scapula and part of < lavicle, 331 upper two-thirds, 321 qfti Amputation of linger, little, with part of metacarpal, 296 with part of metacarpals, 295 of fingers, at first jihalanx, by palmar flap, 286 at first phalanx, by short dorsal and palmar flaps, 287 at last phalanx, by palmar flap, 2S3 at last phalanx, in general, 283 at second phalanx, by palmar flap, 285 at second phalanx, by short dorsal and long palmar flaps, 285 at second phalanx, in general, 2S5 (excluding thumb), with parts of meta- carpals, 297 general surgical considerations, 281 three innermost, with parts of meta- carpals, 297 three inside, with parts of meta- carpals, 296 two contiguous inside, with parts of metacarpals, 296 with parts of metacarpals, 295 of foot, general considerations, 347 of forearm, general considerations, 308 in general, 300 lower third, by circular method (culT variety), 310 lower third, modified circular method, 309 upper two-thirds, 3 1 1 of leg, at lower third, 365 middle third, 367 supramalleolar region, 365 upper third, 368 upper third, bilateral hooded flaps, 370 of lower extremity, 333 of penis, partial, 8g8 total, 000 of thigh, at condyles of femur, 379 just above condyles of femur, 380 just below trochanters, 386 lower, middle, or upper third, anterior and posterior flaps, 382, 384 lower third, 382 of thumb, with part of metacarpal, 296 of toes, at first phalanx, 338 at first phalanx, circular method, 340 at first phalanx, oval method, 339 at last phalanx, 336 at last phalanx, by plantar flap, 336 at metatarsus, 348 at second phalanx, 338 Am|julalion of toes, at second phalanx, plantar flap, 338 general considerations, 335 with part of metatarsals, 347 of upper extremity, 279 osteoplastic, 394 oval, 265 position of assistant in, 229 position of patient in, 229 position of surgeon in, 229 preparation of patients in, 229 quilting of muscles, 256 racket, 266 removal of dressings, 250 removing splintered bone, 252 retraction of skin and fascia in, 238 retraction of soft parts, preparatory to sawing bone, 250 sawing bone, 251 stump, 276 bad, characteristics of, 277 cicatrix of, position, 278 function of, 278 good, qualities of, 276 suturing, 258 tissues of, contractility, 277 vitaUty of, conditions influencing, 277 treatment of nerves, tendons, and tags of muscle, fascia, and skin in, 255 trimming of flaps, 255 Anastomosis, intestinal, 675. See also En- tero-enteroslomy. Anesthesia, regional, intraneural infiltra- tion for, 151 paraneural infiltration for, 153 spinal, subarachnoid puncture for, 538 Aneurism, radical cure of, acupuncture for 124 introdui tion of wire for, 124 ligation for, 120 Matas' operation for, 121 needling for, 1 24 Angciomata, injection of water at high temperature in, 125 Ankle-joint, anatomy, 358 excision of, 427 disarticulation of foot at, 360 disarticulations about, general considera- tions, 359 Annandale's osteoplastic resection of supe- rior maxilla, 455 Anus artificial, closure of, operation for, 96.3 Anus, artificial, permanent, ileostomy for, 73° left inguinal colostomy for, 734 fistula in, operation for, 757 Aorta, abdominal, anatomy of, 78 ligation of, 80 Appendicectomy, 727 McBurney's method, 722 Appendix ceeci, anatomy of, 658 Arm, amputations about, general con- siderations, 319 amputation of, 319 anatomy of, 317 Arterial forcipressure, 1 19 Arteriorrhaphy, 117 Arteriostrepsis, 120 Artery, abdominal aorta, anatomy of, 78 ligation of, 80 auricular, posterior, anatomy of, 42 ligation of, 42 axillary anatomy of, 6i first part, ligation of, 62 third part, ligation of, 63 brachial, anatomy of, 64 ligation of, 65 carotid, common, anatomy of, 31 left, anatomy of, 32 ligation of, 3s right, anatomy of, 31 external, anatomy, 34 ligation of, 35 internal, anatomy of, 50 ligation of, 50 clearing of, for ligation, 22 dorsalis pedis, anatomy of, 106 ligation of, 107 epigastric, anatomy of, 92 ligation of, 93 exposure of, for ligation, 20 facial, anatomy of, 39 ligation of, 40 femoral, anatomy of, 93 common, ligation of, 95 superficial, ligation of, 97 gluteal, anatomy of, 88 ligation of, 89 iliac, common, anatomy of, 81 ligation of, 82 external, anatomy of, 90 external ligation of, 90 internal, anatomy of, 84 ligation of, 84 innominate, anatomy, 26 Artery, innominate, ligation of, 26 intercostal, anatomy of, 76 ligation of, 77 ligation of, 1 7 en masse, 1 1 7 for radical cure of aneurism, 120 in amputation, 253 intermediate, 117 temporar)', 1 16 line of, 18 lingual, anatomy of, 37 ligation of, 38 mammary, internal, anatomy of, 59 internal, ligation of, 60 maxillary, internal, anatomy of, 44 ligation of, 44 meningeal, middle, anatomy of, 45 anterior branch, ligation of, 48 posterior branch, ligation of, 47, 49 topography of, 468 obturator, anatomy of, 85 ligation of, 85 occipital, anatomy of, 41 ligation of, 41 of cerebral hemorrhage, 461 opening sheath of, for ligation, 21 operations upon, 17 peroneal, anatomy of, 112 ligation of, 112 plantar, external, anatomy of, 113 ligation of, 114 internal, anatomy of, 115 ligation of, 115 pojjliteal, anatomy, 99 ligation of, 100 pressure of, 119 profunda fcmoris, anatomy of, <)6 ligation of, 97 |>udic, internal, anatomy of, 87 ligation of, 88 r.-idial, anatomy of, (>y ligation of, 69 sciatic, anatomy of, 85 ligation of, 86 subclavian, anatomy of, 51 left, first portion, ligation of, 53 right, first jmrtion, ligation of, 52 second portion, ligation of, 53 third portion, ligation of, 54 subscapular, anatomy of, 64 ligation of, 64 suprascapular, anatomy of, 5.8 ligation of, 59 Artery, suture of, 117 temporal, anatomy of, 43 ligation of, 43 thyroid, inferior, anatomy of, 57 ligation of, 57 superior, anatomy of, 37 ligation of, 37 tibial, anterior, anatomy of, 103 ligation of, 104 posterior, anatomy of, 108 ligation of, loq torsion of, 120 transversalis colli, anatomy of, 57 ligation of, 58 ulnar, anatomy of, 73 ligation of, 74 vertebral, anatomy of, 55 ligation of, 56 Arthrectomy, 204 Arthrotomy, 204 Astragalus, excision of, 424 Auricular artery, posterior, anatomy of, 42 ligation of, 42 Axillary artery, anatomy of, 61 first part, ligation of, 62 third part, ligation of, 63 lymphatic glands, removal of, 139 region, anatomy of, 138 Bardenheuer's method of iigating in- nominate artery, 30 Barker's incision of hip-joint, 43S Bartholin's duct, anatomy of, 572 operations upon, 572 Bassini's operation for femoral hernia, 957 for oblique inguinal hernia, 948 Battle-Jalaguier-Kammerer method of an- terior abdominal section, 641 Baum's operation for exposing facial nerve, 169 Bennett's modification of Howse's opera- tion for hydrocele, 919 Billroth's method of pylorectomy, 795 Bisection of kidney, 849 Bladder, anatomy of, 875 drainage of, 892 perineal, 892 suprapubic, 892 urethral, 892 female, introduction of sound or catheter into 879 Bladder, male, introduction of sound or catheter into, S78 operations upon, 875 general considerations, 877 instruments for, 878 puncture of. 879 stone in, lateral perineal cystotomy for 883 median perineal cystotomy for, 886 suture of, 887 Boeckel-Langenbeck excision of wrist- joint, 410 Bones, operations upon, 184 resection of, osteoplastic, 448 Bougie, esophageal, introduction of, 561 Bovee's method of uretero-ureterostomy, 866 Brachial artery, anatomy of, 64 ligation of, 65 plexus of nerves, anatomy of, 172 exposure of, 172 Brain areas, localization of, 469 bullet wound of, operation for, 493 parts of, 459 puncture of, exploratory, 488 skull, and scalp, anatomy of, 459 ventricles of. lateral, puncture and drainage of, 495 Braun-Loessen operation for exposure of superior maxillary nerve, 162 Breast female anatomy of, 579 excision of, ordinary, 585 excision of, partial, 581 excision of, radical, Halsted's opera- tion, 5S2 excision of, radical, Warren's opera- tion, 5S4 excision of, subcutaneous, 586 incision of, 580 operations upon, 579 operations upon, general considera- tions, 580 Bronchi, anatomy of, 622 operations upon, 622 Bronchotomy, 623 Bryant's method of colopexy, 742 of posterior thoracotomy, 593 operation for stricture of esophagus 562 Bullet wound of brain, operation for, 493 Bursas, excision of, 228 incision of, 228 operations upon, 228 puncture of, 228 965 Calculus, vesical, lateral perineal cystot- omy for, 883 median perineal cystotomy for, 886 Garden's amputation of thigh, 379 Cardiorrhaphy, 621 Carnochan's operation for exposure of superior maxillary nerve, 161 Cartilages, nasal, ch.mdroplastic resection of, 455 Carotid artery, common, anatomy of, 31 left, anatomy, 32 ligation of, 3^ right, anatomy of, 31 external, anatomy of, 34 ligation of, 35 internal, anatomy of, 50 ligation of, 50 Castration, 916 Catheter, eustachian, introduction of, 517 introduction of, into female bladder, 879 into male bladder, 878 into urethra, 878 Cerebellar abscess, operation for, 497 subarachnoid space, incision of, for drainage, 496 tumor, operation for, 499 Cerebellum, anatomy of, 461 function of, 472 Cerebral abscess, operation for, 496 hemispheres, cortex of basal surface of, functions, 471 extent of, 464 hemorrhage, artery of, 461 tumor, operation for, 498 Cerebrum, extent of, 465 fissures of, 459 lobes of, 460 mesial fissures and lobes of, 460 Cervical esophagectomy, partial, 560 esophagostoray, 556 eso])hagotomy, external, 558 nerves, first, second, third, posterior divisions, exposure of, 171 sympathetic ganglia and cord, anatomy of, 182 ganglia and cord, excision of, total, 183 Cheevcr's method of tonsillectomy, 565 Chiene's method of determining Rolandic fissure, 478 of exposing retropharyngeal space, 556 Chipault's method of cranio-cerebral local- ization, 472 Cholecystectomy, 821 Cholecystendysis, oblique or vertical sub- costal incision, 819 Cholecystenterostomy, by Murphy button, 819 by simple suturing, 820 Cholecystolithotrily, 821 Cholecystotomy, oblique subcostal incision, 816 vertical subcostal incision, 817 Choledochotomy, 824 Cholelithotrity, 826 Chopart's disarticulation of anterior ]jart of foot, 355 Circumcision, 896 Circumflex nerve, anatomy of, 173 exposure of, 173 Clavicle, excision of, 419, 420 Coccyx, excision of, 448 Cock's method of external perineal ure- throtomy, 910 Coffey's method of entero-enterostomy, 701 Collar-bone, excision of, 419, 420 Colopexy, Bri'ant's method, 742 Colostomy. 731 inguinal, left, 732 inguinal, left, for permanent artificial anus, 734 inguinal, left, for temporary fecal fistula, 733 lumbar, left, 736 Convolution, frontal, ascending, topog- raphy of, 467 inferior, topography of, 467 middle, topography of, 467 superior, topography of, 467 Cranial contents, relations of, to cranial bones, 478 Craniectomy, partial, 487 Craniocerebral localization, Chipault's method, 472 Reid's method. 476 operations, general considerations, 478 instruments for, 4S0 region, operations upon, 459 topography, 464 Craniotomy, 480 circular, 481 for fracture of skull, 492 linear, 487 varieties of, 480 Cranium, landmarks of, 463 Crura cerebri, fum tion of, 472 966 Crural nerve, anterior, anatomy of, 178 exposure of, 17S Cuneiform osteotomy, 187 Cushing's right-angled continuous suture of intestine, 668 Cystectomy, partial, S93 total, 8q4 Cystorrhaphy, 88 7 Cystotomy, 880 lateral perineal, for vesical calculus, 883 median perineal, for vesical calculus, 886 suprapubic, 8S0 Czerny-Lembert cntero-enterostomy bv in- terrupted suture, 685 interrupted suture of intestine, 666 Czerny's method of exposing tonsil, 566 Dental nerve, inferior, anatomy of, 166 exposure of, 166 Diaphragm, anatomy of, 595 exposure of, transthoracic, 596 operations upon, 595 Disarticulation about ankle-joint, general considerations, 359 about toes, general considerations, 335 at elbow-joint, anterior ellipse, 314 general considerations, 313 in general, 314 long antero-internal and short postero- external flaps, 316 posterior ellipse, 315 at hip-joint, anterior racket method, 393 external racket method, 392 general considerations, 388 Wyeth's method, 390 at knee-joint bilateral hooded flaps, 374 general considerations, 373 at shoulder-joint, anterior racket method, 327 external or deltoid flap, 330 external racket method, 329 general considerations, 325 in general, 326 at wrist-joint, anterior eUipse, 304 external lateral, or radial flap, 306 general considerations, 303 in general, 304 palmar flap, 305 of finger, index, at metacarpo-phalangeal joint, 290 index, with metacarpal, 298 inner, with metacaroal, 297 Disarticulation of finger, little, at meta- carpo-phalangeal joint, 291 little, with metacarpal, 298 of fingers and thumb, at carpo-meta- carpal joint, 302 at first interphalangeal joint, by palmar flaps, 286 at first interphalangeal joint, by short dorsal and long palmar flaps, 286 at first interphalangeal joint, in general, 2S6 at metacarpo-phalangeal joints, in general, 287 at metacarpo-phalangeal joints, oval method, 287 at Sf. (.mi inlrrphalangeal joint, by at sfiwnd inlrrphalangeal joint, by short dorsal and long palmar flaps, 284 at second interphalangeal joint in general, 284 excluding thumb, with metacarpals, 301 three innermost, with metacarpals, 300 three inside, with metacarpals, 299 two contiguous inside, with meta- carpals, 299 with metacarpals, 297, 301 of foot, anterior part, at medio-tarsal joint, 355 at ankle-joint, heel-flap, 360, 361 at subastragaloid joint, 356 at subastragaloid joint, heel flap, 358 at subastragaloid joint, large interno- plantar flap, 356 of lower extremity, ^^^ of thumb, at metacarpo-phalangeal joint, by oblique palmar flap, 290 at metacarpo-phalangeal joint, oval method, 289 with metacarpal, 298 of toe, great, at metatarso-phalangeal joint, 341 great, with metatarsal, 350 little, at metatarso-phalangeal joint. 341 little, with metatarsal, 352 with metatarsal, 350 of toes, at first interphalangeal joints, 33S at first interphalangeal joints, oval method, 338 967 Disarticulation of toes at metatarso-phalan- geal joint, by equal short dorsal and plantar flaps, 342 at mctatarso-phalangeal joints, 340 at second intcrphalangeal joint, 337 at second intcrphalangeal joint, by plantar flap, 337 at tarso-metatarsal joints, by short dorsal and long plantar flaps, 353 second, third, or fourth, at metatarso- phalangeal joint, 340 two adjoining, at metatarso-phalangeal joint, 342 two or three contiguous, with meta- tarsals, 353 with metatarsals, 349 of upper extremity, 270 Dorsalis pedis artery, anatomy of, 106 ligation of, 107 Dubrueil's method of disarticulation at wrist-joint, 306 Dura mater, venous sinuses of, 462 Ear, operations upon, 516 speculum, introduction of, for examina- tion of membrana tympani, 517 Edebohls's method of nephropexy, 852 Ejaculatory ducts, anatomy of, 921 Elbowing, 672 Elbow-joint, anatomy of, 312 disarticulation at, 314 general considerations, 313 excision of, 412 Enterectomy, partial, 672 Entero-enterostomy, 675 by absorbable bobbins, 697 by absorbable buttons, 698 by absorbable mechanical devices left within intestine, 696 by Coffey's method, 701 by Czerny-Lcmbert interrupted suture, 685 by Halsted's inflatable rubber cylinder, 710 by Halsted's method of interrupted mat- tress suture, 686 by Laplace's intestinal anastomosis forceps, 718 by Lee's intestinal holder. 714 by Maunsell's invagination method, 688 by mechanical means, 710 by Murphy button, 703 Entero-enterostomy bv non-absorbable mechanical devices left in intestine, 702 by simple cunlinuous suture of all coats, followed Vjy interrupted or continuous Lembert sutures of outer coats, 677 by simple suturing, 676 by Ullmann's modification of Maunsell's operation, 699 Enteroplasty, 742 Enterorrhaphy, 663 by continuous suture of all coats, fol- lowed by interrupted Lembert suturing of outer coats, 670 by Cushing's right-angled continuous suture, 668 by Czerny-Lembert interrupted suture, 666 Vjy Halsted's interrupted mattress suture, 667 by Lembcrt's continuous suture. 668 by Lembert' s interrupted suture, 665 for wounds of intestines, 670 Enterostomy. 727 inguinal, right, for permanent artificial anus, 730 for temporary fecal fistula, 728 Enterotomv, 663 Enucleation of eyeball, 515 Epididymes, anatomy of, 918 Epigastric artery, anatomy of, 92 ligation of, 93 Erasion of joint, 204 Esophageal bougie, introduction of, 561 Esophagectomy, cervical, partial, 560 Esophagoscopy, 561 Esophagostomy, cervical, 560 Esophagotomy, cervical, external, 55S internal, 561 thoracic, by posterior mediastinal osteo- plastic flap operation, 623 Esophagus, anatomy of, 557 foreign bodies in, operation for, 561 operations upon, 557 general considerations, 558 instruments for, 558 stricture of, dilatation, direct, 562 dilatation, retrograde, 562 division, by string friction, Bryant's operation, 562 divulsion, direct, 562 divulsion, retrograde, 562 tubage, permanent, 562 Estlaender's operation of thoracoplasty, 604 Eustachian catheter, introduction of, 517 tube, operations upon, 516 Evisceration of eyeball, 516 Excision, 397 general considerations, jt)7 of ankle-joint, 427 external curved and internal angular incisions, 429 transversely curvefl external incision, 428 of astragalus, external angular and in- ternal curved incision, 425 external curved incision, 424 of bones and joints about foot, 424 of bones and joints about toes, 422 of breast, female, ordinary, 585 partial, 581 radical, Halsted's operation, 582 radical, Warren's operation, 584 subcutaneous, 586 of bursse, 228 of cervical sympathetic ganglia and cord, total, 1S3 of clavicle, 419 long axial incision, 420 of coccyx, 448 of collar-bone, 4ig long axial incision, 420 of elbow-joint, 412 by posterior bayonet-shaped incision, 415 by posterior median incision, 413 of femur, 434 diaphysis, parts of, 435 of fibula, 431 by posterior vertical incision, 43: of fingers, 402 first interphalangeal joints, 406 first phalanges, 406 metacarpals, 407 metacarpo-phalangeal joints, 406 second interphalangeal joints, 403 second phalanges, 405 terminal phalanges, 403 of hand, 406 of hip-joint, 435 anterior straight incision, 438 external straight incision, 436 posterior angular incision, 439 of humerus, 416 long external incision, 417 of ileo-cfficum, 720 Excision of index-fing;r, second interpha- langeal joint, 404 second phalanx, 405 of knee-joint, 432 curved transverse anterior incision, 433 of little finger, metacarpal, 408 second interphalangeal joint, 405 second phalanx, 406 of maxilla, inferior, 443, 445 inferior, single incision along inferior and posterior borders, 445 superior, 440, 441 superior, median incision, 441 of OS calcis, 427 of parotid gland, 568 of patella, 432 of radio-ulnar articulation, superior, 416 of radius, 412 of rectum, 745. See also Recleclomy. of rib, 447 of rib and costal cartilage, 447 of scapula, 420 by incisions along spine, 421 of scrotum, partial, gi3 of shoulder-blade, 420 by incisions along spine, 421 of shoulder-joint, 417 by anterior oblique incision, 418 of subungual gland, 572 of submaxillary gland, 571 of temporomaxillary articulation, 444 of tendon-sheaths, 224 of thumb, metacarpal, 408 of tibia, 430 bv internal vertical incision, 430 of toes, first interphalangeal joint, 423 first phalanx, 424 metatarsal bones, 424 metatarso-phalangeal joints, 424 second interphalangeal joint, 423 seccjnd phalanges, 423 terminal phalanges, 423 of tongue, general considerations, 518 instruments for, 519 limited portions, 520 through mouth, after preliminary liga- tion of lingual arteries, 522 through mouth, without preliminary ligation of lingual arteries, 520 together with cervical and submaxil- lary glands, 522 of ulna, 411 of veins, 129 969 Excision of wrist-joint, 408 bv radial and ulnar dorsal incision, 4oq bv single dorso-radial incision, 410 open method, 401 subperiosteal, 398 Exposure of brachial plexus of nerves, in neck, 172 of cervical nerves, first, second, third, posterior divisions, 171 of circumflex nerve, 173 of crural nerve, anterior, 178 of dental nerve, inferior, at mental fora- men, 168 inferior, in mouth, 166 inferior, through ascending ramus of inferior maxilla, 167 of facial nerve, in front of mastoid pro- cess, t6q of gluteal nerve, superior, 179 of infraorbital nerve, 163 of intercostal nerve, 178 of interosseous nerve, 177 of lingual nerve, in mouth, 168 of maxillary nen'e. inferior, 164 superior, by antral route, i6i superior, by orbital route, 162 superior, by pterygomaxillary route, 162 of median nerve, at bend of elbow, 1 74 in middle of arm, 174 of musculocutaneous ner\'e, 173 of musculospiral nerve, 176 of obturator nerve, 179 of occipitalis major nerve, 171 of popliteal nerve, external, 181 internal, 180 of pudic nerve, 179 of radial nerve, 177 of retropharyngeal space, 556 of sciatic nerve, great, 179 of spinal accessory nerve, 170 of supraorbital nerve, 160 of tibial nerve, anterior, 182 posterior, behind, internal malleolus, 181 posterior, between origin and ankle, 180 of ulnar nerve, abnvc middle of arm, 175 just above internal condyle of humerus, 175 Eyeball enucleation of, 515 evisceration of, 516 operations upon, 514 Facial artery, anatomy of, 39 ligation of, 40 nerve, anatomy of, 169 exposure of, 169 topography of, 468 Fallopian tubes, anatomy of, 941 Farabeuf's amputation of leg at upper third, 36S disarticulation at elbow-joint, 314 disarticulation of foot, 356 method of amputating leg at Tower third, 365 method of disarticulation of index-finger at metacarpo-phalangeal joint, 290 method of disarticulation of little finger at metacarpo-phalangeal joint, 291 method of disarticulation of thumb at metacarpophalangeal joint, 290 Fascia in amputation, treatment of, 255 operation upon, 227 Fasciotomy, 227 Fecal fistula, closure of, operation for, 739 temporary, ileostomy for, 728 temporary, left inguinal colostomy for, 73,3 Femoral artery, anatomy of, 93 common, ligation of, 95 superficial, ligation of, 97 hernia, 955. See also Hernia, jemoral. Femur, excision of, 434 excision of parts of diaphysis. 435 Fergusson's excision of superior maxilla, 441 Fibula, excision of, 431 Finger, amputation of, with part of meta- carpals, 295, 296 index-, disarticulation of, at metacarpo- phalangeal joint, 290 disarticulation of, with metacarpal, 298 second interphalangeal joint, excision of, 404 second phalanx, excision of, 405 inner, disarticulation of, with meta- carpal, 297 little, disarticulation of, at metacarpo- phalangeal joint, 291 disarticulation of, with metacarpal, 298 metacarpal of, excision, 408 second interphalangeal joint, excision of, 405 second phalanx, excision of, 406 Fingers, amputation of, at first phalanx, 286 at last phalanx, 283 97° Fingers, amputation of, at second piialanx, -85 excluding thumb, with parts of meta- carpals, 297 general surgical considerations, 281 with parts of metacarpals, 295 anatomy of, 279 and thumb, disarticulation of, at carpo- metarcarpal joint, 302 disarticulation of, at first interphalangeal jomt, 286 at metacarpo-phalangeal joints, 287 at second interphalangeal joint, 284 excluding thumb, with metacarpals, 301 with metacarpals, 297 excision of, 402 excision of first interphalangeal joints, 406 excision of first phalanges, 406 excision of metacarpals, 407 excision of metacarpo-phalangeal joints, 406 excision of second interphalangeal joints, 403 excision of second phalanges, 405 excision of terminal phalanges, 403 three innermost, amputation of, with parts of metacarpals, 297 three innermost, disarticulation of, with metacarpals, 300 three inside, amputation of, with |;>arts of metacarpals, 296 three inside, disarticulation of, with metacarpals, 299 two contiguous inside, amputation of, with part of metacarpals 296 two contiguous inside, disarticulation of, with metacarpals, 299 Fissure, frontal, inferior, topography of, 466 superior, topography of, 466 intraparietal, topography of, 466 longitudinal, great, anatomy of. 459 topography of, 465 parieto-occipital, topography of, 466 postcentral, topography of, 466 precentral, topography of, 466 Rolandic, anatomy of, 460 topography of, 465 Sylvian, anatomy of, 459 topography of, 465 tcmporo-sphenoidal, superior, topog- raphy of, 467 transverse, great, topography of, 465 Fissures, mesial, and lobes of ceiebrum, 460 of cerebrum, 459 Fistula, fecal, closure of, operation for, 739 temporary, ileostomy for, 72S temporary, left inguinal lolostomx' for, 733 Fistula-in-ano, operation for, 757 Foot, amputations about, general con- siderations, 347 anatomy of, 344 anterior part, disarticulation of, at medio-tarsal joint, 355 disarticulation of, at ankle-joint, 360 at subastragaloid joint, 356 excision of bones and joints about, 424 osteoplastic resection of, 452 Foramen of Winslow, anatomy of, 648 Forcipressure, arterial, 119 venous, 129 Forearm, amputation of, 309 amputations about, general considera- tions, 308 anatomy of, 307 Foreign bodies in esophagus, operation for, 561 in larynx, operation for, 548 in trachea, operation for, 553 Fowler's method of antero-lateral abdom- inal section, 645 method of uretero-rectostomy, 870 Fracture of skull, trephining for, 492 ununited, of olecranon, operation for, 200 of patella, operation for, by wiring or suturing, 198 of patella, operation for, Stimson's method, 197 operation for, by frame ligatures of bone, 196 operation for, by intramedullary peg- ging, 196 operation for, by ligation of bone, 195 operation for, b\- ligature and suture, 196 operation for. by nailing, pegging, or screwing ends of bones, 193 operation for, by Parkhill's clamp, 194 operation for, by resection of ends of bones, 189 operation for, by suturing, 193 operation for, by wiring ends of bones, 191 operations for, 188 971 Gall-bladder, anatomy of, S15 operations upon, 815 operations upon, general considerations, 816 operations upon, instruments for, 804 Gall-ducts, anatomy of, 823 operations upon, 823 operations upon, general considerations, Ganglion, basal, function of, 472 topography of, 467 cervical sympathetic, and cord, anatomy of, 182 cervical sympathetic, and cord, excision of, total, 183 gasserian, anatomy of. 155 extracranial exposure of, 158 intracranial exposure of, 155 Meckel's, anatomy of, 160 operations upon, 141 Gasserian ganglion, anatomy of, 155 extracranial exposure of, 158 intracranial exposure of, 155 Gastrectomy, partial, followed by gastro- jejunostomy, closure of abdomen, and jejuno-jejunostomy, 7q8 total, 799 Gastric ulcer, operation for, 800 perforated, operation for, 800 Gastro-enterostomy, 776 anterior, by Murphy button, followed by Jaboulay-Braun method of intestinal anastomosis, 781 Wolfier's operation, 777 posterior, by Murphy button, 785 by von Hacker's method, 783 Gastrogastrostomx-, Wolfier's method, 785 Gastrolysis, 789 Gastropexy, 788 Gastroplasty, 789 Gastroplication, 787 Gastrorrhaphy, 765 Gastrostomy, 766 Albert's method, 769 Hahn's method, 769 Kader's method, 774 Marwedel's method, 772 Ssabanajew-Franck's method, 767 Witzel's method, 76(1 Gastrotomy by median incision, 762 by obUque subcostal incision, 764 Genital organs, female, operations upon, 929 male, operations upon, 895 Gluteal artery, anatomy of, 88 ligation of, 89 nerve, superior, exposure of, 170 Gouley's method of external perineal urethrotomy, 908 Grafting, nerve-, 149 omental, 654 tendon-, 221 Gustatory nerve, anatomy of, 168 exposure of, 168 Guyon's supramalleolar method of ampu- tating leg, 365 Hahn's method of gastrostomy, 769 Halsted's inflatable rubber cylinder, entero- enterostomy by, 710 interrupted mattress suture of intestine, 667 method of entero-enterostom}' by inter- rupted mattress suture, 686 operation for oblique inguinal hernia, 953 radical excision of breast, 582 Hand, anatomy of, 291 excision of, 406 Hands, amputations about, general con- siderations, 294 Hartley-Krause exposure of gasserian gan- glion, 155 Hartley's method of ligating intercostal artery, 78 of preliminarily excising spinous pro- cess, 535 Head and face, bony fair) sinuses of, operations upon, 500 operations upon, 459 Heart, anatomy of, 619 and pericardium, exposure of, by exci- sion of left fifth costal cartilage, 617 and pericardium, exposure of, by osteo- thoracoplastic resection of anterior chest-wall, 619 operations upon, 619 puncture of, 620, 621 right auricle of, paracentesis of, 620 right ventricle of, paracentesis of, 621 suture of, 621 Heinekc-Mikulicz method of pyloroplasty, 789 Hemorrhage, cerebral, artery of, 461 in amputations, control of, 230 intracranial, operation for, 489 972 Hemorrhoids, clamp and actual cautcrj- for, 756 excision of, AVhitehead's operation, 755 ligation and excision of, Allingham's method, 754 Hepatectomy, partial, 814 Hepatopexy, S14 Hepatorrhaphy, 813 Hepatotomy, 805 anterior subcostal transperitoneal, 806 Hernia, femoral, anatomy of, 955 Bassini's operation for, 557 operations for, 955 general considerations, 957 inguinal, anatomy of, 945 oblique, Bassini's operation for, 948 Halsted's operation for, 953 operations for, 945 general considerations, 946 instruments in, 94S operations for, 945 umbilical, anatomy of, 9^8 operation for, 959 Hey's amputation of leg at middle third, 3(17 disarticulation of toes. 354 Hip-joint, anatomy of, 386 disarticulation at, 390 general considerations, 338 excision of, 435 Humerus, excision of, 416 Hydrocele, \'olkmann'6 operation for, 014 Von Bergmann's operation for, 915 Hysterectomy, abdominal, partial, 933 total, 935 vaginal, total, 935 Hysterosalpingo-oophorectomy, partial ab- dominal, 933 total abdominal, 935 Ileoc.ecum, excision of, 720 Ileostomy, for permanent artificial anus, 730 for temporary fecal fistula, 728 Iliac artery, common, anatomy of, 81 ligation of, 82 external, anatomy of, 90 ligation of, 90 internal, anatomy of, 84 ligation of, 84 Implantation of ureters, 868 into bladder, 869 into large intestine, 870 upon skin of loin or abdomen, 873 Incision of burss, 22S Infraorbital nerve, exposure of. 163 Inguinal hernia, 945. See also Hernia, inguinal. lymphatic glands, removal of, 140 Innominate artery, anatomy of, 26 ligation of, 26 Intercostal artery, anatom}' of, 76 ligation of, 77 nerve, anatomy of. 177 exposure of, 178 Interosseous nen'e, anatomy of, 177 exposure of, 177 Intestinal anastomosis, 675. See also En- tero-cnterostomy. approximation, 675. See also Enlero- enteroslomy. implantation, 675. See also Eitlero- entcrostomy. Intestines, adhesions to, operation for, 651 anatomy of, 655 large, anatomy of, 658 operations upon, 655 general considerations, 662 instruments for, 662 small, anatomy of, 655 suture of, 663. See also Enterorrhaphy. wounds of, enterorrhaphy for. 670 Intraneural infiltration for regional anes- thesia, 151 Intraparietal fissure, topography of. 466 Intravenous infusion of salt solution, 130 Intubation of larynx, 547 Island of Reil. anatomy of, 460 topography of, 467 Jaboulay-Be.\un's method of multiple lateral intestinal anastomosis, 709 Jobert's operation for ligating popliteal artery, 100 Joints, erasion of, 204 operations upon, 204 puncture of, 204 resection of, osteoplastic, 448 Jonnesco's operation for excision of cervical sympathetic gangUa and cord, 183 K.\der's method of gastrostomy, 774 Keen's operation for exposure of posterior divisions of first, second, and third cer\ncal nerv'es, 171 973 Kidneys anatomy of, 837 bisection of, 849 exposure of, by abdomino-lumbar opera- tion, 847 retroperitoneal, by Koenig's angular lumbo-abdominal incision, 844 retroperitoneal, by lumbar intramuscu- lar method, 845 retroperitoneal, by obliciue lumbar in- cision, 841 transperitoneal, by median abdominal section, 847 transperitoneal, by vertical incision in linea semilunaris, 845 operations upon, 837 general considerations, 841 instruments for, 841 puncture of, exploratory, 848 suture of, 851 Knee-joint, anatomy of, 38 1 disarticulation at, 374 general considerations, 373 excision of, 432 Kocher's excision of hip-joint, 439 of tongue, 522 method of complete thyroidectomy, 575 of lateral pharyngotomy, 554 of partial thyroidectomy, 573 of pylorectomy, 792 Koenig's method of exposing kidney, 844 Kraske's method of excision of rectum, 745 Laminectomy, 530 Langenbeck's excision of elbow-joint, 413 of hip-joint, 436 osteoplastic resection of superior maxilla, 456 Langcnbuch's method of exposing kidnev. 845 Laplace's intestinal anastomosis forceps, entero-enterostomy by, 718 Larrey's disarticulation at shoulder-joint, Laryngectomy, complete, 545 partial, 546 Laryngoscopy, 548 Larvngotomy, 543 supralhyroid, 54S Laryngotracheotomy, 548 Larynx, anatomy of, 541 artificial, introduction of, 548 foreign bodies in, operation for, 548 Larynx, intubation of, 547 operations upon, 541 tamponing of, 548 Lauenstein's excision of ankle-joint, 428 Lee's intestinal holder, entero-enterostomy by, 714 Leg, amputation of, at supramalleolar region, 365 general considerations, 364 lower third, 365 middle third, 367 upper third, 368 anatomy of. 362 Lembert's continuous suture of intestine, 668 interrupted suture of intestine, 665 Ligaments, lengthening of, 226 operations upon, 226 shortening of, 226 suture of, 226 Ligation of abdominal aorta, by retro- peritoneal method, 81 by transperitoneal method, 80 of artery, 1 7 after-treatment, 25 closure of wound, 25 comment, 26 control of circulation preliminary to, iS dangers, 25 en masse, 1 1 7 for radical cure of aneurism, 120 general considerations, 17 in amputation, 253 incision, 19 indications, 17 instruments for, 17 intermediate, 117 materials for, 18 passing ligature, 22 position of patient, 17 preparation of patient, 17 results, 25 temporary, 116 tying ligature, 24 varieties, 1 7 of auricular artery, posterior, behind ear, 42 of auricular artery, posterior, near origin, 42 of axillary artery, first part, 62 of axillary artery, third part, 63 of brachial artery, at bend of elbow, 66 of brachial artery, in middle of arm, 65 974 Ligation of carotid artery, common, abo\"c omohyoid, 35 carotid artery, common, below omo- hyoid, 34 arotid artery, external, above digas- tric, 36 carotid artery, external, beknv digas- tric, 35 carotid arterv. internal, near origin, 50 dorsalis pedis, just below ankle-joint, 107 epigastric artery, near origin, 93 facial artery, near origin, 40 facial artery, over inferior maxilla, 40 femoral artery, common, at base of Scarpa's triangle, 95 femoral artery, superlicial, at apex of Scarpa's triangle, 97 femoral artery, superfit iai, in Hunter's canal, 9S gluteal artery, nn buttoc k, 89 iliac artery, commcjn, by retroperi- toneal operation, 82 iliac artery, common, Ijy transperi- toneal operation, 84 iliac artery, external, by retroperi- toneal route, 90 iliac artery, external, by transperi- toneal route, 92 iliac artery, internal, by retr[>peri- toneal operation, 84 iliac artery, internal, by transj^eri- toneal operation, 84 innominate artery, by angular inci- sion, 26 innominate artery, liy nbliriue inci- sion, 28 lominate artery, by partial bony resection, through oblique incision, 29 innominate artery, by partial bony resection, through transverse and vertical incisions, 30 innominate artery, by splitting of manubrium sterni, 30 intercostal artery, by intercostal inci- sion, 77 intercostal artery, by subperiosteal ex- cision of rib, 78 lingual artery, beneath hyoglossus, 38 lingual arterv, near origin 38 mammary artery, internal, in second intercostal space, 60 Ligation of maxillary artery, internal, 44 of meningeal artery, middle, anterior branch, 48 of meningeal artery, middle, posterior branch, 49 of meningeal artery, middle, trunk of, 47 of obturator artery, at thvroid foramen, 8S of occipital artery, behind mastoid pro- cess, 41 of occipital artery, near origin, 41 of omentum, 653 of peroneal artery, in middle of leg, 112 of plantar artery, external, at origin, IT4 of plantar artery, external, in sole of foot, of plantar artery, internal, at origin, 115 of plantar artery, internal, in sole of foot, 1 15 of popliteal artery, in lower part, loi of popliteal artery, in upper part, 100 of profunda femoris, near origin, 97 of pudic artery, internal, in perineum, 88 uf pudic artery, internal, on buttock, 88 of radial artery, at lower third. 70 of radial artery, at middle third, 70 of radial artery, at upper third, 69 of radial artery, deep palmar arch, 72 of radial artery, on back of hand, 71 of sciatic artery, upon buttock, 86 of sinus, lateral, 490 of subclavian artery, left, first portion, 53 of subclavian artery, right, first portion, 52 of subscapular artery, 64 of suprascapular artery, at outer margin of sternomastoid, 59 of temporal artery, just above zygoma, 43 of thoracic duct, 133 of thyroid artery, inferior, 57 of thyroid artery, superior, 37 of tibial artery, anterior, in lower third, 105 of tibial artery, anterior in middle third, 105 of tibial artery, anterior, in upper third, 104 o{ tibial artery, jiosterior, behind internal malleolus, 1 1 1 of tibial arterv, jiosterior. in lowi-r third, 1 10 of til)ial artery, posterior, in middle third, 109 975 Ligation of tibial artery, posterior, in u[>per third, lOQ of transversalis colli, at outer margin of sternomastoid, 58 of ulnar artery, in lower third, 76 of ulnar arterv-, in middle third, 74 of ulnar artePi-, superficial palmar arch, 76 • of veins, en masse, 129 in amputation, 253 lateral, 127 temporary, 128 transverse, 128 of vertebral artery, near origin, 56 Ligature, passing, in ligation of artery, 22 tying of, in ligation of artery, 24 Linea alba, anatomy of, 627 Linear osteotomy, by open method, 1S7 by subcutaneous method, 185 Lingual artery, anatomy of, 37 ligation of, 38 nen'e, anatomy of, 168 exposure of, 168 Lisfranc's disarticulation of toes, 353 Lister's modification of Garden's amputa- tion of thigh, 379 Litholapaxy, 888 Lithotrity, 888 Liver, anatomy of, 800 exposure of, by anterior subcostal trans- peritoneal route, 808 by chondro-plastic resection of right costal arch, 813 by intercostal subpleural route, S09 by lateral subcostal transperitoneal route, 809 by subpleural route, 810 by transpleural route, 812 operations upon, 800 general considerations, 802 instruments for, 804 puncture of, exploratory-, 804 suture of, 813, 814 Lobuli testis, anatomy of. 913 Loreta's method of divulsion of stomach, 701 Lungs, anatomy of, 6og operations upon, 6og Lymphatic glands, axillary, removal of, 139 inguinal, removal of, 140 of neck, isolated, removal of, 137 of neck, removal of, 135 operations upon, 132 vessels, operations upon, 132 Macewen's operation for radical cure of aneurism, 124 Mammary artery, internal, anatomy of, 59 ligation of, 60 gland, female, operations upon, 579. See Breast, female. Markoe's method of uretero-ureterostomy, 866 Marvvedel's method of gastrostomy, 772 Mastoid antrum, anatomy of, 501 exposure of, antrum operation of Schwartze, 504 exposure of, Sch%vartze-Stacke opera- tion, 506 operations upon, 500 operations upon, general considera- tions, 503 operations upon, instruments for, 504 cells, anatomy of, 502 exposure of, antrum operation of Schwartze, 504 exposure of, Schwartze-Stacke opera- tion, 506 , operations upon, 500 operations upon, general considera- tions, 503 operations upon, instruments for, 504 Matas's apparatus for paraneural infiltra- tion, 153 method for radical cure of aneurism, 121 Maunsell's invagination method of entero- enterostomy, 688 Maxilla, inferior, excision of, 443, 445 osteoplastic resection of, 457 superior, excision of, 440, 441 osteoplastic resection of, 454, 433, 436 Maxillar>' arten.', internal, anatomy of, 44 ligation of, 44 nerve, inferior, anatomy of, 164 exposure of, 164 superior, anatomy of, 160 exposure of, 161 sinuses, anatomy of, 511 exposure of, through facial aspect, above alveolar margin, 513 exposure of, through second molar tooth, 514 operations upon, 511 operations upon, general considera- tions, 312 operations ujion, instruments for, 513 976 McBurney's method of antcro-lateral ab- dominal section, 637 of appendicectomy, 722 Meatotomy, go4 Meckel's ganglion, anatom\ of, 160 Median nerve, anatomv of. 174 exposure of, 1 74 Mediastinum, anterior, anatomy of, 588 operations upon, 5 88 middle, anatomy of, 592 operations upon, 592 posterior, anatomy of, 592 operations upon, 592 superior, anatomy of, 5S7 operations upon, 587 Medulla, function of, 472 . Membrana tympani, anatomy of, 516 introduction of ear speculum for ex- amination of, 517 Meningeal artery, middle, anatomy of, 45, 461 anterior branch, ligation of, 48 posterior bjanch, ligation of, 49 topography of, 468 trunk of, ligation of, 47 Mesentery, anatomy of, 654 operations upon, 654 general considerations, 655 ?.Ieyer's method of inferior antero-lateral al>dominal section, 644 Mikulicz's method of exposing tonsil, 566 Milton's osteoplastic anterior mediastinot- omy, 588 Mixter's operation for exposure of inferior maxillary nerve, 164 Motor center, exposure of, ojjeration for, 404 Mott's method of ligating innominate artery, 26 Murphy button, anterior gastro-enteros- toiiiy by, followed liy Jaboulay- Braun method of intestinal anasto- mosis, 781 cholecystenterostomy by, Sig entero-enterostomy by, 703 posterior gastro-enterostomy by, 785 Muscle in amputation, treatment of, 255 suture of, 207 Muscle-lengthening, 208 Muscles, operations upon, 207 Musculocutaneous nerve, anatomy of, 173 exposure of. 1 73 Musculospiral nerve, anatomy of, 176 exposure of, 1 76 Myorrhaphy, 207 Mvotomv, 207 N.\s.\L cartilages, chondroplastic resectior "f. 4,v=; cavities, operations upon, 518 Naso-lambdoidal line, topography of. 468 Neck, anatomy of, 541 antero-lateral aspect, anatomy of, 133 lymphatic glands of, isolated, removal of, 137 removal of, 135 operations upon, 541 instruments for, 542 Needling for radical cure of aneurism, 124 Neoplasms, vascular, injection of water at high temperature in, 125 Nephrectomy, partial, oblique lumbar in- .sion, 85 9 subsca]>ular, 860 total, by anterior transperitoneal opera- tiim, 860 by oblique lumbar incision, 85S Nephrolithotomy, 850 Nephrope.xy, by simple suturing, 85 7 Edebohls's method, 852 TufBer's method, 856 Nephrorrhaphy, 851 Nephrotomy, 849 Nerve, circumflex, anatomy of, 173 circumflex, exposure of, 173 compressed, operation for, 151 crural, anterior, anatomy of, 178 crural, anterior, exposure of, 178 dental, inferior, anatomy of, 166 dental, inferior, e.xposure of, 166 facial, anatomy of, i6g exposure of, 169 topography of, 468 gluteal, superior, exposure of, 179 in amputation, treatment of, 255 infraorbital, exposure of, 163 intercostal, anatomy of, 177 exposure of, 178 interosseous, anatomy of, 177 exposure of, 177 lingual, anatomy of, 168 exposure of, 168 maxillary, inferior, anatomy of, 164 maxillary, inferior, exposure of, 164 977 Nerve, maxillary, superior, anatomy of, 1 60 maxillary, superior, exposure of, 161 median, anatomy of, 174 exposure of, 174 musculocutaneous, anatomy of, 173 exposure of, 173 musrulospiral, anatomy of, 176 exposure of, 176 obturator, exposure of, 1 7c) occipitalis major, anatomy of, 1 70 occipitalis major, exposure of, 171 popliteal, external, anatomy of, 181 popliteal, external, exposure of, 181 popliteal, internal, anatomy of, 180 popliteal, internal, exposure of, 180 pudic, exposure of, 179 radial, anatomy of, 176 exposure of, 177 ■ sciatic, great, anatomy of, 179 sciatic, great, exposure of, 179 sphenopalatine, anatomy of, 160 spinal accessory, anatomy of, 170 spinal accessory, exposure of, 170 supra-orbital, anatomy of, 160 exposure of, 160 suture of, 144 tibial, anterior, anatomy of, 182 tibial, anterior, exposure of, 182 tibial, posterior, anatomy of, 180 tibial, posterior, exposure of, i8c trifacial, extracranial exposure of, 158 intracranial exposure of, 155 ulnar, anatomy of, 175 exposure of, 175 Nerve-avulsion, 143 Nerve-grafting, 149 Nerve-implantation, 149 \erve-roots, posterior, intraspinal partial neurectomy of, 539 Nerves, brachial plexus of, anatomy, 172 exposure of, 172 cervical, first, second, third, posterior divisions, exposure of, 171 operations upon, 141 Neurectasy, 142 Neurectomy, 142 intraspinal, partial, of posterior nerve- roots, 539 Xeuroplasty, 147 Neurorrhaphy, 144 Neurotomy, 141 Nose, operations upon, 518 Obturator artery, anatomy of, 85 ligation of, 85 nerve, exposure of, 179 Occipital artery, anatomy of, 41 ligation of, 41 sinus, anatomy of, 462 Occipitalis major nerve, anatomy of, 170 exposure of, 171 0'Dw)'er's method of intubation of larynx, 547 Olecranon, fracture of, ununited, operation for, 200 Ollier's excision of elbow-joint, 415 excision of wrist-joint, 409 Omentum, adhesions to, operation for, 651 anatomy of, 652 grafting with, 654 ligation of, 653 operations upon, 652 Oophorectomy, 942 Orbit, anatomy of, 514 Orchidectomy, 916 Os calcis, excision of, 427 Osteoplastic amputations, 394 Osteoplasty, 202 Osteotomy, 184 cuneiform, 187 indications for, 184 instruments for 184 Unear, by open method, 187 by subcutaneous method, 185 position in, 1S5 preparation of patient for, 185 varieties of, 184 Ovariectomy, 942 Ovaries, anatomy of, 941 operations upon, 941 Pancreas, anatomy of, 833 operations upon, 833 Pancreatectomy, by gastrocolic route, 836 Pancreatotomy, by gastrocolic route, 835 Paracentesis abdominis, 651 of right auricle of heart, 620 of right ventricle of heart, 621 pericardii, 615 thoracis, 601 tunicae vaginalis, 913 tympani, 517 vesicjE, 879 Paraneural infiltration for regional anes- thesia, 153 978 Paravicini's method of exposing inferior dental nerve, i66 Parieto-occipital fissure, anatomy of, 460 topography of, 466 Parkin's incision of cerebellar subarachnoid space for drainage, 406 Parotid gland, anatomy of, 567 excision of, 568 operations upon, 567 Patella, excision of, 432 fracture of, ununited, operation for, by wiring or suturing, iq8 fracture of, ununited, o[)eration for, Stimson's method, 197 Pelviotomy, 850 Penis, amputation of, partial, 8g8 total, goo anatomy of, 895 operations upon, 895 instruments for, 895 Pericardiorrhaphy, 619 Pericardiotomy, through intercostal inci- sion, 616 Pericardium, anatomy of, 614 Pericardium and heart, exposure of, by excision of left fifth costal cartilage, 617 Pericardium and heart, exposure of, by ostcothoracoplastic resection of ante- rior chest-wall, 6ig operations upon, 614 puncture of, 615 suture of, 619 Peritoneum, adhesions of, operations for, 64c) anatomy of, 647 operations upon, 647 general considerations, 649 Peroneal artery, anatomy of, 1 1 2 ligation of, 112 Pfannenstiel's method of median inferior abdominal section, 643 Pharyngotomy, lateral, 554 median, 554 subhyoid, 555 Pharynx, anatomy of, 553 operations upon, 553 instruments for, 553 Phlebectomy, 129 Phleborrhaphy, 126 Phlc-biistrcpsis, 129 PhlclKilomy, 126 Piles, oijcrations for, 754. See also Hemor- rhoids. Pirogoff's disarticulation of foot at ankle- joint, 361 Plantar artery, external, anatomy of, 113 artery, external, ligation of, 114 artery, internal, anatomy of, 115 artery, internal, ligation of, 115 Pleura, anatomy of, 599 operations upon, 599 Pleuracentesis, 601 Pleurotomy, 601 Plexus of nerves, brachial anatomy of, 1 72 exposure of, 1 72 Plexuses, operation upcm. 141 Pneumectomy, partial, through osteo- thoracoplastic flap, 612 Pneumotomy, through thoracoplastic flap, 611 Poggi's method of uretero-ureterostomy, 866 Pons, function of. 472 Popliteal artery, anatomy of, 99 ligation of, 100 nerve, external, anatomy of, 181 nerve, external, exposure of, 181 nerve, internal, anatomj' of, 180 nerve, internal, exposure of, 180 Postcentral fissure, topography of, 466 Precentral fissure, topography of, 466 Proctectomy, 745. See also Reclcclomy. Proctopexy, 743 Proctotomy, 744 Profunda femoris, anatomy of, 96 ligation of, 97 Prostate gland, anatomy of, 922 operations upon, 922 Prostatectomy, 923 Alexander's operation, 926 perineal, 925 suprapubic, 924 Prostatotomy, 923 Psychical centers, area of, locaHzation, 471 Pudic artery, internal, anatomy of, 87 ligation of, 88 nerve, exposure of, 1 79 Puncture and drainage of lateral ventricles of brain, 495 of abdomen, 651 of bladder, 879 of brain, exploratory, 488 of bursa:, 228 of heart, 620, 621 of joint, 204 of kidney, exploratory, 848 979 Punrturc nf liver, exploratory, 804 of pericardium, 615 of spleen, exploratory, 82S of thorax, 601 of tunics vaginalis, 913 of tympanum, 517 spinal, for drainage of subarachnoid space, 53Q subarachnoid, for spinal anesthesia, 538 Pyelotomy, S50 Pylorectomy, 791 followed by end-to-end gastro-enter- ostomy, Billroth's method, 795 followed by posterior gastro-duoden- oslomy, Kocher's method, 792 Pvloroplasty, Heineke-Mikulicz method, '780 Pylorus, divulsion of, Loreta's operation, 79' Radial artery, anatomy of, 67 ligation of, 69 nerve, anatomy of, i 76 exposure of, 177 Radio-ulnar articulation, superior, excision of, 416 Radius, excision of, 412 Re-amputation for im|iroperly made flaps, Rectcctomy, by perineal route, 752 by sacral route, 745 Kraske's method, 745 Rchn-Rydygier osteojilastic flap method, 75° Rectopexy, \'erncuirs method, 743 Rectotomy, external, 744 internal, 744 Rectum, anatomy of, 660 excision of, 745. See also Reckclomy. Rehn-Rydygier method of excision of rectum, 750 Reid's method of cranio-cerebral localiza- tion, 476 Reil, island of, anatomy of, 460 topography of, 4(17 Resection of bones, osteoplastic, 448 of foot, osteoplastic, externo-lateral curved incision, 453 of foot, osteoplastic, transverse upper and lower and oblii|ue lateral inci- sions, 452 of joints, osteo])lastic, 448 Resection of maxilla, inferior, osteo])lastic, 457 of maxilla, superior, osteoplastic, to ex- pose nasopharynx by maxillary route, 456 of maxilla, superior, osteoplastic, to ex- pose nasopharynx by palatine route, 455 of maxilla, superior, osteoplastic, vertical and horiz', anatomy of, 51 left, first portion, ligation of, 53 right, first portion, ligation of, 52 second portion, ligation of, 53 third portion, ligation of, 54 Subhyoid pharyngotomy, 555 Sublingual gland, anatomy of, 572 excision of, 572 operations upon, 572 Submaxillary gland, anatomy of, 570 excision of, 571 operations upon, 570 Subscapular artery, anatomy of, 64 ligation of, 64 Supra-orbital nerve, anatomy of, 160 exposure of, 160 Suprascapular artery, anatomy of, 58 ligation of, 5Q Suprathyroid laryngotomy, 548 Suture of artery, 1 1 7 of bladder, 887 of heart, 621 of intestines, 663. See also Etilerorrhaphy. of kidney, 851 of ligaments, 226 of liver, 813, Si 4 of muscle, 207 of nerve, 144 of pericardium, 619 of spleen, 830 of stomach. 78S of stomach-wall, 765 of tendon, 213 of thoracic duct, 132 of ureters, 865 of urethra, 911 of veins, 126 Sylvian fissure, anatomy of, 459 topography of, 465 Syme's method of disarticulation of foot at ankle-joint, 360 of external perineal urethrotomy, c;o7 Svndesmotomv, 226 Tabatiere, anatomy of, 69 Tamponing of larynx, 548 of trachea, 553 Tarsometatarsus, osteoplastic resection of, 440 Tarsus, anterior, osteoplastic resection of, 449 middle, osteoplastic resection of, 450 posterior, osteoplastic resection of, 45 1 Taste area, localization of, 471 Tauffer's method of uretero-ureterostomy, 866 Teale's method of amputation by unecjual rectangular flaps, 272 Temporal artery, anatomy of, 43 ligation of, 43 Ttmporomaxillary articulation, excision of, 444 Temporosphenoidal fissure, superior, topog- raphy of, 467 Tendon, suture of, 213 Tendon-grafting, 221 Tendon-lengthening, 216 Tendons in amputation, treatment of, 255 operations upon, 211 Tendon-sheaths, excision of, 224 operations upon, 211 ruptured, repair of, 223 Tendon-shortening, 220 Tenorrhaphy, 213 Tenotomy, 211 open, 212 subcutaneous, 212 Testes, anatomy of, 912 operations upon, 912 Thigh, amputation of, 379 at condyles of femur, 379 general considerations, 378 just above condyles of femur, 380 just below trochanters, 386 lower, middle, or upper tiiird, 382 lower third, 382 anatomy of, 376 Thoracentesis, 601 Thoracic duct, anatomy of, 132 ligation of, 133 suture of, 132 tracheotomy, 553 Thoracoplasty, 604 Estlacnder's operation, 604 Schede's operation, 607 Thoracotomy, by partial excision of one or more ribs, 602 Thoracotomy, intercostal, 60 1 mediastinal, anterior, by long median in- cision, 588 mediastinal, anterior, by osteoplastic re- section of part of sternum, 590 mediastinal, posterior, 593 Thorax, anatomy of, 576 operations upon, 576 instruments for, 579 puncture of, 601 Thrombosis of lateral sinus, operation for, 492 Thumb, amputation of, with part of meta- carpal, 296 disarticulation of, at metacarpo-phalan- geal joint, 289 with metacarpal, 298 metacarpal of, excision, 40S Thyroid artery, inferior, anatomy of, 57 ligation of, 57 superior, anatomy of, 37 ligation of, 37 gland, anatomy of, 573 operations upon, 573 Thyroidectomy, complete, 575 partial, 573 Thyrotomy, 544 Tibia, excision of, 430 Tibial artery, anterior, anatomy of, 103 ligation of, 104 posterior, anatomy of, 108 ligation of, 109 nerve, anterior, anatomy of, 182 exposure of, 182 posterior, anatomy of, 180 exposure of, 180 Toe, disarticulation of, with metatarsal, 350 great, disarticulation of, at metatarso- phalangeal joint, 341 great, disarticulation of, with metatarsal, 35° little, disarticulation of, at metatarso- phalangeal joint, 341 little, disarticulation of, with metatarsal, 352 Toes, amputation of, at first phalanx, 338 at last phalanx, 336 at metatarsus, 348 at second phalanx, 338 general considerations, 335 with part of metatarsals, 347 anatomy of, 33 Toes, disarticulation of, at first interpha- langeal joints, 338 at interphalangeal joint, 337 at metatarso-phalangeal joints, 340 at tarso-metatarsal joints, 353 general considerations, 335 with metatarsals, 349 excision of bones and joints about, 422 of first interphalangeal joint, 423 of first phalanx, 424 of metatarsal bones, 424 of metatarso-phalangeal joints, 424 of second interphalangeal joint, 423 of second phalanges, 423 of terminal phalanges, 423 second, third, or fourth, disarticulation of, at metatarso-phalangeal joint, 340 two adjoining, disarticulation of, at meta- tarso-phalangeal joint, 342 two or three contiguous, disarticulation of, with metatarsals, 353 Tongue, anatomy of, 51S excision of, 520 general considerations, 518 instruments for, 519 limited portions, 520 operations upon, 518 Tonsillectomy, complete, through mouth, 564 through neck, 565 partial, through mouth, 564 Tonsillotomy, 563 Tonsils, anatomy of, 563 operations upon, 563 general considerations, 563 instruments for, 563 Torsion of artery, 120 of veins, 129 Trachea, anatomy of, 548 foreign bodies in, operation for, 553 operations upon, 548 general considerations, 549 instruments for, 549 tamponing of, 553 Tracheo-laryngotomy, 552 Tracheoscopy, 553 Tracheotomy, high, 550 low, 552 thoracic, 553 by posterior mediastinal osteoplastic flap operation, 622 Transversalis colli, anatomy of, 57 ligation of, 58 983 Trephining, 481 circular, 48 1 for fracture of skull, 492 linear, 487 varieties of, 480 Trifacial nerve, extracranial exposure of, 1 58 intracranial exposure of, 155 Tufficr's method of nephropexy, 856 Tumor, cerebellar, operation for, 499 cerebral, operation for, 498 of spinal cord, operation for, 539 Tunica albuginea, anatomy of, 913 vaginalis, anatomy of, 912 puncture of, 913 vasculosa, anatomy of, 913 Tympanum, membrane of, anatomy of, 516 introduction of ear speculum for ex- amination of, 517 puncture of, 517 Ulcer, gastric, operation for, 800 perforated, operation for, 800 UUmann's modification of Maunsell's method of entero-enterostomy, 699 Ulna, excision of, 411 Ulnar artery, anatomy of, 73 ligation of, 74 nerve, anatomy of, 175 exposure of, 175 Umbilical hernia, anatomy of, 958 operation for, 959 Ureterectomy, 873 partial, by oblique lumbar incision, 874 total, with removal of kidney, 874 Uretero-rectostomy, 870 Ureterorrhaphy, 865 Ureterotomy, 864 Uretero-ureteral anastomosis, 865 Uretero-ureterostomy, 865 Ureters, anatomy of, 861 exposure of, 863 implantation of, 868 into bladder, 869 into large intestine, 870 upon skin of loin or abdomen, 873 operations upon, 861 general considerations, 862 instruments for, 863 suture of, 865 Urethra, anatomy of, 902 female, anatomy of. 903 Urethra, introduction of sound or catheter into, 878 male, anatomy of, 902 operations upon, 902 suture of, 911 Urethrorrhaphy, 911 Urethrostomy, gii Urethrotomy, 904 external perineal. Cock's method, 910 external perineal, Gouley's method, 908 external perineal, Syme's method, 907 external perineal, Wheelhouse's method, 909 internal, by dilating urethrotome, 905 Uterus, anatomy of, 929 broad hgament of, anatomy of, 930 operations upon, 929 instruments for, 932 round ligaments of, anatomy, 931 Vagina, anatomy of, 931 Van Hook's method of uretero-ureter- ostomy, 867 Varicocele, Bennett's modification of Howse's operation for, 919 operation for radical cure of, 919 Vas deferens, anatomy of, gi8 Vasa deferentia, anatomy of, 918 Vascular neoplasms, injection of water at high temperature in, 125 Vasectomy, partial, gi8 Veins, acupressure of, 129 excision of, 129 infusion of salt solution into, 130 ligation of, en masse, 129 in amputation. 253 lateral, 127 temporary, 128 transverse, 128 operations upon, 126 pressure of, 129 suture of, 126 torsion of, 129 Venesection, 126 Venous forcipressure, 129 Ventricles, lateral, of brain, puncture and drainage of, 495 lateral, of brain, topography of, 468 Verneuil's method of rectopexy, 743 Vertebral artery, anatomy of, 55 ligation of, 56 984 Vesical calculus, lateral perineal, cystotomy for, 883 median perineal cystotomy for, 886 drainage, 892 V'esiculae seminales and part of ejaculatory ducts, total excision of, Young's operation, 921 operations upon, 920 Vischer's method of lateral abdominal section, 646 Volkmann's operation for hydrocele, 914 \"on Bcrgmann's operation for hydrocele, 915 Von Hacker's method of posterior gastro- enterostomy, 783 Warren's radical excision of breast, 584 Weir's method of antcro-lateral abdominal section, 639 modification of Bircher's operation for gastroplication, 7S7 modification of Murphy's button, lateral anastomosis with, 708 Wharton's duct, anatomy of, 570 operations upon, 570 Whfclhouse's method of external perineal urethrotomy, 909 Whitehead's excision of tongue, 520 operation for hemorrhoids, 755 Winslow, foramen of, anatomy of, 648 Winslow's method of uretero-ureterostomy, 867 Witzel's method of gastrostomy, 769 Wladimiroff-Mikulicz osteoplastic resection of foot, 452 osteoplastic resection of foot, modifica- tion, 453 Wolfler's method of anterior gastro-enter- ostomy, 777 of gastrogastrostomy, 785 Wound, bullet, of brain, operation for, 493 Wounds of intestines, enterorrhaphy for, 670 Wrist-joint, anatomy of, 302 disarticulation at, 304 general considerations, 303 excision of, 408 Wyeth's disarticulation at hip-joint, 390 operation for vascular ni'oplasms, 125 Youxg's method of total excision of vesicula? seminales and part of ejacula- tory ducts, 921 SAUNDERS' BOOKS Pathology, Physiology Histology, Embryology and Bacteriology W. B. SAUNDERS & COMPANY 925 WALNUT STREET PHILADELPHIA NEW YORK LONDON Fuller Building, 5th Ave. and 23d St. 9, Henrietta Street, Covent Garden LITERARY SUPERIORITY ^■^HE excellent judgment displayed in the publications of the house * at the very beginning of its career, and the success of the mod- ern business methods employed bj- it, at once attracted the attention of leading men in the profession, and man)- of the most prominent writers of America offered their books for publication. Thus, there were produced in rapid succession a number of works that imme- diately placed the house in the front rank of Medical Publishers. One need only cite such instances as Stengel's " Pathologj'," Hirst's " Obstetrics," the late William Pepper's " Theorj' and Practice of Medicine," Anders' " Practice," DaCosta's " Surgery," Keen and White's "American Te.xt-Book of Surgerj'," Hektoen's "American Text-Book of Pathology," and the " International Text-Book of Surgery," edited by Warren and Gould. These works have made for themselves a place among the best te.xt-books on their several subjects for students and practitioners. A Complete Catalogue of our Publications will be Sent upon Request SAUNDERS' BOOKS ON American Text-Book of Pathology American Text-Book of Pathology. Edited by Ludvig Hektoen, M. D., Professor of Pathology, Rush Medical College, in affiliation with the University of Chicago ; and David Riesman, M. D., Professor of Clinical Medicine, Philadelphia Polyclinic. Handsome imperial octavo, 1245 P^ges, 443 illustrations, 66 in colors. Cloth, $7.50 net; Sheep or Half Morocco, S8.S0 net. MOST SUMPTUOUSLY ILLUSTRATED PATHOLOGY IN ENGLISH The importance of the part taken by the science of pathology in the recent wonderful advances in practical medicine is now generally recognized. It is uni- versally conceded that he who would be a good diagnostician and therapist must understand disease — must know pathology. The present w-ork is the most repre- sentative treatise on the subject that has appeared in English. It furnishes prac- titioners and students with a comprehensive text-book on the essential principles and facts in General Pathology and Pathologic Anatomy, with especial emphasis on the relations of the latter to practical medicine. The illustrations are nearly all original, and those in color, many of which represent the composite result of from seven to ten colors, are printed directly in the text, thus facilitating consulta- tion. In fact, the pictorial feature of the work forms a complete atlas of pathologic anatomy and histology. OPINIONS OF THE MEDICAL PRESS Quarterly Medic£il Journal, Sheffield, Eng;Iand "As to the illustrations, we can only say that whilst all of them are good, most of them are really beautiful, and for them alone the book is worth having. Both colored and plain, they are distributed so profusely as to add very largely to the interest of the reader and to help the student." American Medicine "It is especially praiseworthy and valuable in that throughout pathologic problems aie treated with particular reference to their bearings upon practical medicine and surger>'." The Lancet, London '■ The illustrations, plain and colored, throughout the whole work are excellent, and they add considerably to the value of a thoroughly trustworthy text-book of pathology." PATHOLOGY. Stengel's Text-Book of Pathology Fourth Edition, Thoroughly Revised A Text-Book of Pathology. By Alfred Stengel, M. D., Professor of Clinical Medicine in the University of Pennsylvania. Octavo volume of 897 pages, with 364 text-illustrations, many in colors, and 7 full-page colored plates. Cloth, S5.00 net ; Sheep or Half Morocco, $6.00 net. WITH 364 TEXT-CUTS, MANY IN COLORS. AND 7 COLORED PLATES In this work the practical application of pathologic facts to clinical medicine is considered more fully than is customary in works on pathology. While the subject of pathology is treated in the broadest way consistent with the size of the book, an effort has been made to present the subject from the point of view of the cHnician. In the second part of the work the pathology of individual organs and tissues is treated systematically and quite fully under subheadings that clearly indicate the subject-matter to be found on each page. In this edition the section dealing with deneral Pathology has been most extensively revised, several of the important chapters having been practically rewritten. A very useful addition is an Appendix treating of the technic of pathologic methods, giving briefly the most important methods at present in use for the study of pathology, including, however, only those methods capable of giving satisfactory results. The book will be found to maintain fully its popularity. PERSONAL AND PRESS OPINIONS William H. Welch. M. D.. Pro/esSiir of Pathology. Joktis Hopkins Univenity. Baltimore, Md. " I consider Ihe work abreast of modern pathology, and useful to both students and practi- tioners. It presents in a concise and well-considered form the essential facts of general and special pathologic anatomy, with more than usual emphasis upon pathologic physiology." Ludvig Hektoen, M. D., Professor of P^ilhohgy. Rush Medical College. Chicago. " I regard it as the most serviceable text-book for students on this subject yet written by an .American author." The Lancet, London " 1 his volume is intended to present- the subject of pathology in as practical a form as pos- sible, and more especially from the point of view of the ' clinical pathologist.' These subjects have been faithfully carried out, and a valuable text-book is the result. We can most favorably recommend it to our readers as a thoroughly practical work on clinical pathology." SAUNDERS- BOOKS OX Barton and Well*/*' Medical Thesaurus A NEW WORK— JUST ISSUED A Thesaurus of Medical Words and Phrases. By Wilfred M. Barton, A. M., Assistant to Professor of Materia Medica and Thera- peutics, and Lecturer on Pharmacy, Georgetown University, Washing- ton, D. C. ; and Walter A. Wells, M. D., Demonstrator of Laryn- gology and Rhinology, Georgetown University, Washington, D. C. Handsome octavo of about 650 pages. Cloth, $0.00 net ; Sheep or Half Morocco, go.oo net. THE ONLY MEDICAL THESAURUS EVER PUBLISHED This work is the only Medical Thesaurus ever published. It aims to perform for medical literature the same services which Roget'swork has done for literature in general ; that is, instead of, as an ordinary dictionary does, supplying the meaning to given \\%rds, it reverses the process, and when the meaning or idea is in the mind, it endeavors to supply the fitting term or phrase to express that idea. To obviate constant reference to a lexicon to discover the meaning of terms, brief definitions are given before each word. As a dictionar)' is of service to those who need assistance in interpreting the expressed thought of others, the Thesaurus is intended to assist those who have to write or to speak to give proper expression to their own thoughts. In order to enhance the practical application of the book cross references from one caption to another have been introduced, and terms inserted under more than one caption when the nature of the term permitted. In the matter of synonyms of technical words the authors have per- formed for medical science a service never before attempted. Writers and speakers desiring to avoid unpleasant repetition of words will find this feature of the work of invaluable service. Indeed, this Thesaurus of medical terms and phrases will be found of inestimable value to all persons who are called upon to state or explain any subject in the technical language of medicine. To this class belong not only teachers in medical colleges and authors of medical books, but also every member of the profession who at some time may be required to deliver an address, state his experience before a medical society, contribute to the medical press, or give testimony before a court as an expert witness. PATHOLOGY. Mcrarland's Text-Book of Pathology A Text-Book of Pathology. By Joseph McFarland, M. D., Pro- fessor of Pathology and Bacteriology in the Medico-Chirurgical Col- lege of Philadelphia ; Pathologist to the Medico-Chirurgical Hospital, Philadelphia. Handsome octavo of about 900 pages, beautifully illus- trated. Cloth, go.oo net ; Sheep or Half Morocco, go.oo net. A NEW WORK — JUST ISSUED The science of pathology is the key to the successful diagnosis and treatment of disease. Symptoms and physical signs are but the manifestations of pathologic conditions, and their meaning cannot be properly interpreted^ unless their cause — the morbid processes — is thoroughly understood. Further, it is only upon a sound knowledge of these morbid conditions that any scientific system of thera- peutics can be built up. It is evident, therefore, that a practitioner to be prop- erly eciuipped to cope with disease in its various forms must have at his command the essential facts of the science of pathology. This entirely new work, by a pathologist of recognized ability, is a plain account of the natural history of dis- ease, and covers the field thoroughly, accurately, and completely. Being the work of a teacher who, as such, is eminently familiar with the needs of students, it is arranged in a manner and written in a style best suited to teaching pur- poses. Unlike most works on pathology, it treats the subject, not from the pro- fessor's point of view, but from that of the student, the author ever aiming to render most easy of comprehension the many difficult theories of the science. The work is descriptive, not controversial, debated points usually not being dis- cussed. The text is admirably elucidated by numerous excellent illustrations, many of them having been especially drawn. Indeed, this book of Dr. McFar- land' s" will be found of inestimable value not only to the student and general practitioner, but also to the specialist, as presenting the very latest advances in the science. SAUA'DKRS' BOO AS ON GET /k • THE NEW THE BEST I\ m C r 1 C 2i n standard Illustrated Dictionary Third Revised Edition — Just Issued The American Illustrated Medical Dictionary. A new and com- plete dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy, Chemistry, and kindred branches ; with over lOO new and elaborate tables and many handsome illustrations. By W. A. Newman Borland, M. D., Editor of " The American Pocket Medical Diction- ary." Large octavo, nearly 800 pages, bound in full flexible leather. Price, S4-50 net; with thumb index, $5.00 net. Gives a Maximum Amount of Matter in a Minimum Space, and at the Lowest Possible Cost THIRD EDITION IN THREE YEARS — 12,500 COPIES The immediate success of this work is due to the special features that distin- guish it from other books of its kind. It gives a maximum of matter in a mini- mum space and at the lowest possible cost. Though it is practically unabridged, yet by the use of thin bible paper and flexible morocco binding it is only I % inches thick. The result is a truly luxurious specimen of book-making. In this new edition the book has been thoroughly revised, and upward of one hundred important new terms that have appeared in recent medical literature have been added, thus bringing the book absolutely up to date. The book contains hun- dreds of terms not to be found in any other dictionary, over 100 original tables, and many handsome illustrations, including 24 colored plates. PERSONAL OPINIONS Howard A. Kelly, M. D.. Professor of Gynecology, Johns Hopkins University, Baltimore. " Dr. norland's dictionary is admirable. It is so well gotten up and of sucli convenient size. No errors iiave been found in my use of it." Roswell Park. M. D., Professor of PriricipU-s and Practice of Surgery and of Clinical Surgery, University of Buffalo. " I must aclinowledge my .istonishment at seeing how much he has condensed withi;\ rela- tively small space. I find nothing to criticize, very much to commend, and was interested in finding some of the new words which are not in other recent dictionaries." EMBRYOLOGY. Heisler's Text-Book of Embryology Second Edition, Thoroughly Revised A Text-Book of Embryology. By John C. Heisler, M. D., Pro- fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. Octavo volume of 405 pages, with 196 illustrations, 32 of them in colors. Cloth, $2.50 net. WITH 196 ILLUSTRATIONS. 32 IN COLORS The fact of embryology having acquired in recent years such great interest in connection with the teaching and with the proper comprehension of human anatomy, it is of first importance to the student of medicine that a concise and yet sufficiently full text-book upon the subject be available. In its first edition this work met this want most admirably, and in its present form it will prove even more valuable. The work has been thoroughly revised, and such additions have been made as the progress of the science has rendered necessary. Moreover, the entire work has been generally improved. The chapter treating of the Decidua; and the Placenta has been rewritten, as has also the greater part of that upon the Chorion. In addition to these changes, several new illustrations have been added. PERSONAL AND PRESS OPINIONS G. Carl Huber. M. D., Junior Professor of Anatomy and Physiology. University of Michigan, Ann Arbor. " I find the second edition of 'A Text-Book of Embryology* by Dr. Heisler an improve- ment on the first. The figures added increase greatly the value of the work. I am again recommending it to our students." William Wathen, M. D., Professor of Obstetrics, Abdominal Surgery, and Gynecology, and Dean, Kentucky School of Medicine, Louisville, Ky. " It is systematic, scientific, full of simplicity, and just such a work as a medical student will be able to comprehend. " Birmingham Medical Review, England ■' W'.- . a7i most rc.iifid.ntly rccomriu-nd Dr. Heislcr's book to the student of biology or medicine fur his careful study, if his aim be to acquire a sound and practical acquaintance with the subject of embryology." SACA-DEJ^S- BOOKS ON Mallory and Wright's Pathologic Technique Second Edition, Revised and Enlarged Pathologic Technique. A Practical Manual for Workers in Patho- logic Histology, including Directions for the Performance of Autopsies and for Clinical Diagnosis by Laboratory' Methods. By Frank P. Mallory, M. D., Associate Professor of Pathology, and James H. Wright, M. D., Instructor in Pathology, Harvard University Medical School. Octavo of 432 pages, with 137 illustrations. Cloth, ^3.00 net. WITH CHAPTERS ON POST-MORTEM TECHNIQUE AND AUTOPSIES In revising the book for the new edition the authors have kept in view the needs of the laboratory worker, whether student, practitioner, or pathologist, for a practical manual of histologic and bacteriologic methods in the study of patho- logic material. Many parts have been rewritten, many new methods have been added, and the number of illustrations has been considerably increased. Among the many changes and additions may be mentioned the amplification of the de- scription of the Parasite of Actinomycosis and the insertion of descriptions of the Bacillus of Bubonic Plague, of the Parasite of Mycetoma, and Wright's methods for the cultivation of Anaerobic Bacteria. There have also been added new staining methods for elastic tissue by Weigert, for bone by Schmorl, and for con- nective tissue by Mallory. The new edition of this valuable work keeps pace with the great advances made in pathology, and will continue to be a most useful laboratory and post-mortem guide, full of practical information. PERSONAL AND PRESS OPINIONS Wm. H. Welch, M. D.. Professor ,f Pathology, Johns Hopkins Uni-jcrsily, Baltimore. ■' I have been looking forward to the publication of this book, and I am glad to say that I find it a most useful laboratory and post-mortem guide, full of practical information and well up to date." Boston Medical and Surgical Journal ■' riiis manual, since its first appearance, h.as been recognized as the standard guide in patho- logical technique, and has become well-nigh indispensable to the laboratory worker." Journal of the American Mediced Association " One of the most complete works on the subject, and one which should be in the library of every physician who hopes to keep pace with the great advances made in pathology." HISTOLOGY. Bohm, Davidoff, and Huber's Histology A Text-Book of Human Histology. Including Microscopic Tech- nic. By Dr. A. A. Bohm and Dk. M. von Davidoff, of Munich, and G.Carl Huber, M. D., Junior Professor of Anatomy and Director of the Histological Laboratory, University of Michigan, Ann Arbor. Hand- some octavo of 503 pages, with 351 beautiful original illustrations. Cloth, 5350 net. INCLUDING MICROSCOPIC TECHNIC The work of Drs. Bohm and Davidoff is well known in the German edition, and has been considered one of the most practically useful books on the subject of Human Histology. The excellence of the te.xt and illustrations, attested by all familiar with the work, and the cordial reception which it has received from both students and investigators, justify the belief that an English translation will meet with approval from American and English teachers and students. This American edition has been in great part rewritten and very much enlarged by Dr. Huber, who has also added over one hundred original illustrations. Dr. Huber' s exten- sive additions have rendered the work the most complete students' text-book on Histology in existence. The book contains particularly full and explicit instructions in the matter of technic, and it will undoubtedly prove of the utmost value to students and practical workers in the Histologic Laboratory. Special attention is called to the fulness of the text, the large amount of matter on technic, and the numerous handsome illustrations. OPINIONS OF THE MEDICAL PRESS British Medical Journal '■ The combined autliorship of so m.iny distinguished men has led to the production of a most valualile work. The illustrations are most beautiful, and beautifully executed, and their study will be an education in themselves." Boston Medical and Surgical Journal " Is unquestionably a text-book of the first rank, having been carefully written by thorough masters of the subject, and in certain directions it is much superior to any other histological manual." American Medicine " It is recognized as the highest authority in Germany. ... A book on histology which surpasses anything of its kind now in print." SAC'A'BE/^S- BOOKS OX McFarland's Pathogenic Bacteria fourth Edition, Rewritten and Enlarged A Text=Book Upon the Pathogenic Bacteria. By Joseph McFar- LAND, M. D., Professor of Pathology and Bacteriology in the Medico- Chirurgical College of Philadelphia, Pathologist to the Medico-Chirur- gical Hospital, Philadelphia, etc. Octavo volume of 629 pages, finely illustrated. Cloth, $3.50 net. JUST ISSUED This book gives a concise account of the technical procedures necessary in the study of bacteriology, a brief description of the life-history of the important patho- genic bacteria, and sufficient description of the pathologic lesions accompanying the micro-organismal invasions to give an idea of the origin of symptoms and the causes of death. The illustrations are mainly reproductions of the best the world affords, and are beautifully and accurately executed. Although but a short time has elapsed since the appearance of the previous edition, e.xtensive progress has been made in the subjects of which it treats. In this edition, therefore, the entire work has been practically rewritten, old matter eliminated, and much new matter inserted. The chapters upon Infection and Immunity have been greatly extended by the addition of the many new facts recently added to our knowledge. The value of the work has been considerably enhanced by the introduction of a large number of references to the literature. PERSONAL AND PRESS OPINIONS H. B. Anderson, M. D., Pro/issor of Pathology and Bacteriology, Trinity Medical College, Toronto. " The book is a satisfactory one, and I shall take pleasure in recommending it to the students of Trinity College." The Lancet, London " It is excellently adapted for the medical students and practitioners for whom it is avowedly written. . . . The descriptions given are accurate and readable, and the book should prove useful to those for whom it is written." New York Medical Journal "The author has succeeded admirably in presenting the essential details of bacteriological technic, together with a judiciously chosen suminary of our present knowledge of pathogenic bacteria. . . . The work, we think, should have a wide circulation among English-speaking students ot medicine." />'.■/ CTERIOLOG y AND PA THOLOG J '. Eyre's Bacteriologic Technique The Elements of Bacteriologic Technique. A Laboratory Guide for the Medical, Dental, and Technical Student. By J. W. H. EvRE, M. D., F. R. S. Edin., Bacteriologist to Gu)-'s Hospital, London, -and Lecturer on 'Bacteriology at the Medical and Dental Schools, etc. Octavo volume of 375 pages, with 170 illustrations. Cloth, ^2.50 net. FOR MEDICAL, DENTAL. AND TECHNICAL STUDENTS This book presents, concisely yet clearly, the various methods at present in use for the study of bacteria, and elucidates such points in their hfe-histories as are deliatable or still undetermined. It includes only those methods that are capable of giving satisfactory results even in the hands of beginners. The excel- lent and appropriate terminology of Chester has been adopted throughout. The illustrations are numerous and practical, the author considering that a picture, if good, possesses a higher educational value and conveys a more accurate impres- sion than a page of print. The work is not intended for the medical and dental student ainne. having been designed with the needs of the technical student gen- erally constantly in view, whether he be of brewing, dairying, or agriculture. Warren's Pathology and Therapeutics Surgical Pathology and Therapeutics. By John Collins Warren, M. D., LL.D., I-". R. C. S. (Hon.), I'rofessor of Surgery, Harvard Medical School. Octavo, 873 pages, 136 relief and lithographic illustrations, ^^ in colors. With an Appendix on Scientific Aids to Surgical Diagnosis and a series of articles on Regional Bacteriology. Cloth, §5-00 net ; Sheep or Half Morocco, $6.00 net. SECOND EDITION, WITH AN APPENDIX In the second edition of this book all the important changes have been em- bodied in a new Appendi.x. In addition to an enumeration of the scientific aids to surgical diagnosis there is presented a series of sections on regional bacteriology, in which are given a description of the flora of the affected part, and the general principles of treating the affections they produce. Roswell Park, M. D., /// the Hiin'ani Graduate Ma^^azine. " I think it is the most creditable book on surgical pathology, and the most beautiful medical illustration of the bookmakers' art that has ever been issued from the American press.' SAUNDERS' BOOKS ON Dtirck and Hektoen's Special Pathologic Histology Atlas and Epitome of Special Pathologic Histology. By Dr. H. DuRCK, of Munich. Edited, with additions, by Luuvig Hektoen, M. D., Professor of Pathology, Rush Medical College, Chicago. In two parts. Part I. — Circulatory, Respiratory, and Gastro-intestinal Tracts. 120 colored figures on 62 plates, and 158 pages of text. Part II. — Liver, Urinary and Sexual Organs, Nervous System, Skin, Muscles, and Bones. 123 colored figures on 60 plates, and 192 pages of te.xt. Per part : Cloth, $3.00 net. In Saunders' Hand-Atlas Scries. The great value of these plates is that they represent in the exact colors the effect of the stains, which is of such great importance for the differentiation Tx>i* Fourth Revised Edition, American Pocket Dictionary just issued Borland's Pocket Medical Dictionary. Edited by W. A. New- man Dorland, M. D., Assistant Obstetrician to the Hospital of the University of Pennsylvania. Containing the pronunciation and defini- tion of the principal words used in medicine and kindred sciences, with 64 extensive tables. Handsomely bound in flexible leather, with gold edges, $1.00 net ; with patent thumb index, $1.25 net. " I can recommend it to our students without reserve." — J. H. HOLLAND, M. D., Dean of the lefferson Medical College, Philadelphia. ^-^