^S3Z /85f Columbia JMwafftp intijeCttpofJtogork College of $i)pgictan£i ano gmrgeong Hibrarp Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries http://www.archive.org/details/manualofoperativ1895stim A MANUAL OPERATIVE SURGERY. BY LEWIS A. STIMSON, B.A., M.D., SURGEON TO THE NEW YORK, BELLEVUE, AND HUDSON STREET HOSPITALS ; PROFESSOR OF SURGERY IN THE UNIVERSITY OF THE CITY OF NEW YORK ; CORRESPONDING MEMBER OF THE SOCIETfc DK CHIRURGIE, PARIS. AND JOHN ROGERS, Jr., B.A., M.D., ASSISTANT DEMONSTRATOR OF ANATOMY IN THE COLLEGE OF PHYSICIANS AND SURGEONS (COLUMBIA COLLEGE), NEW YORK ; SURGEON OF THE OUT-PATIENT STAFF, HUDSON STREET HOSPITAL. TH IRD EDITION WITH THREE HUNDRED AND THIRTY-FOUR ILLUSTRATIONS. PHILADELPHIA: LEA BROTHERS & CO. 1895. ^D St*> Iff*)*' Entered according to the Act of Congress, in the year 1S95, by LEA BROTHERS & CO., In the Office of the Librarian of Congress. All rights reserved. PHIJ.AhKU'IUA : HO UNA N, PKINTKR. PREFACE TO THIRD EDITION, In the preparation of this third edition, it has been found necessary almost wholly to rewrite the book in order to note the important changes that have taken place during the last ten years in the planning and execution of many of the operations that have been preserved, to substitute others, and to make the numerous additions. Of the operations formerly in vogue, a number have been left out because they had their origin and found their useful- ness only in conditions and dangers of the process of repair that are now rarely met with, and others because superior substitutes have been introduced. The most important addi- tions and modifications have been made in the surgery of the cranium and of the abdomen. To Dr. Rogers has fallen all the labor of collecting and making the descriptions, seeking and verifying references, obtaining the cuts and drawings, and of composition. He had my advice and assistance in the selection of subjects, and I revised the manuscript before publication and read all the proof. LEWIS A. STIMSON. New York, 34 East Thirty -third Street, October, 1895. CONTENTS. PART I. THE ACCESSORIES OF AN OPERATION. PAGE PAGE Anaesthesia , 13 Sutures, Twisted, 22 Local, 13 Preparation of materials used in an General, 14 operation, 23 Administration of ihe anaes- Catgut, 23 thetic, 15 chromicized, 24 Rectal, 16 Silk, 24 Arrest of hemorrhage, 17 Silkworm gut, 24 Ligature, 17 Sponges, 24 Torsion, 18 Absorbent gauze, 24 Pressure, 19 Bichloride gauze, 25 Cold or heat, 19 Iodoform gauze, 25 Position, 19 Drainage-tubes, 25 Artificial ischsemia, 19 Absorbent cotton, 26 Sutures, 21 Rubber tissue, 26 Interrupted, 21 Sterilization, 26 Continuous, 22 ' The wound and its treatment, 27 PAE r ii. LIGATURE OF ARTERIES. General directions, 30 Anatomy of the supra-clavicular region, 33 Ligature of the innominate artery, 34 Anatomy, 34 Operation, 35 Ligature of the subclavian artery, 36 1st portion, left subclavian, 37 1st portion, right subclavian, 37 2d portion, 37 3d portion, 38 Ligature of the superior thyroid, 39 Ligature of the inferior thyroid, 39 Ligature of the vertebral artery, 40 Ligature of the axillary artery, 41 Under the clavicle, 41 In the axilla, 41 Ligature of the brachial artery, 43 Anatomy, 43 Operation, 44 Ligature of the radial artery, 45 Anatomy, 45 Operation, upper third, 45 Operation, lower third, 46 Ligature of the ulnar artery, 46 Anatomy, 46 Operation at the junction of the upper and middle thirds, 46 Operation in the lower third, 47 Ligature of the common carotid, 47 At the place of election, 47 Ligature of the external carotid, 48 Anatomy, 49 Operation, 51 Ligature of the internal carotid, 51 Ligature of the lingual artery, 51 Anatomy, 51 Operation, 52 Ligature of the facial artery, 53 Ligature of the occipital artery, 53 Ligature of the temporal artery, 54 Ligature of the abdominal aorta, 54 Ligature of the common iliac, 55 Anatomy of the common, inter- nal, and external iliac arteries, 55 Extra-peritoneal, 56 Intra-peritoneal, 57 Ligature of the internal iliac, 57 Ligature of the external iliac, 5S Ligature of the gluteal, sciatic, and internal pudic arteries, 59 Ligature of the femoral artery, 60 Anatomy, 60 Operation, 61 At the apex of Scarpa's tri- angle, 61 In the middle of the thigh, 61 In Hunter's canal. '62 CONTENTS. Ligature of the popliteal artery, Ligature of the anterior tibial, Anatomy, Operation, Ligature of the dorsalis pedis, PAGE 62 63 63 63 65 PAGE Ligature of the posterior tibial, 65 Guthrie's method, 65 Lateral method, 65 In the lower third and behind the ankle, 67 PART III. AMPUTATIONS. Circular method, 1st time, 2d time, (6) Alanson's method, (c) Cutaneous sleeve, 3d time. Oval method, Flap method, Skin flaps and circular division, Long anterior flap, Teale' s method, Amputation of the fingers, Phalanges, Through the metacarpo-phalan- geal articulation, Amputation of the metacarpal bones, Amputation at the wrist, Circular method, Antero-posterior flaps, External lateral flap, Amputation of the forearm, Amputation at the elbow-joint, Anterior flap, (a) The joint opened from behind, (d) The joint opened from in front, Lateral flap, Circular, Amputation of the arm, Amputation at the shoulder-joint, General considerations, Oval method (Baron Larrey), Double flap method (Lisfranc), Spencc's method, Amputation of the arm, scapula, and clavicle, a mputation of the toes, Distal phalanx of the great toe, Disarticulation of the great toe, Two adjoining toes, Amputation of a metatarsal bone, Disarticulation of the 1st or 5th metatarsal Disarticulation of all the metatarsal bones (Lisfranc's amputation), Modifications, Medio-tarsal amputation (Chopart), Triplets, Sub-astragaloid amputation, 94 Amputation at the ankle-joint (Syme), 95 Modifications, 98 A. Internal lateral flap (Roux), 98 B. Pirogoft's amputation, 99 Comparison of the different meth- ods ot partial and total ampu- tation of the foot, 102 Amputation of the leg, 102 A. Lower third, 102 1. Circular method, 104 Bran's 104 2. Modified circular, 101 3. Long anterior flap (Bell), 104 4. Elliptic posterior . flap (Guyon), 105 B. Middle third, 106 1. Long anterior curved flap 106 2. Single posterior flap, 106 3. Skin flaps and circular division, 106 C. Upper third, 107 1. Long anterior rectangu- lar flap (Teale), 107 2. Long posterior rectangu- lar flap (Lee), 108 3. Modified flap (Bell), 108 Large external flap, 108 Comparison of the different meth- ods, 109 Amputation at the knee, 110 A. Disarticulation, 110 Lateral flaps, 111 B. Amputation through the condyles, oval , 111 Anterior flap (Carden), 111 Gritti's modification, 112 Amputation of the thigh, 114 Teale and Carden, 115 Modified flap, in lower third (Syme), 115 Long anterior flap, 115 Circular, 116 Amputation at the hip-joint, 117 Anterior racket or oval, 119 External racket or modified oval, 120 Anterior flap, 121 CONTENTS. VII PART IV. EXCISION OF JOINTS AND BONES. General considerations, Major articulations, Excision of the shoulder-joint, Ollier's method, Von Langenbeck's method By a transverse incision, Excision of the head of the scapula, Excision of the elbow-joint, Central longitudinal incision (v. Langenbeck), Ollier's method, Nelaton's method, Long radical incision (Hueter), Osteoplastic method, Bilateral incisions, Vogt, Partial excision, Excision of anchylosed elbow, Ollier's method, P. Heron Watson's method, Operative reduction of old disloca- tion, Excision of the wrist, Bilateral incisions (Lister), Radial incision (Oilier), Dorso-radial incision (Von Lan- genbeck), Excision of the hip-joint, Say re's method, Ollier's method, Langenbeck, Anterior incision, Arthrectomy, Anchylosis of the hip-joint, treated by subcutaneous division of the neck of the femur (Adams), Division below the trochanter, Excision, Excision of the knee-joint, Semilunar incision, Transverse incision, Arthrectomy, Excision of the ankle-joint, Vogt's method by removal of the astragalus, Osteoplastic excision of foot (Mikulicz), Operative reduction of old Pott's fracture, Excision of the bones and smaller articulations, Excision of the superior maxilla, Operation by a median inci- sion, Subperiosteal excision (Oilier), Excision of lower portion, Excision of upper portion, Simultaneous excision of both superior maxillae, Partial and temporary excisions of the superior maxilla to facili- tate the removal of naso- pharyngeal polyps, PAGE PAGE 124 Partial osteoplastic resection of ante- 127 rior portion of hard palate 127 (Chalot), 170 128 Resection of the upper portion 129 (Von Langenbeck), 171 130 Other methods of gaining access to the pharynx through the 130 nose, 172 131 Boeckel, 172 Oilier, 173 132 Excision of the inferior maxilla, 174 133 General considerations, 174 134 Resection of the anterior por- 134 tion of the body, 176 135 Resection of the lateral por- 136 tion of the body, 177 137 Resection of the ramus and 137 half the body, 177 137 Excision of the entire bone, 178 138 Subperiosteal method, 178 Partial excisions, 179 139 Anchylosis of the jaw, 179 140 Excision of the condyle, 180 141 Resection of the sternum, 180 144 L- Resection of the ribs, Estlander's operation for em- 181 145 pyema. is; 146 Excision of the clavicle, 182 146 Excision of the scapula, 183 147 Subperiosteal method (Oilier), 184 148 Opening of the joint, 185 148 Partial excisions of the scapula, 186 149 Resection of the humerus, 186 Upper portion, 186 Middle portion, 186 Lower portion, 186 150 Total excision, 187 151 Excision of the ulna. 187 152 Excision of the radius, 187 152 Partial excisions of the ulna 153 and radius, 187 154 Excision of the metacarpal bones 155 and phalanges, 188 155 Resection of a phalanx, 188 Resection of the bones of the pelvis, 18S 157 Excision of the coccyx, 189 Resection of the shaft of the femur, 189 159 Resection of the shaft of the tibia, 190 Resection of the fibula, 191 161 Of its upper extremity, 192 Of the lower portion, 192 162 Excision of the entire fibula, 192 162 Excision of the bones of the foot, 193 Calcaneum, 193 164 A. Holmes's method, 193 166 B. Subperiosteal method 167 (Oilier), 194 16S C. Farabeuf, 195 Astragalus, 196 169 Ollier's method, 196 When dislocated, 196 When shattered, 196 Metatarsal bones and pha-, 169 langes, 197 Ylll CONTENTS. Trephining, Of the cranium, General considerations, Temporary, by omega flap, Craniectomy," For fracture, Relation of brain to overlying parts (Reid), Relation of brain to overly in parts (Kocher), Position of lateral sinus, To open lateral sinus, iGE PAGE 197 Trephining— 197 For cerebral abscess due to mid 197 die-ear disease, 211 200 Of cerebellum, 212 202 Puncture of lateral ventricles, 213 202 For middle meningeal hemor- rhages, 213 203 Resection of fifth nerve within the skull, 215 207 Of the frontal sinus, 216 209 Of the antrum, 216 210 PART V. NEUROTOMY AND TENOTOMY. Division and resection of nerves, Supra-orbital nerve, Subcutaneous division, Excision of a portion, A. Above the eyebrow, B. Below the eyebrow, Supra-trochlear nerve, Superior maxillary nerve, A. Division of the nerve on the face, 1. Subcutaneously, 2. Through the mouth, 3. By external excision, B. Resection of the infra- orbital portion, Tillaux's method, Malgaigne's method, Lticke's method, Inferior dental nerve, A. At the mental foramen, B. Within the canal, C. Before its entry into the canal, 1. From within the mouth, 2. Through the cheek, At the foramen ovale. Buccal nerve, Lingual nerve, 217 Lingual nerve, Moore's method, 226 217 Facial nerve, 227 218 Brachial plexus, 227 218 Posterior roots, 228 218 Cervical plexus, 228 218 Spinal accessory, 229 219 First, second, and third nerves for 219 wry-neck, 229 Median nerve, 230 219 Ulnar nerve, 231 220 Musculo-spinal nerve, 231 220 Great sciatic nerve, 232 220 Internal popliteal nerve. 232 External popliteal nerve, 232 220 Anterior crural nerve, 232 220 Neurorrhaphy, 232 221 Tenotomy," 233 221 General considerations, 233 222 Tendo-Achillis, 234 222 Tibialis posticus, 234 223 A. Above the malleolus, 235 B. On the side of the foot. 235 223 Tibialis anticus, 235 223 Peronei, 235 223 Flexor tendons at the knee, 235 221 Sterno-cleido-mastoid, 235 22.', Levator palpebral, 235 226 Tenorrhaphy, 236 MIKCKLLANICOLS OPKRATION8. Thiersch's skin grafting, 238 lie tumors, 240 Birth-mark, 242 Separation of web-lingers, 243 Cicatricial Bexlon of phlanges, 244 Dupuytren'a contraction, 215 ingrown toenail, 245 Removal of cervical glands, 247 O.-teotomy, 249 Femur, 249 Maccwen, 260 Osteotomy, femur, Ogston, 251 Tibia, 252 For hallux valgus, 252 ( lunelform, for talipes, 258 Operations for ununited fracture, 256 Suture of patella, 257 Open method, 257 M'. 688. - Prof. W. IJ. Van Buren, on "Aneurism." Paper read before the International Medical Congress, Philadelphia, 1876. LIGATURE OF THE ARTERIES. 37 in the left is much longer, more vertical in its direction, and situated more posteriorly even than the innominate ; a separate description therefore is required only for the first portion. Operation. A V-shaped incision similar to that described for ligature of the innominata (Fig. 18) is made upon the left side, and carried through the sterno-cleido-mastoid and outer fibres of the sterno-thyroid and sterno-hyoid muscles and the middle cervical fascia as before described. The carotid is then recognized, and, together with the internal jugular, drawn outward with a blunt hook. The muscles are now relaxed by bending the head and neck forward, and the cellular tissue torn through with forceps and direc- tor. The knife should no longer be used, on account of the risk of injury to the thoracic duct, which is imbedded in the loose tissue between the vessels and the vertebra?, and is rendered very difficult of recognition by its small size and thin walls. It runs directly across the route to the artery while passing from the bodies of the vertebrae to the ante- rior border of the scalenus anticus, and can best be avoided by making the search below and to the outer side of it in the lower angle of the wound. The finger, passed downward and backward behind the carotid, soon feels the artery by pressing it against the side of the spinal column, the loose cellular tissue surrounding it is easily separated with the director, the vessel cleaned, and the needle passed from the inner side. The needle should have a short curve, and its point should be kept close agaiust the vessel, so as to avoid injuring the pleura. 1st Portion. Right Subclavian. It is exposed in the same manner as the innominate artery, and the ligature passed from the outer side, the pneumogastric and phrenic nerves being pressed inward toward the carotid. The great danger of this operation lies in the proximity of collateral branches. 2d Portion. This operation, first proposed and performed by Dupuytren, is rendered dangerous by the fact that one, and sometimes several large branches are given off from this part of the artery. The preliminary steps are the same as those employed in ligature of the 3d portion ; after 3 38 OPERATIVE SURGERY. the middle cervical fascia has been divided, the tubercle of the first rib and the external border of the scalenus anticus are sought, the muscle bared and divided upon a director, the phrenic uerve which lies upon its auterior aspect being carefully avoided. As soon as the muscular fibres are cut they retract and leave the artery in full view. 3c? Portion. Anatomy. The 3d portion of the subclavian lies between the outer border of the scalenus anticus and the tubercle of the first rib in front and the brachial plexus behind, and below the posterior belly of the omohyoid ; it is crossed on a much more superficial plane by the external jugular, which enters the subclavian near the middle of the clavicle. In muscular subjects the clavicular insertions of the trapezius and sterno-cleido-mastoid muscles lie near to, or may even join, one another ; in others they are from two to three inches apart. Ordinarily the vessel lies at a depth of one or one and a half inches below the surface, but in very fat persons, or when the clavicle has been pushed upward by an axillary aneurism, this distance may be increased to three inches. Operation. Beginning an inch outside of the sterno- clavicular articulation, make an incision three or four inches long parallel to and half an inch above the clavicle (Fig. 18, B). Divide the skin and the platysma ; when the ex- ternal jugular is exposed draw it to the inner side or divide it between two ligatures. Divide on a director the super- ficial fascia, and the clavicular portion of the mastoid muscle if necessary, and seek the posterior belly of the omohyoid. Draw this muscle outward and upward, and feel for the tubercle of the first rib, following down the outer border of the scalenus anticus. Depress the shoulder as much as pos- sible, denude the artery with the finger-nail or the point of a director, and pass the needle from below, taking care not to include the lowest bundle of the brachial plexus in the ligature. In order to avoid mistaking this bundle for the artery, the tubercle of the first rib should always be found ; the artery lies against it, between it and the nerve. Skey prefers, in difficult cases, a curved incision "com- menced about two and a half or three inches above the clavicle, upon, or immediately on the outer edge of, the LIGATURE OF THE ARTERIES. 39 mastoid muscle. This incision is carried slightly outward and downward, toward the acromion, aud then curved in- ward along the clavicular origin of the mastoid muscle." (Fig. 18, C.) Ordinarily the external jugular is left to the outer side of the incision. LIGATURE OF THE SUPERIOR THYROID ARTERY. It arises close to the bifurcation of the common carotid at the upper border of the thyroid cartilage, and is in rela- tion with the superior laryngeal nerve on its inner side. Operation. A two-inch incision is made along the ante- rior border of the sterno-mastoid muscle, with its centre opposite the upper border of the thyroid cartilage. The skin fascia aud platysma are divided, the sterno-mastoid drawn out, and the carotids recognized. The superior thyroid artery will be found springing from the anterior surface of the external carotid close to the bifur- cation of the common carotid artery. Pass the needle from above down, avoiding the superior laryngeal nerve. LIGATURE OF THE INFERIOR THYROID. Anatomy. After passing vertically upward, the artery curves inward to reach the under surface of the thyroid gland. The highest point of its curve is half an inch below the prominence on the transverse process of the sixth cervical vertebra, named by Chassaignac the carotid tubercle. In old people it is somewhat higher. It lies behind the common carotid and internal jugular, and is separated from them by more or less dense cellular tissue. The guides to the vessel are the carotid and Chassaignac's tubercle. Operation. Make an incision three and a half or four inches in length along the anterior border of the sterno- cleido-mastoid, ending an inch above the clavicle (Fig. 18, D). Lay bare the border of the muscle, and draw it outward, tear through or divide the middle fascia, and draw the carotid and internal jugular outward with a retractor. Flex the head slightly to relax the parts, feel with the finger 40 OPERATIVE SURGERY. for the carotid tubercle, and seek the artery below it, sepa- rating the cellular tissue with a director. Pass the ueedle between the artery and vein. Drobeck 1 makes an iucision along the outer border of the sterno-mastoid muscle from the clavicle to the thyroid cartilage. The omohyoid muscle and, just below and par- allel to it, the transversalis colli artery cross the wound transversely beneath the sterno-mastoid, and overlie the phrenic nerve as it passes vertically down on the scalenus anticus. At the inner border of the latter is the ascending cervical artery. The sterno-mastoid and great vessels are drawn toward the median line, and either the ascending cervical or transversalis colli artery is followed back to the thyroid axis. The inferior thyroid artery will be found at the inner side of the ascending cervical close to the inner border of the scalenus anticus just below the carotid tuber- cle. The recurrent laryngeal nerve lies still nearer the median line, and must not be included in the ligature, which should be passed from within outward. LIGATURE OF THE VERTEBRAL ARTERY. Anatomy. The vertebral artery passes from the first portion of the subclavian upward and backward to the transverse process of the sixth cervical vertebra. It is ac- companied by a vein which lies in front, and is covered by the deep cervical fascia. The guide to it is the carotid tubercle. Operation. The first incision is the same as for ligature of the inferior thyroid (Fig. 18, D). The anterior edge of the sterno-cleido-mastoid is exposed and drawn outward. The middle fascia is divided, and the carotid and jugular drawn inward. The gap between the longus colli and the scalenus anticus is then felt for about half an inch below the carotid tubercle, the deep fascia covering it torn through, the muscles separated, the vertebral vein pushed aside, and the artery exposed. Chassaiguac prefers an incision along the posterior border • CeotralM. flu Chlrurgle, 1887, p. 592. LIGATURE OF THE ARTERIES. 41 of the mastoid muscle, and reaches the carotid tubercle by- drawing the muscle aud vessels inward. If the muscle is very broad some of its clavicular fibres must be divided. LIGATURE OF THE AXILLARY ARTERY. Anatomy. The axillary extends from the middle of the clavicle to the lower edge of the tendon of the teres major. The axillary vein lies on the inner side and in front of it, aud the brachial nerves invest its lower portion closely. It can be tied below the clavicle in the clavi-pectoral triangle formed by the clavicle, inner border of the pectoralis minor, and the thorax, or in the axilla. The strong fascia which unites the coracoid process and clavicle, and forms the sus- pensory ligament of the axilla, the costo-coracoid fascia, sends a prolongation about the upper portion of the axillary vein which keeps its walls from sinking in ; the cephalic vein ascending in the groove between the deltoid and pec- toralis major perforates this fascia and joins the axillary vein at the inner border of the tendon of the pectoralis minor, close by the origin of the acromial thoracic artery. A. Ligature under the Clavicle (Fig. 18, JS.) Make an incision extending from the summit of the coracoid pro- cess four or four and a half inches along the lower border of the clavicle. Divide successively the skin, subcutaneous tissue, superficial fascia, and pectoralis major, and then tear carefully through the costo-coracoid fascia, avoiding injury to the cephalic vein at the outer part of the wound. The pectoralis minor is now exposed, and after separating the cellular tissue with the point of a director the axillary vein is seen crossing from the upper edge of the muscle to the clavicle. The artery is completely hidden by it, lying on the outer side and a little behind. The vein must now be drawn inward, the needle entered between it and the artery, and the ligature applied as near as possible to the clavicle on account of the proximity of the acromial thoracic branch. B. Ligature in the Axilla. Anatomy. The tissues and organs ou the outer side of the axilla are arranged in the 42 OPERATIVE SUJRGERY. following order : (1) the skin ; (2) the subcutaneous cellular tissue ; (3) the fascia ; (4) the axillary vein ; (5) the internal cutaneous and ulnar nerves; (6) the axillary artery; (7) the median nerve; (8) the coraco-brachialis; (9) the humerus and articular capsule. The old rule for exposing the artery here was to make a longitudinal incision at the junction of the anterior and middle thirds of the axilla, find the vein, count two nerves, and look for the artery just beyond the last one. This is a difficult and dangerous method, and a Fig. 19. H; y ' h J A. Ligature of the axillary artery. B. Ligature of the brachial artery. much simpler one has beeu substituted by Malgaignc, who was the first to point out that the coraco-brachialis muscle is the real guide to the artery. Operation. The arm is abducted completely, the incision commenced at the inner border of the coraco-brachialis over the head of the humerus and carried two and a half or three inches down the arm parallel to the course of the artery. It should involve the skin only, so as to avoid injury to the basilic vein. If the edge of the coraco-brachi- alis cannot be distinguished, the incision should be made according to the old rule, at the junction of the inner and middle thirds of the axilla. The aponeurosis is now divided upon a director over the coraco-brachialis, and the fibres of the inner border of this muscle exposed. The parts are then relaxed by bringing the arm nearer the trunk, and the posterior side of the wound, including the vein, ulnar and internal cutaneous nerves, is drawn back with a retractor; and the artery, overlain by the median nerve, usually ap- LIGATURE OF THE ARTERIES. 43 pears at the bottom, covered, perhaps, by the posterior part of the sheath of the coraco-brachialis. LIGATURE OF THE BRACHIAL ARTERY. Anatomy. The brachial artery runs from the junction of the anterior and middle thirds of the axilla to the middle Fig. 20. Transverse section of the arm at its middle (Tii.la.ux). 1. Skin. 2. Subcutaneous tissue. 3. Enveloping aponeurosis 4. Aponeurosis separating the anterior and posterior loges on the inner side. 5. Division on the outer side. 6. Brachial artery and veins. 7. Median nerve. S. Basilic vein. 9. Internal cutaneous nerve. 10. Ulnar nerve. 11. Its artery and veins. 12. Muscular cutaneous nerve. 13. Muscular spinal nerve. 14. Superior profunda artery. 15. Cephalic vein. of the anterior aspect of the elbow. It occupies, when the forearm is supinated, the groove between the biceps and. 44 OPERA TI VE SUE GEE Y. triceps, being partly covered by the former in muscular subjects, aud separated from the bone by the inner edge of the eoraco-brachialis, and of the brachial is anticus. It lies in the anterior loge of the arm, which is bounded posteriorly on this side by a prolongation of the enveloping aponeuro- sis, extending down to the bone between the biceps in front aud the triceps behind. It lies, consequently, within the sheath of the biceps, and the inner edge of this muscle is the sure guide to it. It lies between two satellite veins, which anastomose frequently, and has the median nerve in immediate relation with it on the side next the skin. The basilic vein directly overlies it between the skin and the aponeurosis. The artery presents frequent anomalies. The most common is its premature bifurcation into the radial and ulnar, which may take place as high as in the axilla, in which case one of the branches is superficial, perhaps even subcutaneous, while the other follows the usual course. The median nerve occupies the same sheath with the artery, lying first on the outer side and then crossing, in front or behind, very obliquely to the inner. The ulnar nerve, accompanied by an artery and two veins, lies in the sub- stance of the triceps immediately behind the brachial artery and median nerve, separated from them only by the above- mentioned prolongation of the enveloping aponeurosis, and as they form a group differing from the other only in size, the artery may be mistaken for the brachial if met with (Fig. 20). This error will not be made if the fibres of the biceps alone are exposed and the incision confined to the anterior loge. Operation Arm abducted, forearm supinated. Make an incision three inches long in the middle third of the arm, along the inner border of the biceps through the skin and subcutaneous cellular tissue, taking care not to injure the basilic vein, which should be kept posterior to the incision. Divide the aponeurosis and expose the fibres of the biceps, if the muscle is large draw it forward, and the sheath in- closing the artery, nerve, and veins will be disclosed. This is turn through carefully with a director, the median nerve Separated and pushed aside, the artery separated from its veins, and the ligature passed from the side of the nerve. LIGATURE OF THE ARTERIES. 45 Fig. 21. Ligature ot the brachial artery. LIGATURE OF THE RADIAL ARTERY. Anatomy. The radial artery extends in a straight line from a point half an inch below the centre of the fold of the elbow to the ulnar side of the styloid process of the radius ; it occupies the groove bounded on one side by the supinator longus, on the other by the pronator radii teres and flexor carpi radialis. It is covered only by the skin, cellular tissue, and aponeurosis ; but in muscular subjects the muscular interstice in which it lies may be very deep. It is accompanied by two veins, and by no nerve. It occu- pies in its upper third the sheath of the pronator, and con- sequently the fibres of the supinator longus should not be exposed in the search for the artery, although the edge of the muscle may be taken as a guide to it. The radial nerve lies within the sheath of the supinator longus, and at first comes quite close to the artery ; it then passes behind and to the outer side of the tendon of the muscle. It should not be seen during the operation. Operation. In the upper third. Make an incision two and one-half inches long in the line above mentioned, be- o-inniuff one and one-half inches below the fold of the elbow. • • • Avoiding the superficial veins, carry the incision through the cellular tissue. Recognize the edge of the supinator longus, and divide the aponeurosis along the ulnar side of it, exposing the fibres of the pronator. Press apart the two muscles if necessary, separate the artery from its veins, and pass the ligature. 3* 46 OPERATIVE SURGERY. In the lower third (Fig. 22). Make an incision in the above-mentioned line, if the position of the artery cannot be made out by its pulsations, two inches fig. 22. long, ending an inch above the wrist. ! Divide the skin and cellular tissue, and J then the fascia carefully upon a director. i I Separate the artery from the two veins, \ f and pass the ligature. LIGATURE OF THE ULNAR ARTERY. |_ A Anatomy. In its first third the ulnar I artery passes obliquely underneath the superficial layer of muscles, including the superficial flexor of the fingers to the inner side of the arm, where it be- comes superficial, and lies between the B flexor carpi ulnaris on the inside aud the flexor sublimis digitorum on the out- I'i If side. It then descends to the wrist in I . the direction of a line uniting the inter- \ \ nal condyle of the humerus with the \ outer border of the pisiform bone. It Ligature of the radial is accompanied by two veins, and is and ulnar arteries. joined by the ulnar nerve just before it becomes superficial, the nerve lying upon the inner or ulnar side of the artery. It may be tied at any point in the middle and lower thirds. As the deep and super- ficial flexors of the fingers are separated by a fascia, and as the artery lies below this fascia, it is covered in the lower part of its course by two distinct fascia?, the enveloping fascia of the limb and this second one which unites the tendon of the flexor carpi ulnaris with those of the flexors. Operation. At the junction of the upper and middle thirds. Beginning four finger-breadths below the internal condyle of the humerus make an incision three and one-half or four indies long in the line above mentioned (Fig. 22). Expose the enveloping fascia clearly, and, drawing back the posterior lip of the wound, seek the first muscular inter- stice in front of the ulna. It is that between the flexor LIGATURE OF THE ARTERIES. 47 carpi ulnaris and the flexor snblimis digitornm, aud can be recognized by the finger as a slight depression, or by the eye as a white line under the fascia. Divide the aponeu- rosis, beginning at the lower angle, where the space between the muscles is broadest, and theu, instead of following the interstice directly backward, raise the flexor sublimis and advance transversely across the arm in the search for the artery which lies upon the deep flexor. Isolate the artery, and pass the needle from the side of the nerve. In the lower third (Fig. 22). Make an incision slightly to the radial side of the tendon of the flexor carpi ulnaris, or in the line before mentioned, two inches long, and end- ing an inch above the end of the ulna. Divide the envel- oping fascia upon a director, and tear through the second over the vessel, which can be seen and felt through it. Isolate the artery, and pass the needle from within outward so as to avoid the nerve. LIGATURE OF THE COMMON CAROTID. The place of election for ligature of the common carotid is just above the omohyoid muscle, but the lesion which renders the ligature necessary may require it to be applied at a much lower point. The vessel has been tied success- fully at a point one-eighth of an inch from its origin at the bifurcation of the innominata. The steps necessary to place a ligature upon the common carotid in the first part of its course are the same as for ligature of the first portion of the subclavian or of the innominata (q. v.). After the vessel has been exposed, the internal jugular is pressed to the outer side, the artery denuded, and the needle passed from the side of the vein. At the place of election. The bifurcation of the com- mon carotid is on a line with the upper border of the thy- roid cartilage. The place of election for tying it is about three-quarters of an inch below its bifurcation. The guide to the artery is the anterior border of the sterno-cleido- mastoid muscle, and the danger is of wounding the jugular vein, which, when full, entirely covers the artery on the outer side. 48 OPERA TIVE S URGER Y. Operation. Make aloug the anterior border of the sterno- cleido-mastoid an incision three inches in length, the centre of which corresponds with the crico-thyroid space (Fig. 23). Divide the skin, platysma, cellular tissue, and aponeurosis, and seek for the interstice between the sterno-cleido-mastoid and the sub-hyoid muscles. When found, the latter must be pressed inward, and the artery will appear at the edge of the sterno-cleido-mastoid, the vein, which is external to it, remaining covered. The artery is bared with a director, and the needle passed from without inward. Fig. 23. Ligature of the common carotid at the place of election. If, instead of pressing the trachea and its muscles inward, the mastoid is drawn outward, the vein is exposed, almost completely overlying the artery, and, by its presence and the necessity of handling it, increases the difficulty and danger of the operation. LIGATURE <>K THE EXTERNAL CAROTID. The free anastomoses which exist within the cranium be- tween the two internal carotids render ligature of the common carotid insufficient to arrest hemorrhage from the LIGATURE OF THE ARTERIES. 49 external carotid ; the ligature must be applied to the vessel itself, despite the number of its branches aud the difficulty of recognizing them at the bottom of the incision. The operation is a difficult one, for there are many important organs to be avoided, and there is no direct guide to the vessel . Anatomy. The comon carotid divides opposite the upper border of the thyroid cartilage (a little lower in females) into the external and internal carotids, which occupy nearly the same autero-posterior plane, the former being in front. At about three-quarters of an inch above the bifurcation the arteries cross, the external becoming posterior, the inter- nal anterior. The internal carotid gives off no branches outside the cranium, while the external gives off eight. Of these the superior thyroid arises at or very near the bifur- cation, the lingual, facial, ascending pharyngeal, and occi- pital near the point where the artery passes under the digastric, about an inch above the bifurcation, the others at a considerable distance above. The hypoglossal nerve loop- ing around the occipital artery at its origin crosses the ex- ternal carotid to the hyoid bone, sending a branch, the descendens noni, down the outside of the artery. There are thus three means of distinguishing the external carotid : (1) its branches; (2) its position with reference to the internal carotid ; (3) its immediate relations with the hypoglossal nerve, the internal carotid occupying a deeper plane. In a search for the external carotid the operator may be satisfied with either of these guides, accordingly as one or the other presents itself. Should the nerve be first encountered, he will tie the vessel upon which it lies; should both vessels lie at the bottom of the incision, he will know that the anterior one is the external carotid ; and if the vessel which he isolates has a branch, he knows it caunot be the internal carotid. Although the force of the objection has been greatly diminished by the employment of antiseptic silk or catgut ligatures, which admit of primary union throughout the wound, it is still desirable that the ligature should be ap- plied at a distance from branches of considerable size; and from this point of view the first half-inch of the artery and the portion underlying the digastric are the places of elec- 50 OPERATIVE SURGERY. tion, and of these two the former alone is practicable. The connective tissne surrounding the two arteries at their origin is, however, unusually compact, rendering their denudation so difficult that any search for branches would be dangerous to the nutrition of the vessel's wall. M. Guyon 1 has shown that, while the lingual and superior thyroid arteries vary greatly in their points of origin, the average distance between them is from 12 to 18 millimetres, or over half an inch ; he calls the portion of the vessel between them the " trunk of the external carotid," and sug- gests that the ligature should be applied 6 mm. below the point at which the hypoglossal nerve crosses the artery, this nerve being, in the great majority of cases, in immediate relation with the origin of the lingual artery. Dolbean, in his report upon this paper, advises that the superior thyroid should also be tied, and that the carotid should be sought for from below upward instead of from above downward, on account of the greater depth of its upper portion and Fig. 24. f ' ■■■■ i Ligature of— A. Lingual artery. B, External carotid. C. Occipital. D. Temporal. E. Facial. the supposition of large veins. M. Guyon collected twenty- four cases of ligature of the external carotid without espe- 1 Momoirs de la Soc. de Chirurgie, 1864, p. 555. LIGATURE OF THE ARTERIES. 51 cial reference to the proximity of branches, and in only one of them did secondary hemorrhage occur. Operation. When the head is extended and the face turned to the opposite side, an incision carried from the angle of the jaw to the anterior border of the sterno-cleido-mas- toid opposite the top of the thyroid cartilage will cross the artery obliquely (Fig. 24, B). It must be carried through the skin, platysma, and subcutaneous cellular tissue, the exter- nal jugular being drawn aside when encountered. The superficial fascia is then divided in the line of the incision, care being taken not to deviate to the right or left, and the deeper and denser layer then torn through with the director. When the artery has been exposed and cleaned, the needle is passed from behind forward. The lymphatic glands of the region are numerous and often large, and may be mistaken for the artery. There is no objection to removing any that may interfere with the search for the vessel. LIGATUEE OF THE INTEENAL CAEOTID. This is to be done according to the method described for the external carotid. LIGATUEE OF THE LINGUAL AETEEY. Anatomy. The lingual artery arises from the external carotid, on a level with the great horn of the hyoid bone, and passes between the middle constrictor of the pharynx and the hyoglossus upward and forward. It is occasion- ally accompanied by a small vein, but the lingual vein is separated from it by the thickness of the hyoglossus muscle. Its one important branch, the sublingual, sometimes has its origin at or near the point where the lingual is usually tied, and may be mistaken for it. The artery may be tied near its origin, between the great horn of the hyoid bone and the posterior belly of the digastric, but its depth at this point, and the presence of large veins, make the operation difficult and dangerous. The place of election is in the 52 OPERATIVE SURGERY. triangle bounded posteriorly by the posterior belly of the digastric, anteriorly by the posterior border of the mylo- hyoid, and above by the hypoglossal nerve. It is covered at this point by the skin, platysma, cervical aponeurosis, submaxillary gland, and the hyoglossus muscle, the fibres of which form the floor of the triangle just described. Operation. Make a curved incision two inches long, its concavity directed upward, its centre one-quarter of an inch Fig. 25. AROTID GLA No Occipital a Facial a. Mylo-hyoid n. Submental a. Hypoglossal n Descendens noni n Lingual a. Internal jugular v. Superior thyroid a Common carotid a. Anatomical relations of the lingual and facial arteries. above the hyoid bone at a point midway between the median line and the extremity of the great horn (Fig. 24, A). Divide the skin and platysma, pushing the superficial veins aside, and then the cervical aponeurosis, which may be very thin. liaise the submaxillary gland, find the posterior belly of the digastric, its attachment to the hyoid bone, the pos- terior border of the mylohyoid, and the hypoglossal nerve accompanied by the lingual vein. Draw the hyoid bone LIGATURE OF THE ARTERIES. 53 slightly downward with a blunt hook fixed in the lower angle of the triangle bounded by these organs, and then, pinching up the fibres of the hyoglossus with a pair of for- ceps, divide them carefully along a line parallel to the nerve, and midway between it and the boue. As the cut fibres retract, the artery is disclosed below them ; separate it from its vein, if there be one, and pass the ligature. LIGATURE OP THE FACIAL ARTERY. The facial artery crosses the inferior maxilla just in front of the anterior edge of the masseter, from which it is sepa- rated by the facial vein (Fig. 25). A depression, in which it is lodged, can usually be felt on the lower edge of the bone. The artery can be exposed by a vertical incision along its course, or by a horizontal one along the lower border of the maxilla. Operation (Fig. 24, E) Beginning at the lower edge of the maxilla, make an incision one inch iu length along the course of the artery; divide the skin, subcutaneous tissue, aud fascia ; separate the artery from the vein and pass the needle between them. If the horizontal iucision is used, it should extend three- quarters of an inch on each side of the artery, the anterior edge of the masseter should be recognized, and the vessel sought for immediately in front of it. LIGATURE OF THE OCCIPITAL ARTERY. At the Mastoid Process. The guides to frhe vessel are the apex and posterior border of the mastoid process, the digas- tric groove on its inner surface, and the digastric muscle. Operation (Fig. 24, (?). Starting from a point half an inch below and in front of the apex of the mastoid process, carry the incision two inches obliquely backward parallel to the border of this process. Divide the skin and enveloping fascia, and then the sterno-mastoid and its insertion through- out the entire length of the incision. Then divide the sple- nius and its shining aponeurosis, and feel for the digastric 54 OPERATIVE SURGERY. groove. Pinch up and carefully divide a thin fascia which covers the anterior face of the splenitis. Starting from the belly of the digastric, separate the cellular tissue in the anterior angle of the wound with a director, denude the artery and tie. (Chauvel.) LIGATURE OF THE TEMPORAL ARTERY. (Fig. 24, D.) Make a transverse incision one inch long, extending from the tragus of the ear forward over the zygo- matic arch. Separate the subcutaneous cellular tissue, which is very dense and fibrous, with a director, and seek the artery imbedded in it about a quarter of an inch in front of the ear. Press the vein backward, pass the needle from behind forward, taking care not to include in the ligature the tem- poral branch of the auriculo-temporal nerve, which is some- times in close relations with the artery. LIGATURE OF THE ABDOMINAL AORTA. This operation has been performed about a dozen times, with a fatal result in each case. The patients survived for periods varying from a few hours to ten days. The artery may be reached through the abdominal cavity by an incision in the median line, or, without dividing the peritoneum, by an incision in the flank similar to Konig's for extirpation of the kidney (q. v.). The objection to the former is the danger consequent upon exposure of the peritoneal sac and its contents, but the steadily improving results of abdominal surgery show that this is not exceptionally great. On the other hand, the application of a ligature, even under the most favorable circumstances, after the artery has been ex- posed by the other method, requires the utmost dexterity, the chance of exciting peritonitis is great, and, finally, the presence of the aneurism and the displacements and adhe- sions it has caused may render it impossible to reach the vessel. Operation. Through the Peritoneal Cavity. An incision in the linea alba, extending from a point three inches above LIGATURE OF THE ARTERIES 55 the umbilicus to one three inches below it, and curving to one side to avoid the umbilicus. Divide the peritoneum upon a director, press the intestines aside, tear through the peritoneum covering the aorta with the finger-nail, separate the uerves from its anterior surface, and pass the ligature from the outer side. Cut both ends short, and close the external wound as in ovariotomy. LIGATURE OF THE COMMON ILTAC. Anatomy of the Common, Internal, and External Iliae Arteries. The aorta bifurcates usually on the left side of the fourth lumbar vertebra, and the direction of the com- mon and external iliacs is represented by a line drawn from a point an inch above the umbilicus to another one-half an inch external to the centre of Poupart's ligament. The common iliac is usually two inches long, and bifurcates at the sacro-iliac synchondrosis, but it must be remembered that this bifurcation may take place at any point between one and a half and three or even four inches from the origin of the artery. The common iliac gives off no branches. The external iliac runs downward and outward along the brim of the pelvis from the bifurcation to a point under Poupart's ligament midway between the anterior superior spine of the ilium and the symphysis pubis. Its two branches, the epigastric and circumflex ilii, are given off nearly opposite each other, a short distance above Poupart's ligameut, sometimes much higher. The internal iliac runs downward and backward into the pelvis for one and a half inches, dividing at the upper border of the great sacro-sciatic foramen into two large trunks. The ureter crosses the vessels at or just below the bifurca- tion of the common iliac, the vas deferens two and a half or three inches lower. Both are more closely adherent to the peritoneum than to the arteries. The iliac veins lie upon the inner side and posterior to the arteries ; both pass behind the right common iliac, the right vein at its bifur- cation, the left vein much higher up. The spermatic ves- sels and ffenito-crural nerve lie iu front of the external iliac 56 OPERATIVE SURGERY. at the lower part of its course, and the circumflex iliac vein crosses it at the same place. The abdominal wall at the point where the incisions are made is composed of the following layers in the order named : skin, subcutaneous cellular tissue, fascia, external oblique or its aponeurosis, internal oblique, transversalis, and transversalis fascia. Extraperitoneal Operation. Beginning at a point a finger's breadth above Poupart's ligament and just outside of the external iliac artery, make an incision four, five, or six inches in length, according to the thickness of the abdominal wall, parallel at first to Poupart's ligament, and curving upward after passing the anterior superior spine of the ilium (Fig. 26). Divide the skin, subcutaneous tissue, Fig. 26. Ligature of— A. Common iliac. B. External iliac. C. Femoral iu Scarpa's space. and fascia, exposing the aponeurosis of the external oblique ; divide the latter upon a director throughout the whole extent of the incision, and then divide the fibres of the internal oblique and transversalis in the same manner, or by pinching them up with the forceps and cutting carefully with repeated slight touches of the knife, until the fascia transversalis, which varies much in density, is exposed. Raise the fascia at the lower angle of the wound, where it is most dense, with forceps, and make a hole in it large enough to admit the finger. Pass the forefinger through LIGATURE OF THE ARTERIES. 57 this hole, press back the peritoneum with it, and enlarge the hole upward in the line and to the full extent of the incision, the finger being kept between the peritoneum and the knife. The peritoneum is now raised from the psoas and iliacus muscles and drawn upward and inward by an assistant, while the operator seeks for the external iliac and passes the forefinger of his left hand along it to the common iliac, the thighs being flexed to relax the abdominal walls. As it is seldom that a good view of the artery can be obtained, the finger must be kept upon it, and the loose cellular tissue in which it is imbedded very gently separated with the point of a director or the finger-nail. When the artery has been properly cleaned, pass the needle from within outward. Intra-peritoneal Operation. Open the abdomen in the median line by an incision extending from the symphysis pubis to or a little above the umbilicus, and, after pushing aside the intestines with flat sponges or pads, tear through the peritoneum overlying the artery and pass the ligature from within outward. Care must be taken not to include the ureter, which usually crosses the vessel at its point of bifurcation. In the extra-peritoneal operation there is less clanger of this accident, as the ureter is adherent to the peritoneum, and is lifted out of the way as this membrane is stripped up. LIGATURE OF THE INTERNAL ILIAC. Its accompanying vein lies behind and on the inner side. Extra-peritoneal Operation. Same as for ligature of the common iliac. After the peritoneum has been lifted up, the finger is passed along the external iliac to the bifurca- tion, and then downward for half an inch along the internal iliac. The vein being carefully protected, the artery is bared, and the ligature passed from within outward. The intra-peritoneal operation 1 does not differ enough 1 Dr. F. S. Dennis discusses this operation in its application to spontaneous gluteal and sciatic aneurisms in the Medical News, Nov. 20, 18S6. 58 OPERATIVE SURGERY. from that for tying the common iliac to require a separate description. Ligature of the iuterual iliac has beeu seldom employed, except for traumatic gluteal aneurism, and in these cases, as Professor Van Buren 1 has pointed out, the treatment should be to cut down upon the sac, and tie both ends of the artery, hemorrhage being controlled by digital pressure made upon the internal iliac from within the rectum. LIGATURE OF THE EXTERNAL ILIAC. Various cutaneous incisions have been recommended for this operation. Sir Astley Cooper's extended from the external abdominal ring to within a short distance of the superior spine of the ilium ; the objections to it are that it involves the division of the superficial epigastric, and, per- haps, of the internal epigastric also, and that the ligature can be applied only to the lower part of the artery. Aber- nethy's extended outward from the internal inguinal ring parallel to Poupart's ligament; by it the vessel is reached at a greater depth, but it has the great advantage of allow- ing extension, so that if it should prove necessary the liga- ture may be applied even to the common iliac. By curving the outer portion of the incision upward away from the superior spine of the ilium, the main branches of the cir- cumflex ilii may be avoided. Operation. Beginning over the outer side of the artery a finger's breadth above Poupart's ligament, make an in- cision three or four inches in length, at first parallel with Poupart's ligament, and then curving upward (Fig. 26). Carry this incision through the abdominal wall, and raise the peritoneum from the surface of the iliacus and psoas muscles in the same manner as for ligature of the common iliac. Flex the thighs so as to relax the abdominal muscles, and, while an assistant draws the peritoneum and the con- tained intestines upward and inward, seek the artery upon the inner border of the psoas. Clean it with a director or pair of forceps, and pass the needle from within outward. For the intra-peritoneal operation an incision along the 1876 1 Report on "Aneurism," Proceedings of the International Medical Congress, LIGATURE OF THE ARTERIES. 59 lower part of the linea semilunaris would generally be better than one in the median line. LIGATURE OF THE GLUTEAL, SCIATIC, AND INTERNAL PUDIC ARTERIES. The proper treatment of injury to either of these arteries is to enlarge the wound and tie both ends of the divided vessel, but it may happen that this would be impossible, Fig. 27. Ligature of— A. Gluteal artery. B. Sciatic and internal pudic. and that ligature in continuity is required. The necessary incisions are those shown in Fig. 27. The place at which the gluteal artery emerges from the great sciatic notch may be roughly stated as opposite a point at the junction of the upper and middle thirds of a line joining the posterior superior spine of the ilium with the great trochanter. The sciatic, where it crosses the spine of the ischium, lies opposite the junction of the middle and lower thirds of a line joining the tuberosity with the posterior superior spine of the ilium. After division of the skin and fascia, the fibres of the 60 OPERATIVE SURGERY. gluteus maximus are separated and held apart with long retractors, the deep fascia torn through, and the artery sought for. The gluteal artery is to be sought for above the pyri- formis muscle at the upper border of the great sacro- sciatic notch, where it can be felt near a small bony tubercle. It is covered by many large veins, which require very careful handling. The ligature should be applied as close to the notch as possible. The sciatic and internal pudic arteries leave the great sciatic notch at the lower edge of the pyriformis ; the former divides almost immediately, the latter re-enters the pelvis through the lesser sacro-sciatic notch, lying on the inner side of the sciatic artery during its passage over the spine of the ischium. LIGATURE OF THE FEMORAL ARTERY. Anatomy. The femoral artery is the continuation of the external iliac, and extends in a straight line from a point midway between the anterior superior spine of the ilium and the symphysis pubis to the ring in the tendon of the adductor magnus about four finger-breadths above the tuber- cle of insertion of that muscle on the upper portion of the inner condyle of the femur. In the first one or two inches of its course it gives off the superficial external pudic, epi- gastric, and circumflex ilii, and the much larger and more important profunda arteries. The anastomotica magna arises near its lower end. The artery is accompanied throughout by the femoral vein, which, at first, lies upon the inner side, and then becomes posterior. They are separated at first by a distinct septum, which disappears in the lower third. The anterior crural nerve emerges from below Pou part's ligament, about half an inch external to the artery ; it divides up rapidly, and one of its branches, the internal or long saphenous, enters the sheath of the vessels three or four inches below the groin, and leaves it again after the artery has entered Hunter's canal ; this name being given to the condensed sheath for a short distance above and below the point when; it passes through the tendon of the adduc- LIGATURE OF THE ARTERIES. Q\ tor magous. The artery passes under the sartorius at about the junction of its upper and middle thirds. Ligature of the femoral above the origin of the profunda has proved unsatisfactory, and has been generally aban- doned for that of the external iliac. The artery may be tied at any part of its course, but the point generally chosen is at the apex of Scarpa's triangle, next that in the middle of the thigh, and, lastly, in Hunter's canal. Operation. A. At the Apex of Scarpa's Triangle (Figs. 26 and 28). Make an incision three or four inches long, .•..•■.•.••■■••"•.••''•' Fig. 28. -~. ■m^ Ligature of the femoral artery. the centre of which shall be a little above the point where the inner border of the sartorius crosses a line drawn from the middle of Pou part's ligament to the inner tuberosity of the femur. The internal saphenous vein should be out of danger on the inner side of the incision. Divide the skin, subcutaneous tissue, and the fascia lata, exposing the fibres of the sartorius, which may be recognized by their direction downward and inward, those of the adductors, on the con- trary, being downward and outward. The limb should now be slightly flexed, the vessels recognized by the touch at the inner border of the sartorius, this muscle drawn outward, and the sheath of the vessels pinched up with forceps on the outer side (the vein lying on the inner) and opened. The needle is then passed from within outward. B. In the Middle of the Thigh. Here the vessel lies underneath the sartorius which overlaps it ou both sides. 4 62 OPERATIVE SURGERY. The incision is made in the line above mentioned, its centre being a little above the middle of the thigh ; the sartorius is exposed and drawn outward after the leg has been further flexed. The vessel is then sought for, exposed, and tied as before. C. In Hunter's Canal. Abduct and flex the thigh, and rotate it outward so as to make the adductors tense; feel for the tendon of the adductor magnus and make au incision three or four inches long, the centre of which is at the junction of the lower and middle thirds of the thigh, in the direction of the tendon, which is that of a liue drawn from the spine of the pubis to the tubercle on the inner condyle of the femur. Divide the skin and subcutaneous tissue carefully so as not to wound the internal saphenous vein, and then the aponeurosis upon a director. Recognize the fibres of the sartorius and of the vastus internus which are at right angles with one another, and by pressing the former inward or the latter outward the tendon of the adductor and the curved glistening fibres arching from it to the vas- tus internus are exposed. If the saphenous nerve is now encountered it should be traced upward, a director passed into the orifice through which it emerges, and the aponeurosis divided upward; if the nerve is not seen it should not be sought for, but the aponeurosis should be pinched up and divided close to the tendon of the adductor. The sheath of the vessels is now opened, and the artery is separated from the closely adherent vein. The needle should be passed from within outward. Some surgeons prefer to make the first incision in the direction of the artery rather than in that of the tendon. LIGATURE OF THE POPLITEAL ARTERY. This is an operation which is required only in the rare cases of rupture of the artery when an attempt is to be made to save the limb. The artery lies very deep between the condyles of the femur, imbedded in fat, and directly covered by the vein, the walls of which are thick and stiff like those of an artery. The short saphenous vein perfor- LIGATURE OF THE ARTERIES. 63 ates the fascia near the centre of the popliteal space, and empties into the main trunk. Operation. Make an incision three or four inches long in the vertical diameter of the popliteal space, the centre of which shall correspond to the point at which the ligature is to be placed. Divide the skin and cellular tissue, taking care not to injure the saphenous vein, and then the aponeu- rosis to the full extent of the cutaneous incision. Flex the leg, have the sides of the wound drawn widely apart, and work down through the fat and lymphatic glands to the artery, leaving first the nerve and then the vein upon the outer side. Protecting the vein with one finger, denude the artery and pass the needle from without inward. Jobert (de Lamballe) reached the popliteal artery in the upper part of its course by an incision on the inner aspect of the leg, passing between the tendon of the adductor raagnus on one side, and the sartorius, semi-membranosus, and semi-tendinosus on the other. The artery is found lying close to the femur. LIGATURE OF THE ANTERIOR TIBIAL ARTERY. Anatomy. After perforating the interosseous membrane at the upper part of the leg, the anterior tibial runs in a direction which is that of a line drawn upon the anterior aspect of the leg from the upper tibio-fibular articulation to a point midway between the malleoli. It lies at first between the belly of the tibialis anticus and that of the extensor communis digitorum upon the interosseous mem- brane, afterward between the tibialis anticus and the exten- sor proprius pollicis or their tendons upon the tibia. It is accompanied by two veins and the anterior tibial nerve, which latter lies first upon the outer side and then crosses in front to the inner side. It may be tied at any point in its course. Operation Make in the above-mentioned line an inci- sion the kngth of which will vary according to the depth at which the artery is placed. Divide the skin and cellular tissue, lay bare the fascia, and divide it along the first mus- cular interstice, which shows as a white line under it ; make 64 OPERATIVE SURGERY. also a transverse incision through the fascia from the middle of the longitudinal one to the crest of the tibia, so as to give more room. Flex the foot upon the leg, separate the Fig. 29. Transverse section of the leg, upper third. (Tii.laux.) T. Tibia. F. Fibula. EF. Enveloping fascia. DF. Deep fascia dividing to inclose. PT. Posterior tibial artery and nerve, and PA. Peroneal artery. TA. Tibialis anticus muscle. AT. Anterior tibial artery and nerve. IM. Interosseous membrane. P. Peroneus longus muscle. IS. Internal saphenous vein. ES External saphenous vein and nerve. muscles from below upward with the ringer, draw them apart with retractors, isolate the artery without raising it, and pass the needle from the side of the nerve. LIGATURE OF THE ARTERIES. 65 LIGATURE OF THE DORSALIS PEDIS. This artery is the continuation of the anterior tibial, and passes through the posterior end of the first metatarsal space to the plantar aspect of the foot. It lies on the outer side of the tendon of the extensor proprius pollicis, and is crossed in its lower portion by the inner tendon of the ex- tensor brevis. It is covered by the skin, superficial fascia, the edge of the extensor brevis, or its tendon, and a deep fascia. Its direction is that of a line drawn from a point midway between the malleoli to the posterior end of the first metatarsal space. The incision should be in this line, and the tendon of the extensor proprius pollicis should be left on the inner side. LIGATURE OF THE POSTERIOR TIBIAL. The posterior tibial artery in its upper and middle por- tions lies upon the tibialis posticus and the flexor communis digitorum, and is covered by the soleus, from which it is separated by the deep fascia. Near the ankle it is covered only by the integument and fascia. In its upper portion it can be reached by two routes: (1) the one employed by Guthrie, and approved of by Spence and Holmes, through the middle of the calf; (2) the one in more common use, from the inner side of the calf. Operation (Guthrie). Beginning at the lower angle of the popliteal space, make an incision six inches in length directly downward, avoiding as far as possible the super- ficial veins, carry this incision through the soleus, divide the deep fascia, separate the artery from the vein and nerve, which are superficial to it, and pass the needle from their side. Lateral Method. Beginning in the middle of the upper third of the leg, make an incision from four to five inches long, parallel to and half an inch behind the inner border of the tibia. Carry the incision down to the fascia, leav- ing the internal saphena on the tibial side; divide the fascia, draw the gastrocnemius backward, and separate the soleus 66 OPERATIVE SURGERY, at its attachment to the tibia, leaving the deep fascia attached to the bone. Raise the heel and flex the leg upon the thigh, draw back the calf, enlarge the incision if necessary, seek the artery and tear carefully through the deep fascia over it ; isolate the artery, leaving the nerve on the outer side, and pass the needle between. Tillaux 1 has proposed a modifi- cation. Instead of detaching the soleus from the tibia, he Fig. 30. '•■ „\V" Fig. 31. Ligature of the anterior tibial artery. Ligature of the posterior tibial artery. passes between it and the gastrocnemius, and then divides the former muscle longitudinally over the course of the artery. If this incision does not at once expose the artery, the vessel must be sought for on one side or the other by pressing back the sides of the incision. The centre of the soleus is occupied by an intra-muscular septum parallel to the deep fascia, and sometimes so stout 1 Anatomie Topographique, Paris, 1877, p. 1145. LIGATURE OF THE ARTERIES. 67 as to be mistaken for it. Close attention is required for the avoidance of this error. In the Loiver Third and Behind the Ankle. The artery lies midway between the tendo Achillis and the inner edge of the tibia or the malleolus, and is covered by the super- ficial and deep fascia?, the latter of which forms the annular ligament at the ankle. Operation. Midway between the tendo Achillis and inner edge of the tibia, or a finger's breadth behind the latter, make an incision three inches long parallel to the tibia, if the ligature is to be placed above the ankle, or a curved line parallel to the posterior border of the malleolus, if it is to be placed behind the ankle. Seek the bundle of vessels, tear through the deep fascia covering them, taking care not to open the tendinous sheaths which lie in front, and pass the needle from without inward. / PART III. AMPUTATIONS. Amputations may be in continuity (through the bone), or in contiguity (through a joint) ; to the latter the term disarticulation is usually applied. The methods of opera- tion are classified as circular, oval, aud flap, and the choice of a method is determined by the disposition of the soft parts about the bone, the facility with which the joint can be opened in a disarticulation, the form of the resulting stump, and the position of the cicatrix. The comparative merits of these methods and their various modifications will be discussed in connection with the different opera- tions. They may be essentially modified by accidental circumstances, and by the necessity which sometimes arises, as in cases of injury, of fashioning the flap from such tis- sues as are available. CIRCULAR METHOD. 1st Time. The cutaneous incision .should be made at a distance below the point where the bone is to be divided equal to two-thirds of the diameter of the limb at that point. While an assistant draws the skin firmly and evenly toward the root of the limb, the operator passes his hand below and beyond it, and places the heel of the knife upon its upper surface, its point directed toward his own shoulder. lie then sweeps the knife entirely around the limb, divid- ing the skin and subcutaneous cellular tissue, down to the enveloping fascia, and terminating the incision at the point where it began. AMPUTATIONS. 69 2d Time. a. The skin and cellular tissue are retracted and the muscles divided in succession, the deeper ones at higher levels, so that the surface of section forms a cone, the apex of which is directed upward. The muscles whose origins are most distant must be cut long to allow for their greater retraction. b. {Alanson's method) The point of the knife is passed obliquely down from the edge of the skin to the bone at the point where it is to be divided, and carried around the limb, always at the same angle with the bone, so as to form the muscular cone by a single incision. c. [Cutaneous sleeve.) The skin and cellular tissue are separated cleanly from the deep fascia and turned back over the limb, the raw surface outward. The sleeve thus formed is lengthened by drawing it up and dividing its attachments to the fascia, care being taken to include all the subcutaneous cellular tissue in it, until the dissection has nearly reached the height at which the bone is to be divided. The fascia and muscles are then cut through to the bone transversely with a single sweep of the knife, held as for making the cutaneous incision. 3d Time. Division of the Bone. The soft parts being drawn up and protected by a piece of leather or a cotton band four inches wide and two feet long, split for half its length so as to pass on each side of the bone (called the retractor), and the periosteum having been divided circu- larly with the knife along or a little below the line to be traversed by the saw, the operator peaces the heel of the saw upon the bone, steadies its edge with the thumb-nail of his left hand, and draws it slowly toward himself, cut- ting a deep groove in the bone ; he then completes the division with a few rapid strokes of the instrument, while the limb is firmly held by two assistants, so as to prevent binding of the saw or splintering of the bone. The peri- osteum may first be dissected up for half an inch, so as to form a sort of curtain to overhang the end of the bone. If there are two bones the retractor should be split into three instead of two parts, and the central one passed be- 4* 70 OPERATIVE SURGERY. tween the bones. The saw should be first applied to the larger bone, and, after cutting a deep groove in it, should be inclined backward or forward, so as entirely to divide the second before completing the division of the first. OVAL METHOD. A scalpel is used instead of the amputating knife ; the incision is commenced at the level at which the bone is to be divided, is carried downward on one side, across the back of the limb, and upward ou the opposite side to the point at which it began. The details will be given in connection with certain disarticulations to which this method is especi- ally applicable. FLAP METHOD. The flaps may be single or double, antero- posterior, bilat- eral, long rectangular (Teale), or skin flaps with circular division of the muscles (modified flap operation). They may be made by transfixion or from without inward. In making a flap by transfixion it is well first to mark its out- line by an incision through the skin and cellular tissue with a scalpel, as otherwise there is danger of making its point too narrow or its edges jagged. The point of the amputat- ing knife is then entered at the nearest angle of the incision and passed through to the other, hugging the bone on its way, and the cut made steadily downward and outward, with sawing movements of the knife. It is then re-entered and brought out at the same points, but passing on the opposite side of the bone, and the second flap cut in the same manner as the first. The fibres on each side of the bone which have escaped are then divided, the retractor applied, and the bone sawed through as above. In cutting a flap from without inward the scalpel must be entered at one of the angles of the base of the proposed flap, carried along a curved line down to the apex of the flap, and thence up to the other angle of the base. The presence of a tumor, or injury to, or disease of, the soft parts may render it necessary to modify the shape of the AMPUTATIONS. 71 flap or vary the obliquity of the incision, so as not to include any unfit tissue in the former. Skin Flaps and Circular Division of the Muscles. In this operation the flaps include only the skin and subcuta- neous cellular tissue dissected off from the deep fascia ; the latter and the muscles are divided transversely by a sweep of the knife at the base of the flap, the retractor applied, and the bone cleaned and divided a little higher up. Long Anterior Flap. An anterior flap, its length some- what greater than the antero-posterior diameter of the limb at its base, is cut by transfixion, or from without inward ; the posterior muscles and segment of skin are cut straight across a little below the point of division of the bone, and the anterior flap brought down to cover their cut surface. This method furnishes a good covering for the bone, free drainage for the secretions of the wound, and a well-placed cicatrix. In every amputation it is well to dissect out the main nerve trunks, and cut them off high up between the muscles, so that their ends may not become imbedded in the cicatrix or involved in the suppuration. The choice of one or another method will often be deter- mined by the anatomical and pathological circumstances of the case. When any one may be used, the preference is usually given now to the skin flap with circular division of the muscles. Teale's Method. In the method to which Mr. Teale's name has been given a very long rectangular anterior flap, comprising half the circumference of the limb and all the tissues down to the bone, is made aud doubled back upon itself, thus furnishing a thick pad for the bone and a posterior cicatrix. The method of operating is as fol- lows : (Fig. 46, B) A rectangular anterior flap (posterior in the forearm), equal in length and breadth to half the cir- cumference of the limb at the base of the flap, is marked out by one transverse and two parallel longitudinal inci- sions, the latter involving only the skin, the former being carried down to the bone. The lougitudinal incisions should 72 OPERATIVE SURGERY. be so placed that the principal vessels and nerves will not be included in this flap, but in the posterior one, which is also bounded by a transverse incision carried down to the bone, and is only one-fourth as long as the anterior one. The two flaps are now in turn dissected up close to the bone, and the saw applied at their base. After the vessels have been secured the long flap is doubled back upon itself, and its square end fastened to that of the other with sutures ; two or three points of suture are also required to keep the sides of the short flap and of the reversed portion of the long- flap in contact with the rest of the latter. It is found that by retraction of the short posterior flap the cicatrix is drawn up behind and out of the way of the bone, and that a soft mass without any large vessels or nerves is the result of the partial atrophy of the long flap, and forms an excellent, non-sensitive stump. The principal objection to this method, and one which greatly restricts its applicability, is the great length of the anterior flap, which can be obtained in many cases only by dividing the bone at a much higher point than would otherwise be necessary. AMPUTATION OF THE FINGERS. Phalanges. When the injury or disease is limited to one or two fingers, and it is of such a nature that the mem- ber will be useless, if preserved, the affected phalanx or finger should be removed without hesitation ; but usually it is desirable to save as much as possible of the parts, and therefore whenever a choice can be made amputation in continuity is to be preferred to disarticulation higher up. The incisions should be so arranged that the cicatrix will not lie upon the palmar surface, and for this, as well as for anatomical reasons, the principal flap should be taken from the flexor aspect. No special directions are required for amputation or disarticulation of the middle and distal pha- langes. For amputation through the shaft the incision may be circular with a longitudinal addition one-third of an inch long on each side, or the single anterior flap by transfixion may be used. In disarticulation it is best to enter the joint from the dorsal side with a narrow-bladed knife, and cut AMP VTA TIONS. 73 the anterior flap by carrying the knife through the joint and then forward, hugging the bone. It must be remembered that the folds on the palmar sur- face of a finger do not correspond exactly to the joints ; the first being half an inch beyond, the middle one a line above, and the distal one a quarter of an inch above the articular surfaces, and also that the prominence of a knuckle when the finger is flexed is formed entirely by the head of the proximal and not by the base of the distal phalanx. When the tissues have not become thickened and infiltrated the articular depressions can also be felt upon the sides. Amputation through the Metacarpophalangeal Articula- tion. The articular depression can be found very easily by passing the thumb and forefinger along the sides of the finger, especially if the latter be at the same time drawn forcibly away from its metacarpal bone. The incision should be commenced over the dorsum of the metacarpal bone a quarter of an inch above the articu- lation, carried through the interdigital web, and then back on the palmar face to a point a quarter of an inch above the flexor fold (Fig. 32, C) ; a similar incision, beginning and ending at the same points, is made on the other side of the finger, the flaps dissected back, the lateral ligaments divided while the finger is drawn first to one side and then to the other so as to facilitate access to them and at the same time make them tense, and then the tendon^and the remainder of the capsule divided as the finger is with- drawn. Or an incisiou may be made only on the side correpond- ing to the right hand of the operator, the flap dissected back to the joint, the lateral ligament divided, the knife carried transversely through the joint, dividing the tendons and the other lateral ligament, and the other flap cut from within outward, care being taken to make it sufficiently broad. The head of the metacarpal bone should be removed only in cases where it is more desirable to diminish the deformity than to preserve the strength of the hand. An artery on each side will have to be secured, and the wound closed with sutures. 74 OPERATIVE SURGERY. The incisions may be advantageously modified for the index and little fingers by making a full lateral flap on the free side and carrying the incision transversely across the palmar surface to the angle of the web, and thence obliquely back to the knuckle (Fig. 32, E). AMPUTATION OF THE METACARPAL BONES. As the articulations of the first and fifth metacarpal bones with the carpus do not communicate with the other and A. Disarticulation of the phalanx, anterior llap. B. Amputation in contin- uity, circular. C. Metacarpo-phalangcal disarticulation. D. Amputation of a metacarpal bone in continuity. K, Disarticulation of little finger. F. Disartic- ulation of fifth metatarsal. Q. Amputation of wrist, circular. 77. Amputation of wrist. (Dubrueil.) larger synovial sacs, these bones may be entirely removed without much danger of sotting up inflammation within the AMPU1ATI0NS. 75 wrist-joint, but in the case of the other three amputation in continuity is preferable to disarticulation. The relations of the synovial sheaths of the flexor tendons are also of importance in the operation. There is no communication between the main sheath in the palm of the hand and the sheaths of the second, third, and fourth fingers, and con- sequently, if the tendons are divided as low down as the metacarpo-phalangeal articulation, inflammation of the main sheath with all its disastrous consequences will prob- ably be avoided. The incisions are the same as for amputation through the metacarpo-phalangeal articulation, with a prolongation up- ward as far as may be necessary over the back of the bone (Fig. 32, D). After its posterior and lateral surfaces have been bared, the bone is cut through with pliers at the point determined on, or disarticulated from the carpus, and the distal fragment is raised from its bed, and, beginning at the upper end, its under surface carefully separated from the soft parts. In disarticulation of the fifth metacarpal, the incision should be made along the inner border of the hand, and carried down to the bone between the skin and the abductor minimi digiti rather than through the fibres of the latter (Fig. 32, F). This gives easier access to the palmar liga- ments uniting the bone to the carpus. The lower end of the incision should form a loop with its centre in the inter- digital web, and its point on the line of the knuckle. I c AMPUTATION AT THE WEIST. (Radio-carpal Disarticulation.) Circular Method (Fig. 32, G). While an assistant re- tracts the skin upon the forearm, the operator sweeps his knife transversely around the wrist, half an inch below the point of the styloid process of the radius. The skin and as much cellular tissue as possible are divided and dissected back as far as the joint, which is then opened by entering the point of the knife just below the styloid process of the 76 OPERATIVE SURGERY. radius, and the disarticulation completed while the hand is drawn firmly away from the arm. Antero-posterior Flaps. The absence of muscular fibres at the wrist deprives this method of most of the advantages which it offers at other points, and the projection on the palmar surface of the trapezium and pisiform bones renders its execution difficult, and makes it practically identical with the circular method supplemented by lateral incisions. It should be reserved for cases in which the skin is so infil- trated that it cannot be readily dissected back. An incision curved downward is carried across the back of the wrist from one styloid process to the other, the flap dissected up, the hand flexed forcibly, the extensor tendons divided, the joint opened beneath them, and the palmar flap, which should extend as far down as the base of the meta- carpal boues, cut from within outward. Or the palmar flap may be made from without inward, or by transfixion, before the joint has been opened. External Lateral Flap. Dubrueil 1 (Fig. 32, H). The hand is pronated, and the operator makes a curved incision, which, beginning on the dorsal aspect a quarter of an inch below the radio-carpal articular line, at the junction of the outer and middle thirds, passes downward, crosses the outer side of the first metacarpal bone at its centre, and returns to a point on the palmar surface opposite that at which it began. Its two ends are then joined by a transverse inci- sion passing around the inner side below the end of the ulna. The external flap is dissected up, the joint opened at the radial side, and the disarticulation completed. AMPUTATION OF THE FOKEARM. The forearm may be divided, with reference to surgical considerations, into upper, middle, and lower thirds. Its shape is cylindrical near the elbow, and gradually flattens and narrows toward the wrist. The lower half of the radius 1 Mcdeeine Operatoire, ]>. 171. AMPUTATIONS. 77 and the whole length of the ulna are subcutaneous. The coverings of the lower third are composed almost exclusively of skin and tendons, while thick muscular masses cover the upper two thirds, especially on the anterior aspect. The absence of suitable coverings in the lower third, aud the presence there of so many synovial sheaths, the inflamma- tion of which may give rise to dangerous complications, have led some surgeons (Baron Larrey, Sedillot) to advise strongly against amputating at this part. On the other hand, it is important for the subsequent usefulness of the limb that the movements of pronation and supination should be preserved, and this can only be done by dividing the bones below the insertion of the pronator radii teres, which is just above the middle of the radius; if the division has to be made above this point the rule is to save as much as possible, especially the insertion of the biceps. For the reasons stated, the only method applicable to the lower third is the circular one, and if the conicity of the limb or the infiltration of the parts should otherwise render it impossible to carry the dissection of the cutaneous sleeve to a sufficient height, the circular incision must be supple- mented by a short longitudinal one in front. The division of the tendons should be on the same level with that of the bone, and is best accomplished by passing the knife under them, and cutting directly outward. In the upper two-thirds the difficulty of dissecting a cutaneous sleeve is l'kely to be still greater, and has led to general rejection of 'the circular method. On the other hand, lateral flaps are impossible, and the bones have a tendency to project at the angles if antero-posterior flaps are made. Many methods have been proposed to obviate this difficulty, in all of which the essential point is the same, namely, to divide the bones at least half an inch above the angles of the incision through the skin. Sedillot made short thin musculo-cutaneous flaps, and divided the deep muscles obliquely according to Alanson's method (p. 69) ; Richet makes short flaps, including all the soft parts, dissects them up circularly from the bones for about three quarters of au inch, and divides the latter at the height thus reached. Tillaux recommends short skin flaps to be dissected up for three-quarters of an inch above their base, and then short 78 OPERATIVE SURGERY. muscular flaps to be made parallel to the former by trans- fixion at the higher level. When there is sufficient avail- able material ou the back of the arm for a long flap, Teale's method gives good results. High up in the upper third, where the position of the bones is more central, and thick muscular masses lie upon the sides, the short flaps should be lateral. AMPUTATION AT THE ELBOW-JOINT. The guides to the articulation are the epitrochlea on the inuer, the epicondyle and the head of the radius ou the outer side. The smooth rounded prominence formed by the latter can be readily felt about half an inch below the epicondyle ; aud the interarticular line starting from it passes at first transversely and then downward aud inward toward a point an inch below the epitrochlea, and forms an angle, opening inward, with the transverse diameter of the lower end of the humerus. It is therefore unnecessary to expose the epicondyle and epitrochlea in disarticulating ; and these relative positions should be constantly kept in mind during the operation. The skin is freely movable in front, but is adherent to the ulna behind. The methods in common use are the iuterior flap, lateral flap, and circular. Anterior Flap. The joint may be opened (a) from be- hind, or (b) from in front. a. From behind. (Sedillot.) The forearm is flexed, and an incision, slightly convex downward and interesting only the posterior third of the circumference, is made one and a half inches below the tuberosities of the humerus. The skin is dissected up to the tip of the olecranon, the tendon of the triceps divided, the point of the knife passed into the joint and carried first to one side and then to the other, cutting the posterior and lateral ligaments. A longitudinal incision two and a half inches long is then carried down- ward from the outer end of the first, the forearm, still flexed, is pressed backward and inward, and the disarticulation readily completed bypassing the knife through the joint, AMPUTATIONS. 79 and cutting down and out on the anterior aspect while the skin is forcibly retracted. b. From in front. (Fig. 33, A.) The flap may be made by transfixion, or from without inward ; in either case it should be at least three inches long, and its base should be par- allel to and three-quarters of an inch below a line drawn through the epi- condyle and the epitrochlea. Some surgeons prefer to make the line of the base oblique downward and out- ward, because the muscles on the outer side have their origins at higher points on the humerus, and retract more than those on the inner side. The posterior incision should be slightly convex downward, and should begin and end at the same points as the anterior one. The head of the radius is then sought for, and the joint opened by entering the knife between it and the humerus and completely divid- ing the external lateral ligament. The capsule is divided in front by passing the point of the knife along the edge of the ulna over the coro- noid process to the internal lateral ligament, which should be cut as high as possible. The olecrauon is disengaged from the humerus by drawing it down forcibly, the attach- ment of the triceps divided, the knife passed behind the bone, and the remaining tissues divided from within out- ward. Amputation at the elbow- joint. A. Anterior flap. B. External flap. C. Circular method. Lateral flap. (Fig. 33, B.) An external flap four or five inches long is made by transfixion from a point in the median line in front, a finger's breadth below the bend of the elbow ; or from without inward by an incision begin- ning at the same point and ending half an inch higher on. 80 OPERATIVE SURGERY. the posterior face of the ulna. A second iucision is made transversely across the inner side of the arm about an inch below the upper end of the first. The radio-humeral joint is opened, and the disarticulation completed as before. Instead of a single external flap, two lateral flaps may be made, but the external should be half au inch longer than the internal one. Circular. (Fig. 33, 0.) An incision, transverse or a little lower on the outer than on the inner side, is made about the limb three and and a half inches below the epi- trochlea, and carried down to the enveloping fascia ; the cutaneous sleeve is dissected up for about an inch, and the muscles divided transversely at its base. They are then retracted forcibly by an assistant so as to form a cone with its apex directed downward, and the deep muscles of the anterior aspect are again divided transversely on a level with the radio-humeral articulation, the external lateral ligament being included in the incision and the joint there- by opened. The disarticulation is completed as before described. AMPUTATION OF THE ARM. This may be performed at any poiut below the attach- ments of the muscles of the axilla. Disarticulation at the shoulder is preferable to amputation in continuity above these attachments. As the bone is centrally placed and well covered on all sides, any one of the usual methods of amputation may be employed. As a general rule the biceps should be divided at a lower level than the other muscles because it is not adherent to the humerus, and therefore retracts more than the others. The circular incision should be half an inch lower on the inner thau on the outer side. In muscular subjects flaps should be cut rather thin, and, when possible, it is better that the main artery should be in the posterior flap. AMPUTATION AT THE SHOULDER-JOINT. General ( '<,nsi from before backward and inward. The posterior tibial vessels lie behind the inner malleolus, and must be carefully avoided. Beginning at the outer side of the heel, nearly an inch below the tip of the external malleolus, an incision, extend- ing through to the bone, is carried straight forward to the base of the fifth metatarsal bone; thence, curving forward, across the dorsum of the foot to the base of the first meta- tarsal ; thence obliquely backward and outward across the AMPUTATIONS. 95 sole of the foot and around its outer border, rejoining the first and horizontal part of the incision at the calcaneo- cuboid articulation. The soft parts must be separated from the outer surface of the calcaneum and cuboid with division of the peroneal tendons, the dorsal flap dissected back to the head of the astragalus, and, on the inner side, beyond the tubercle of the scaphoid, thus dividing the tendon of the tibialis anticus and the anterior portiou of the internal lateral ligament. The interosseous ligament can then be easily reached by depressing the toes, passing the knife be- tween the astragalus and scaphoid, and cutting backward and inward along the under surface of the former. The soft parts on the inner side are then separated from the cal- caneum, injury to the vessels being avoided by keeping close to the bone, between it and the tendon of the flexor com- munis, the foot depressed, and the tendo Achillis divided. This last is a very difficult part of the operation, and great care must be taken to keep the edge of the knife close to the bone, so as not to cut through the skin. The posterior tibial nerve should be dissected out and cut off as high up as possible, so that it shall not be pressed upon the stump. Farabeuf has slightly modified this, as follows: The incision is begun at the outer margin of the tendo Achillis, close to the upper border of the os calcis, and car- ried horizontally forward along the outer side of the latter bone, passing about one inch below the external malleous. At the base of the fifth metatarsal it turns over the dorsum of the foot to the base of the first metatarsal, thence across the sole to its outer margin opposite the base of the fifth metatarsal. From this point it passes backward along the outer edge of the plantar surface of the foot to the poste- rior external tubercle of the os calcis, whence it curves up- ward to the starting-point at the upper and back part of the os calcis and outer border of the tendo Achillis. AMPUTATION AT THE ANKLE-JOINT. Syme's Amputation, Tibio-tarsal Amputation. (Figs. 41, 42, J5.) Amputation through the ankle-joint by the cir- 96 OPERATIVE SURGERY. cular method, lateral flaps, or a long anterior flap taken from the dorsum of the foot, as proposed by Baudens, did not meet with favor, because the delicacy of the coverings or the vicious position of the cicatrix rendered the stump practically useless; and, although occasional successes were reported, the choice still lay between Chopart's operation and amputation of the leg, until Prof. Syme, in 1843, 1 showed how the excellent plantar flap could be obtained. About the same time Jules Roux, of Toulon, met the same indication by means of a large internal lateral flap carried across the plantar aspect of the heel. By greatly restricting the necessity for amputation of the leg this operation has become one of the most important and frequently performed of all amputations. The objec- tions urged against it, and the unfavorable results that have sometimes followed its use, seem to have had their origin in a failure to understand or carry out all the details of its execution, or in the introduction of improper modifications. It has seemed desirable, therefore, to reproduce here Prof. Syme's directions for performing it, as published in 1848, 2 six years after he had first put it iuto practice. " Succeeding experience taught me that a much smaller extent of flap than had originally been considered necessary was sufficient for the purpose, and that hence the operation could not only be simplified in performance, but increased in safety from bad effects. " The foot being placed at a right angle to the leg, a line drawn from the centre of one malleolus to that of the other, directly across the sole of the foot, will show the proper extent of the posterior flap. The knife should be entered close up to the fibular malleolus,' 5 and carried to a point on the same level of the opposite side, which will be a little below the tibial malleolus. The anterior incision should join the two points just mentioned at an angle of 45° to the sole of the foot, and long axis of the leg. In dissecting the posterior flap, the operator should place the fingers of his left hand upon the heel, while the thumb rests upon the edge of the integuments, and then cut between the nail of the 1 Lond. and Edin. Monthly Journ. of Med. Science, Feb. 1843. - Contributions to the I'ath. and Practice of Surgery. Edinburgh, 1848. • " The lip of the external malleolus, oralittle posterior to it; rather nearer the posterior than the anterior margin of the bone." — Syme, in Lancet, 1855. AMPUTATIONS. 97 thumb and tuberosity of the os calcis, so as to avoid lacer- ating the soft parts, which he at the same time gently, but steadily, presses back until he exposes and divides the tendo Achillis. 1 The foot should be disarticulated before the malleolar projections are removed, which it is always proper to do, and which may be most easily effected by passing a knife round the exposed extremities of the bones and then sawing off a thin slice of the tibia connecting the two processes." Disarticulation is accomplished by opening the joint in front and dividing the lateral ligaments by entering the point of the knife between the sides of the astragalus and the malleoli. The essentials of the method, as pointed out by the more recent Scotch writers (Lister, Spence, and Bell), are that the plantar incision should run from the tip of the external malleolus directly across the heel, should on no account in- cline forward, and should terminate at least half an inch below the tip of the internal malleolus (behind and below, according to Lister). In case the heel is unusually long the incision may even incline backward. It is not only unnecessary, but actually dangerous, to make the flap longer than this, for it then becomes impossible to dissect out the calcaneum without scoring the subcutaneous tissue in all directions, and increasing the chances of sloughing. If the incision is made further back and carried any higher on the inner side, the posterior tibial will be cut before its division into the two plantar arteries. Erichsen and Lister both claim that the integrity of the posterior tibial is not of great importance, the vitality of the flap depending mainly upon anastomosing branches of high origin which lie quite near the bone. Erichsen 2 calls attention to the existence of a " branch of considerable size which arises from the posterior tibial artery, about one and a half to two inches above the ankle-joint, and passes down to the inner side of the os calcis," communicating freely above, below, and behind this bone with the peroneal artery on the other side. As these anastomosing loops lie 1 It is now generally considered better to divide the tendon from above down- ward, after disarticulating, keeping the edge of the knife close to the upper and posterior aspect of the bone. 2 Science and Art of Surgery, vol. i. p. 77. Lea, Phila., 1873. 98 OPERATIVE SURGERY. much nearer the bone than the skin, great numbers of them will be divided, and the vitality of the flap endangered, unless the edge of the knife is kept close against the bone during the dissection. Lister goes so far as to say that sloughing of the flap is always the fault of the surgeon, and Bell intimates the same thing. Roux 1 has shown that this close dissection is not without its dangers from the other side. In two of his cases osteo- phytes developed within the stump from portions of the periosteum left adherent to the flap. The autopsy in one of these cases showed that six osteophytes had formed and become carious within a year after the operation. A short longitudinal iucision through the deep parts along the middle of the plantar aspect of the calcaneum will sometimes render this step of the operation easier, and be less disadvantageous than the employment of great force. Modifications. A. Internal Lateral Flap. When the outer side of the foot has been so altered by injury or disease that the heel flap cannot be obtained, a very good substitute may be had in the large internal flap suggested by Jules Roux, aud adopted with slight changes by Sedil- lot, Mackenzie, and others. Prof. Spence says this stump can hardly be distinguished from Syme's. An iucision (Fig. 43) is commenced at the outer side of the tendo Achillis, a little above its insertion, carried straight forward under the outer malleolus, then in a curved line across the instep half an inch in front of the anterior articu- lar edge of the tibia, and backward to a point just in front of the inner malleolus; thence directly downward to the sole, across it obliquely backward to its outer border, and then backward and upward around the heel to the point at which it began. The edges of the flaps are next dissected up for a short distance, the joint entered at the outer side, and the internal flap completed from within outward after disarticulation. Sedillot's modification of this consists in making the flap more quadrilateral than triangular, by a semicircular incision across the dorsum three finger-breadths in front of the mal- 1 Hull, de la Soc. G Excision of the wrist, Lister. A. The radial artery. B. Extensor secundi internodii pollicis. D. Ext. eonim. digitoruni. E. Ext. min. dig. F. Ext. prim. int. pol. G. Ext. oss. met. poll. H. I. Ext. carp. rad. long, and brev. A'. Ext. carp. uln. L, L. Line of radial incision. with the longitudinal part of the incision. The removal of the trapezium is reserved till the rest of the carpus has been taken away. The soft parts on the ulnar side of the incision are now dissected up as far as is convenient, the extensor tendons being relaxed by bending back the hand. The knife is next entered on the inner side of the arm, two inches above the end of the ulna, immediately anterior to the bone, and is carried downward between it and the flexor carpi ulnaris, and on in a straight line as far as to the middle of the fifth metacarpal bone at its palmar aspect (Fig. 58, B). The dorsal lip of the incision is raised, and the tendon of the extensor carpi ulnaris cut at its insertion EXCISION OF JOINTS AND BONES. 143 into the fifth metacarpal, and dissected up from its groove in the ulna, care being taken to avoid isolating it from the integuments, and thus endangeriug its vitality. The ex- tensors of the fingers are then readily separated from the carpus, and the dorsal aud internal ligaments divided, but the connections of the tendons with the radius are purposely left undisturbed. The anterior surface of the ulna is then cleared by cut- ting toward the bone, so as to avoid the artery and nerve ; the articulation of the pisiform is opened, if that has not been already done in making the incision, and the flexor tendons are separated from the carpus. While this is being done the knife is arrested by the process of the unciform bone, which is clipped through at its base with pliers. The knife must not be carried further down the hand than the bases of the metacarpal bones, so as not to injure the deep palmar arch. The anterior ligament of the wrist-joint is divided, after which the junction between the carpus and metacarpus is severed with cutting-pliers, and the carpus extracted through the ulnar incision by seizing it with strong forceps and touching with the knife any ligamentous connections that may remain undivided. The hand being now forcibly everted the articular ends of the radius and ulna will protrude at the ulnar incision. If they appear sound or only superficially affected, the articular surfaces only are removed. The ulna is divided obliquely with a small saw, so as to take away the cartilage- covered rounded part over which the radius sweeps, while the base of the styloid process is retained. The end of the radius is then cleared sufficiently to allow a thin slice to be sawn off parallel to the general direction of the inferior articular surface and the articular facet on the ulnar side of the bone is clipped away with bone-forceps. If, on the other hand, the bones prove to be deeply carious, the pliers or gouge must be used with the greatest freedom. The metacarpal bones are next dealt with on the same principle. If sound, only the articular surfaces are clipped off. The trapezium is next seized with forceps and dissected out, so as to avoid cutting the tendon of the flexor carpi radialis, which is firmly bound into the groove on its palmar 144 OPERATIVE SUROEBY. aspect, the knife being also kept close to the bone elsewhere to preserve the radial artery. The articular end of the first metacarpal is then removed. Lastly, the articular surface of the pisiform is clipped off, the rest of the bone beiug left if souud. The process of the unciform is also left if sound. The radial wound may be closed with sutures, but the ulnar one must be kept open for drainage, and the limb must be bound upon a splint in such a manner that while the wrist is firmly fixed passive motion can be given regularly to the fingers. Radial Incision (Oilier). Fig. 58, C. An incision involving only the skin is begun on the outer side of the wrist, an inch below the styloid process of the radius, and Fig. 58. Excision of the wrist. A. Lister's radial incision. B. Lister's ulnar incision. C. Oilier. D. Von Langenbeck. carried upward along the outer border of the bone for a greater or less distance, according to the amount to be re- moved. A cutaneous branch of the radial nerve is exposed and drawn aside, the fascia divided, and the extensor ten- dons of the thumb recognized. These tendons are a guide which is easily found. They are superficial, and contained in a separate groove. On opening the sheath and drawing them aside, the insertion of the supinator longus is exposed, EXCISION OF JOINTS AND BONES. 145 on the outer side of which, and parallel to the tendoD, the periosteum of the radius must then be divided. Using a straight, sharp elevator, the surgeon next de- taches the tendon of the supinator, preserving its relations with the periosteum, and then denudes the lower end of the radius inward, removing periosteum and capsule. Then, bending the hand forcibly toward its inner side, he sepa- rates the remaining fibrous attachments and dislocates the lower end of the radius outward. The ulna can be pro- truded through the same wound and denuded from below upward, but it is better to make a longitudinal incision on the inner side for this purpose. The ends of the radius and ulna are then sawn off, and through the gap thus left the carpal bones are successively removed with gouge and forceps. Dorso-radial Incision (Von Langenbeck). Fig. 58, D. The hand is bent toward the inner side, and an incision is begun at the ulnar border of the second metacarpal bone near its middle and carried upward four inches, crossing the ulnar edge of the tendon of the extensor carpi radialis brevior, where it is inserted into the base of the third meta- carpal bone, and splitting the dorsal ligament of the wrist exactly between the tendons of the extensor secundi iuter- nodii and extensor of the forefinger. This incision should be carried down to the bone, and the soft parts detached on the radial side with an elevator ; the tendons, where they lie in the grooves, are raised bodily with the periosteum, and their sheaths are not opened. The hand is flexed so as to make the first row of carpal bones present in the wound ; the scaphoid is separated from the trapezium and taken out, and followed in turn by the semilunar and cuneiform, the interosseous ligament being cut and the bones pried out with a small elevator. The trapezium and pisiform are left if possible. To take out the second row, the operator steadies the round articular end of the os magnum with the fingers of his left hand, and, while an assistant abducts the thumb, he divides with a knife the connection between the trapezium and trapezoid, passes the knife into the carpo- metacarpal joint, and cuts the ligaments on the dorsal side of the ends 146 OPERATIVE SURGERY. of the metacarpal bones while an aid flexes them. In this way the trapezoid, magnum, and unciform can be brought out together. The lateral ligaments are then carefully separated from the radius and ulna, the bones protruded and sawn through. EXCISION OF THE HIP-JOINT. In this joiut, as in the shoulder, the disease is often con- fined to the head of the bone, and under such circumstances partial excision should be performed. When the acetabulum is diseased the loose pieces must be picked out and the gouge applied to the roughened surface. The line of sec- tion of the femur should pass below the great trochanter, however limited the disease may be, for if this process is left it is liable to protrude through the wound and obstruct the escape of the secretions. If the disease extends be- yond this point, additional slices must be removed, or the gouge used until healthy bone is reached. The anatomical disposition of the parts is such that the joint is best approached from the outer and posterior aspect, the incision passing over the top of the great trochanter. Different surgeons have inclined the upper part of the in- cision forward and backward at various angles, or have dissected up a triangular flap, its apex directed sometimes upward, sometimes downward. Sayre's Method. (Fig. 59, A.) Enter the point of the knife midway between the anterior superior spine of the ilium and the top of the great trochanter, and drive it down to the bone; then, keeping it firmly in contact with the bone, draw it in a curved line to the top of the trochanter, midway between its centre and posterior border, thence for- ward and inward, making the whole length of the incision from four to eight inches, according to the size of the thigh. Make sure that the periosteum is divided throughout. Then, drawing aside the soft parts, divide the periosteum transversely just opposite to, or a little above, the lesser trochanter, carrying the division as far as possible around the bone. Beginning at the angle formed by the two in- cisions, raise flic periosteum on each side, together with its EXCISION OF JOINTS AND BONES. 147 membranous attachment, as far as the digital fossa. Then, substituting a knife for the periosteal elevator, divide the insertions of the muscles at this point, keeping close to the bone, and afterward separate the remaining periosteum as far as can be done without tearing it. Then adduct the leg slightly and raise the head of the femur gently out of the acetabulum ; this will detach the last of the periosteum, and allow the finger to be passed around the bone as a guide for the saw, which should be applied just above the lesser tro- chanter. If the bone cannot be readily dislocated, saw it through first, and then remove the head with the forceps or elevator. Fig. 59. Excision of the hip. A. Sayre. B. Oilier. If the acetabulum is perforated, the edges must be chipped off very carefully down to the point at which the periosteum on the pelvic side is still adherent. Ollier's Method. (Fig. 59, B.) Oilier makes a some- what similar incision. It begins four fino-cr-breadths below 148 OPERATIVE SURGERY. the crest of the ilium, and the same distance behind the anterior superior spine, runs downward to the most promi- nent part of the great trochanter, and thence directly down the shaft of the femur. Its upper part should involve the skin and fascia only. The posterior lip, including the glutseus maximus, is drawn back, exposing the glutseus medius, the fibres of which are then separated without cut- ting them. This permits the attachments of the glutseus medius to be preserved, and the glutseus minimus can be exposed by drawing apart the edges of the opening made in the other, and then divided in the same manner or drawn forward with a blunt hook. The capsule is split from the edge of the cotyloid cavity to the digital fossa, and detached together with the ten- dinous insertions. The head of the femur is dislocated backward, the ligamentum teres divided, and the deuuda- tion continued downward to the lesser trochanter. The bone is then protruded and sawn off with a chain or com- mon saw. LangenbecJc's Method. The thigh is flexed at an angle of 45° and rotated inward. The knife is entered just below a point opposite the junction of the upper and mid- dle thirds of a line joining the posterior superior spine of the ilium and great trochanter ; in other words, just below the most anterior portion of the great sciatic notch. Thence following the long axis of the flexed femur it is carried in a straight line over the outer surface of the great trochanter, making an incision which penetrates to the bone through- out aud is about four or five inches long. The glutei are thus divided in the direction of their fibres, the margins of the wound retracted, and the capsule opened by a longi- tudinal aided by a transverse incision close to the edge of the acetabulum. After severing the attachments of the mus- cles to the great trochanter the head of the bone is dislo- cated backward and brought out of the wound aud sawed off. Anterior Incision. Roser recommends, in order to pre- serve the trochanter, an anterior incision in the line of the neck of the femur, beginning just outside the crural nerve, and dividing the iliacus, rectus, sartorius, and tensor vaginre EXCISION OF JOINTS AND BONES. 149 femoris. The capsule is divided in the same line, the head turned forward into the wound by rotating the thigh out- ward, and sawn off. Liicke and Schede have modified this by making the in- cision vertical instead of transverse, beginning outside the crural nerve a little below and to the inner side of the ante- rior superior spine of the ilium, and running directly down- ward. The inner borders of the sartorius and rectus are exposed and drawn outward, and then the outer border of the psoas-iliacus exposed and drawn inward. Then the thigh is flexed, abducted, and rotated outward, and the capsule divided. A similar incision and approach to the joint may be used in the operative reduction of old dorsal dislocation. Barker 1 employs the following method : The incision begins on the front of the thigh half an inch below the anterior superior spine of the ilium, and extends about three inches downward and a little inward. The muscles are recognized as the successive layers of tissue are divided. The tensor vagina? femoris and glutei are drawn to the outer side, the sartorius and rectus to the inner, and the neck of the femur exposed. The external cutaneous nerve will be encountered in the upper angle of the incision ; lower down and deeper are the external circumflex vessels. The deeper part of the incision need not be made as long as the more superficial. Any abscess which may be opened should be thoroughly washed out before proceeding fur- ther. The neck of the femur is divided with a narrow saw in the direction of the external wound, and the diseased head removed with sequestrum-forceps. The acetabulum and all other parts of the joint-cavity are explored by the forefinger, and any diseased tissue cut or scraped away. Mr. Barker fills the wound with iodoform emulsion and generally closes it up tight. The patient is placed upon a double Thomas splint for several weeks. Arthreetomy of the Hip-joint by Chiselling through the Great Trochanter (Tiling). An incision three or four i Brit. Med. Journ., 19, 18S9. 150 OPERATIVE SURGERY inches long is made along the anterior border of the great trochanter, which is chiseled off and laid back. The cap- sule of the joint is divided longitudinally, the periosteum elevated from the neck of the femur, and the head of the femur dislocated. Then the lesser trochanter is also chiseled off aud the acetabulum cavity is freely accessible. ANCHYLOSIS OF THE HIP- JOINT. 1 When the anchylosis is not associated with the loss of a great part of the head and neck of the femur — that is, when it follows inflammation of the joint due to rheumatism, pyaemia, traumatism, or chronic disease that has been ar- rested at an early stage — Mr. Adams's operation of sub- cutaneous division of the neck of the femur may be appli- cable, but usually division below one or both of the trochan- ters, or excision of the head aud neck, is to be preferred. Pig. 60. Subcutaneous division of the neck of the femur. Division below the lesser trochanter is only undertaken to remedy a faulty position of the limb, for there can be no question of establishing a new joint below the insertion of 1 This subject, which properly belongs under osteotomy, Is placed here on ac- count of Its Intimate relations with excision of the joint. EXCISION OF JOINTS AND BONES. 151 the psoas and iliacus. It is doubtful also if a permanently movable joint can be obtained by division at a higher point ; it certainly cannot unless a portion of the bone is removed, and probably not even then, for the tendency of the cut ends to unite after a time is very great. Subcutaneous Division of the Neck of the Femur (Adams 1 ). The only special instrument needed is a saw somewhat resembling a tenotomy knife, the cutting part being one and a half inches long and three-eighths of an inch wide, and the shank about two and a half inches long. (Fig. 61.) A tenotomy knife is entered a little above the top of the great trochanter and pushed straight into the neck of the femur, dividing the muscles and opening the capsule freely. The soft parts being fixed by the thumb and fingers of the left hand, the knife is withdrawn and the saw passed promptly down to the bone through the track made by it. Fig. 61. Adams's saw for subcutaneous division of the neck of the femur. The bone is then sawn through from before backward, so that the line of section shall be at right angles to the long axis of the neck, care being taken to avoid cutting obliquely through the neck, or in a direction parallel with the shaft of the bone. Subtrochanteric Osteotomy (Gant's Operation 1 ). An inci- sion is made from one to two inches long on the outer aspect of the thigh an inch to an inch and a half below the great trochanter, according to the size of the patient. It should expose the external surface of the femur just below the site of the lesser trochanter. The blade of the osteotome is introduced through this incision, and the bone divided just below the trochanter minor. After each stroke of the mallet the chisel is loosened and its direction slightly changed 1 An operation for bony anchylosis of the hip-joint with malposition of the limb, by subcutaneous division ot the neck of the thigh bone, by William Adams. London, 1871. Reprinted from the British Medical Journal of December 24,1870, 2 Gant's " Science and Practice of Surgery," 1886. 152 OPERATIVE SURGERY. to cut forward or backward. The bone should not be cut entirely through, but when it seems evident that only a thin shell is left it should be carefully fractured. The after- treatment consists in simple extension. The operations of Adams and Grant are the ones most gen- erally employed for the correction of deformity following anchylosis at the hip in a faulty position. Adams's method is, of course, only applicable to those cases in which the femur still possesses a neck, and inasmuch as the disease which most frequently calls for this kind of interference — namely tuberculosis — generally causes more or less destruc- tion of the head and neck of the femur, the operation of Gant, or subtrochanteric osteotomy, has a wider use. Excision. Posterior incision as above described, with such modifications as may be made necessary by disloca- tion ; division of the neck with the saw, if possible ; other- wise with the chisel ; then removal of the head, or what remains of it, by chiselling. The upper end of the bone is then lodged in the acetabu- lum, after subcutaneous division of such muscles and soft parts as interfere, and removal of the upper part of the trochanter, if necessary. Extension by weight and pulley must be kept up for a long time. EXCISION OF THE KNEE-JOINT. This should always be complete to this extent, that a slice should be taken from each bone; but it is not always necessary to remove the entire articular surface of the femur. In children the amount removed should be as small as is consistent with removal of all that is diseased. The patella may be dissected out and removed entire, or the diseased portions extirpated with the gouge or rongeur ; or it may be sawn through parallel with its articular surface. As a general tiling the latter method is preferable, unless the bone is so extensively affected that the preservation of even its anterior surface is incompatible with a thorough removal of all the disease. As anchylosis should always be aimed at, the incision EXCISION OF JOINTS AND BONES. 153 may cross the front of the joint and divide the ligamentum patellae or the patella. Some surgeons provide for drainage by making a dependent opening in the popliteal space, but this seems fig. 62. to be unnecessary. Semilunar Incision. (Fig. 62, A.) The knife is entered on one side of the limb at the posterior part of the condyle, and carried across midway between the patella and the tuberosity of the tibia to a corresponding point upon the other side. This incision should extend down to the bone through- out, dividing the ligamentum pa- tella?. The flap is reflected, the crucial ligaments divided close to their attachment to the tibia, the lateral ligaments divided, the end of the femur cleared as far as may be necessary, with especial care for the safety of the popliteal vessels, protruded through the wound, and sawn off at the point indicated in Figs. 63 and 64. The line of section must be parallel to the line of the articulation, not at a right-angle to the axis of the shaft, for that is directed inward and downward. If necessary, additional slices of the bone are removed, or the gouge is used. All the articular cartilages should be removed. The end of the tibia is next projected, cleaned, and sawn off about half an inch below its upper surface. In sawing the bones it is best not to make a complete section with the saw, but to stop a little short of the poste- rior surface and complete the separation by fracturing what is left. Finally, the patella is taken out, and diseased portions of the synovial membrane scraped or clipped off, or the articular surface of the patella may be removed with the saw or rongeur, and the anterior bony shell which is at- tached to the quadriceps tendon left. The operation is Excision of the knee-joint. A. Semilunar incision. B. Ollier's incision. 154 OPERATIVE SURGERY. completed by suturing in position the divided ligamentum patellae. Fig. 63. Fig. 64. Sections to show the position of the epiphyseal cartilage at the knee and the points at which the section ought to be made in excision. Transverse Incision. The incision should cross the pa- tella at or just below its centre and extend beyond the centre EXCISION OF JOINTS AND BONES. 155 of the condyle on each side ; at each end should be made a longitudinal incision extending two inches above and one inch below the transverse one ; the patella is then divided at its centre transversely, and the fragments turned up and down, and the joint thus opened and cleaned. At the close of the operation the patella is replaced and united with sutures ; the patella may be entirely removed ; or, in the first place, after exposing the boue, the patella may be dissected out, and at the close of the operation the quadriceps tendon reunited. Arthrectomy, or Extirpation of the Knee-joint. This term has been given to the systematic removal of the synovial membrane and any small portions of the rest of the artic- ulation which may on inspection be found to be diseased. The above-described semilunar incision is employed, and the anterior flap containing the patella reflected. After removing all pulpy and degenerated tissue in the subcrural pouch the lateral and crucial ligaments, if necessary, are cut, although the latter should be spared whenever possible. The joint is thus thoroughly exposed, and all the diseased parts in its interior excised, together with the semilunar cartilages. Foci of inflammation in the bone must be removed with the sharp spoon or rongeur. The field of operation is then flushed out with some antiseptic solution, the ligamentum patelhe sutured in position, and the cuta- neous wound loosely united. Whenever it is deemed desir- able drainage-tubes may be inserted in the posterior angles of the incision. Immobilization of the leg in extension must be maintained for several weeks. EXCISION OF THE ANKLE-JOINT. The results of excision of the ankle-joint have been, on the whole, so unfavorable that the English and German surgeons are inclined to abandon it entirely. When the operation has been undertaken on account of caries, the disease has usually returned in the tarsal bones, and ren- dered secondary amputation necessary. When, on the other hand, it has been performed on account of injury, the mor- tality has been great, secondary amputation has been fre- 156 OPERATIVE SURGERY. Fig. 65. quently required, and the position of the foot in the cases that recovered has usually been faulty. The results of conservative expectant treatment have been no better, and, in part, for the same reasons. In correspondence, as has been pointed out, with the late con- solidation of the epiphysis, inflammation of this extremity is likely to be severe, and its destructive results extensive ; the reproduction of bone is also very abundant and leads almost necessarily to anchylosis, so that, unless great atten- tion is given to maintaining the foot in a proper position during the whole period of treatment, it will unite at a faulty angle, with inversion or eversion of the sole, and inability to support the weight of the body. As anchylosis is to be expected, the rule in excision is to remove the smallest possible amount of bone, and to make partial instead of complete excision when the disease does not extend to the whole joint. The retention of one or the other malleolus is a great help in preventing shortening, and in the use of a plaster splint. The interosseus membrane between the tibia and fibula must be pre- served carefully. It not only has a great tendency to ossify, but also seems to favor the reproduction of bone. Operation (total excision). An incision involving only the skin is begun two inches above the external malleolus and a little behind the middle of the fibula, carried directly dowD to the end of the bone, and thence forward and slightly upward toward the instep for an inch (Fig. 65). The periosteum covering the fibula is divided throughout and dissected up from the bone with the attachment of the lateral ligaments, especial care being taken not to open the sheath of the peroneal muscles at the posterior border of the malle- olus, and to remove all the thick periosteum and the interos- Excision of ankle. EXCISION OF JOINTS AND BONES. 157 seous membrane on the inner side. If necessary, a trans- verse liberating incision may be made through the perios- teum at the upper end of the cut. The bone is then divided with a keyhole saw or chisel, the upper end of the lower fragment drawn out of the wound to expose and facilitate the separation of the remaining attachments, and the piece removed. The soft parts are then held out of the way with retrac- tors, and the upper articular surface of the astragalus sawn off with the keyhole saw, but not removed. The foot is next turned upon its outer side, and a longi- tudinal incision two or three inches long made along the side of the tibia, ending half an inch below the tip of the malleolus, where it is then crossed by a short horizontal one involving the skin only. The periosteum of the tibia is divided in the line of the incision and transversely at its upper end, and dissected off, the bone sawn through, and the piece removed. Langenbeck makes the line of section oblique downward and outward, because it is easier to do so, but most surgeons prefer to have it transverse. The upper part of the astragalus, which has been previously sawn off, is then removed through the same incision. The gouge is used to scrape away any diseased parts found on the cut surface of the astragalus, or the bone may be seized with strong forceps and dissected out entirely. If the injury has affected the astragalus only (as in some gunshot wounds), its splinters are best removed through a longitudinal incision upon the dorsum of the foot between the extensor tendons of the first and second toes. Vogfs Method, by Removal of the Astragalus. A serious objection to the use of the preceding operation in cases of tuberculous disease lies in its insufficient exposure of the interior of the joint to view, and it has been proposed by Hueter to return to the old method of an anterior trans- verse incision with division of all the extensor tendons, and by Busch to open the joint by cutting across the sole and sawing through the calcaneum. Vogt, 1 however, has pro- 1 Centralblatt fur Chirurgie, 18S3, p. 289. 158 OPERATIVE SURGERY. posed and employed another method, which avoids the extensive division of the soft part and which enables the surgeon to explore the joints thoroughly, and, if necessary, to excise the synovial membrane. It consists in primary methodical extirpation of the astragalus without resection of the malleolus. Operation. A longitudinal incision on the outer side of the extensor tendons, three or four inches long, beginning above between the tibia and fibula, and ending below at the line of the calcaneo-cuboid joint ; after division of the fascia the tendons are raised in their sheaths, carefully separated from the underlying parts, and strongly retracted to the inner side. The extensor brevis is then cut, the outer side of the incision retracted, the capsule split longitudi- nally to its full extent and separated on both sides from the bone with knife and elevator, the head and neck of the astragalus cleared, and the astragalo-scaphoid ligament divided. A second incision is made from a point somewhat below the centre of the first backward below the external mal- leolus, dividing everything down to the astragalus, but sparing the peroneal tendons. The foot is then supinated, the anterior ligaments cut away from the external mal- leolus, and the strong interosseous ligament divided by thrusting a small strong knife into the groove between the astragalus and calcaneum. The head of the astragalus is then drawn forcibly outward with a stout hook, while the foot is supinated, the deep portion of the internal lateral ligament cut by passing a knife between the malleolus and the astragalus, the latter drawn forward into the incision, and its posterior attachments cut. The remainder of the operation will vary with the extent and character of the disease. All the adjoining bones are freely exposed to inspection, and can be scraped, gouged out, or sawn off. I have found the execution of this operation easy, even when the capsule was much thickened by disease, and its exposure of the interior of the joint is very satisfactory. EXCISION OF JOINTS AND BONES. 159 osteoplastic excision of the foot (heel and ankle) (Mikulicz). This ingenious operation, the results of which have proved very satisfactory, was introduced by Mikulicz in 1881. 1 It is specially applicable to cases in which the in- tegument about the heel has been extensively destroyed. Fig. 66. Osteoplastic excision of the foot. (Mikulicz.) Operation. (Fig. 66.) Abdominal decubitus. An in- cision beginning a little in front of the tubercle of the 1 Archiv fur klinische Chirurgie, vol. xxvi., p. 191. 160 OPERATIVE SURGERY. scaphoid is carried directly across the sole of the foot to a point just behind the base of the fifth metatarsal bone. From each end of this one another incision is carried back- ward and upward to the base of the corresponding mal- leolus, and the upper ends of the last two incisions are then united by a fourth which passes horizontally across and divides the tendo Achillis. In all the incisions the knife is made to touch the bone throughout. The lateral ligaments of the ankle are next divided, the joint opened from behind, and the calcaneum and astra- galus carefully dissected from the tissues in front of the incisions and removed by disarticulating at the medio- tarsal joint. Finally, the malleoli and lower articular surface of the tibia and the posterior portion of the cuboid and scaphoid are sawn oif, as shown by the dotted lines in the figure, the cut being made from behind forward. Fig. 67. External incision for the operative treatment of old unreduced Pott's fracture. The astragalus is displaced backward. Its articular surface is partially occupied by the new osteoid tissue developed under the periosteal bridge at the lower end of the posterior surface of the tibia. The cut surfaces of bone are then brought into apposi- tion and fastened together with nails or sutures, and the wound closed. Fig. 66, B, represents the result. EXCISION OF JOINTS AND BONES. 161 Operative Treatment of Old Unreducible Pott's Fracture. 1 The Esraarch rubber bandage or tourniquet is applied and tied below the knee. An incision is begun on the outer side three inches above the ankle, and carried down along the front of the fibula to the malleolus, and thence in a curve forward toward the fifth metatarsal (Fig. 67). The seat of the fibular fracture is exposed, and the lower frag- ment again separated with the chisel. A second longitudinal incision about five inches long is made over the inner side, extending past the malleolus to the tubercle of the scaphoid (Fig. 68). Through it the Fig. 68. Internal incision for the operative treatment of old unreduced Pott's fracture. The astragalus is represented as displaced backward. mass of new tissue that has formed between the astragalus and the internal malleolus is removed or the broken and displaced malleolus is mobilized. By now working through both incisions the back of the lower end of the tibia can be freed of such cicatricial tissue or new bone as has formed there, and the foot so mobilized that it can be brought back to its proper place. The perios- teum and ligaments are sutured in position with catgut, the wound loosely closed without drainage, and after applying a bulky dressing the tourniquet is removed. 1 Stimson : N. Y. Medical Journal, June 25, 1892. 1 62 OPERATIVE SUBGEB Y. EXCISION OF THE BONES AND SMALLER ARTICULATIONS. EXCISION OF THE SUPERIOR MAXILLA. This operation may be required on account of malignant tumors of the bone or antrum, or of suppurative osteitis and necrosis, or to give access to the base of implantation of a naso-pharyngeal polyp. In the first case the perios- teum should not be retained ; in the second its separation from the boue is in great part accomplished by the inflam- matory process; in the third it should be carefully retained so as to diminish the subsequent deformity. In total excision the bony connections that require to be divided are : (1) The one with the malar bone below the outer angle of the orbit. (2) That with the opposite bone along the centre of the hard palate. (3) Those formed by the nasal process near the inner angle of the orbit; and (4) that with the palate bone and pterygoid process of the sphenoid. (Fig. 69.) The first may be divided by nicking the anterior surface of the bone with a saw, and completing the division with cutting forceps, or with chisel and mallet, or by passing a chain-saw around it, through the spheno- maxillary fissure in the orbit and zygomatic fossa. The second is divided, after having drawn one or both incisor teeth, by means of a saw passed into the nostril, or with cutting forceps with long narrow blades, or a chisel. The third is easily divided with forceps or a chisel, and the fourth by twisting the bone downward after all the other connections have been severed. The periosteum, covering the floor of the orbit, is thick and easily detached ; that on the hard palate is thick and difficult of removal, on account of the irregularities of the surface. There is but little danger of injury to the internal maxillary artery, and it is seldom necessary to apply more than one or two ligatures to its divided branches. Oozing is arrested by parking with aseptic or iodoform gauze. In partial excision the orbital plate is left, the line of division of the bone passing through the anterior wall of the antrum from the nostril to the lower corner of the EXCISION OF JOINTS AND BONES. 163 union with the malar bone. The remaining attachments are then broken as before. There are also other varieties of partial excision for the removal of naso-pharyngeal polypi ; removal of the nasal process with the nasal bone ; removal of part of the hard palate (Nelaton) ; and tempo- rary removal of different portions, preserving the connec- tion with the soft parts, and replacing them after the polypi has been removed. Fig. 69. Lines of bony division in the different operations on the superior and inferior maxillae. A, B, C. Total excision of the superior maxilla. X>. Boeckel's operation. E, C. Guerin's operation. F, F. Langenbeck's operation for naso-pharyngeal polypus. G. Excision of inferior maxilla. H. Removal of a portion of the alveolus (e. g., for epulis). I. Esmarch's operation for anchylosis of inferior maxilla. The incisions that have been proposed may be classed as (1) external and (2) median ; the former extending from 164 OPERATIVE SURGERY. the augle of the mouth upward and outward to the malar bone ; the latter passing from or near the middle of the lip up toward the inner angle of the eye. The former are open to the objections that they divide the branches of the facial nerve, endauger Steno's duct, and leave a conspicuous scar. The preference is now generally accorded to the median in- cisions. These follow the outline of the side of the nose more or less closely, and some of them are supplemented by a transverse incision, passing a quarter of an inch below the lower margin of the orbit. For partial excision Guerin recommends an incision passiug from the side of the wing of the nose aloug the naso-labial fold to the augle of the mouth (Figs. 69, 70, 71). In order to avoid the swallowing of blood, it is well not to carry the incision through the lip or divide the gingivo- labial fold until after the anterior face of the bone has been denuded as far as possible. It is possible to remove the superior maxilla through the mouth without making any cutaneous incisions, but it is a very difficult and painful operation, and the hemorrhage is most embarrassing. Larghi has removed both bones through the mouth, upon the cadaver, and says it is easier to remove both together than one aloue in this way. In simultaneous excision of both superior maxillse, the same incisions may be made on both sides as for the re- moval of only one, or Dieffenbach's median incision may be made along the ridge of the nose and the middle of the upper lip. Operation by a Median Incision. (Fig. 70, B). The usual method of operation is as follows : The incision is begun half an inch below the inner canthus of the eye. It is carried down the line of the junction of the nose with the face and along the groove which limits the ala nasi, thence horizontally to the septum, and so down to the free border of the lip in the median line. This incision may be supplemented, if necessary, by one joining it at the inner canthus and following the edge of the orbit outward. The cartilage of the nose is separated from the bone and reflected inward with the small internal flap, the edge of EXCISION OF JOINTS AND BONES. 165 the orbit cleared, and the external flap dissected outward as far as to the malar bone above and the tuberosity of the maxilla below, if possible, the infraorbital nerve being divided at its point of emergence from the foramen. Fig. 70. Excision of superior maxilla. A. External incision. B. Nelaton's incision. C. Boeckel's incision. The periosteum of the floor of the orbit is then detached with the handle of the knife, as far as the spheno-maxillary fissure, the malar process or bone cut through with the saw or forceps, and the thin plate of bone forming the floor of the orbit divided with the knife obliquely inward and for- ward from the anterior end of the spheno-maxillary fissure. The superior maxillary nerve, which can be readily distin- guished through the bone, should also be divided as far back as possible. Finally, the nasal process is divided. The incision is then carried through the lip, and the de- tachment of the external soft parts completed. The mucous membrane of the roof of the mouth is divided transversely on a line with the last molar tooth, and longi- tudinally in the median line. An incisor tooth is then drawn, and the hard palate divided with saw or forceps close to the septum. If the mucous membrane of the roof of the mouth is not diseased it may be retained. Instead of the incisions through it just mentioned, one is made along the inner border of the alveolar process, its edge raised, and the membranes de- tached inward and backward to the median line. After the removal of the bone it unites with the cheek, closes in the 8* 166 OPERATIVE SURGERY. mouth as before, and may become strengthened by a deposit of bone. Finally, the bone is grasped with strong forceps, twisted downward to break its posterior connections, and removed, generally bringing with it part of the palate bone, the hamular process of the pterygoid, and some attached mus- cular fibres. Subperiosteal Excision (Oilier). This method can be employed with the median incision above mentioned, but Oilier prefers an external one (Fig. 71, B). Fig. 71. A. Guerin's incision for partial removal of superior maxilla. B. Ollier's in- cision for subperiosteal excision of superior maxilla. 0. Dieffenbach's median incision for removal of tooth bones. L. Langenbeck's incision for nasopharyn- geal polypus. K. Boeckel's incision for naso-pharyngeal polypus. 1. Cutaneous Incision. An incision is made from the middle of the malar bone to a point on the upper lip one- third of an inch from the angle of the mouth. If necessary, a second incision must be made at the middle of the lip and carried upward around the nostril. 2. Incision of Mucous Membrane. The incision is begun on the outer surface at the interval between the second in- cisor and the canine tooth (he does not remove the inter- maxillary bone, that which supports the incisor teeth) close to the edge of the gum, carried back around the last molar, EXCISION OF JOINTS AND BONES. 167 then forward on the inside to a point corresponding to tha* at which it was begun, and thence obliquely backward to the median line. A short incision through the periosteum is next made from the anterior external extremity of the former upward and inward to a point a quarter of an inch external to the anterior nasal spine. 3. Separation of the Periosteum. The periosteum of the anterior surface is then detached with an elvator, care being taken, however, to divide the infraorbital nerve with a knife at its point of emergence, and the denudation is carried along the floor of the orbit. Unless it is necessary to re- move the nasal process of the maxilla, the lachrymal sac and duct can be left uninjured and adherent to the peri- osteum. The periosteum of the roof of the mouth is then separated from without inward as far as the median line. 4. Section of the Bone. The nasal and malar processes are divided with forceps, chisel, or chain-saw, as before de- scribed, the canine tooth drawn, the edge of the chisel in- serted in the gap left by it, and pressed gently backward and inward to the median line, thence directly backward along the suture. The bone is then twisted out, the palatal sutured to the external periosteum, aud the wound closed. Excision of the Portion of the Superior Maxilla Lying Below the Infraorbital Foramen ( Guerin's Operation). (Figs. 69, E C, 71, A.) An incision, slightly convex externally, is made from the ala of the nose to the angle of the month, following the crease usually present in the features at this situation. The alveolar mucous membrane is divided at the point of reflection on to the cheek from the level of the last molar tooth to the middle line anteriorly. The soft parts are dissected up and the nostril opened in front. A narrow saw is passed through the nares and the maxilla sawn horizontally outward. The saw cut passes below the infraorbital canal well above the teeth and through the malar process and maxillary tuberosity ; or the bone may be chiselled through on this line. The soft palate is detached from the hard by a transverse incisiou at the last molar tooth. A middle incisor tooth is next removed and 168 OPERATIVE SURGERY. the hard palate divided in the median line with a saw, chisel, or forceps introduced through the nostril. The de- tached piece of bone is loosened with a periosteal elevator and wrenched out. This operation may be performed subperiosteally (usually for naso-pharyngeal polypus), either by the above-described or by a median incision. The muco-periosteum is divided horizontally along the free margiu of the inner and outer faces of the alveolar process on the affected side, from the anterior nasal spine around behind the last molar tooth, and elevated to the middle line of the hard palate and to its posterior border, aud upward to near the infraorbital foramen on the outer surface of the superior maxilla. The lower half of the latter is next removed as indicated above, and at the close of the operation the mucous membrane is united as far as possible by sutures, thus shutting off the nasal from the oral cavity. This operation affords an excellent view of the naso- pharynx. Removal of the Superior Maxilla Above the Alveolar Pro- cess (Berard's Operation). The median incision is used from below the inner canthus of the eye, following the junction of the nose and face through the centre of the upper lip (Fig. 70, B). The soft parts on the affected side are raised as for total extirpation of the maxilla, and the periosteum of the floor of the orbit is detached as far as the sphenomaxillary fissure. The malar process is di vided, and then the orbital plate inward and forward from the anterior end of the spheno-maxillary fissure. The superior maxillary nerve is cut as far back as possible, and, finally, the nasal process. A horizontal saw-cut is then made outward from the nose above the alveolar process. Any adherent structures between the outer extremity of this cut and that through the malar process are freed with the knife or periosteal elevator, and the piece of bone thus mapped out is pried or wrenched away. The sound alveolar process is left in situ. EXCISION OF JOINTS AND BONES. 169 SIMULTANEOUS EXCISION OF BOTH SUPERIOR MAXILLAE. An incision may be made from each angle of the mouth to the malar bone and the broad flap reflected toward the forehead, or Dieffenbach's incision made along the ridge of the nose (Fig. 71, C), with or without a transverse one pass- ing across it and below the margin of each orbit. The bones are removed together, not separately. The malar processes or bones are divided in the usual manner, the nasal processes divided with a chain-saw passed from one orbit to the other through the lachrymal bones, and the vomer separated with cutting forceps. The periosteum of the hard palate is separated from the gums by a semicircu- lar incision and dissected back, the posterior connections broken, and the bone removed by twisting it downward and forward. PARTIAL AND TEMPORARY EXCISION OF THE SUPERIOR MAXILLA TO FACILITATE THE REMOVAL OF NASO-PHARYNGEAL POLYPS. Resection of Posterior Portion of Hard Palate (Nelaton). The soft palate is first divided from before backward along the median line, and the incision prolonged forward through the periosteum of the hard palate as far as may be judged necessary. A transverse incision is next made on one side from the anterior extremity of the first toward the teeth, and the flap, including half the soft palate, dissected off the bone from the median line outward. The mucous membrane on the floor of the corresponding nostril is then divided close to the septum, the bone perforated at the an- terior corners of the denuded surface, and the separation of the quadrilateral piece accomplished with cutting forceps. After removal of the polyp the soft parts are replaced and stitched together. The bone is sometimes reproduced. A little larger opening may be obtained by making the transverse incision extend from one side of the hard palate to the other, and then chiselling away the included bone — in other words, nearly the whole of the bony floor of the 170 OPERATIVE SURGERY. nasal cavity (Fig. 72, A). At the close of the operation staphylorrhaphy is performed. Osteoplastic Resection of the Anterior Portion of the Palate (Chalot, Fig. 72, B). The upper lip is everted and the raucous membrane cut in the line of its reflection from the Fig. 72. Resection of hard palate to expose nasal fossse. A. Nelaton's operation. B. Chalot's operation. bicuspid teeth of one side to a corresponding point on the other — the nasal fossa is thus entered, the canine teeth are extracted, and the alveolus and hard palate divided on each side by the chisel and knife. The line of section runs through the canine sockets and passes back through the hard palate close to its lateral margins as far as its posterior EXCISION OF JOINTS AND BONES. 171 border. The vomer is then separated, and the quadrilateral piece of bone thus marked out is turned down, the unsev- ered attachments of the soft palate serving as a hinge. At the close of the operation it is replaced and sutured in position. Resection of the Upper Portion, leaving the Hard Palate and Alveolar Process (Von Langenbeck). The following is somewhat abridged from the description in the Deutsche Klinik, 1861, page 283: An incision convex downward from the ala of the nose to the malar bone, and along the zygoma backward. A second incision from the nasal process of the frontal along the lower border of the orbit, meeting the first at the middle of the malar bone (Fig. 71, L). The knife penetrates to the bone throughout. The peri- osteum and overlying soft parts are only separated suffi- ciently to permit the use of a saw or chisel along the lines thus indicated. But the periosteum on the upper side of the second incision is detached from the floor of the orbit as far back as the spheno-maxillary fissure. Next the masseter is separated from the exposed portion of the malar bone, and a pointed elevator is passed hori- zontally below the zygomatic arch and through the ptery go- maxillary fissure to the outer wall of the nasal cavity. It is recognized here by a finger introduced through the mouth. A fine saw is passed in this line and n.ade to cut through the zygoma and malar bone upward into the spheno-maxil- lary fissure ; it then follows the floor of the orbit and ends just short of the lachrymal bone ; or the cut may be made with a chisel from before backward. The saw is then re-entered into the pterygo-maxillary fissure at the outer extremity of the line of bony division at the lower border of the malar bone, aud passing through the walls of the antrum very nearly in the line ot the lower cutaneous incisiou enters the anterior nares close to the nasal floor. An elevator is now passed a second time into the pterygo-maxillary fissure, and the portion of the superior maxilla which has been separated is forced up till the free portion of the malar bone is brought into the middle line of the face. The attachments of this fragment consist of 172 OPERATIVE SURGERY. the nasal bone and the nasal process of the superior maxilla, with the hitherto undisturbed periosteum and soft parts at the base of the original tongue-shaped incision. A less satisfactory view of the naso-pharyngeal region is obtained if the floor of the orbit is preserved. The periosteum on the upper side of the orbital incision is not disturbed. The zygoma is cut through as before into the spheno-maxillary fissure. A chisel is driven from before backward in the line of the upper cutaneous incision through the anterior and outer walls of the antrum just below the orbital plate, then through these openings the inner wall of the antrum is divided. The chisel penetrates to the spheno- maxillary fossa. The lower line of bony division is the same as in the last method described, and the fragment is turned over in the same manner. After the completion of the operation it is replaced and maintained in position by sutures or pressure. Von Langenbeck's operation is difficult ; it destroys the orbicular branches of the facial nerve, often damages the lachrymal duct, and gives very little better view of the nasal cavity than Guerin's partial extirpation of the supe- rior maxilla. OTHER METHODS OF GAINING ACCESS TO THE PHARYNX THROUGH THE NOSE. These may here be described, although properly speak- ing they are not resections of the superior maxilla. BoecMs Operation. (Fig. 69, D, and Fig. 71, K.) The incision begins near the root of the nose slightly to one side of the median line. It passes in a curved direction down to the lower free border of the nasal bone ; from here to the junction of the ala and cheek and a short dis- tance outward on the cheek. The second incision passes from the origin of the first at the root of the nose along the edge of the orbit to the infra-orbital foramen. It must clear the lachrymal sac. This tongue-shaped flap is raised with the periosteum and exposes a triangular surface of bone. After retracting the soft parts a chisel is driven through the superior maxilla so as to divide it vertically EXCISION OF JOINTS AND BONES. 173 just inside the infra-orbital foramen between the margin of the orbit and the upper surface of the hard palate. The chisel should be obliquely directed and enter the nasal cavity near the vertical plate of the palate bone. The nasal process of the superior maxilla and the nasal bone are cut very nearly in the line of the upper cutaneous incision. The lachrymal sac must be spared. The bony division is carried down to the lower free border of the nasal bone. Finally the chisel is driven into the nasal cavity through the anterior and inner walls of the antrum on a line reaching from the lower termination of the first bony incision to the floor of the nose. The inferior and middle turbinated bones are removed with the mass thus marked out, which is more or less pyramidal in shape with the apex toward the posterior nares. At the close of the operation the periosteum and skin are replaced and sutured in position. Oilier turns the whole nose downward. He begins his incision at the edge of the bone close behind the ala of the Fig. 73. Ollier's operation for removal of a naso- pharyngeal polyp, very large polyp. B. Modification for a nose, carries it upward along its side to the highest part of the depression between the eyes, then across and down to the corresponding point on the other side (Fig. 73, ^4). The bone is sawn through in the line of the incision, the necessary liberating incisions made in the septum or the sides, and the nose turned down. 174 OPERATIVE SURGERY. The septum is pressed aside, the polyp extracted, its base of implantation scraped, and the nose replaced. A modification which is sometimes desirable on account of the size of the polyp or the distance of its implantation is indicated in Fig. 73, B. The incision runs more ob- liquely backward, and a transverse one is made from each end to the ala of the nose. The bone is divided in the direction of the cutaneous incisions, in the vertical one as before described, in the horizontal one by passing a fine saw across the nostrils through holes made between the bone and cartilages, and sawing backward. This line of section must be high enough to avoid the roots of the teeth. In some cases it is sufficient to mobilize the lower end of the nose by an incision under the lip in the gingivo-labial fold, and then by carrying it and the lip upward very free access to the nasal fossse is obtained. Annandale, 1 after turniug the lip and nose upward in this fashion, saws through the alveolus and hard palate in the middle line close to one side of the vomer. The soft palate may also be split if more space is required. The saw cut can then be made half an inch or more wide by prying apart the maxillae. This affords a somewhat limited means of access to the naso-pharyngeal region. EXCISION OF THE INFERIOR MAXILLA. This may be total or partial ; and partial excision may involve the removal of any part of the body of the bone or of the ascending ramus. Partial excision of the body may sometimes be accomplished through the mouth without the aid of a cutaneous incision, or by an incision along the lower border of the bone with or without another at right angles to it extending toward or even through the lip, or by two vertical incisions downward from the angles of the mouth when only the upper part of the body of the bone is to be removed. When the ascending ramus also is to be resected the in- cision should pass along the lower border of the bone to the angle of the jaw, and then upward along the posterior 1 Lancet, Jan. 5, 1889. EXCISION OF JOINTS AND BONES. 175 border of the ramus to the level of the lobule of the ear. If the incision is carried higher the facial nerve is neces- sarily divided with consequent paralysis of the muscles supplied by it, a complication which should be avoided. The horizontal portion of the incision should be a little below the border of the bone in order that the cicatrix may be less conspicuous. Syme removed the entire ramus with the condyle, without opening into the cavity of the mouth, by an incision slightly convex backward extending from the zygoma to, and a little beyond, the angle of the jaw. The principal danger is of injury to the internal maxil- lary artery, which lies almost in contact with the inner side of the neck of the condyle. The lingual nerve also is in close relation with the inner side of the ramus, lying be- tween it and the internal pterygoid muscle. Maisonneuve introduced a modification of the method of operating which has rendered it almost easy and has diminished the above- mentioned danger. It consists in separating the attach- ments of the condyle by twisting and tearing out the bone after all the connections have been divided. If this modi- fication, which sounds, perhaps, rougher and less surgical than it really is, is not adopted, the joint must be ap- proached from in front so as to avoid the external carotid, which lies close behind the bone in the substance of the parotid. It is sometimes allowable to divide the neck of the condyle, or even the ramus below the sigmoid notch, with cutting pliers, and leave the upper fragment in place. Another danger is in the division of the attachments of the genio-hyo-glossus muscles to the bone. The tongue, de- prived of its support, falls back upon and closes the glottis. As a preliminary, therefore, to any operation in which these attachments are divided, a stout ligature should be passed through the tip of the tongue and held by an assistant. After the operation it should be fastened to a harelip pin in the external incision, or to the skin of the face by a strip of adhesive plaster, and retained for a couple of days, at the end of which time the muscles will usually have formed new attachments. The bone should be sawn through with a chain or com- mon saw, according to circumstances, or merely nicked with the saw, and its division completed with cutting-pliers, 176 OPERATIVE SUBGERY. The tooth occupying the proposed line of section should first be drawn. Ligature of one or both carotids has been proposed and performed as a preliminary operation to prevent excessive hemorrhage, but it has proved to be not only unnecessary but ineffectual. In Mott's case the main operation had to be adjourned to allow the patient to recover from the shock of the preliminary one. In another case in which both carotids had been tied, the main operation had to be aban- doned on account of hemorrhage. 1 Syme says the pre- liminary ligation is unnecessary, because the only arteries that need to be divided are the facial and the transverse branches of the temporal, bleeding from which can be easily controlled, and, furthermore, all the advantages offered by ligation of the carotids can be obtained by their temporary compression during the operation. The attempt should be made, when possible, to get pri- mary union of the intra-buccal wound and to drain through the external one. This makes it easier to keep the wound sweet, diminishes the danger of purulent infection, and avoids the risks incident to the swallowing of the decom- posing discharges. The results of the operation are usually very good, and the deformity less than might be expected. Subperiosteal excision has been followed by reproduction of the entire bones with condyles and diarthrodial cartilages, and even when the periosteum is not preserved the cicatrix becomes very firm and fibrous, and able to support a plate with arti- ficial teeth. Resection of the Anterior Portion of the Body. This may be done by means of a vertical incision in the median line, or of a horizontal one below the free border of the bone, or from within the mouth without any cutaneous incision. If one of the incisions is made, the external and internal surfaces of the bone are cleared through it, a tooth drawn at each of the proposed points of section, and the bone sawn through. 1 Mentioned by Syme in Contributions to the Pathology and Practice of Sur- gery, Edinb., 1848, p. 19. EXCISION OF JOINTS AND BONES. 177 If no external incision is made, the external surface of the bone is cleared, beginning at the edge of the gum or in the giugivo-labial fold, according as the periosteum is or is not to be preserved, and the lip drawn down under the chin so that the bone protrudes through the mouth. It can then be easily sawn through and freed from its attach- ments on the inner side. Resection of the Lateral Portion of the Body. The in- cision extends along the lower border of the jaw from its angle nearly to the symphysis, and then is carried vertically upward to the base of, but not through, the lip. The flap is dissected up, the elevator being used, of course, if the periosteum is to be preserved, the inner surface of the bone cleared near the symphysis for the passage of a chain-saw, and the section made if possible at a short distance from the median line, so as not to disturb the insertion of the genio-hyo-glossus. This section may be made with a nar- row saw from before backward if preferred. The bone is then drawn downward and outward, its inner surface cleared, and the saw applied behind the last molar tooth or at any suitable point. Dr. McBurney 1 has devised a remarkably efficient means of maintaining the proper relations of the remaining por- tions to each other until repair has taken place, and of thereby avoiding the great interference with function which formerly ensued. Resection of the Ramus and Half of the Body. (Fig. 74.) An incision is begun close to the posterior border of the ramus on a level with the lobule of the ear, carried down to the angle of the jaw, and thence along its lower border to the symphysis, where it is met, if necessary, by a vertical one, beginning below the free border of the lip a little to that side of the median line on which the bone is to be removed. The flap thus marked out is dissected up from the bone as far as can be done without opening into the buccal cavity, and the divided facial artery tied. The inner surface of the bone is then cleared in the same man- ner, an incisor tooth drawn, and the bone sawn through. 1 Annals of Surgery, 1S94. 178 OPERATIVE SUBQERY. The jaw is then drawn downward and forward, the denu- dation of its inner surface completed by dividing the attach- ment of the mucous membrane and of the internal ptery- goid, and the inferior dental nerve cut squarely across at the point where it enters the bone. Fig. 74. Excision of inferior maxilla. The insertion of the temporal muscle upon the coronoid process is divided with curved scissors while the jaw is forcibly depressed, or the process itself is cut through if it is so long that its extremity cannot be reached. The remaining soft parts are carefully detached upward toward the condyle, the knife, or better, the elevator or the handle of the scalpel, being kept close to the bone, and the separation completed by twisting the jaw out. Excision of the whole of the Inferior Maxilla. The in- cision is made from the lobule of one ear down to the angle of the jaw, along the lower border of the bone to the other angle, and then up to the lobule of the other ear. The outer and inner surfaces of the jaw arc denuded, the bone sawn through in the median line, and each half removed as before described. In the subperiosteal method the incisions are the same, except that the vertical incision may be in the median line, EXCISION OF JOINTS AND BONES. 179 since the genio-hyo-glossus and genio-hyoid muscles remain attached to the periosteum. The attachment of the tem- poral muscle is not cut, but is freed with the elevator, as is also that of the external pterygoid to the condyle. Partial Excisions of the Inferior Maxilla. Removal of a portion of the alveolar process is often necessary in the operation for epulis. The teeth in the involved segment are drawn. The muco-periosteum at a sufficient distance from the growth is cut through and the bony segment thus marked out removed through the mouth with a chisel or rongeur. If a portion of the body of the jaw is to be removed it should be approached by an incision along the lower border of the maxilla. Whenever possible the removal should be so limited as not wholly to destroy the continuity of the bone. The part represented in Fig. 69 is the ordinary amount removed for epulis, and it can be accomplished through the mouth. ANCHYLOSIS OF THE JAW. The most common cause of anchylosis of the jaw is fouud in cicatricial retraction or adhesions left behind by intra buccal ulceration. Rizzoli (1858) was the first to point out that the proper aim of an operation intended to relieve this infirmity should be the establishment of a pseud- arthrosis in front of the adhesions or cicatricial bands when the cause itself could not be removed. His operation con- sisted in the division of the inferior maxilla behind the last molar tooth by means of a specially constructed osteotome introduced through the mouth. Bony union of the fracture was then to be preveuted by motion. Esmarch (1859) proposed the removal of a wedge-shaped piece of the bone. By some surgeons the base of the wedge is taken from the alveolar process, by others from the lower border of the jaw. Dieffenbach proposed to divide the ascending ramus horizontally from before backward by means of a chisel passed through the mouth to the anterior border of the ramus. Operation (removal of wedge-shaped piece). An incision 180 OPERATIVE SURGERY. is begun at the angle of the jaw and carried two inches for- ward along the lower border. A narrow strip of bone is then cleared on both sides up to the edge of the gum, just anterior to the inasseter and in front of the contracted tis- sues, a tooth drawn if necessary, and the bone sawed through. The anterior fragment is then depressed and protruded through the wound, and a wedge-shaped piece from one-third to one-half of an inch in width at its widest part cut off with cutting forceps. (Fig. 69, I.) Excision of the Condyle. This may be required for the relief of anchylosis due to bony or fibrous union between the condyle and the temporal bone. The incision is begun at the lower margin of the zygoma close in front of the temporal artery where it adjoins the ear, and carried forward along the zygoma about one and a quarter inches, the tissues being divided layer by layer until the bone is reached. A second incision, involving only the skin, is then carried from the centre of the first directly downward for about an inch. The soft parts are next carefully separated with knife and elevator from the margin of the zygoma and the outer surface of the joint and drawn downward with a hook, thus preserving the parotid, nerves, and vessels from injury. The neck of the condyle is then freed by working around in front and behind with a small elevator, keeping close to the bone, so as to avoid injury to the internal maxillary artery, and finally divided with the chisel and rongeur. If there is bouy union between the condyle and temporal bone the chisel must be again used to separate them, its edge being kept directed somewhat downward, so as not to break through into the cavity of the cranium. The condyle is then grasped with forceps and twisted out. The knife or scissors may be used to sever any remaining connections, but must be kept close to the bone. RESECTION OF THE STERNUM. Oilier 1 reports the following case : Vertical incision four inches long ; detachment of periosteum, and removal of a 1 Traite de la R6g6n6ration des Os, vol. ii. p. 53. EXCISION OF JOINTS AND BONES. \ 81 " red vascular sequestrum one and one-quarter inches square, adherent to the rest of the bone only by medullary granu- lations." The adjoining rarefied bone was gouged away, portions of the internal plate being left at a few points. The projecting and denuded ends of two costal cartilages, the fourth and fifth, were cut off. Three years afterward the patient died of phthisis, and the autopsy showed reproduction of all the parts removed. RESECTION OF THE RIBS. This is best performed in those regions where the muscu- lar layer covering the bone is thin. In the middle third of the rib the intercostal artery lies in a groove on the inner side of the lower border. The incision should correspond in length and direction with the portion of bone to be removed, and may be crossed at each end by a short transverse one. The flaps are then dissected up, the periosteum separated as far as possible, a chain-saw passed at the limits of the diseased portion, and the piece removed. Instead of the saw, cutting-pliers may be used. In Estlander's operation for empyema (thoraco-plastik), in which portions of several adjoining ribs are resected to allow the chest wall to sink inward and unite with the vis- ceral pleura, the position of the incision is usually deter- mined by that of the fistula. The incision is made along the intercostal space occupied by the fistula, and the adjoin- ing ribs dissected as above described. The limits of the cavity are then determined, and other ribs resected, if necessary, through a vertical incision made from the centre of the first. If the costal pleura is so thick as to prevent the attainment of the desired object, it must be cut away from a sufficient part of the area of resection. From three to six ribs have been thus resected, in lengths varying from one to three inches. The operation has been restricted to the ribs between the third and eighth, but in one case a small portion of the clavicle also was removed. Sometimes the thickened visceral pleura has also been dissected off. 182 OPERATIVE SURGERY. EXCISION OF THE CLAVICLE. On account of the proximity of the large vessels of the neck this has been considered the most dangerous of all the excisions. The danger, however, varies greatly with the nature and extent of the disease which renders the opera- tion necessary. Thus, when there is osteitis with thicken- ing and loosening of the periosteum, the operator can easily keep close to the bone, and the danger of injury to the vessels, as well as of exciting diffuse inflammation below the deep fascia, is reduced to the minimum. On the other hand, when caries has existed for a long time, the soft parts have become infiltrated and bound down, and the bone thickened and roughened, the difficulties are immensely increased ; and when the bone is the seat of a malignant tumor, extending in all directions, its removal may tax the powers of the most skilful. Valentine Mott spoke of his case as the most difficult and tedious operation he had ever witnessed or performed ; it lasted four hours, and more than forty ligatures were applied, including two upon the internal jugular vein. As only the inner half of the bone is in close relation with the vessels, and the danger is especially great at the sterno-clavicular joint, it is advisable first to raise the outer end of the bone from its place by opening its articulation with the acromion or by dividing it a little to the inner side of that joint, and then, after clearing the posterior surface from without inward, to divide the attachments ot the inner end while twisting the bone upward about its long axis, and keeping the edge of the knife against it. When this is impracticable the periosteum must be carefully separated near the middle, and the bone sawn through with the usual precautions against injury to the underlying parts. Each half is then raised in turn and dissected out. For the removal of a tumor no fixed rules can be given. In other cases the directions are as follows : Operation. The subperiosteal method must be employed throughout. The incision is made along the anterior sur- face of the bone, and corresponds in length with the portion to be removed. A short transverse incision is then made EXCISION OF JOINTS AND BONES. 183 at each end of the first, the flaps dissected up, and the denudation carried as far as possible around the bone above and below. The bone is then freed at its acromial end, or divided in the middle, and the separation completed as above described. EXCISION OF THE SCAPULA. It is impossible to lay down fixed rules for making the incisions when the operation is rendered necessary by a tumor of the bone. They will be determined by the cir- cumstances of the case, and especially by the extent of the disease, for while in some cases the acromial end of the clavicle must also be removed, in others the acromion and neck of the scapula may be left behind. Mr. Holmes 1 says : " The surgeon turns down appro- priate skin flaps. . . . When the whole tumor is thus exposed, the muscles inserted into the vertebral border of the bone should be rapidly divided, as also those which are attached to the spine of the scapula. The tumor should be lifted well up and freed from its other attachments, com- mencing from its lower angle. The subscapular artery is divided near the end of the operation, and can be held till the tumor is removed, or can be at once tied. The liga- ments of the shoulder are then easily divided and the mass removed." Gross 2 made a vertical incision sixteen inches long down- ward from the superior angle of the scapula, and circum- scribed an oval portion by a second curved incision, begin- ning five inches below the upper end of the first and ending about the same distance above its lower end, and removed the bone after sawing through the acromion and neck of the scapula. Velpeau 3 recommends three incisions : one along the spine of the scapula, the others starting from the anterior extrem- ity of the first and running, one toward the root of the neck, the other toward the axilla behind. 1 A System of Surgery, vol. v. p. 669. 2 Gross's System of Surgery, vol. ii. p. 1078. 3 Medicine Operatoire, vol. ii. p. 659. 184 OPERATIVE SURGERY. Sytne made two incisions crossing each other near the centre of the tumor. Other surgeons have made triangular or semilunar flaps. In January, 1878, Dr. George A. Peters removed, at the New York Hospital, the entire scapula for malignant dis- ease, leaving the arm. He made an incision along the spine of the scapula, divided the fibres of the deltoid and trape- zius, and exposed the tumor, which involved only the acro- mion and adjoining portion of the spine. He then made a vertical incision across the centre of the first, beginning two inches above it and extending to the inferior angle of the scapula, reflected the flaps, dissected out the under surface of the boue from behind forward, separated the acromion from the clavicle and humerus, and then, raising the lower angle of the scapula toward the head, approached the cora- coid process from below, and found no difficulty in sepa- rating it from its attachments. Only two vessels required ligation, the supra-scapular aud a large branch of the sub- scapular. The result was very good ; six weeks afterward the wound had closed, and the patient possessed a certain degree of control over the humerus. Subperiosteal Excision of the Scapula (Oilier). Fig. 75. 1 . Incision of the Skin and Muscular Interstices. An inci- sion is made along the whole length of the spine of the scapula, and from its posterior extremity two others are made, one following the posterior border down to the infe- rior angle, the other running obliquely forward aud upward for about an inch. A short transverse incision may also be needed at the anterior end of the first. 2. Denudation of the Bone. The attachments of the del- toid and trapezius to the acromion and spine are separated, the periosteum of the posterior border of the scapula divided in the interstice between the rhomboideus and infra-spinatus, and the infra-spinous fossa carefully denuded. The peri- osteum is very thin in its lower third. The lower angle is freed by detaching the teres major and serratus magnus, the bone raised, and the subseapularis detached from below upward. I f the marginal cartilage is not completely ossified and united with the bone, it should be separated and left adherent to the periosteum. EXCISION OF JOINTS AND BONES. 185 The supra-spinous fossa is then cleared, care being taken not to injure the supra-scapular nerve in the supra-scapular notch, but to raise it up with the periosteum and its fibrous sheath. The posterior part of the bone is then carried up- ward and forward, and the denudation of its under surface and anterior border completed. If the extent of the disease permits, the denudation should stop at the neck of the scapula, which is then divided with a chain-saw or cutting forceps. Fig. 75. Excision of the scapula. 3. Opening of the Scapulo-humeral Joint. Detachment oj the Articular Capsule and Denudation of the Coracoid Process. The acromion is next separated from the clavicle, the scapula turned upward, the joint opened from below, and as the bone is pressed steadily upward everything that holds is detached with an elevator. After the coracoid process has been thus separated from most of its muscular and ligamentary attachments, the few that remain can be broken by twisting the bone away. In suitable cases the coracoid process may be divided at its base and left in 186 OPERATIVE SURGERY. place, and thus the most difficult and laborious part of the operation done away with. The partial excisions of the scapula do uot require de- tailed description. The acromion, spine, and posterior bor- der are reached by straight or slightly curved incisions along the portion to be removed. A crucial or H incision is required at the angles. RESECTION OF THE HUMERUS. The position of the musculo-spiral nerve is the most im- portant element in this operation. In its passage around the posterior aspect of the humerus the nerve lies close to the bone within the sheath of the triceps muscle, and leaves the latter on the outer side of the arm to enter that of the supinator longus at its origin. In approaching the bone, therefore, on the outer side near the junction of the middle and lower thirds, the operator should lay bare the outer border of the brachialis anticus and follow down within its sheath to the bone. Upper Portion. Same incision as in Oilier' s method of excision of the shoulder carried further down along the outer edge of the biceps. The cephalic vein must be sought for and drawn aside. Periosteum and capsule divided, bone denuded and removed as in excision of the shoulder-joint (q. v.). Middle Portion. Incision along the posterior border of the deltoid and outer edge of the biceps. Outer border of the brachialis anticus laid bare and followed down to the bone. Division of the periosteum and denudation of the bone, with especial care for the safety of the musculo-spiral nerve. Oilier prefers to seek the nerve and draw it aside. He also recommends that whenever it is possible to leave a por- tion of the shaft connecting the extremities it should be done, as a precaution against shortening and the formation of a pseudarthrosis. If this is not possible the chain- saw is passed at two points, and the intermediate piece removal. Lower Portion. Incision on outer side of the posterior EXCISION OF JOINTS AND BONES. 187 aspect of the arm, between the triceps and supinator longus, as in Oilier' s excision of the elbow (q. v.). Total Excision. Combination of incisions for upper and lower portions. After the ends have been denuded of peri- osteum the middle portion can be cleared by pushing one end out through its incision and peeling the periosteum back like the finger of a glove until the middle is reached. The bone is then sawn off, and the other half removed in a sim- ilar manner through the other incision. EXCISION OP THE ULNA. Longitudinal incision along the posterior aspect of the bone, joined at its upper end by a short one running ob- liquely upward and outward between the triceps and anco- neus. The triceps is drawn to the inner side, and the olecranon freed. After separation of the periosteum the bone is sawn through in the middle, and each piece is dis- sected out in turn. EXCISION OF THE RADIUS (OLLIEE). An incision involving the skin only is made from the styloid process of the radius along the outer border of the forearm to the radio-humeral articulation. The fascia is divided and the posterior border of the supinator longus found. By following it toward the wrist the knife can be kept between it and the extensor tendons of the thumb, which can then be drawn backward and saved from injury. By following it upward the interstice between it and the extensores carpi radiales is found, through which the oper- ator penetrates to the radius now covered only by the supinator brevis. The latter muscle is then divided longi- tudinally and the periosteal sheath opened. The periosteum is detached laterally, the bone sawn through at its middle, and each fragment removed sepa- rately. Partial Excisions of the Ulna and Radius. The incisions and methods are the same as those above described, 188 OPERATIVE SUEGERY. EXCISION OF THE METACARPAL BONES AND PHALANGES. The metacarpal bones should be exposed by a longitu- dinal incision along the dorsum. As the extensor tendons cross the bones obliquely this incision should involve ouly the skin at first, the tendou is then drawn aside, and the iucisiou carried down to and through the periosteum, which must be retained when possible. It is advisable that the joints, especially the rnetacarpo-phalangeal, should not be opened. The bone is then divided in the middle with cutting for- ceps and each end dissected out, or the gouge alone may be used. The after-treatment is important. Extension must be made upon the corresponding finger for a long time to keep it from being drawn up into the hand. In the case of the metacarpal bone of the thumb lateral pressure must also be made. For resection of a phalanx the incision should be made on the side of the finger near the dorsum. For the ter- minal phalanx the incision should be U-shaped, the arms passing along the sides of the phalanx, the curve around its end. Resection of the different portions of the thumb, even if not subperiosteal, is to be preferred to amputation, but the contrary is true of the phalanges of the other fingers. Lateral pressure, by means of splints or an India-rubber glovefinger, and extension by weight must be made to insure the necessary length and proper shape of the member. RESECTION OF THE BONES OF THE PELVIS. Oilier 1 reports a case in which he removed the ascending ramus of the ischium and most of the pubis for suppurative osteo-arthritis of these bones and the pubic synchondrosis. The incision was about four inches long and extended from a fistula in thegenito-crural fold up toward the pubis. The 1 De la K6gC-n6ration des Ob, vol. ii. p. ISO. EXCISION OF JOINTS AND BONES.' 189 periosteum was detached, the ascending ramus of the ischium removed, and then the ascending ramus, body, and part of the horizontal ramus of the pubis. The bone that was removed was eroded and rarefied, but not necrotic. EXCISION OF THE COCCYX (OLLIER). This may be required on account of disease of the coccyx, or as a preliminary to operations upon the rectum. Oilier has removed it for osteitis, Simpson and Nott for the relief of coccygodynia, and Verneuil in cases of imperforate anus, and to facilitate the removal of cancers of the rectum. The limits of the bone are determined by the finger in the rectum, and a longitudinal incision made through the skin and fibrous covering of the bone, from a quarter of an inch above its upper to the same distance below its lower end, and a transverse incision made at the upper end of the first. The posterior surface of the bone is then denuded. The sacro-coccygeal articulation haviug been opened by this denudation, its fibro-cartilage is divided, and the cornua cleared on both sides. An elevator is then passed through the joint and used as a lever to force out the coccyx, peel- ing off at the same time the fibrous coveriug of its anterior surface. If the sacrum is also diseased, and the gouge is used upon it, it must be remembered that the sacral canal extends to its very end, and is there formed posteriorly not of bone, but of fibrous tissue. RESECTION OF THE SHAFT OF THE FEMUR. A longitudinal incision is made on the outer side in the groove betweeen the vastus externus and biceps, with a transverse liberating incision at each end. Denudation is carried as far around as possible, the chain-saw passed at each end of the diseased portion, and the denudation com- pleted as the piece is raised from its bed. In the case of a child extension should be made, and the limb kept at the same length as the other; in the case of. 9* 190 OPERATIVE SURGERY. an adult the fragments should be brought nearer together as the patient is older, aud his power of regeneration less ; and, in many cases, it is better to bring the fragments into contact. Shortening is less of an infirmity than pseudar- throsis. RESECTION OF THE SHAFT OF THE TIBIA. If the entire diaphysis of the tibia become necrotic it may be removed subperiosteally and a fairly useful limb obtained, especially iu children. The incision is made par- allel to aud just in front of the internal border. At the upper end it lies behind the tendons of the sartorius, gra- cilis, and semitendinosus ; further down the internal saph- enous nerve is recognized aud drawn to one side. The periosteum is incised on this line, and raised with au elevator which should be well curved to get around the sharp angles of the bone. When the denudation has been completed, if the bone is not already detached, the elevator is used to press back aud protect the soft parts behind, while the bone is chiselled or sawn through as close to the dead area as possible. A transverse incision through the perios- teum at this point will save undesirable denudation of ad- joining healthy bone. The operation is most frequently required to remove the necrosed fragments which may result from a compound fracture or an osteomyelitis. It is wise to delay interference till separation of the frag- ment has occurred, aud then the location of the incision will depend largely on the position of the sinuses. Iu gen- eral it should extend between the two which are most widely separated ; or, if there is only a single sinus, the centre of the incision should correspond to this. It is made in the long axis of the limb as already described, aud the perios- teum elevated. If there is an involucrum, it must be chiselled away very freely on each side of the central cavity, so as practically to abolish the latter, and the sound bone at each end of this cavity must be freely cut away, so as to leave a surface sloping easily down to the bottom (posterior wall) of the EXCISION OF JOINTS AND BONES. 191 cavity. The object of this free removal of bone is to per- mit the soft parts to come everywhere into contact with the bone when they are brought back and sutured together over it. No anxiety as to subsequent weakness of the bone need be felt, for the new formation of bone will be ample. If it is necessary to reach the tibia on its external surface the skin iucision should lie a little to the outer side of the crest. The periosteum is cut into close to the anterior bor- der of the bone, aud elevated with the attached tibialis anticus muscle. When the gap after a compound fracture involves the entire thickness of a portion of the shaft, a cor- responding length must be removed from the shaft of the fibula to secure good apposition of the parts. The fibula is best approached at some distance above or below the site of the tibial injury, as thus there will be less danger of infecting this fresh wound, and subsequent immobility can be more readily secured. The posterior surface of the tibia is best approached around its internal border. At the upper extremity the incision is made as already described behind the sartorius, gracilis, and semitendinosus, and the periosteum elevated with the attached popliteus muscle. RESECTION OF THE FIBULA. The lower portion of the fibula is subcutaneous, its upper portion is covered by the peroneal muscles. The biceps is attached to its head, and the external popliteal or peroneal nerve, after following the posterior border of the tendon of that muscle, winds around the outer side of the neck of the fibula, and divides into the anterior tibial and musculo- cutaneous, the latter of which soon becomes superficial. Sometimes this division, and even the subsequent ones, take place as high up as the head of the fibula, and then there is danger of dividing some of the branches during resection of the upper extremity of the bone, unless the method indi- cated by Oilier is strictly carried out. The earlier authors considered the division of this nerve unavoidable. As the upper tibio-fibular articulation communicates in a large proportion of cases with that of the knee, it should 192 0PERA1IVE SURGERY. not be opened, except when it shares in the disease. The head of the fibula should be divided or gouged out in such a way as to leave this articulation covered by a thin but complete plate of bone. Resection of the Upper Extremity of the Fibula (Oilier). 1 A longitudinal incision is begun an inch above the head of the fibula at the posterior border of the tendon of the bi- ceps, and carried down a little behind the bone along the interstice between the soleus and the peroneal muscles. The incision should involve only the skin and fascia. The nerve is then sought for where it passes around the neck of the fibula, and protected by two blunt hooks placed about an inch apart. While thus protected, it is freed from the cellular tissue, which binds it to the bone, and then drawn forward so as to permit the division of the periosteum. This division is made on the posterior border of the bone, and carried downward as far as is necessary in the interstice between the soleus and peroneal muscles. The periosteum is then detached and the bone removed, either by dividing it at two points with a chain-saw or chisel and removing the intermediate portion, or by di- viding it at the lower limit of the disease, and twisting out the upper fragment, or by modifying the latter method to the extent of dividing the head of the bone with a sharp chisel in such a manner as to leave the tibio-fibular ioint unopened. Resection of the Lower Portion of the Fibula. Longi- tudinal incision along the antero-external aspect of the bone. Denudation and removal of the bone in the usual manner. For other details, see excision of the ankle-joint. EXCISION OP THE WHOLE FIBULA. As the incisions for the resection of the upper and lower portions lie on opposite sides of the peroneal muscles, they cannot be made continuous with eaeh other. Each half of the bone must be removed separately. 1 Trait6 do la Iteg6u6ration des Os, p. 207. EXCISION OF JOINTS AND BONES. 193 EXCISION OF THE BONES OF THE FOOT. Calcaneum. Disease of the tarsal bones is apt to origi- nate in the calcaneo-astragaloid articulation and then in- volve the calcaneum mainly, the astragalus being only superficially affected. The disease in the former is usually central, leaving a sequestrum inclosed in a shell of rarefied vascular bone, or a cavity is formed within a similar shell by ulceration and discharge through one or more fistula?. The removal of the entire thickness of the bone gives better results than simple gouging out of the diseased portions, evidement de I'os, but the anterior portion should if possible be left, as it favors reproduction of the bone. The English surgeons do not usually employ the sub- periosteal method, claiming 1 that the results obtained by the ordinary method are so good that they are disinclined to make any change. So far as can be judged from the published descriptions, these results, although satisfactory so far as the restoration of function is concerned, are inferior to those obtained by the superiosteal method. The absence of the calcaneum destroys the plantar arch and the sightli- ness if not the usefulness of the foot, whereas in some of Ollier's superiosteal cases the new heel was as prominent and firm as that of the other foot. A. Holmes's Method. An incision is commenced at the inner edge of the tendo Achillis, and drawn horizontally forward along the outer side of the foot to a point some- what in front of the calcaneo-cuboid articulation. This incision should go down at once upon the bone, so that the tendon should be felt to snap as the incision is commenced. It should be on a level with the upper border of the os calcis. Another incision is then made vertically across the sole, commencing near the anterior end of the former inci- sion and ending at the outer border of the internal surface of the os calcis. The bone being now denuded by throwing back the flaps, the calcaneo-cuboid and calcaneo-astragaloid joints are sought for and laid open. The calcaneum having been thus separated from its bony connections by the free 1 Holmes : System of Surgery, vol. v. p. 720. 194 OPERATIVE SURGERY. Fig. 76. use of the knife, aided, if necessary, by the lever, lion- forceps, etc., the soft parts are next to be cleaned off its inner side with care, in order to avoid the vessels, and the bone will then come away. B. Subperiosteal Method (Oilier.) Fig. 76, A. An in- cision involving only the skin is begun at the outer border of the tendo Achillis about an inch higher than the tip of the external malleolus, carried down below the outer tuberosity of the calcaneum and then forward and slightly upward to the up- per part of the base of the fifth metatarsal. The edge of the ten- do Achillis and the upper border of the plantar muscles being- recognized, the incision is car- ried down to the bone, care being taken not to cut the peroneal tendons. The posterior half of the bone is then denuded with an ele- vator, and the tendo Achillis a. Excision of the calcaneum. detached and pressed to the inner b. Excision of the astragalus, side. The under surface and posterior third of the inner sur- face are next cleared, the peroneal tendons drawn aside with blunt hooks, the external lateral ligament detached, the anterior portion of the outer surface denuded, and the calcaneocuboid joint opened. The interosseous ligament is divided with a narrow bis- toury, the bone grasped with lion-forceps and turned down- ward so as to open the calcaneo-astragaloid joints and give access to the calcaneo-scaphoid and internal lateral liga- ments and to the inner surface of the bone. It is difficult, if not impossible; to avoid opening some of the tendinous sheaths during the operation, but the damage is very much less than that inflicted by the former method. I {cscction of the posterior portion alone can be accom- plished much more expeditiously. The portion to be re- moved is denuded and then sawn off, either directly or by EXCISION OF JOINTS AND BONES. 195 perforating the bone and sawing it from above downward with a chain-saw. C. Farabeufs Method. (Fig. 77, C.) The incision begins opposite the base of the fifth metatarsal bone exter- FlG. 77. A. Excision of astragalus. (Vogt v B. Excision of ankle. C. Excision of calcis. (Farabeuf.) nally, and is carried horizontally backward just above the margin of the sole. It passes on the same level around the back of the heel and is prolonged forward about an inch on its internal aspect. A second incision extends from this about two inches vertically upward beside the external border of the tendo Achillis. These incisions involve the skin only. The vertical cut is now deepened and the peri- osteum divided in this line, taking care not to damage the peroneal tendons which lie just anteriorly. The periosteum with the associated ligaments is elevated first on the outer surface, aided by deepening the horizontal incision in this part down to the bone. The attachment of the tendo Achillis is cut and the posterior aspect cleared as far as pos- sible. The periosteum of the anterior end is next separated together with its attached ligaments, and afterward the plantar area is denuded. The anterior extremity is grasped with forceps and twisted outward, while the remaining attachments are severed with the knife, which must be 196 OPERATIVE SUBGEBT. kept close to the bone. The superior surface is reached through the outer incisiou and the interosseus ligament cut. By careful work with the elevator the internal sur- face is freed from the periosteum and attached ligaments aud the boue finally removed without damage to the vessels and nerves on its inuer side. Astragalus. Excision of the astragalus may be rend- ered necessary by dislocation, comminuted fracture, or caries, or it may be made as a preliminary step in excision of the ankle. Oilier considers this operation, under nor- mal circumstances, the most difficult of all excisions. He employs the following method on the cadaver : Operation (Oilier). Fig. 76, B. — Curved incision across the dorsum of the foot, with convexity directed forward, beginning on the inner side at the point where the tendon of the tibialis anticus crosses the tibio-tarsal articula- tion, running forward and outward to the middle of the scaphoid, and then backward to a point a little below the tip of the external malleolus. This incision must expose but not involve the tendons. The extensor tendons are lifted out of their sheaths aud drawn aside, the extensor brevis cut across or detached at its origin, and the neck and outer non-articular surface of the astragalus cleared. The capsular and ligamentary attach- ments of the bone to the scaphoid and tibia are separated, the interosseous ligament divided, and the foot being turned inward the insertion of the strong internal tibio- astragaloid ligament is detached. The remaining connec- tions are then ruptured by grasping the bone with strong forceps and twisting it out. Verneuil thinks the operation is made easier by saw- ing through the neck of the boue and first removing the head. See also Vogt's (Fig. 77) excision of the ankle, p. 195. When dislocated the astragalus may be easily removed by a straight, curved, or crucial incision made over the most prominent part, and avoiding vessels, nerves, aud tendons. When badly shattered, as in gunshot injury, the fragments may be removed through a longitudinal incision between the extensor tendons of the first and second toes. EXCISION OF JOINTS AND BONES. 197 For simultaneous removal of the calcaneum and astraga- lus see Osteoplastic excision of the foot, p. 159. Metatarsal Bones and Phalanges. A metatarsal bone should be exposed by an incision along the dorsum involv- ing only the skin ; the tendon is then drawn aside, the periosteum divided, the bone denuded, sawn through, and removed. Whenever possible, the upper extremity of the bone should be left. For the first and fifth metatarsals it is better to make the incision more upon the side than upon the dorsum. If the corresponding toe is to be preserved, extension must be made upon it for a long time, in the manner and for the reasons mentioned under excision of the metacarpal bones. The phalanges and their articulations are best excised by lateral incisions. TREPHINING. Trephining of the Cranium may be undertaken for the evacuation of an intra-cranial abscess or hemorrhagic effu- sion, or for the removal of a suspected tumor of the brain or meninges, or for the cure of epilepsy, or after fracture to raise depressed portions of the bone. In all except the latter case the advisability of the operation may be diminished by the difficulty of determining the point at which the trephine should be applied. Among the more or less trustworthy indications, according to which the surgeon must make his selections of this point, may be mentioned : the history of an injury more or less recent, 1 with or without pain and inflammation of the soft parts (Pott's puffy tumor) at the point where the injury was received ; constant, well localized pain at any one point; injury over the course of one of the larger meningeal arteries with rapidly super- vening symptoms of compression, functional disturbance of certain groups of motor nerves. The results obtained by certain physiologists in their efforts to determine the location of motor centres in the cor- tex of the brain have inspired the hope that the injured or 1 In a case of Dupuytren's there was no sign of the abscess until ten years after the receipt of the injury. 198 OPERATIVE SURGERY. compressed portion of the brain might be localized exactly in any given case by consideration of the muscles or groups of muscles paralyzed. This hope has been in part realized and surgical interference has been successfully based upon paralytic symptoms in fracture of the cranium, abscess of the brain, tumor of the brain, intra-cranial hemorrhage, etc. To secure success in the operative surgery of the brain, the most scrupulous asepsis must be observed. The head is to be entirely shaved twenty -four hours before operation, aud cleaned, and the fissures of Rolando and Sylvius and any other desired landmarks painted on the skin with iodine. After the ad- ministration of the anaesthetic, and be- fore any incision is made, the scalp should be punctured with an awl or some sharp instrument to mark upon the skull the position of the guiding- line and the exact spot for the applica- tion of the trephine point. This is for reference after the skin has been divided and retracted. Trephine. The incision is horseshoe shaped, with base downward, in order to secure the best nutrition for the flap, and so situated that it can be enlarged if found necessary later on. It should be made three-fourths of its expected length with one sweep of the knife. After the vessels have been tied it is enlarged to its intended size. The pericranium is not dissected up with the skin flap, but is afterward elevated from the area of bone to be removed. In general the trephine hole should be at least one and a half inches in diameter, and if more room is needed it can be enlarged by the rongeur, or two trephine holes can be made and the intervening bone chis- elled or sawn away. If Horsley's electric saw is used a thin, flat steel instrument must be kept beneath it between the bone and the dura to protect the latter. The centre-pin of (he trephine having been protruded one-sixteenth of an inch and fastened in its place by the binding screw on the side, it is forced by to-and-fro rotatory movements upon its point into the bone at the place selected, and these movements continued until the EXCISION OF JOINTS AND BONES. 199 circular edge of the trephine has cut a groove sufficiently deep to iusure its steadiness without the aid of the pin, which must then be withdrawn, so as to avoid injury by it to the dura mater. The rotatory movements are continued very cautiously, and all parts of the groove frequently examined with a probe, as its depth increases, so as to have timely notice of complete perforation. The teeth of the trephine must be freed from dust from time to time by means of a brush or by dipping the instru- ment into sterilized water. If, as is usually the case, per- foration takes place upon one side of the groove before it does upon the other, the trephine must be slightly inclined so as to act only upon the unsawn portion ; or a thin- bladed elevator may be used to lift or pry out the disk, breaking the thin shell which remains. It is possible to replace even large plates of bones and secure bony union, although the attempt more often fails. If this is to be attempted, wrap the fragment removed in a towel dampened with a 1 to 2000 solution of bichloride of mercury, or immerse it in a plain sterilized salt solu- tion, and in either case keep it at the temperature of 99° F. Hemorrhage from the diploe is checked by simple sponge pressure or by plugging the larger vessels with decalcified bone, softened catgut, a piece of aseptic sponge, or Hors- ley's wax. This is made of wax 7 parts, oil 2 parts, car- bolic acid 1 part. The dura mater is cut one-quarter of an inch from the bony margin, and the incision should have a horseshoe shape. It is lifted carefully to avoid injury to the vessels of the pia, as the hemorrhage from these may be profuse and troublesome. Any arteries on the dura are ligated before their division by passing a small curved needle. Hemorrhage from the pia or brain is checked by sponge or gauze pressure. If these fail the vessels are clamped and tied with fine catgut ligatures. The Paquelin cautery may be used as a last resort. The brain can be punctured cautiously with a probe or hypodermic needle, but all lat- eral movements should be avoided. CEdema of the pia is evacuated by a few small incisions aided by the pressure of a sponge. If the brain has to be incised pass the knife through the 200 OPERATIVE SURGERY. summit of a convolution, as the hemorrhage is less than when the incision is made at the bottom of a sulcus. A clot can be wiped out with fine sponges or picked out with forceps. An encapsulated tumor is enucleated with curved blunt-pointed scissors, aided by the finger. But one that infiltrates the brain must be cut out with the knife. The use of the sharp spoon is not allowable in this situation. A superficial cyst is either enucleated, or, after cutting off its superficial surface, it is simply packed and drained. A deeper cyst is evacuated and packed or continuous drain- age maintained by a strip of rubber tissue. A cavity re- maining after the removal of a cyst or tumor is packed with gauze, which is removed gradually to prevent the space filling with a blood clot. A clot may be allowed to form if there is perfect confidence that asepsis has been maintained. If bulging of the brain occurs the protrud- ing part should be held back by a thin spatula, which is gradually withdrawn as the dural incision is closed over it by a continuous catgut suture. If it is impossible thus to hold the brain back the protruding part may be sliced away or wiped off with a sponge. True hernia cerebri after an operation is rare when perfect asepsis has been maintained. Any alarming hemorrhage from a sinus or large vein can usually be checked by gauze pressure; if this fail artery clamps can be applied and left in the dressings for several days. A bleeding sinus has been sutured successfully, but it is difficult. At the close of the operation a folded strip of rubber tissue is passed as a drain beneath the dura, which is stitched with catgut except at this point, and brought out of the lower angle of the skin wound. Often the drain is unnecesary, and the wounds in the dura and skin may be closed up tight, the former with catgut, the latter with silk, and dressed aseptically. Temporary Resection of the Skull by Omega Flap. The incision takes the form of a Greek SJ, with base downward to secure the best nutrition to the flap. Everything is divided down to the pericranium. The horizontal feet of the loop are each about half an inch long and separated from each other across the base by at least an inch of sound skin. The size of this pedicle varies with that of the flap, EXCISION OF JOINTS AND BONES. 201 its width being a good half of that of the latter. The horizontal cuts serve as liberating incisions to facilitate the turning down of the flap with its attached bone. The dimensions of the loop can of course be made to vary to suit the requirements of each case, but as used by Wagner. 1 They are follows : Vertical length, 6.5 cm. ; greatest breadth, 5 cm.; with a pedicle of undivided sound tissue, 3 cm. wide. After the soft parts have retracted the periosteum is cut close up and parallel to the inner edge of the skin in the loop and its horizontal continuations below, and the bone chiselled through along the entire curved portion. A perios- teal elevator is cautiously pushed in as a lever at the top of the curve and the bone flap snapped at its base by a sudden quick application of force and laid back without disturbing the attached parts. It may be necessary to aid this breaking by chiselling of the outer table from either or both angles part way across the bone. The dura is opened as described in the operation of trephining. When the bone fragment is replaced it is held in position and pre- vented from pressing unduly upon the dura by the project- ing spicules of the vitreous plate formed by the fracture. The skin flap overlaps the line of bony division about one- quarter to one-half an inch, and is united by interrupted silk sutures, with or without drainage in the lower angle of the wound. By this method it is claimed the bone can be replaced with less danger of necrosis than when it has been entirely separated from its sources of nutrition, and if it does necrose it is just as easy to remove as in the cases where the bone has been replaced after an ordinary trephin- ing- This is the description of the operation as given by its originator, but practically the horizontal " feet " of the Q may generally be dispensed with. Their only use is in liberating skin incisions to facilitate the turning down of the flap. If needed they can be made after the section of the bone. To chisel through the skull, two gouges, one larger than the other, will be found most useful. The outer table is divided with the larger instrument, the inner table with the smaller one along the groove made by the first. 1 Centralblatt f. Chir., 1889, p. 833. 202 OPERATIVE SURGERY. Oranieciomy (Lannelongue). An incision parallel to and a finger-breadth to one side of the longitudinal sinus is made from the lambdoid to the coronal suture. The perios- teum is elevated in this line, and at one extremity of it the skull is perforated with a half-inch trephine. Then with the rongeur or chisel a strip of bone from a quarter to half an inch wide and from four to six inches long, parallel to the sagittal suture and about an inch distant from it, is ex- sected. This has sometimes been extended to reach from the frontal eminence nearly to the transverse sinus. A similar strip of bone has occasionally been removed at the same time from the opposite side of the head, and Lannelongue has performed the operation in the transverse diameter of the skull, the incision and exsected bone cor- responding nearly to the coronal suture. A flap, concavity downward, is sometimes fashioned so as to prevent the lines of skin and bone division from coinciding. Trephining for Fracture of the Skull. The scalp is shaved and cleaned over all the surrounding area. If a wound already exists it is enlarged ; if not, a semilunar incision is made and placed with due regard to the arteries leading into the flap. The periosteum is divided and de- tached and the fracture examined. It is generally possible after removing loose fragments with dressing forceps to introduce an elevator and pry up the depressed portion, using of course only the sound part of the skull as a ful- crum. If some projecting fragment of bone prevent this it may be chiselled away enough to admit of lifting or prying up the depressed part. When the trephine is used the point is so placed on the sound bone that about one-third of the cutting edge only overlaps the injured area, and the rest will expose any widespreading comminution of the inner table. If there is reason to think a sinus has been wounded, the trephine opening should be planned to give ready access to the bleeding point. All splinters and loose fragments are taken out with care to strip off any adherent dura on the inner surface; but depressed fragments still retaining a hold on sound bone are simply.elevated and left. Wounds of the dura are sutured with fine catgut, and hemorrhage from it is checked by gently applied pressure EXCISION OF JOINTS AND BONES. 203 or ligature. Bleeding from a diploic vein is stopped by plugging its lumen with aseptic sponge or catgut or by crowding in a little of the surrounding bone tissue. After thoroughly cleaning all parts of the wound and removing every hair or trace of dirt, it is closed with interrupted silk and drained at the most dependent angle. Fig. 79. B. Fissure of Bichat. e. a, p. External angular process of frontal bone. Sy. a. fis. Ascending limb of Sylvian fissure. +. Parietal eminence. F. G. D.H. E. Perpendiculars to base line locating tbe fissure of Rolando (F.H.). p. o. fis. Parietooccipital fissure, l.fr.f. First frontal fissure. 2. fr.f. Second frontal fis- sure. asc.fr. con. Ascending frontal convolution, i.par.f. Intra-parietal fissure, s. m. c. Supra-marginal convolution, ang. g. Angular gyrus. 1. t. s. c. First tem- poro-sphenoidal convolution. 2. t. s. c. Second temporo-spbenoidal convolution. 3. t. s. c. Third tempo ro-sphenoidal convolution, l.t.s.f. First temporo-spbe- noidal fissure. 2. t. s.f. Second temporo-sphenoidal fissure. (Starr). The Relation of the Brain to the Overlying Parts. Reid's method. 1 The "base line" is drawn through the lowest part of the infra-orbital margin and the centre of the ex- ternal auditory meatus. The great longitudinal fissure is marked by a line run- ning in the middle line of the skull from the glabella to the external occipital protuberance. 1 Lancet, September 27, 1884. 204 OPERATIVE SURGERY. The transverse fissure, or the fissure of Bichat, by one from the external occipital protuberance through the audi- tory meati. The Sylvian fissure starts one and one-quarter inches horizontally behind the external angular process of the fron- tal bone, and extends to a point three-quarters of an inch below the most prominent part of the parietal eminence. The ascending line of this fissure starts at a point in this line two inches behind the external angular process, and ascends vertically about one inch. Pig. 80. Showing the location of the centres on the cortex of the brain. (Starr.) Fissure of Rolando. Draw a perpendicular to the base line starting in the depression in front of the external audi- tory meatus, and another perpendicular to the base line starting from the posterior border of the mastoid process at its root. The fissure of Rolando is indicated by a line drawn from the intersection of this second line with the line mark- ing the great longitudinal fissure, to the point of intersec- tion of the anterior perpendicular with the horizontal limb of the fissure of Sylvius already laid out. A simpler way of indicating the Kolandic fissure is to draw a line three and EXCISION OF JOINTS AND BONES. 205 three-eighths inches long at an augle of 67° with the sagit- tal meridian of the head, from a point which lies back of the glabella in this meridian 55.7 per cent, of the distance from the glabella to the inion. Cheyne's method of measur- ing this angle is to halve a right angle by doubling a square piece of paper into a triangle, and then halve the 45° thus obtained by folding one of the triangles. By unfolding the crease first made, leaving the last unchanged, there re- sults the sum of 45° and 22|°, or 67J°, which is near enough for all practical purposes. The line three and three- eighths inches long is then laid off at this angle by means Fig. 81 Showing the position of the cortical centres with reference to the Sylvian and Rolandic fissures marked on the surface of the skull. (Starr.) of the folded bit of paper from a spot half an inch behind the mid-point between the glabella and the external occipi- tal protuberances. The parieto-occijntal fissure. The horizontal limb of the fissure of Sylvius is prolonged to meet the longitudinal fissure. A trephine opening over the inner inch of this line will reveal a whole or part of the parieto-occipital fissure. It varies slightly up or down in its location. The frontal lobe lies between the lines indicating the fissures of Rolando aud Sylvius and the longitudinal fissure and a line drawn from the glabella close to and parallel to 10 206 OPERATIVE SURGERY. the supra-orbital arch to meet the prolongation of the Syl- vian fissure. The first frontal fissure is indicated by a line drawn from the supra-orbital notch parallel to the longitudinal fissure and ending three-quarters of an inch in front of the fissure of Rolando. The second frontal fissure is indicated by the frontal part of the temporal ridge. The ascending frontal convolution occupies a space three- quarters of an inch broad in front of the fissure of Ro- lando. The parietal lobe lies between the fissure of Rolando, the horizontal limb of the fissure of Sylvius, the longitudinal and parieto-occipital fissures. The intra-parietal fissure begins on the horizontal limb of the Sylvian fissure — more correctly a little above it — one inch behind its junction with the fissure of Rolando, and passes upward three-quarters of an inch behind the latter for the first third of its length. Then it arches backward and downward and passes half an inch to the outer side of the outer extremity of the line indicating the parieto-occipital fissure. The ascending parietal convolution lies between the fissure of Rolando and this first third of the intra-parietal fissure. The inferior parietal lobule lies between the horizontal limb of the Sylvian fissure and the intra-parietal fissure. TJie supra-marginal convolution occupies the anterior portion of this space in the most prominent part of the parietal eminence. The angular gyrus occupies the posterior portion. The temporo- sphenoidal lobe lies between the Sylvian fis- sure and the base line, and is limited behind by a line join- ing the termination of the horizontal limb of the Sylvian fissure, with the centre of the line from the external occi- pital protuberance to the posterior border of the root of the mastoid process. The first temporo-sphenoidal fissure is indicated by a line parallel to and one inch below the Sylvian fissure. The second temporo-sphenoidal fissure by a line three- quarters of an inch below this. EXCISION OF JOINTS AND BONES. 207 Kocher's Method. Kocher uses a specially constructed instrument of pliable steel bands to mark out the position on the shaved scalp of the different parts of the brain which lie beneath. By reference to the figure the nature of this instrument can be readily understood. An ordinary Fig. 82. Kocher's cranial topography. (All the points on the sagittal meridan, D, C, E, X, lie further back than indicated in this figure. metal tape measure can be made to answer the purpose. The band ADCEB extends from the glabella along the median line to the lowest point of the external occipital protuberance. The horizontal baud A J Q V B is placed at right angles to this around the side of the head between the same two points. For convenience the lines thus marked out are called the sagittal and horizontal meridians of the head. From the centre, C, of the sagittal meridian two bands each at the same angle of 60° to the sagittal meridian pass downward to meet the horizontal meridian at the points J and V. The sagittal meridian is now divided into thirds, the last of which begins at E ; and next into fourths, the last of 208 OPERATIVE SURGERY. which begins at F. At a point midway between E and F the band X Y Z Q passes at right angles to the sagittal meridian to join the horizontal at Q, which is usually about half an inch behind J. This oblique band X J2 is divided into thirds at Y and Z. C J and C V are also divided into thirds at G, H, S, and T. The horizontal meridian marks the lower border of the cerebrum. The point J lies about at the pterion or junction of the frontal parietal and spheuoidal bones, and marks the anterior end of the Sylvian fissure at the spot where the ascending joins the horizontal limb. It also indicates the point of contact of the frontal and temporal lobes. V lies over the boundary between the temporal and occipital lobes, and is one centi- metre below the edge separating the outer and uuder sur- faces of the brain. C indicates the uppermost point of the anterior central convolution, and is in front of the fissure of Rolando. At G the anterior central convolution meets the first and second frontal convolutions, and at II the second and third. S lies over the intra-parietal fissure just above the supra- marginal gyrus. T indicates the posterior extremity of the first temporo-sphenoidal fissure and is below the angu- lar gyrus. X is over the apex of the lambdoidal suture and at the point of meeting of the parieto-occipital and great longitudinal fissure. Q indicates the anterior ex- tremity of the first temporo-sphenoidal fissure. The pos- terior end of the first third of the sagittal meridian, D, is at the bregma. A trephine opening close to one side of C reaches the centre for the lower extremity — the thigh and leg are near the middle line, the foot and toes slightly posterior. Between H and G is the centre for the upper extremity, in the upper part and in front of the fissure of Rolando the shoulder and elbow, and in the ascending parietal con- volution a little lower down the centre for the wrist, fingers, and thumb. A little above II the trephine exposes the centre for the upper face muscles, just below H the lower face muscles. A finger-breadth directly above il lies the centre govern- ing the movements of the larynx and pharynx. EXCISION OF JOINTS AND BONES. 209 In front of the middle of the line H J is the centre, injury to which produces motor aphasia. The auditory centre lies under the posterior half of the line Z Q. The centre for visual aphasia is below the point T, and just above the line B V is the centre for psychical vision or psychical blindness. C. Winkler 1 has elaborated another system of cerebral topography, and Langdon 2 still another. D'Antona's 3 method is simple and easily applied, but as Reid's original scheme and its modifications are most generally known and used, it has not seemed worth while to do more than call attention to these few of the numerous others which have recently been devised. THE POSITION OF THE LATERAL SINUS. According to Birmingham 4 the limit of the up-and-down variation of the position of the lateral sinus is determined thus : At a point one and a half inches behind the centre of the external auditory meatus it begins to arch down- ward. Measure this distance along the base line. Then, at a point one and a quarter inches above the base line at this spot, draw a line slightly convex upward to a point half an inch above the external occipital protuberance. Take another point half an inch below the external occipital protuberance and connect it with the point on the base line one and a half inches behind the centre of the meatus. Outside of these limits there is no danger of opening the lateral sinus. In its average location it c^iends from the external occipital protuberance, gradually rising to a point three- quarters of an inch above Reid's base line. The highest point is reached one and a half inches behind the centre of the external auditory meatus. From here with a gradual or sharp turn it runs downward and forward on the inner 1 Nederlandsch. Tijdschrift voor Geneeskunde, 1892, p. 158. 2 Cincin. Med. Journ., Aug 16,1894. 3 Annals Surg., Dec. 1892. 4 Dub. Journ. Med. Science, 1891, p. 116. 210 OPERATIVE SURGERY. surface of the mastoid portion of the temporal bone imme- diately in front of a ridge, which on the outer surface of the skull sometimes prolougs the posterior margin of the mastoid process upward and backward and in front of the Fig. 83. A. External occiptal protuberance and lateral sinus. 77 | Limit of up and down variation in position of the lateral sinus. D. Incision for exposure of the Gasserian ganglion. posterior margin of the process itself. Here it lies about half an inch behind the meatus. At the level of one- quarter or one-sixth inch below the floor of the meatus it turns into the base of the skull. To Open the Lateral Sinus. Incision about two inches in length, starting near the lower end of the mastoid pro- cess, and passing upward along the ridge on its posterior margin. The periosteum is divided and elevated. The EXCISION OF JOINTS AND BONES. 211 pin of a three-quarter-inch trephine is placed at a point one aud one-quarter inches behind the centre of the external auditory meatus on a level with its upper border. Accord- ing to Birmingham this will always open up the sinus. The opening in the bone may be enlarged as circumstances require. TREPHINING FOR CEREBRAL ABSCESS DUE TO SUPPU- RATIVE DISEASE OF THE MIDDLE EAR. The pus in these cases is most frequently found in the temporo-sphenoidal lobe — next in order of frequency in Fig. 84. 1. Trephine opening to enter the mastoid antrum. 2. Trephine opening for abscess following otitis media. 3. Trephine opening to expose the cerebellum. 4-5. Trephine opening for middle meningeal hemorrhage. A. Lateral sinus.. JJ-C. Limit of its up-and-down variation. 212 OPERATIVE SURGERY. the cerebellum. According to Barker 1 the abscess gen- erally occupies a space between two lines drawn perpendic- ular to Reid's base line. The first passes through the centre of the meatus, the second one and one-quarter inches behind this (Fig. 84, 2.) A semilunar incision, convexity downward, is made just above and behind the pinna. The periosteum is divided and elevated sufficiently for the use of a three-quarter-inch tre- phine. The pin of this is placed one and one-quarter inches above the base line in the centre of the space enclosed by the perpendiculars. Birmingham 2 shows that in a certain pro- portion of cases a trephine thus applied will come down on the bend of the lateral sinus, and proposes as a safer location to place the point of the trephine at least one and three- quarter inches above the base line, or, better still, two inches. Keen places the pin of the trephine an inch and a quarter behind and the same distance above the external auditory meatus. After the removal of the button of bone the dura is incised with the knife, and the opening enlarged in the shape of a crucial incision with blunt-pointed scissors. The abscess is located with an aspirating needle, and an opening large enough for a drainage tube is made with some blunt instrument. The flaps are then adjusted and partially sutured in posi- tion, leaving sufficient room for the escape of pus. TREPHINING OF THE CEREBELLUM. A transverse incision is made along the superior curved line of the occiput. Everything is divided down to the bone. The sterno-mastoid, trapezius, and underlying muscles are raised with the periosteum. These soft parts will con- tain the divided occipitalis minor and major nerves and the occipital artery. The skull is opened below the superior curved line and behind the masto-occipital suture by placing the pin of a three-quarter-inch trephine one incli below > British Medical Journal, 1887, vol. i. p. 407. ! Dublin Joum Med. Science, lS'Jl, p. 111). EXCISION OF JOINTS AND BONES. . 213 Reid's base line at a point two inches behind the centre of the external auditory meatus measured along the base line (Fig. 84, 3). Barker advises one and one-half inches behind the centre of the meatus and one inch below the base line, but Bir- mingham says a three-quarter-inch trephine would wound the occipital artery in many cases in this situation. PUNCTURE OF THE LATERAL VENTRICLES (kOCHER). An inverted U-shaped incision is made to expose the skull at T (Fig. 80). The enclosed flap should be about one and one-half inches long by an inch wide. After turning down the skin and securing the vessels the periosteum is incised and elevated, and the point of the trephine entered just below and in front of T. The skull is thin in this region. This exposes the posterior end of the first temporo-sphe- noidal fissure. The posterior horn of the lateral ventricle lies about 1 cm. distant from the bottom of the sulcus directly inward. Another method of locating the opening to be made in the skull (Keen) is to measure one and one-quarter inches back of the external auditory meatus along Reid's base line and then one and one-quarter inches vertically upward. At this point apply the pin of a half-inch trephine. After incising the dura push a grooved director or trocar in a straight line toward a spot about two and one-half or three inches above the opposite meatus. The ventricle will nor- mally be reached at a depth of about two inches — if dis- tended it lies somewhat nearer the surface — and can be recognized by the diminution of resistance offered to the instrument and the escape of fluid along the groove of the director. Drainage is provided for by inserting a small rubber tube or a folded strip of rubber tissue. TREPHINING FOR MIDDLE MENINGEAL HEMORRHAGE. An inverted U-shaped incision is made from the upper part of the posterior border of the frontal process of the malar. 10* 214 OPERATIVE SURGERY. boDe upward nearly to the temporal ridge, and thence backward and downward in a gentle curve, to terminate at the superior border of the posterior exremity of the zygoma. This flap, including a part of the temporal muscle, is turned down and the boue sufficiently bared of periosteum to admit the use of the trephine at the spot presently to be indicated. Kocher makes an incision from the external angular process of the frontal bone to the eminentia articularis, thence upward and backward for about an inch in front of the ear. Wagner 1 employs the Q flap with osteoplastic resection of the skull, the same as for exposure of the second and third divisions of the fifth nerve within the cranium (see p. 215). After the soft parts have been raised the skull is opened over the anterior division of the artery by placing the pin of a three-quarter inch trephine a thumb's breadth behind the external angular process of the frontal bone and two finger-breadths above the zygoma. Both divisions can be exposed simultaneously by applying the trephine imme- diately above the middle of the zygoma (Kocher). Kronleiu determines the location of the branches by drawing a line through the upper border of the orbit backward parallel to Reid's base line. The anterior divi- sion of the artery lies on the upper line 3 to 4 cm. behind the external angular process of the frontal bone, and the posterior at the intersection of the upper line with another drawn perpendicular to the base line from a point 3 to 4 cm. behind the external auditory meatus — roughly, from about the posterior border of the mastoid process. The following may be taken as accurate enough for all practical purposes: To expose the anterior division of the artery apply the pin of a three-quarter inch trephine one inch above the middle of the zygoma, and then enlarge the open- ing downward with the rongeur if it is found necessary to secure the trunk of the vessel. If for the latter purpose the method l>y osteoplastic resection of the skull is cra- i Centralb. f. Chir.. 1889, p. 833. EXCISION OF JOINTS AND BONES. 215 ployed, the bone should be chiselled through in the lines of the lower extremities of the inverted U incision, clown to the level of the zygoma or nearly to the pterygoid ridge on the greater wing of the sphenoid. To expose the posterior division of the artery apply the trephine just below the most prominent portion of the par- ietal eminence. Any clot which may be found is scooped or irrigated out, and the bleeding points in the dura are secured by ligatures passed around them by means of a fine curved needle. Hemorrhage from the trunk of the middle meningeal as it lies in its bony canal may be checked by packing with gauze or strands of catgut. RESECTION OF THE SECOND AND THIRD DIVISIONS OF THE FIFTH NERVE WITHIN THE SKULL. 1 The omega-shaped incision is used with its base on the zygoma and the top of the curved part at the temporal ridge. It starts at the external angular process of the frontal bone, and passes horizontally along the upper border of the zygoma for about half an inch. Thence in the curved portion upward to the temporal ridge and down to the zygoma and again horizontally about half an inch to the tragus of the ear. The periosteum is divided and the bone chiselled through and turned down with its attached soft parts, as already described. The middle meningeal artery is secured by passing a sharply curved needle and ligature beneath it, and the dura is carefully separated from the bone below so as to expose the middle fossa of the skull. Any hemorrhage is checked by pressure. With broad retractors the dura and brain are lifted, taking great care to avoid injury to the other cranial nerves in the immediate vicinity. The first, second, and third divi- sions of the fifth nerve, as well as the carotid artery and cavernous sinus are well exposed. The dura is stripped back from the second and third divisions to beyond the i Hartley : N. Y. Med. Journ., 1893, vol. 55, p. 317. 216 OPERA TIVE SUBGEB Y. Gasserian ganglion, and the parts lying between it and the foramen ovale and rotundum are excised. The flap is then replaced and united with interrupted silk sutures. OPENING OF THE FRONTAL SINUS. The eyebrow is shaved. The incision starts at the cen- tre of the supra-orbital ridge and follows the curve of the upper border of the eyebrow to the median line above the root of the nose. Everything is divided down to the bone — the periosteum is raised on each side and the trephine or chisel entered at the inner end of the superciliary ridge. Antrum of Highmore. A very small trephine should be used, and, in order to avoid a scar, it should be ap- plied through the mouth after dividing the gingivo-labial fold, and dissecting up the soft parts as far as to the infra- orbital foramen, just below and to the outer side of which the opening into the antrum should be made. The antrum may also be opened by drawing the first or second molar tooth, and enlarging its socket with a drill. No additional directions are needed for trephining the Hat bones or the epiphyses of the long ones. PART V. ] NEUROTOMY AND TENOTOMY. DIVISION AND KESECTION OF NERVES. Division of a nerve of sensation, or even of a mixed nerve in extreme cases, may be required for the relief of neuralgic pain. It is seldom that simple division is more than temporarily sufficient. At least half an inch of the trunk of the nerve should be excised, and, as additional security against reunion, the end of the distal segment may be bent back upon itself. Prof. Weir Mitchell 2 has seen severe constant pain follow the bending back of the end of the proximal segment. SUPRA-ORBITAL NERVE. The frontal nerve, main branch of the first division of the trigeminus, divides just behind the upper margin of the orbit into the supra-orbital and supra-trochlear nerves; both branches are distributed to the forehead, the former emerging from the orbit through the supra-orbital notch or foramen, the latter a little nearer the nose. The former is much the larger and more important of the two, the latter supplying only a narrow strip of integument near the me- dian line. The supra-orbital notch or foramen is found at the junction of the inner and middle thirds of the supra- orbital arch, or a little to the inner side of the junction. When it is a notch it can be readily felt through the skin, and is then an important guide in the operation. The nerve may be divided subcutaneously after its emer- 1 A description of all known operations on cranial nerves, with the bibliography, can be found in Chir. Operat. du Syst. Nerveux, by Chipault. Paris : Rueff & Co., 1894. 5 Oral communication. 218 OPERA TIVE S UBGER Y. geuce from the notch, or it may be exposed by a transverse incision above or below the eyebrow. Subcutaneous Division. A tenotomy knife is entered between the eyebrows midway between the nerve and the median line, and passed horizontally beneath the skin until its point has passed beyond the nerve. Its edge is then turned backward and pressed against the bone, and the nerve, lying between it and the bone, divided by with- drawing the knife. Or the knife may be entered at the same point, but passed close to the bone instead of just under the skin, its edge turned downward toward the margin of the orbit, and the nerve divided by sweeping the knife downward across the mouth of the supra-orbital foramen. Excision of a Portion of the Nerve. A. Above the Eye- brow. (Fig. 85, A.) An incision one to one and a half .1, /;. Resection of supra-orbital nerve. C. Resection of superior maxillary nerve. inches long is made just above and parallel to the eyebrow, its centre corresponding to the position of the nerve. This incision is carried down to the bone, the distal end of the nerve recognized, seized with forceps, dissected out, and '•111 off. V>. Ilclow the Eyebrow. (Fig. 85, B.) The eyebrow being drawn up and the eyelid down, the surgeon makes an incision one to one ;iinl a half inches in length along the edge of the supra-orbital arch, dividing successively the skin, orbicular muscle, and tarsal ligament, lie then seeks the NE UR TO MY A ND TENO TOMY. 219 nerve in the notch, traces it back as far as necessary, while depressing the eye and levator palpebral with a retractor, and cuts out a portion with curved scissors. Swpra-trochlear Nerve. Konig resected this nerve by making a curved incision under the eyebrow at the upper inner edge of the orbit, and seeking the trochlea and the superior oblique muscle. On making the latter tense with a hook the two fine nerves became visible, were seized with forceps, and resected. SUPERIOR MAXILLARY NERVE. After leaving the cavity of the cranium by the foramen rotundum, the superior maxillary nerve crosses the spheno- maxillary fossa, traverses the infra-orbital canal, and ap- pears upon the face at the infra-orbital foramen, where it at once divides^up into numerous branches distributed over the cheek, nose, lip, and lower eyelid. Within the infra- orbital canal it gives off the anterior dental branch, and posterior to this canal it gives off the posterior dental, and through branches to the spheno-palatine ganglion, the pala- tine nerves distributed to the palate and nasal fossa. The point at which the nerve should be divided will vary accord- ing to the region affected ; but in this, as in other cases, simple division has usually proved insufficient, and it has been found necessary to excise all that portion of the trunk which lies in the canal. Sometimes the nerve has been cut above the branches going to the ganglion, and the latter torn out forcibly. The roof of the infra-orbital canal is composed in its pos- terior half of fibrous tissue, in its anterior half of thin bone, which becomes thicker as it approaches the margin of the orbit. The infra-orbital foramen lies directly above the second bicuspid tooth and from one-quarter to one-half an inch below the margin of the orbit. The nerve is accom- panied on its passage through the canal by the infra-orbital artery. A. Division of the Nerve on the Face. This may be done: (1) subcutaneously ; (2) through the mouth; (3) by an external incision. 220 OPERATIVE SURGERY. 1. Subcutaneously. A tenotomy knife is entered about an inch to the outer side of the foramen, carried below it into the canine fossa, hugging the bone, and then swept upward along the surface of the bone so as to divide the nerve close to the foramen, the lip being drawn downward and forward to make the tissues tense. 2. Through the Mouth. An incision is made in the gingivo-labial fold, and the soft parts dissected away from the bone until the nerve is reached and divided. Guerin advises that a small portion of the distal eud be excised. 3. By External Incision. The incision may be trans- verse, oblique, or curved ; it is only necessary that its centre should correspond to the foramen. The tissues are divided successively until the bone is reached and the nerve found either by following up one of its branches or by seeking it at its point of emergence. B. Resection of the Infra-orbital Portion. (Tillaux 1 ). Fig. 85, C. A vertical incision is made along the side of the nose from the lachrymal tubercle or the bony ridge of the nasal process of the superior maxilla, which is contin- uous with the lower edge of the orbit, down to the ala of the nose. A second horizontal one is then begun at the upper portion of the first and carried outward along the lower margin of the orbit beyond its centre. These inci- sions should involve all the soft parts down to the bone. The lower flap is dissected up, the nerve found, and a silk ligature thrown around it close to the foramen. The upper flap is then raised, together with the lower eyelid and eyeball, exposing the floor of the orbit as far back as possible, upon which the infra-orbital canal can be recognized as a grayish line running obliquely backward and inward. The canal is opened with a knife or chisel, the nerve isolated from the artery, raised from its bed with a small hook, and dissected out as far back as may be considered necessary. It is then divided with curved scissors, and the distal portion drawn out by means of the ligature applied 1 Traite d'Anat. Topographique, p. 310, and Bull.de la Soci6t0 do Chirurgie. ■ 08. NEUROTOMY AND TENOTOMY. 221 to it iu the beginning. The length of the portion removed by Tillaux was six centimetres. Dolbeau 1 divided the nerve with curved scissors on the central side of the branches going to the spheno- palatine ganglion, and tore out the ganglion by drawing upon the nerve. Malgaine's Method. Pass a stout tenotome along the floor of the orbit for nearly an inch in the direction of the nerve ; cut transversely with its point through the floor of the orbit; the bone being thin will offer no resistance. This divides both canal and nerve. Expose the nerve at the infra-orbital foramen by a simple transverse incision, seize it with forceps and tear it out of the canal. The first part of this operation has been modified by Von Langenbeck and Hueter as follows : A strong tenotome with slightly blunted point is entered close below the external palpebral ligament and pushed backward and downward along the outer wall of the orbit until its point is felt to leave the bone and enter the fissure; its edge is then turned forward against the sharp border of the orbital process of the superior maxilla and made to scrape along it as the knife is brought forward. Lucke's Method. 2 An incision, beginning one centimetre above the outer angle of the eye and close behind the margin of the orbit, is carried downward and slightly forward across the malar bone, dividing its periosteum ; from its lower end a second incision is carried backward and upward, terminat- ing over the outer surface of the zygomatic process of the temporal, about a quarter of an inch behind its junction with the malar bone. The latter bone is next divided in the line of the first incision by means of a saw or chisel, after pre- liminary division of the soft parts and periosteum on its under and inner surface with a small knife, and the zygoma then cut through at its posterior extremity. The attach- ments of the masseter to the intermediate piece are then separated, and the flap of bone and soft parts raised with a sharp hook. If necessary, some of the anterior fibres of the temporal muscle should now be divided in order to expose the spheno- 1 Oral communication. - Deutsche Zeitschrift fur Chirurgie, vol. 4, p. 322. 222 OPERATIVE SURGERY. maxillary fossa thoroughly, the fat occupying the fossa pressed backward with a retractor, and the sphenomaxil- lary fissure recognized with a probe. The nerve and artery can be distinguished by the difference in their course, the former running downward, outward, and forward, the latter upward, inward, and forward. The nerve is seized with forceps and divided with a tenotome well forward in the fis- sure, and then again with scissors as near as possible to the foramen rotundum. The flap is then put back, and the wound drained at it lower angle. An objection to this method is that, iu consequence of its interference with the masseter and temporal muscles, the mouth subsequently cannot be freely opened. Lossen and Braun 1 avoid this difficulty by leaving the attachments of the masseter untouched and turning the flap downward in- stead of upward, after making the second incision from the upper end of the first instead of from its lower end, and separating the temporal fascia from the malar bone. Czerny 2 has employed this modification five times with good results. If wounded vessels cannot be seized and tied, the hemor- rhage must be arrested by plugging with antiseptic gauze. INFERIOR DENTAL NERVE. This nerve may be divided (A) after its exit from the dental canal, (B) in the canal, (C) before its entrance into the canal. The nerve enters the canal by the inferior dental foramen on the inner side of the ascending ramus of the lower jaw at the level of the crowns of the lower teeth ; the canal runs obliquely downward and forward just below the alveoli, and the nerve emerges through the mental fora- men which lies midway between the alveolar process and the lower margin of the jaw below the second bicuspid tooth. A. At the Mental Foramen. An incision is made in the gingivo-labial fold above the foramen, and the soft parts 1 < :oiitmlljlatt fUr Ohirurgie, 1878, pp. 05 and 148. 2 ibid., 1882, p. 249. NEUROTOMY AND TENOTOMY. 223 dissected off until the nerve is reached, usually about one- third of an inch below the bottom of the fold. B. Within the Canal. An incision is made through the skin down to the bone along the course of the nerve in front of the masseter, the periosteum raised, and the canal opened with a chisel or small trephine. After removal of the outer table of the bone the nerve is easily found in the canal and divided. Or the canal may be opened at two points and the inter- mediate portion of the nerve excised. A better method is to make a curved incision behind and below the angle of the jaw, and elevate the periosteum and masseter on its outer surface as far as the alveolar margin. Then chisel into the middle of the exposed bone. The oral cavity should not be opened. C. Before its Entry into the Canal. 1. From within the mouth. The mouth being held widely open and the com- missure of the lips drawn backward and outward, an inci- sion extending from the last upper to the last lower molar tooth is made one-third of an inch on the inner side of the sharp anterior border of the coronoid process, and carried through the mucous membrane to the tendon of the temporal muscle. The surgeon passes his finger into the incision and along the inner surface of the bone, between it and the internal pterygoid muscle, until he touches the bony point which marks the orifice of the canal. Passing a blunt hook along the finger, he raises the nerve upon it, isolating it, if possi- ble, from the accompanying artery, and divides it with blunt-pointed scissors or knife. Or, without introducing the finger, the hook may be passed back beyond the nerve, its point constantly in contact with the bone, then rotated inward so as to carry its point across and behind the nerve, and then withdrawn. 2. Through the cheeh. A curved incision is made around the angle of the jaw or around the lower anterior insertion of the masseter and carried through to the bone along its lower portion ; then with the elevator and knife the muscle is detached from below upward, and the flap raised with a 224 OPERATIVE SURGERY. hook until the level of the inferior dental foramen is reached. The bone is then cut away with a chisel or small trephine and the nerve exposed and excised. With the same curved incision around the angle of the jaw the inner surface of the latter may be freed from the periosteum and internal pterygoid muscle upward till the lingula is felt. Then, with or without dividing this pro- cess the nerve can be isolated and divided, or a vertical in- cision may be made through the skin and fascia, the fibres of the masseter separated, and the bone thus exposed. At the Foramen Ovale. Braun's modification of Liicke's method for exposing the superior maxillary nerve can be employed with slight changes for this purpose. The tem- poral muscle must be retracted or partially divided near its insertion, or the coronoid process cut through at its base. Kronlein 1 suggests the following method : An incision is made from half an inch behind the angle of the mouth to terminate a similar distance in front of the lobule of the ear. Only the skin and subcutaneous fat are divided, the buccinator and oral mucous membrane being spared. The masseter is cut back to the anterior border of the parotid gland, thus sparing the latter and Steno's duct, which lies well above the line of incision. The coronoid process is bared at its base with a periosteal elevator, divided from the semilunar notch downward and forward, and drawn upward, together with the attached temporal muscle. The branches of the inferior maxillary nerve are then exposed by a blunt dissection on the outer surface of the internal ptery- goid muscle. The external pterygoid is drawn upward and the nerves traced back to the base of the skull. At the close of the operation the coronoid process and divided masseter muscle are sutured. He exposes the superior and inferior maxillary nerves simultaneously at their exit from the skull iu the following manner : 2 A curved incision, concavity upward, is made, starting from the most prominent portion of the malar bone, passing down to the level of the lobule of the ear, thence 1 Archly, f. fclin. Chir.. Bd. xliii. p. 13. a Deutecb. Zeltech. f. chir., 1884, vol. xx. p. 484. NEUROTOMY AND TENOTOMY. 225 backward and upward in a gentle curve, to terminate over the posterior extremity of the zygoma. The flap of skin and subcutaneous fascia is turned up, the temporal fascia divided along the upper border of the zygoma, aud the latter sawn through at its anterior and posterior extremities, as in Liicke's operation. The coronoid process is exposed and cut through at its base downward and forward, and drawn upward with the attached temporal muscle. The internal maxillary artery is secured and the attachment of the exter- nal pterygoid muscle separated from the under surface of sphenoid bone. This exposes the inferior maxillary nerve at the foramen ovale, and by working along the spheno- maxillary fissure the superior maxillary nerve is found and followed back to the foramen rotundum. At the close of the operation the parts are replaced and sutured in their proper position. Salger 1 recommends a curved incision, convexity upward, extending from one extremity of the zygoma to the other. Everything is divided down to the skull, the zygoma sawn through at each extremity, and the flap of skin, fascia, tem- poral muscle, aud zygoma turned down. The coronoid pro- cess is depressed by opening the mouth, and the nerve found below the external and on the outer surface of the internal pterygoid muscle, and divided as high up as desired. BUCCAL NERVE. The buccal nerve, a branch of the inferior maxillary, is not infrequently the seat of painful and persistent neuralgia. It is best approached through the mouth by the following method : The surgeon places his finger-nail upou the outer lip of the anterior border of the ascending ramus of the lower jaw at its centre, and divides in front of this border the mucous membrane and the fibres of the buccinator verti- cally. He then seeks for the nerve, separating the tissues with a director, and divides it. Zuckerkandl exposes the nerve from the outside of the 1 Wien. med. Wochenschr., 1887, vol. xxsvii. p. 461. 226 OPERATIVE SURGERY. cheek. A horizontal incision a finger's breadth below the zygoma is made from the anterior border of the masseter muscle nearly to the canine eminence. The fascia overly- ing Steno's duct is divided, and the latter exposed and drawn downward with its accompanying nerves. The fat on the posterior part of the buccinator muscle is torn through, and the nerve found to the inner side of the inser- tion of the temporal muscle on the front of the coronoid process. It lies about an inch back of the anterior border of the masseter muscle. LINGUAL NERVE. Division of this nerve may be required for the relief of pain in cases of carcinoma of the tongue. When the mouth is opened widely the pterygo-maxillary ligament can be readily seen and felt as a prominent fold behind the last lower molar, and the lingual nerve can be felt just below the attachment of the ligament on the inner side of the lower jaw, close to the bone below the last molar tooth. The tongue should be drawn aside by an assistant, the mucous membrane divided for about an inch parallel to the margin of the alveolar process, beginning at the last molar tooth over the position of the nerve, or, according to Chau- vel, 1 one-fifth of an inch from the attachment of the mucous membrane to the side of the tongue. The nerve is then readily found in the submucous tissue, raised upon a hook and divided, or a portion excised. Moore's Method. Mr. Moore has employed the follow- ing method successfully in five cases : He cuts the nerve about half an inch from the last molar tooth, at a point where it crosses an imaginary line drawn from that tooth to the angle of the jaw. He enters the point of the knife nearly three-quarters of an inch behind and below the tooth, presses if down to the bone and cuts toward the tooth. This necessarily divides the nerve. This projection of the alve- 1 Prtcls d'Opirationa de Cblrurgie, p. 435. NEUROTOMY AND TENOTOMY. 227 olar ridge might protect the nerve from a straight bistoury, and therefore a curved one should be used. The lingual nerve may also be readied from outside the mouth by any one of the methods for resecting the inferior maxillary, or by an incision aloug the lower border of the jaw just in front of the masseter muscle. In the latter case (Lobker) the upper margin of the wound is drawn up and a portion of the inferior maxilla, where the alveolar process adjoins the ramus, is exsected and the nerve ex- posed on the outer surface of the internal pterygoid. Or the dissection can be carried up under the inner surface of the jaw (Luschka). The submaxillary gland is displaced downward and forward, the posterior border of the mylo- hyoid muscle divided and the nerve found under the pos- terior end of the sublingual gland. Thence it can be fol- lowed backward and upward and divided as high as desired. FACIAL NERVE. This nerve has occasionally been stretched and crushed for the relief of clonic spasms of the corresponding mus- cles. A semilunar incision is made around the lower attachment of the ear with a short liberating incision down- ward from its centre; the flaps are dissected back, and the nerve exposed by drawing the parotid forward and out- ward. The nerve is more easily exposed at the posterior border of the ramus. For this an incision is made from just in front of the tragus of the ear to the angle of the jaw. After dividing the parotid fascia the cervico-facial branch will probably be exposed first, and can then be followed back to its junction with the temporo-facial. BRACHIAL PLEXUS. Tins plexus consists of the four lower cervical nerves and the greater part of the first dorsal. It crosses the floor of the subclavian triangle of the neck, and lies be- tween the anterior and middle scaleni muscles. Its shape 228 OPERATIVE SURGERY. is triangular, with the base at the spiue and the apex to the outer side of the subclavian artery below the clavicle. Operation. The head and neck are extended, and the face turned to the opposite side. An incision, starting half an inch above the clavicle in the interval between the sterno- cleido-mastoid and trapezius, is carried forward, for about three inches, parallel to the anterior border of the latter. The skin and platysma are divided and the external jugular vein either cut between two ligatures or drawn to one side. The deep cervical fascia is divided in the line of the external incision, avoiding the supra-clavicular branches of the cer- vical plexus, and the outer border of the anterior scalenus muscle recognized. The plexus is felt with the finger just outside the latter and isolated by a little careful dissection. Any particular cord can be identified by tracing it to its point of emergence from the spine through the interval between the scaleni muscles. Resection of the posterior roots of the brachial plexus. This operation has been performed several times for severe neuralgia of the peripheral branches. An incision about six iuches long, with its centre just above the spine of the seventh cervical vertebra, is made parallel and close to the ligamentum nuchas and deepened alongside of the spines till the laminse of the fifth, sixth, and seventh vertebra? are reached. These lamina? are then bared of soft parts on the affected side out to the bases of the articular processes, and removed with the chisel, rongeur, or bone forceps, thus exposing the posterior roots of the nerves previous to their exit from the intervertebral foramina. CERVICAL PLEXUS. An incision about two inches in length is made parallel to and over the posterior border of the sterno-mastoid muscle. Its centre should correspond to the centre of the muscle. The skin, superficial fascia, and platysma are divided and the superficial branches of the cervical plexus are exposed at the middle of the posterior border of the NEUROTOMY AND TENOTOMY. 229 sterno-mastoid muscle and can be traced back toward the spine. SPINAL ACCESSORY NERVE. Anatomy. After passing outward beneath the digastric and stylo-hyoid muscles and occipital artery, the nerve about half an inch below the apex of the mastoid process enters the under surface of the sterno-mastoid muscle in its upper part, leaves it at about the centre of its posterior border, and passes beneath the trapezius at about the junc- tion of the middle and lower thirds of its anterior border. In the substance of the sterno-mastoid muscle it commu- nicates with the second cervical nerve, in the occipital triangle with the second and third, and beneath the trape- zius with the third and fourth cervical nerves. Operation. An incision about three inches in extent is made downward from the tip of the mastoid process along the auterior border of the sterno-mastoid muscle, the cervi- cal fascia divided, and the muscle strongly retracted to put the nerve on the stretch. The nerve is then sought for external to the jugular vein about an inch and a half be- low the tip of the mastoid process on the fascia covering the rectus capitis anticus major. If it is not immediately apparent the nail of the index finger may be drawn across the bottom of the dissection to irritate the filaments (recog- nized by contraction of the sterno-mastoid and trapezius muscles), and thus help to locate the nerve. Section of the posterior divisions of the first, second, and third cervical nerves for spasmodic wry neck. The chief posterior cervical rotators of the head and their nerve sup- ply are as follows : The rectus capitis posticus major is supplied by the suboccipital or posterior division of the first cervical nerve. The inferior oblique is supplied by the posterior divisions of the first and second cervical nerves, and the splenitis capitis by the posterior divisions of the second and third cervical nerves. Operation. (Modified from Keen.) 1 A transverse in- i Annals Surg., Jan., 1891. 11 230 OPERATIVE SURGERY. cision about three inches long is made extending hori- zontally outward from the middle line of the neck, or slightly overlapping it, an inch and a half below the ex- ternal occipital protuberance. It is carried through the trapezius and posterior border of the splenius capitis mus- cles until the complexus is recognized ; the trapezius is dissected up from the complexus, and the occipitalis major nerve found at the upper part of the complexus. Divide the complexus transversely and follow the nerve back to its origin from the posterior division of the second cervi- cal nerve, and divide the latter as near the vertebra as possible. Recognize the suboccipital triangle, which is bounded by the superior and inferior oblique and the rectus capitis posticus major muscles. Within this lies the suboccipital nerve close to the occiput and vertebral artery ; it must be traced and severed close to the spine. The posterior divi- sion of the third cervical nerve is found beneath the com- plexus about an inch lower down than the occipitalis major, and must be cut close to the bifurcation of the main trunk. Smith 1 made a longitudinal incision about three inches long from the occiput downward about an inch and a half to one side of the middle line. It passed through the trapezius to the edge of the splenius, then through the complexus, and eventually exposed the posterior divisions of the cervical nerves. The great occipital nerve was recognized, separated, and drawn aside ; a part of the external branch of the posterior division of the second nerve was excised ; the splenius and complexus separated from the parts beneath, and the entering nerve filaments divided. The suboccipital nerve was not divided. The result of this operation seems to have been perfect. Median Nerve. In the arm it is exposed by the method given for ligation of the brachial artery. At the wrist it is reached by an incision about an inch and a half long, parallel to and just to the ulnar side of the tendon of the pal maris longus. » Brit. Med. Journ., 1891, vol. 1, p. 752. NEUROTOMY AND TENOTOMY. 231 Ulnar Nerve. Except in the extreme upper part of its course the nerve closely accompanies the triceps and is completely separated from the median nerve and brachial artery by the fascial septum that passes down to the bone between the biceps and triceps. Except near the elbow, it should be sought through an incision parallel to and a little posterior to the brachial artery, and after exposure of the triceps. Above the elbow it can be easily found through an in- cision an inch and a half long, curving upward between the internal epicondyle and the olecranon. In the forearm its course is indicated by a line drawn from the space between the internal epicondyle and the olecranon to the radial side of the pisiform bone. At first, it lies over the flexor profundus beneath the flexor carpi ulnaris. At the wrist it is superficial, and lies on the annu- lar ligament with the ulnar artery on its radial side. It is easily reached at the wrist by an incision about two inches long extending upward through the skin and fascia from the pisiform bone. The incision is parallel to and close to the radial side of the flexor carpi ulnaris tendon. MUSCULO-SPIRAL NERVE. Anatomy. It winds around the humerus in the mus- culo-spiral groove between the internal and external heads of the triceps, and reaches the outer side of the arm at about the junction of the middle and lower thirds, and is accompanied by the superior profunda artery. It then pierces the external intermuscular septum and descends in the groove between the brachialis anticus and supinator longus to the front of the external condyle. At this point it is most easily found. Operation. An incision about three inches long is made at the upper part of the supinator groove, the fascia di- vided, and the nerve sought iu the bottom of the groove ; it is then followed upward or downward, according to the circumstances of the case. 232 OPERATIVE SURGERY. Great Sciatic Nerve. An incision three or four inches long is made vertically downward from the gluteal fold, midway between the tuberosity of the ischium and the great trochanter. After division of the skin and fascia the lower border of the gluteus maximus is observed and the hamstring muscles recognized. The nerve lies on the external rotators of the thigh just in front of and to the outer side of the hamstring muscles. Internal Popliteal Nerve. It is reached by the incision for ligation of the popliteal artery. It is superficial to the vein and artery and slightly external. External Popliteal Nerve. This nerve lies close behind and to the inner side of the tendon of the biceps, and is exposed by an incision two or three inches long parallel to and close to the inner side of that tendon. Anterior Crural Nerve. A longitudinal incision about two inches in length is made downward from Poupart's ligament, about an inch to the outer side of the femoral artery. The superficial circumflex iliac vessels will be divided ; the nerve will be found close beneath the fascia. NEURORRHAPHY. I. Primary Suture. An incision is made in the course of the nerve, exposing it at the point of division. The ends are brought together by a couple of fine sutures of silk or catgut passed directly through the substance of the nerve or through the nerve sheath. They must be so placed and tied as not to strangulate the fibres. II. Secondary Suture. A long incision will probably be necessary ; it should be made in the normal course of the nerve and extend well above and below the point of division. The trunk of the nerve should be sought for both above and below the cicatricial tissue of the original NEUROTOMY AND TENOTOMY. 233 wound, and traced downward and upward respectively to the divided and separated ends. Such part of each end as is bulbous or imbedded in cicatricial tissue should be cut away and the divided surfaces brought iuto apposition and sutured. Tension should be relieved by freeing the nerve above and below and by flexing adjoining joints. It is not absolutely necessary to success that the divided ends should be brought close together ; reunion has taken place across gaps of considerable length, one or two centi- metres ; it has been thought to be favored under such cir- cumstances by the presence of a suture connecting the two ends. When there has been a considerable loss of nerve sub- stance, rendering it impossible to bring the divided ends near together, flaps have been cut from the proximal and dis- tal stumps and unfolded, and their extremities united as in tenorrhaphy (Fig. 90) ; or the distal stump may be freshened and then inserted and sutured between the fibres of a neighboring uninjured nerve of similar, or at least partly similar, character. TENOTOMY. Professor Sayre, 1 in answering the question, How are we to determine whether, in any given case, we shall be com- pelled to resort to tenotomy? lays down the following rule as of universal application : "Place the part contracted as nearly as possible in its normal position, by means of manual tension gradually applied, and then carefully retain it in that position ; while the parts are thus placed upon the stretch, make additional point-pressure with the end of the.finger upon the parts thus rendered tense, and if such additional pressure pro- duces reflex contractions, that tendon, fascia, or muscle must be divided, and the point at which the reflex spasm is excited (the point at which the pressure is applied) is the point where the operation should be performed." According to Prof. Sayre, the blade of a tenotomy knife should be one inch long, its shank one and three-quarters, 1 Orthopedic Surgery and Diseases of the Joints. New York, 1876, p. 27. ' 234 OPERATIVE SURGERY. its handle strong and marked in such a way that the sur- geon can see at a glance in which direction the edge of the blade is turned. The blade may be straight or curved, it should be thick at the heel, very narrow, and the point should be somewhat rounded and sharpened from side to side like a wedge or chisel. A fold of skin should be pinched up at the side of the ten- don, and the knife entered at its base, so that a continuous track will not be left on its withdrawal. A preliminary punc- ture may be made with a sharp-pointed knife or lancet to facilitate the entry of the tenotome. The knife must be entered " on the flat " and passed either under the tendon or betweeu it and the skin ; its edge is then turned toward the tendon and the division effected with gentle sawing movements, the thumb being pressed firmly against the tendon if the knife has been passed under it. During the entry of the knife and the division of the tendon the latter must be kept firmly upon the stretch, and as soon as the division is complete the knife must be turned upon its side and withdrawn, while the surgeon follows its point with his thumb or finger so as to force out any blood that may be in its track and to prevent the entrance of air. Seal the wound with plaster or collodion, and then bring the member into the desired position. lendo Achillis. The knife should be entered on the inner side of the tendon near its border, about one inch above the upper surface of the calcaueura. In this way the pos- terior tibial artery, which lies between the tendon and the inner malleolus and below the deep fascia, is secured from injury. The heel must be depressed as much as possible, so as to make the tendon more prominent and give addi- tional security to the artery. Tibialis Posticus. The tendon of this muscle may be divided (A) above the malleolus, or (B) on the side of the foot just behind its insertion into the scaphoid. NEUROTOMY AND TENOTOMY. 235 A. Above the Malleolus. The muscle is made tense by everting the foot ; the knife is entered at the inner side of the tendon and passed behind it. B. On the Side of the Foot. Same position given to the foot. The knife should be directed from above downward, and passed under the upper border of the tendon at a point half an inch below and in front of the tip of the malleolus. Bell 1 prefers to cut toward the bone. Tibialis Anticus. Can be easily made prominent and isolated. Peronei. May be divided at the posterior face of the lower end of the fibula, or on the side of the foot below and in front of the tip of the outer malleolus. Flexor Tendons at the Knees. It must be remembered that the external popliteal nerve accompanies the tendon of the biceps closely, lying upon its inner side. Sterno-cleido-mastoid. The danger to be avoided in this operation is that of injury to the external jugular vein at the outer border of the muscle, or to the anterior jugular vein at its inner border. The first can usually be seen under the skin and avoided, the other leaves the muscle about three-quarters of an inch above the sternum and passes backward. The muscle should be divided about half an inch above the top of the sternum, and most au- thorities agree in preferring to divide from before back- ward. The knife should be entered at the outer border of the muscle. Levator Palpebrce. In a case of paralysis of the orbi- cularis palpebrarum followed by retraction of the levator palpebr?e with inability to close the eye, and subsequent ulceration of the cornea, Professor Detmold divided the latter muscle at its attachment to the upper edge of the tar- sal cartilage. The result was very good. 1 Manual of Surgical Operations, 3d edition, p. 288. 236 OPERATIVE SURGERY. TENORRHAPHY. Primary. Performed immediately after the injury. Antiseptic precautions are especially necessary. The distal end of the tendon can usually be recognized in the wound without difficulty. The proximal end will sometimes re- tract several inches, especially if it was on the stretch at the time of the injury, and an extensive dissection and splitting of the sheath may be necessary to briug it within reach. The divided tendon ends are drawn into apposition and Fig. 86. Tenorrhaphy by a suture passed through the substance 01 each segment. stitched together with fine silk, silkworm-gut, or catgut. The common forms of suture are represented in Figs. 86, 87, 88, 89. If the divided surfaces cannot be brought into apposition and kept there without undue tension, one or both ends of Fig. 87. Tenorrhaphy. The tendon ends cut obliquely to increase the surfaces in contact. the tendon may be split and turned down to lengthen it as indicated in Fig. 90, or the cut ends of the tendon sheath may be carefully sutured in hopes that union of the tendon NEUROTOMY AND TENOTOMY. 237 within may occur as after tenotomy performed by the sur- geon. Another method is to draw the cut ends of the tendon together as much as possible by one or two catgut sutures, which are left in the gap to act as a nidus for new Tenorrhaphy. Showing the method of inserting a suture which does not readily pull out. tendon tissues. Ingrafting of portions of tendon taken from another regiou or even another animal has been per- formed, aud it is said successfully. (Bulletin de la Soc. de Chir., 1886, p. 357.) Fig. 89. A B Tenorrhaphy by four ligatures inserted and tied (.4) in each stump, and their free ends then UDited (B). In all cases of tenorrhaphy the tendon sheath when it exists must be preserved as far as possible. It is impor- tant to immobilize the limb during healing in the position of greatest relaxation of the sutured tendon. Secondary. Performed after a considerable interval of time has elapsed since the injury. The divided tendon 11* 238 OPERATIVE SURGERY. ends will have to be sought for in a mass of cicatricial tissue and brought into the best possible apposition. The ends can be split and lengthened as already described ; if Fig. 90. Tenorrhaphy by flaps to bridge over a gap between the tendon ends. this will not do or the proximal end of the tendon cannot be found the distal end may be sutured to a neighboring tendon having the same general anatomical course. The surface from which union is expected should be freshened by scraping. MISCELLANEOUS OPERATIONS. Thiersch's skin grafting. The wound to which the graft is to be applied must be fresh, clean, dry, and perfectly aseptic. If it is already a granulating surface all pus must be carefully washed away with a sterilized brush, soap and water, and the granula- tions freely shaved away with a knife. It is then thor- oughly washed with a sterilized salt solution (about 5j of common salt to Oj of water). Bleeding is checked by the pressure of a sterilized compress maintained until the grafts are ready to be applied, in order to preserve the asepsis and to prevent the formation of clots of blood which would separate the graft from contact with the raw surface. The graft is commonly taken from the front or outer surface of the thigh, as this presents a conveniently broad surface of skin of the requisite thickness. It must be pre- viously shaved and scrubbed, then rinsed off with alcohol NEUROTOMY AND TENOTOMY. 239 and finally with sterilized water. The skin of the thigh is drawn tense and flat by one hand graspiug the thigh just above the knee and pulling down. With the other hand a broad-bladed razor, ground flat on the surface held next the thigh, is drawn downward toward the knee by quick sawing motions through the skin parallel to and just be- neath its surface. The cutting must be done with accuracy and the razor's edge must lie always in the papillary layer of the skin. Practically it must pass just deep enough to have the cut surface studded with minute specks of blood which do not coalesce for an appreciable length of time. If the knife exposes any particle of the subcutaneous fat the corresponding part of the intended graft must be re- jected. The sterilized salt solution already mentioned is allowed to trickle on the skin immediately in front of the advancing razor-edge, and serves to float the graft up into the concavity on the anterior surface of the razor, and with a little practice facilitates the cutting. A strip six or eight inches long and one and a half or two inches wide can be cut and retaiued on a broad blade. The attached end of the graft is severed with scissors. The graft is then immediately unfolded on the prepared wound surface by retaining the whole width of the free end against one margin of the area to be covered, and gently withdrawing the razor while its edge is kept constantly in contact with the wound surface. If any portions of the graft get turned over so as to op- pose the epidermic layer to the wound surface, they must be carefully unfolded. In addition all air-bubbles must be pressed out toward the edges ; and, in short, every part of the freshly cut papillary layer of the graft must be brought into accurate contact with the underlying raw sur- face which is to be covered. Successive grafts are cut and applied until the entire surface is covered. The grafts are then covered completely with strips of sterilized rubber tissue about an inch wide (after rinsing them in the sterilized salt solution), placed side by side with the edges slightly overlapping. This arrangement permits drainage and allows the graft to be kept damp with the next applied sterilized com- 240 OPERATIVE SURGERY. presses, wrung out in either the sterilized salt solution or a sterilized saturated solution of boric acid. The compresses are covered with a sheet of sterilized rubber tissue to prevent drying. This dressing must be very carefully bandaged in place with even pressure and without disturbing the grafts. From time to time, till it is removed at the end of five days, it must be moistened with the sterilized salt or boric solution. ERECTILE TUMORS. The usual methods of treating erectile tumors are by the ligature, caustic, cautery, coagulating injections, electrolysis, Fig. 91. Subcutaneous ligature of ncevus. and excision. Physick cured one upon the ringer by cir- cumscribing it with a deep incision. Ligatures should be so applied as to cut off the supply of blood entirely. Figs. 91, 92, 93, 94, and 95 represent good methods. The caustic treatment is applied to small najvi ; nitric acid, or the acid nitrate of mercury, may be used. The actual cautery is applied by passing white-hot needles into or through the tumor; sometimes a very dis- NEUROTOMY AND TENOTOMY. 211 figuring scar results. Coagulating injections usually give good results, but the method is considered dangerous on Fig. 92. Subcutaneous ligature of nsevus. The needle passed under the tumor; one thread divided. account of the possibility that the coagulation may extend into the larger vessels, and give rise to embolism. The Fig. 93. Fig. 94. The other end of the divided thread passed into the needle's eye, and the needle passed through at right angles to its former direction. The needle removed and the nsevus strangulated in quarters. solution, persulphate of iron, should be injected, three or four drops at a time, at several points by means of a hypo- dermic syringe; or the nsevus maybe incised longitudi- nally and the iron applied directly to the surface of section. If not too extensive the whole nsevus should be dissected out and the hemorrhage controlled by pressure, ligation, or the actual cautery. The resulting gap is closed by a plas- tic operation or by Thiersch grafts. Electrolysis is applic- able to a capillary nsevus or birth-mark. The poles of a 242 OPERATIVE SURGERY, battery are connected with a pair of fine platinum needles, which are plunged into the growth about a quarter of an Fig. 95. Ligature of large neevus. The white loops are divided on one side and the black on the other, and the corresponding ends A A' and B B' tied together. inch apart, and a current of from 2 to 10 milliamperes thus passed. The punctures must be repeated all over the dis- eased area. BIRTH-MARK. Balmanno Squire 1 has introduced a very simple method of removing " Port- wine birth-marks." He freezes the spot with the ether spray and makes a number of fine parallel incisions from one-thirty-second to one-sixteenth of an inch apart, and extending about half through the skin, or at most to the depth of one-sixteenth of an inch. A piece of steril- ized blotting paper is then laid over the incision and pressed steadily down upon the skin for five minutes, with just enough force not to cause the incision to gape. In twenty or thirty minutes the blotting paper must be thoroughly wet with a 1:.0000 solution of bichloride of mercury and removed by pulling it in the direction of the cuts; the i Essays on the Treatment of Skin Diseases, No. III. London, 1X7<>. NEUROTOMY AND TENOTOMY. 243 underlying thin film of blood clot must also be gently and patiently washed off with a camel's-hair brush. If this is properly done no bleeding will occur and no scar will be left, while if the clot is not removed it is likely to cause suppuration and prevent primary union. In some cases it is necessary to make cross-markings at right angles to the first to eifect a complete cure. SEPARATION OF WEB-FINGERS. Experience has shown that simple division of the mem- brane uniting the two fingers is insufficient, because reunion, beginning at the angle, is certain to extend over the whole length of the incision. A simple way of overcoming this difficulty is to pass a leaden or silver wire through a punc- ture made at the interdigital angle, keep it there until cica- trization has taken place around it, as around an ear-ring, and then divide the membrane. The angle being already cicatrized, the lateral wounds heal separately. Fig. 96. Web fingers. Another plan is to mark out a palmar and a dorsal trian- gular flap at the interdigital angle, its apex turned toward the ends of the fingers (Fig. 96, A), then to split the re- mainder of the membrane longitudinally, pare off the ends of the triangular flaps, and unite them in the interdigital 244 OPERATIVE SURGERY. angle. By this means a bridge of integument is formed which prevents reunion of the sides. These two methods answer very well when there is a dis- tinct interdigital membrane, but some other is required when the fingers are closely approximated. The one which yields the best results is represented in Fig. 96, B, and Fig. Fig. 97. 97. A rectangular flap is dissected up from the dorsum of one finger, and a similar flap from the palmar surface of the other finger, each being left adherent by its long side. The fingers are then separated and each flap turned in to cover one of the raw surfaces. CICATEICIAL FLEXION OF THE PHALANGES. The cicatrix must be divided thoroughly to allow com- plete extension, and then if skin flaps can be obtained from the sides they may be turned in to cover the palmar surface opposite the joints. In dissecting up the flaps care must be taken not to go deeply enough to involve the artery which runs along the side, otherwise the ends of the finger may slough. Instead of small lateral flaps for the flexures of the joints the skin covering the sides of the finger may be mobilized by lateral or dorsal longitudinal incisions and brought to- gether in the median line of the palmar surface, the gaps created on the sides by their removal being left to heal by granulation. NEUROTOMY AND TENOTOMY. 245 dupuytren's contraction of the fingers. Open Method. A. A simple transverse incision is made through the skin and palmar fascia wherever the band is most prominent, and the gap covered with a Thiersch skin graft. B. A longitudinal incision is made through the skin over the most prominent portion of the constricting band, and crossed at each end by a transverse incision. The flaps thus marked out are dissected up from the aponeurosis, which is then divided transversely or excised. Eesultant gaps in the skiu should be closed by flaps or skin grafts. INGROWN TOENAIL. The base of the toe is constricted with a rubber tourni- quet and a few minims of a 2 per cent, solution of cocaine in- jected on the sides and dorsum. The nail is then torn out (in all cases) with forceps, one blade of which is pushed up under it to free it from the matrix. Fig. 98. Ingrown toenail. A. A, B, D, C, flap operation (parts removed shown in B. A', B', C, D'). B. R,D', S, wedge operation— M', N', sho-ving part removed by Cotting's opera- tion. I. A rectangular flap, D, E, F, B (Fig 98, A), about one-quarter of an inch square, is made and the skin con- 246 OPERATIVE SURGERY. tained in it reflected. The strip of matrix underlying it (Fig. 98 A, A, B, D, C), and the corresponding- part of the nail in front, is then thoroughly dissected off, care being taken to carry the dissection eutirely beyond the base and side. The flap is next replaced and secured and a light dry dressing applied. II. The exuberant tissue and adjoining skin is pared off close up to the margin of the nail and matrix (M 7 , N'). The resulting wound is left to close by granulation. (Cotting). (Fig. 98 B, M', W and Fig. 99 A, M, N.) III. In certain cases a wedge-shaped piece can be ex- cised from the side of the toe, and by closing this gap with sutures the irritated part is drawn away from the nail. (R, S, D', Fig. 98 B). Fig. 99. A. X, Y, Auger's method. M, N, Cotting's method. B. X', Y', Anger's method (viewed from underneath). IV. Anger's Method. 1 With every antiseptic precaution the nail is split longitudinally in the middle and the half on the diseased side torn out. A knife is then made to transfix the toe vertically from beneath the overhanging fold of skin at the posterior angle of the exposed matrix, and is carried straight forward along the side of the pha- lanx through all the tissues, closely following the lateral border of the matrix. i Bull, et Mem. 'lit laSoC. do Chir. . 289. Also New York Medi- NEUROTOMY AND TENOTOMY. 247 The flap is turned back and the exposed granulation and epidermic tissue is ablated, and the uncovered matrix very thoroughly excised up to the split edge of the nail. The flap is then replaced and sutured, and the wound dressed antiseptically. THE OPERATIVE TREATMENT OF DISEASED CERVICAL GLANDS. The operations required in the treatment of diseased cer- vical glands comprise opening abscesses, scraping and slit- ting up sinuses, and partial or complete removal of the enlarged lymph nodes. When the latter have not become broken down aud matted together into an indistinct mass by inflammatory processes — in other words, when the glands can be felt as rounded, more or less movable tumors, each will be found enclosed in a distinct capsule, which, if once opened, permits of the gland being readily "shelled out" with a Yolkmann spoon. There remains only a small pedicle of vessels to be secured at the base of the node. Removal is ordinarily accomplished through a more or less longitudinal incision which follows the general direc- tion of the underlying structures, and is placed over the most prominent part of the tumefaction. This is gener- ally along the anterior or posterior border of the sterno- mastoid muscle ; occasionally it may be necessary to make it along nearly the whole length of both borders to obtain sufficiently free access to all the glands. The incision must be long enough to give a clear view of each structure as it is encountered, and to permit of ready control of the hemor- rhage. The difficulties attending a thorough removal of all dis- eased parts by even a double longitudinal incision are so great that Dr. Hartley, of New York, 1 has devised an operation in which cutaneous flaps are raised from the sur- face of the tumor. At first sight it appears unnecessarily severe, but the results hitherto have been excellent, and the scarring is not so noticeable as to offset the great advan- 1 This description has been revised by Dr. Hartley, wbo expects to publish bis method with a report of cases, 248 OPERATIVE SURGERY. tages gained by a complete exposure of all the important parts which are in close relationship with the enlarged glands. The incision is S-shaped (Fig. 100, B, C, D), and involves only the skin, subcutaneous tissue, aud fascia ; starting below the chin it passes in a curve downward and backward to Fig. 100. B, C, D, Hartley's incision for the removal of enlarged cervical glands. A. Point where the sterno-mastoid is divided. the hyoid bone, then np behind the angle of the jaw to near the lobule of the ear, whence it sweeps down along the an- terior border of the trapezius, forward over the sterno- mastoid, and downward and backward again to terminate above the middle of the clavicle. (Fig. 100). The flaps thus formed are dissected up, exposing nearly the whole length of the sterno-mastoid, and the latter cut transversely near its centre and the ends reflected, care being taken not to injure the spinal accessory nerve above. The point where the muscle is divided must not be in the line of the NEUROTOMY AND TENOTOMY. 249 cutaneous incision, but under the middle of one of the flaps, preferably the upper. (Fig. 100, A). The great ves- sels are thus exposed from the mastoid process to the cla- vicle, and the operator can excise the adherent and diseased glands and avoid injury to the adjacent important struc- tures. At the close of the operation the divided ends of the sterno-mastoid are united with catgut, the flaps replaced and loosely sutured in position, and drainage provided for in the most dependent angles. This large incision is only used when the glands in the superior and inferior carotid and submaxillary triangles are involved simultaneously. For less extensive disease the upper or lower flap may be employed alone, or one may be fashioned with a pedicle in a position the reverse of that shown in the figure. The incision for a single flap should approximately correspond to the circumference of the tumor, which is then exposed in its entirety by division of the sterno-mastoid below the joint where it is entered by the spinal accessory nerve. The flap consists of skin, subcu- taneous tissue, platysma, and fascia, and after reflecting it the muscle is always cut beneath the centre of the flap, and not in the line of the cutaneous incision. OSTEOTOMY. Osteotomy of the Femur — I. Through the Neck (Adams's operation), described on page 151. II. Below the Great Trochanter (Gant's operation), de- scribed on page 151. III. Osteotomy of the Shaft of the Femur. In a normal femur the epiphyseal line is about on a level with the tubercle of the adductor magnus and horizontal in direction. But in cases of genu valgum it is oblique and parallel with the articular surface. This is due to the fact that geuu valgum is produced by an overgrowth of the dia- physis of the femur and not of the epiphysis (Fig. 101). Osteotomy of the Shaft of the Femur from the Outer Side. The knee is partially flexed and supported on a sand-bag 250 OPERATIVE SURGERY beneath its inner surface. A longitudinal incision down to the bone is made on the outer aspect of the thigh about two inches above the top of the external condyle and in front of the tendon of the biceps. The osteotome is intro- duced, is turned at right angles to the long axis of the femur, and is driven with short strokes of the mallet at Fig. 101. .,■■*« . ■'■•'■ ■ ' fefgL 1 /i'i*li J." ■) \ ''• ,■". J ■ '.I -' \ Vertical section through the lower end of the femur in a case of severe genu valgum. Epiphyseal line. B. Transverse line drawn through the adductor tubercle. C. Line of bone section in Macewen's operation. least two-thirds th rough the bone, or far enough to render it easy for the operator to complete the division of the bone by fracturing it. This must be done cautiously, to avoid splintering, by first freely extending the knee and then ad- ducting the leg, while counter pressure is made against the inner surface of the thigh ; after each stroke of the mallet the chisel is loosened but not withdrawn. At the conclu- sion of the operation the wound is closed and dressed anti- septically, and the limb is immobilized in the corrected — straight — position. Macewen's Supra-condyloid Osteotomy of the Femur. The hip and knee are flexed, and the thigh supported on its NEUROTOMY AND TENOTOMY. 251 outer side. A longitudinal incision about one inch long is carried down to the bone on the inner surface of the thigh. It should be one-half an inch anterior to the tendon of the adductor magnus, and with its centre on a line drawn trans- versely a finger's breadth above the top of the external condyle. Before the knife is withdrawn the osteotome is slipped in by its side until it touches the bone. Its cutting edge is then turned at right angles to the long axis of the thigh, but without using pressure enough to tear off the perios- teum, with which it is kept in contact. The edge is passed over the inner surface of the bone until it reaches the pos- terior internal border, and is then driven from behind for- ward and toward the outer side. The internal surface is next divided, and after this the chisel is directed from be- fore backward aud toward the outer posterior angle of the femur. This definite order of procedure leaves the opera- tor certain of what has been divided and what is still to be done. The osteotome is not withdrawn till all the bone has been cut through except a thin shell on the outer sur- face of the femur. This is snapped or bent by adducting the leg, while counter pressure is made with the hand at the point of incision. The wound needs no sutures or drain- age, and is simply dressed antiseptically and immobilized in the straight position. IV. Ogston's Operation (division of the internal condyle). The point of a narrow-bladed knife is entered in the centre of the inner surface of the thigh about two inches above the adductor tubercle. With the edge directed toward the bone it is passed downward and outward over the inner and anterior surface of the femur till the groove between the front of the condyles is reached, and the joint opened. The cutaneous opening on the inner surface of the thigh is made large enough to admit a fine saw, and the junction of the internal condyle with the femur is sawn through ob- liquely. Many surgeons now prefer to use the chisel instead of the saw. By adducting the leg the loosened condyle is displaced upward on the femur, and the genu valgum thus cor- rected. 252 OPERATIVE SURGERY. This operation has been largely superseded by transverse division of the shaft above the condyles. Fig. 102. Fig. 103. Genu valgum. Genu valgum. OSTEOTOMY FOR BENT TIBIA. A longitudinal incision is carried down to the bone over its inner surface at the point where the abnormal curvature is most marked. At this point the bone is chiselled through transversely, partially or completely. The fibula usually does not need division. The opera- tion is completed by forcibly straightening the leg. In ex- treme cases a wedge-shaped piece of bone may have to be removed. Its base will usually correspond to the crest of the tibia. OSTEOTOMY FOR HALLUX VALGUS. A longitudinal incision about half an inch in extent is carried down to the periosteum on the inner surface of the first metatarsal bone. It should be placed so that a narrow- bladed osteotome can divide transversely the shaft of the bone just posterior to the enlarged digital extremity. NEUROTOMY AND TENOTOMY. 253 The toe is then forcibly brought inward into line with its metatarsal bone. But this simple division of the bone will rarely be found sufficieut. It is more often necessary to remove about a quarter of an inch of the shaft at this point. Then the digital extremity can turn on the trans- verse metatarsal ligament as a radius, and the end of the toe is brought much further inward. The operation of incision of the metatarso-phalangeal joint for this deformity should be condemned. CUNEIFORM OSTEOTOMY FOR TALIPES EQUINO- VARUS. A horizontal incision is made along the outer side of the foot from about the centre of the anterior portion of the outer surface of the os calcis across the cuboid to the base of the fifth metatarsal bone. If necessary this is joined at its centre by a liberating incision passing perpendicularly to the horizontal incision across the outer surface and dorsum of the foot to or over the scaphoid. The base of the wedge of bone to be removed will con- sist mainly of the cuboid with portions of the os calcis, the astragalus, and perhaps a part of the external cuneiform and base of the fifth metatarsal. The apex will correspond to a point on the inner surface of the scaphoid. The amount of bone which may need removal will of course depend upon the extent of the deformity, but in extreme cases it may include portions of all the tarsal and some of the metatarsal bones. In every case the cuboid will form a large proportion of the wedge. With a blunt periosteal elevator all the soft parts are de- tached from the bone that is to be removed ; the peronsei tendons are retracted or protected ; a thin blunt elevator may be pushed close under the plantar surface of the bones to protect the soft parts of the sole. The chisel is then driven in for the first bone cut, generally at the anterior end of the outer surface of the cuboid. It is directed toward the lower part of the scaphoid tubercle. The second line of bony division will usually need to pass just behind the anterior articular surface of the os calcis and through the neck of the astragalus to meet the first incision at the sca- 12 254 OPERATIVE SURGERY. phoid tubercle. This wedge of bone is then pried or wrenched out entire, while any remaining attachments be- neath are severed with blunt-pointed scissors or a knife kept close to the bone. If then it is found that the foot cannot be made to assume the proper position without ten- sion another slice of bone is chiselled off, especially toward the apex of the wedge. This may be supplemented by tenotomy of any resisting tendons. The thickened epider- mis and the bursa usually found over the site of the cuboid can be excised if there is found to be a redundancy of skin after straightening the foot. No wiring of the bones is necessary. The soft parts are sutured and the wound dressed antiseptically. Any oozing which may subsequently occur will dry and make of a simple antiseptic dressing a very useful splint. Of the great number of other operative procedures which may be used singly or in combination with each other or with cuneiform osteotomy for correcting pes varus or equino- varus mention should be made of tenotomy of resisting tendons (q. v.), extirpation of the astragalus (q. v.), extir- pation of the cuboid or of several tarsal bones simulta- neously, linear osteotomy of the tibia and fibula just above ankle-joint (q. v.), excision of a portion of the shaft of the fibula near the base of the external malleolus, followed by forcible abduction of the foot, 1 and Phelps's 2 operation. The latter, although not an osteotomy, will be described here. 3 It is extensively used for remedying talipes equino- varus, and consists in a simple division of all structures which re- sist correction of the deformity. The tendo Achillis is first divided subcutaneously ; then, while the foot is flexed dor- sally, abducted and everted, an incision through the skin is made from just in front of the internal malleolus verti- cally downward across the inner third of the sole of the foot. After making the parts tense the tibialis autieus and posticus, the deltoid ligament, part of the abductor pollicis, the plantar fascia, and the flexor brevis and lougus digito- 1 Hopkins : Annals of Surgery, April, 1895, p. 461. 2 New England Medical Monthly, ]8'J1. 1 This excellent operation is discussed and the results detailed in Transactions Am. Orthopaedic Asso., vol. vii. p. 43. NEUROTOMY AND TENOTOMY. 255 rum are severed as encountered in the wound. The plantar vessels and nerves are spared if possible, although their in- ternal branches have been cut without bad effect. As each structure is divided an attempt is made to forci- bly place the foot in its proper position. Phelps employs a powerful system of levers, and ruptures any resisting ligamentary or fibrous bands. When all opposition has been properly overcome the anterior segment of the foot can be bent backward in overcorrection, thus probably opening the astragalo-scaphoid and calcaneo-cuboid joints. Only in about 10 per cent, of all cases, according to the originator of this operation, will osteotomy be required. When necessary to correct the deformity after all the re- sisting soft parts have been cut, the neck of the astragalus should be divided from the inside ; then, if this is insuf- ficient, a wedge may be removed from the anterior por- tion of the os calcis ; the base of the wedge lies externally, the apex where the neck of the astragalus has been divided. The open wound on the inner side of the foot is either lightly packed with iodoform gauze or allowed to heal under a moist blood clot ; over this an antiseptic dressing is applied and encased in plaster of Paris, the foot being maintained in a slightly overcorrected position. CUNEIFORM OSTEOTOMY FOE TALIPES EQUINUS. Two horizontal incisions are employed. The inner incision passes along the internal surface of the neck of the astragalus and across the scaphoid to ter- minate at the internal cuneiform bone. The external inci- sion extends from the middle of the anterior portion of the outer surface of the os calcis across the cuboid to terminate at the base of the fifth metatarsal bone. The soft parts are raised from the dorsum of the foot, and a flat periosteal elevator can be passed close beneath the plantar surface of the bones to protect the soft parts of the sole. A wedge is then cut from the tarsal bones with the base on the dor- sum of the foot. Its extent will depend on the degree of the deformity, but the apex must reach to the plantar sur- face of the bones. A metacarpal saw or chisel can be used. 256 OPERATIVE SURGERY. The wedge, which may be extracted in one piece, will consist chiefly of the scaphoid and cuboid bones, with per- haps portions of the anterior extremities of the astragalus and os calcis. At the close of the operation the soft parts which have been divided are sutured and the foot immobilized with the bones in apposition. CUNEIFORM OSTEOTOMY FOE TALIPES VALGUS. An incision is begun just below the apex of the internal malleolus and carried forward two inches. The soft parts are carefully raised from the inner and under surface of the astragalus and a suitable wedge removed from it. The base of the wedge should lie below and include either the neck alone of the astragalus or the articular surfaces of the astrag- alus and scaphoid. OPERATIONS FOR UNUNITED FRACTURE. The aim of the operative treatment for old ununited fracture is to place the freshened ends of the bone in con- tact and to keep them immobilized in this position. A free incision is necessary. In general it should be in the long axis of the limb, and so placed as to reach the point of fracture by the shortest route with the least pos- sible damage to nerves and vessels. Any tissue which may be found intervening between the ends of the bone is dis- sected out and removed. It will often be found advan- tageous to protrude the ends of the bone through the wound. The extremity of each fragment is then pared off with the rongeur or chisel till fresh cancellous tissue is ex- posed over the whole section of the shaft. If, the frag- ments override, enough bone is removed to allow the ends to be easily brought into apposition. In such cases the exposed ends of the bones are sometimes dovetailed into each other or sawn off in such a manner as to bring large surfaces in contact. Then nails or pegs are driven in at right angles to the shaft. If these latter are employed I here is a great probability of suppuration, with more or NEUROTOMY AND TENOTOMY. 257 less necrosis, and they should always be placed with a view to their early subsequent removal. Wiring is to be con- demned as superfluous. It will seldom be found necessary to do more than freshen the ends of bone and maintain them in quiet apposition with a suitable splint. If there is the least doubt about their remaining in this position while the spliut is applied and subsequently, it is better to drill a small hole about half an inch from the fracture line on each side and tie the ends together with a piece of kan- garoo-tendon or stout chromicized catgut. This of course has no great strength, but if the limb is haudled carefully it will keep the bones in contact and prevent the interposi- tion of soft parts till the limb has been immobilized. In addition to this the periosteum is as far as possible preserved, and any divided soft parts in the neighborhood should be placed in proper position and reunited. This will serve as a sling for the bones to rest in. The wound is then closed layer by layer and dressed antiseptically, with provision for temporary drainage. If pegs or nails have been used they should reach to the skin surface and be included in the dressings. SUTURE OF THE PATELLA. I. Open Method. Every antiseptic precaution is necessary. A median longitudinal incision is made about three inches in extent, its centre opposite the point of fracture. Everything is divided down to the bone. Any bloody effusion or coagu- lum between the fragments is simply pressed out, and noth- ing is introduced into the interior of the joint. Interposed fibrous and periosteal shreds are cleared away. The bone is drilled in the median line on each side of the point of fracture. Both holes are oblique and start on the anterior surface of the bone half an inch from the edge of the frac- ture. They should terminate opposite each other in the fractured surface close to but not including the articular cartilage. The fresh surfaces of bone are then brought into accurate contact by a silver wire passed through the drill holes. The 258 OPERATIVE SURGERY. wire is cut short and the ends hammered into the bone or left to protrude from the wound, to be subsequently with- drawn. A better procedure is to use silk or silkworm-gut instead of wire. The skin wound is then closed and dressed antiseptically and the leg immobilized by a plaster-of-Paris splint. Fig. 104. Mediate suture for fracture of the patella. II. Mediate Silk Suture (Fig. 104). This may be done with cocaine anaesthesia, but the chance of infection is somewhat increased thereby. A longitudinal median incision is made extending well above and below the fragments. Clots are removed from the joiut and the fibro-periosteal fringe lifted up if one has been found. Then, with a full-curved needle, a stout silk ligature is passed transversely through the ligamentum patella? close to the apex of the patella, then transversely in the opposite direc- tion through the tendon of the quadriceps close to its inser- tion, and then drawn tight and tied while the fragments are held together. The incision is then closed without drainage. Many other more or less complicated methods of holding the fragments together have been devised ; this one seems to be as simple as any, and has proved to be efficient and safe in more than fifty personal cases. OPERATION FOR NON-UNrON AFTER FRACTURE OF THE OLECRANON PROCESS. A median longitudinal incision is made over the posterior surface of the olecranon and ulna, exposing the bone at the NEUROTOMY AND TENOTOMY. 259 point of fracture. The interposed fibrous tissue is cleared away and the ends of the fragments freshened. The ole- cranon and ulna are drilled obliquely without perforating the articular surface. The holes start on the posterior sur- face about one-quarter of an inch from the edge of the fracture and terminate in the fractured surface. The fragments are drawn together with a silk suture or silver wire, as in the patella, and the limb immobilized by an antiseptic dressing in complete extension. Mediate suture, with silk passed through the tendon of the triceps and a hole drilled transversely through the shaft of the ulna half an inch or more below the fracture, is probably to be preferred to direct suturing. LAMINECTOMY/ An incision five or six inches long is made in the median line over the summit of the spinous processes in question, and quickly deepened close to one side of them till the lamina? are exposed, from which the periosteum with the attached muscles is raised with an elevator out to the artic- ular and transverse processes. The bases of the spinous processes are next cut through with a chisel or bone for- ceps, and the opposite laminae freed in the same way of periosteum and muscle, without disturbing the muscular at- tachments of the spinous processes. Some operators prefer to make two parallel incisions on each side of the spinous processes, which are then excised, and Horsley, to better expose the lamina?, divides the lumbar aponeurosis and muscles at right angles to the mid- dle of the longitudinal incisions. The sides of the wound are well retracted and the lamina? are divided close to the transverse processes with a rongeur, bone forceps, or chisel, and the posterior arch thus removed. If the trouble is not then apparent before opening the dura a probe should be passed up and down to make sure that the cord has been exposed in the proper locality. If, 1 Thorburn: Surg, of Spin. Cord. Lloyd: Amer. Journ. Med. Sciences, 1891, vol. 102, p. 25. 260 OPERA TIVE SURGES, Y. then, it is considered necessary, the dura is pinched up and opened longitudinally in the median line behind. Subsequently the wound in the dura is closed with fine catgut or silk sutures and the overlying parts brought together by buried and superficial sutures over a drainage- tube placed in the deepest portion of the wound. PART VI. PLASTIC OPERATIONS ON THE FACE. Plastic operations are required for the relief of congen- ital defects or for the restoration of parts lost by disease or injury. The methods most commonly employed are of two kinds : 1. By Approximation of the Edges. This is applicable to cases in which the loss of tissue is not great and the ad- joining parts are supple. The edges of the gap are simply pared and brought together. It is sometimes necessary to make " liberating incisions " on one or both sides for the relief of tension. 2. By Transfer of a Flap. A flap of suitable shape and size is dissected up and transferred, by turning it about its base, to the place where it is needed, its vitality being insured by the preservation of its base or pedicle. This method admits of a great variety of modifications in its details, from a simple sliding of a skin flap, which differs but slightly from the method by approximation, to the transfer of skin, muscle, and bone, or the taking of the flap from another limb or individual. The names Indian, Italian, French, and German methods have been given to the different varieties, but Verneuil 1 has pointed out the impropriety of continuing to employ them, especially since at least two of them, the French and Ger- man, have their origin in an oversensitive patriotism not mindful enough of the actual facts. The Indian and Italian methods were first employed for the restoration of the nose; in the former a flap was taken from the forehead and brought down by twisting the pedicle which occupied the space be- 1 M6moires de Chirurgie, vol. i. Chirurgie RSparatrice, p. 401. 12* 262 OPERATIVE SURGERY. tween the eyebrows. The term is now applied to any oper- ation in which the flap is made with a long pedicle situated at some distance from the space which the flap is to cover, and in which also the flap is brought into place by rotation over a greater or less arc described about the base of the pedicle as a centre (see Fig. 133). In the Italian method the flap is taken from a distant part of the body, as in restoration of the nose by a flap taken from the arm (Fig. 135). Tagliacozzi, of Bologna, the originator of this method, allowed the flap to suppurate for a few days, so as to increase its thickness, before fas- tening it in its new situation. Graefe sought for primary union, and gave, rather pompously, the name German method to this modification, ignorant of the fact that it had been suggested more than a century before by Reneaulme de la Garanne, and unmindful of the other fact that it contained no new principle, and must have been entertained by Tag- liacozzi, and only rejected for the sake of another advantage incompatible with it. In the so-called French method, the principles of which are found in Celsus, the flap has a broad base, and is brought into place, not by rotation, but by traction in the direction of its axis (Figs. 116 and 128). The variations and com- binations of these methods are now so numerous that the names no longer have much descriptive value. General Principles. The edges of the flaps must be brought together without tension, and united very accu- rately by means of fine silk, catgut, or silver sutures ; and it is well to cut the edges obliquely so as to have a broader surface of contact as proposed, I believe, by Dr. Packard. All hemorrhage "must cease before the flaps are brought into place. The presence of a clot of blood under a trans- ferred flap is one of the most common causes of failure. Flaps must be taken from healthy non-cicatricial skin, and whenever the skin is thin and not very vascular the subcu- taneous layer should be taken with it to insure its vitality. The base of a flap should occupy the quarter from which the main supply of blood is received, and the direction and shape of tin.' nap should hi' such that it can be brought into place with the least amount of twisting of the base. PLASTIC OPERATIONS ON THE FACE. 263 The flap should be made considerably larger than the space it is to fill, and, to insure accuracy, it is well to cut it according to a pattern previously made of paper or oil silk. It is well also to mark the angles by fine pins plauted erect in the skin. The raw surface left by the dissection of a flap may be partly covered by drawing its edges together with sutures ; the remainder must be left to granulate or may be covered by Thiersch grafting. Dr. Gurdon Buck 1 recommended a dressing for it which he calls the " collodion crust ;" it is made by covering the surface with dry scraped lint, and then with an additional layer of lint saturated with col- lodion. Every antiseptic precaution is necessary to prevent or diminish suppuration, and thereby restrict the formation of cicatricial tissue. If strict asepsis is observed greater ten- sion can be made with the sutures than would otherwise be safe, and the chances of failure or of the occurrence of ery- sipelas, for instance, become less. CHEILOPLASTY. A. Lowe?' Lip. Restoration of the lower lip is usually undertaken to make good the loss of substance occasioned by the removal of an epithelial tumor. The choice of a method depends upou the extent of the disease. 1. M-Incision (Fig. 105). When the tumor is small, involving not more than one-quarter or one-third of the lip, it may be removed by a V-incision, and the sides of the gap brought together with one or two points of twisted suture. The mucous membrane on the inside of the lip should be excised to the same extent as the skin, although it is not usually involved in the disease. If not removed it forms a disagreeable fold or pucker in the lip. The harelip pins must be deeply placed, passing close to the mucous membrane on the inside. This insures confron- tation of the raw surfaces throughout their entire breadth, and the pressure of the twisted sutures prevents hemorrhage. 1 Reparative Surgery, 1876, p. 13. 264 OPERA TIVE S UR GER Y 2. Oval Horizontal Incision (Fig. 1 06). When the tumor covers a considerable extent of surface, but does not pene- Fig. 105. Cheiloplasty, V-incision. trate deeply, it may be safely excised by cutting under it with curved scissors. The mucous membrane and skin Fig. 106. Oval horizontal incision. may then be stitched together, or the wound allowed to heal by granulation. PLASTIC OPERATIONS ON THE FACE. 265 3. Method of Cehus or Serves (Figs. 107 and 108). The V-incision is supplemented by a horizontal one on each side carried outward from the angle of the mouth for about two inches, and comprising the whole thickness of the cheek for Fig. 107. Fig. 108. Cheiloplasty. Celsus's incisions. Cheiloplasty. Celsus's flaps in place. the first two-thirds of its length, but dividing the mucous membrane at a somewhat higher level than the skin. The lower gingivo-labial fold is divided close to the gum on both sides, and the dissection carried downward close to the periosteum, and backward toward the angle of the jaw until Fig. 109. Cheiloplasty. Dieffenbach's method. the edges of the gap in the lip can be brought together without tension. The sides of the V are then brought together, and the lip formed from the lower parts of the horizontal incisions (Fig. 108). The mucous membrane and skin are stitched together along the edge of the new lip, and the remaining portion of the lower flap on each 266 OPERATIVE SURGERY. side (that which remains external to the new angle of the mouth) is reunited to the upper flap. The mucous mem- brane at the outer end of the horizontal incision is stitched to the skin and covers the angle. 4. Dieffenbach (Fig. 109) adds a vertical incision at the end of each horizontal one, thus marking out two quad- rilateral flaps which are brought together in the median line. The gaps left in the cheek by the transfer are allowed to close by granulation. Fig. 110. Fig. 111. Syme-Buchanan incisions. Syme-Buchanan flaps in place. 5. Syme-Buchanan (Figs. 110 and 111). The method by latero-inferior flaps is ascribed by some to Syme, by others to Buchanan, of Glasgow. After the tumor has been removed by the usual V-inci- siou, the incisions are prolonged downward and outward for nearly an inch, aud then curved upward and outward. These flaps are dissected off the bone aud brought together in the median liue. The mucous membrane and skin are stitched together along the upper edge, the gaps left below by the shifting of the flaps drawn together as much as possible, and the remainder left to heal by granulation. RanJce aud TrSlat (Figs. 112 and 113) make the flap on one side longer, and lift it over the other to form the new lip, the shorter flap being used as a support for the former. 6. BucVs Method (Figs. 1 14 and 115). Buck preferred to make two operations. lie first removed the tumor by the V-incision, brought the sides of the gap together, and allowed them to unite. After the union had become com- PLASTIC OPERATIONS ON THE FACE. 267 plete be restored the angle of the mouth and lengthened the lower lip with material taken from the upper one by the following method :* Fig. 112. Fig. 113. In Fig. 108, B B represent two pins inserted a finger's breadth below the under lip border, one on either side of the chin, a little to the outside of the angle of the mouth, and equidistant from the median line ; D D are also two pins inserted, one on either side, into the upper lip at the Fig. 114. Restoration of lower lip. Buck's incisions. margin of the vermilion border, equidistant from the me- dian line, and at such distance apart as to include between them sufficient length of lip border for a new upper lip. 1 Reparative Surgery, 1876, p. 22 et seq. 268 OPERATIVE SURGERY. The steps of the operation are then the following : With the forefinger of the left hand placed on the inside of the month, the left cheek is to be kept moderately on the stretch while it is transfixed with a sharp knife at the point B. An incision is then carried through the entire thickness of the cheek, upward and a little outward, a distance of one inch and a half to a point, E, near the middle of the cheek. The corresponding side of the upper lip should next be Fig. 115. Restoration of tbe lower lip. Buck's flaps in place. transfixed at the point D, and the incision carried through the lip and cheek outward and a little upward to join the first incision at JE. The next step is to transfer the triangular patch, thus marked out, from the cheek to the side of the chin. For this purpose an incision should be made on the side of the chin from B vertically downward to the edge of the jaw and to the depth of the periosteum. The edges of this incision, retracting wide apart, afford a V-shaped space for the lodgment of the triangular patch, which is now brought around edgewise, and adjusted by sutures in its new posi- tion (see Fig. 115). The gap left in the cheek is closed by bringing its edges together and securing them in contact by sutures. By this adjustment a new and naturally shaped angle is formed for the mouth at the point J). The incisions should be made with the utmost precision, and special care should be taken that the lining mucous membrane is divided exactly to the same extent as the skin. The same procedure may be applied to the other side of the mouth, and executed at the same operation. PLASTIC OPERATIONS ON THE FACE. 269 7. Square Lateral Flaps, Malgaigne (Fig. 116). The tumor is circumscribed by two vertical incisions carried downward from the edge of the lip, and a third horizontal Fig. 116. Cheiloplasty. Malgaigne. one unitiDg the lower ends of the first two. To fill the square gap thus created, two horizontal incisions are made on each side — one from the angle of the mouth, the other from the lower corner of the gap. The flaps circumscribed by these incisions are brought forward and united in the median line, and the mucous membrane stitched to the skin along the edge of the lip and at the commissures. (See also 3. Method of Celsus, p. 265, and Stomatoplasty, v. inf.) Fig. 117. Cheiloplasty. Sedillot. 8. Square Vertical Flaps (Fig. 117). Sedillot made the flap at right angles to the line of the mouth. The incisions 270 OPERATIVE SUEGEBY. are shown in Fig. 117. Each flap is swung around to meet the other in the median line, its iuner vertical border becoming the edge of the lip. B. Angle of the Mouth (Stomatoplasty). An attempt to restore a large portion of either lip by means of material taken from the other, or to close a gap by simple approx- imation, not infrequently leaves the mouth small, rounded, and pouting, with obliteration of one or both angles. This defect can be overcome by the operation described (p. 266) as Buck's method of restoration of the lower lip, or by extending the mouth laterally by a horizontal incision in- volving both skin and mucous membrane, and then pre- venting reunion by stitching the skin and mucous mem- brane together on both sides and at the angle of the incision. Sedillot considers it indispensable to excise a portion of the skin so as to have a comparative excess of mucous mem- brane, which when stitched to the skin will roll outward and form a vermilion border. This simple method has been modified by Dr. Buck as follows : Buck's Operation 1 for Enlargement of the Mouth and Restoration of its Angle. (Fig. 118.) An incision is made with great exactness along the line of the vermilion border circumscribing the circular half of the mouth, and extending to an equal distance on the upper and lower lips (a to b). This incision should only divide the skin, without involving the mucous membrane. A sharp-pointed, double-edged knife should then be inserted at the middle of this curved incision, and directed flatwise toward the cheek, between the skin and mucous membrane, so as to separate them from each other as far as the new angle of the mouth re- quires to be extended. The skin alone is next divided from the commissure of the mouth outward toward the cheek. The underlying mucous membraue is then divided in the same line, but not so far outward. The angles at the outer ends of the two incisions are then accurately united by a single thread suture. The fresh-cut edges of skin and mucous membrane above and below, that are to form the 1 Reparative Surgery, p. 28 et seq. PLASTIC OPERATIONS ON THE FACE. 271 new lip borders, are shaped by paring first the skin and then the mucous membrane in such a manner that the latter Lengthening of the mouth. Buck. shall overlap the former, after they have been secured to- gether by fine thread sutures inserted at short intervals. Fig. 119. Fig. 120. Cheiloplasty of upper lip. Sedillot. Sedillot. Flaps in place. C Upper Lip. The V-incision and the oval horizontal incision (p. 264) may be used when the loss of tissue will 272 OPERATIVE SURGERY. be small. Also the square lateral flaps (p. 269) when the 2;ap to be filled is iu the centre of the lip and rather large. 1. Vertical Flaps (Figs. 119 and 120). These may be made with the base directed upward (Sedillot) or down- ward (Chauvel). Chauvel claims that the latter method is to be preferred because the retraction of the cicatrix in the former tends to draw the new lip upward and expose the teeth. The flaps comprise the entire thickness of the cheek, are turned inward at right angles to their former position and united in the median line. The gaps left in the cheek by their removal are brought together with sutures or left to granulate. 2. Infero-lateral Flap (Buck). Fig. 121. For loss of the right half of the upper lip Dr. Buck employed the fol- lowing method, enlarging the mouth afterward and re-estab- lishing the angle by the method described above (p. 270) : Fig. 121. Repair of upper lip by infero-lateral flap. Buck. The extremity of the under lip, where it joined the right cheek, was divided through its entire tliiekness at right angles to its border, and the division carried to the extent of one inch from the border (a to l>, Fig. 121). A second incision was made from the terminus of the first parallel to PLASTIC OPERATIONS ON THE FACE. 273 the lip border for a distance of one inch and a half toward the chin, 6 to c. The quadrilateral flap thus formed from the under lip was folded edgewise upon itself, and made to meet the remaining half of the upper lip, and be adjusted to it by its free extremity. In order, however, to make this fold, the under lip had first to be divided obliquely half across its base, c to d. The left half of the upper lip was prepared for the new adjustment by dividing the buccal mucous membrane close to the jaw and detaching the parts above toward the orbit from the underlying periosteum, and secoudly by paring a strip of vermilion border from the extremity of the half-lip of sufficient length to permit the end of the half-lip to be matched to the free extremity of the under-lip flap. The parts concerned having been thus prepared, the under-lip flap was doubled edgewise upon itself, and its free extremity adjusted to the half of the upper lip, and the two secured to each other in a vertical line below the columna nasi by sutures. The space between the newly adjusted half of the mouth and the neighboring cheek was closed by ap- proximating the opposite parts and securing them to each other by sutures after their edges had been carefully matched. (Fig. 118 shows the result of this operation.) HARELIP. If the patient is a youug child its arms should be securely bound to its sides with a towel, and its head firmly held by an assistant. After anaesthesia has been obtained it can be easily kept up by applying to the nostrils from time to time sponges saturated with ether. Single Harelip, Simple. The simplest method of opera- ting is to pare the sides of the cleft and bring the raw surfaces together by a few sutures. The objection to the method is that the retraction of the scar produces a more or less considerable depression in the free border of the lip. It has therefore been generally abandoned for one of the following : 1. Double Flaps (Fig. 122). In order to hold the parts 274 OPERATIVE SURGERY. upon the stretch and insure precision in making the cuts, a stout ligature should be passed through the lip at each angle of the cleft, or each angle should be seized with artery forceps. The lip beiug drawn forward and downward by means of the ligature or forceps, the mucous membrane is divided close to the gum and the dissection carried upward and backward as far as may be necessary to allow the sides of the cleft to be brought together without teusiou. Fig. 122. Simple single harelip, double flaps. A. Incisions. B. Flaps turned down. C. Ligature for hokliug lip tense. D. Incisions to shorten and adjust flaps. E. Thread passed through the ends of the flaps. Then making one side of the cleft tense, by drawing upon its ligature, the lip is transfixed near the angle and the incision carried upward along the border of the cleft to its top, or, if necessary, into the nostril, thus cutting out a narrow flap which remains attached at its lower extremity to the lip (Fig. 122, A). A similar flap is then made upon the other side, the two are turned down, so that their raw surfaces face other, and a thread passed through their free ends (Fig. 122, E). The freshened edges of the cleft are then confronted, a harelip pin placed near the vermilion border and another near the nostril, and two or three fine silk or silver sutures inserted between them. The ends of the dependent flaps are then cut off' obliquely, enough being left to form a dis- tinct projection on the lip after they have been united with fine sutures. By this means the formation of a notch by the retraction of the cicatrix is avoided. 2. When the cleft was shallow, Nolaton left the flaps attached to each other at the apex, turned them down, and PLASTIC OPERATIONS ON THE FACE 275 brought the raw surfaces together as above described (Fig. 123.) 3. Single Flap (Fig. 1 24.) A flap is made upon one side only, usually the shorter portion of the lip. The oppo- FlG. 123. Harelip. Nelaton's method. A. Incision. B. Flap turned down. site side of the cleft, and a portion of the free border of the lip adjoining it are freshened by the removal of a strip of skin and mucous membrane. The sides of the cleft are Fig. 124. Harelip. Single flap. approximated, and the flap applied to the free border of the lip. Fig. 125. Harelip. Giraldes's method. 4 Giraldes's Method (Fig. 125). This is applicable only when the cleft extends into the nostril. The flap on 276 OPERATIVE SURGERY. the short side is made, as before described, with its base below ; that on the long side is reversed, being left attached at its upper end. A third, horizontal incision is carried outward from the edge of the nostril, at the point of the first flap, to make that portion of the lip more movable. The second flap is then turned upward across the nostril, the first brought down to take its place, and the two raw surfaces thus brought into contact united by sutures. The long side of the lip may also be mobilized, if desirable, by a horizontal incision running from the gap close below the columna and the corresponding nostril. Double Harelip, Simple (Fig. 126). Flaps are made upon the lateral portions, A and B, as before described (p. 273, I), and the sides of the central portion, C, are pared. The flaps are then brought together, as shown in the figure, after mobilizing the lip by free division of the gingi vo-labial fold aud carrying the dissection well upward and outward, pins passed to include the sides and the central portion at the base and apex of the latter, the flaps trimmed and united with fiue sutures. Fig. 126. Double harelip. li' the parts are too scanty to permit the use of this method, liberating incisions must be made around the ahe nasi, or flaps obtained from the cheek. (See Upper Lip, p. 272 el seq.) Complicated Harelip. Harelip may be complicated by fissure of the palate and alveolar process. When the fissure is single the bone on the long side of the lip projects beyond PLASTIC OPERATIONS ON THE FACE. 277 its proper line. In very young children, it may sometimes be forced back into place by making pressure upon it with the thumb, but it is easier to fracture it first with Butcher's pliers ; the bent blade of this instrument being applied upon the anterior surface near the further nostril. The two por- tions of the alveolar arch soon unite after they have been brought into contact, especially if the opposing surfaces have been pared. Sutures are not needed. When there is double fissure, the intermediate portion of bone containing the incisor teeth projects so far that it seems to be an appendage of the nose rather than of the mouth. In order to restore it to its place, it is necessary to divide the vomer with strong scissors, or, better, to cut a triangular piece out of the septum of the nose. It is not necessary to fasten the bones together with sutures. The portion of skin covering the projecting bone must be dis- sected off, and used to lengthen the columna nasi or fill out the lip. In extreme cases it may be proper to cut away the pro- jection entirely ; but whenever it can be saved and brought Fig. 127. Cheek compressor. into line, it renders valuable service by giving the upper jaw its proper length, and furnishing a space into which artificial teeth can be fitted. The three or four teeth which are found in this piece are always so defective and irregu- larly placed that they have to be drawn. It is sometimes desirable to take the strain off the sutures 13 278 OPERATIVE SURGERY. by means of a cheek compressor, simular to that represented in Fig. 127. For uranoplasty, etc., see Operations upon the Mouth. EHINOPLASTY. The different kinds of rhinoplastic operations may be classified according to the nature and extent of the loss which they are designed to repair: 1st. A superficial loss not involving the bones or septum. 2d. Loss of the septum and nasal bones, the skin remaining entire. 3d. Loss of more or less of the surface and septum. As the loss of tissue is always the result of injury or dis- ease, it presents so many variations in form and extent, that it is difficult in practice to determine the exact boundaries between the classes, and this classification is chosen for con- venience of description, and not with the intention of limit- ing the choice of an operation in any given case to those described in the class to which the lesion might belong. For the same reason, a description of an operation as actually performed will sometimes be more serviceable than any general rules that might be laid down. As may be readily understood, the existence or non- existence of the septum and nasal bones affects materially, not only the method of operating, but also the result. If unsupported centrally, the new member tends constantly to shrink and flatten, and the surgeon has the mortification of seeing that he has merely substituted one deformity for an- other. Oilier tried to meet this want by including the peri- osteum in the flap taken from the forehead by the Indian method. There was, however, no new formation of bone, and the operation in that respect was a failure. On another occasion he took a strip of healthy periosteum from one of the limbs, and tried to graft it under the skin of the fore- head, hoping thereby to procure a lamella of bone, which could be used to give solidity to the new nose. Thinking the graft had failed, he withdrew the strip of periosteum after a few days, and then discovered that it had united nicely at one point. There is reason, therefore, to think that a more patient repetition of the experiment might be PLASTIC OPERATIONS ON THE FACE. 279 successful. On a third occasion, he included the periosteum of the forehead in a flap transferred by a modification of the French method, and by folding it together longitudi- nally along the centre he got reproduction of bone where the two layers faced each other. 1. /Superficial Defect not Involving the Bones or Septum. If the loss of tissue is confined to the integument, that is, if the cartilage is spared, as it usually is in cases of epi- thelioma, no plastic operation should be undertaken. The tumor must be carefully dissected off, and the wound grafted or left to granulate. The slight mobility of the integu- ment of the region prevents deformity by cicatricial retrac- tion, and the wound heals over, leaving a scar which does not contrast offensively with the neighboring skin. If, on the other hand, there is a gap to be filled, one that is small and does not involve the free border of the ala, square lateral flaps may be made by horizontal incisions (Fig. 128), and drawn together after they have been ren- dered freely movable by dissection from the underlying parts. Fig. 128. Rhinoplasty. Lateral flaps. If the gap is larger, or if one of the ala? is lost, suitable oblique or vertical flaps may be taken from the nose or cheek and transferred by rotation. Three of the many variations of this method are shown in Figs. 129 and 130. Fig. 129, A, represents a vertical flap taken from the cheek beside and below the nose, and left adherent at its 280 OPERA TIVE SURGER Y. upper end. The flap should be cut long enough to allow a natural appearance to be given to the free border of the ala by turning it in upon itself. This device will also prevent excessive cicatricial contraction of the border and conse- quent narrowing of the nostril. Fig. 129. Fig. 130. Rhinoplasty. A. Single lateral flap. B. Langenbeck's method. Rhinoplasty. Denonvillier's method. Denonvillier's Method (Fig. 130) sometimes makes it possible to secure this object more certainly by supplying a border that is already cicatrized. Supposing the lower portion of an ala to be lost, a triangular flap, left adherent to the lobe of the nose, is marked out by an incision which, starting from a point near the lobe on the unaffected side of the median line, is carried directly upward nearly to the root of the nose, and thence obliquely downward to the upper outer corner of the affected ala. The flap is mobi- lized by careful dissection of the bone and cartilage, and transferred downward. The gap left by the transfer heals by granulation or can be closed by a Thiersch graft. For the sake of giving more stiffness to the border, Denonvil- lier sometimes included a strip of cartilage in it. Von LangenbecW restored an ala by taking a triangular flap from the opposite side of the nose (Fig. 129, B). The flap was left adherent at the apex of the triangle, which lay near the inner angle of the eye of the affected side, I. gaisde Chirm-gin I'lastique d'apres les Preceptes du Prof. B. von Langen- bcek, Bruxelles, 18. r >ii, quoted by Vernuuil. PLASTIC OPERATIONS ON THE FACE. 281 while its base occupied the opposite ala. It was dissected up carefully so as not to include the cartilage, transferred to the other side, and fasteued to the freshened edges of the gap. The wound left by the removal of the flap healed by grau ulation, and so perfectly that it was difficult to recog- nize there had been any loss of tissue at that point. Michon restored the ala by taking a triangular flap from the septum. The base of the flap was placed anteriorly, parallel to the ridge of the nose, and the apex lay near the junction of the septum with the floor of the nasal fossa. The flap was dissected up and attached to the margin of the loss of substance, its mucous surface directed outward, its apex made fast to the cheek. The columna, with or without the tip of the nose, can be restored from the upper lip. Dupuytren and Dieffenbach cut a vertical cutaneous flap, adherent at its upper end, im- mediately below the columna, turned it upward, twisting it upon its pedicle so that its cutaneous surface remained external, and secured it in place. As the twisting of the pedicle created considerable deformity, Sedillot and Blandin made the flap of the entire thickness and length of the lip, pared off its cutaneous surface, and turned it directly upward without twisting the pedicle, the mucous membrane thus forming the outer surface. The gap left in the lip was then closed with sutures. In Blaudin's case the result was excellent, and the mucous membrane gradually assumed the characteristics of ordinary skin ; but in Sedillot's case, in which the tip of the nose had also to be restored, the mem- brane remained red and covered with thick epidermic scales, and the end of the nose looked much like a cherry. 1 In all his rhinoplastic operations Liston made the columna separately by this method, and found that the mucous mem- brane soon took on the appearance of ordinary integument. 2. Loss of the Septum and Nasal Bones, the SM71 re- maining entire. Baron Larrey, about 1820, operated upon a soldier the bridge of w r hose nose had been shattered and depressed by the explosion of a gun. He removed the de- formity by dissecting up the adherent portions of skin and 1 Sedillot : Medecine Operatoire, 2d ed., vol. ii. p. 233. 282 OPERATIVE SURGERY. replacing them in their original position. The details of the operation are lacking. Dietfenbach published in 1829 the description of an ope- ration by which he overcame the great deformity resulting from the loss of the septum and bones of the nose by scro- fulous disease. As the case is a classical one, quoted, aud often very incorrectly, 1 in the text-books, and is an indica- Fig. 131. Dieffenbach's operation. B. The result. C. The flaps. tion of what may sometimes be accomplished in extreme cases, the following description of it is given : 2 The patient was a girl twelve years of age. She had lost the ossa nasi, nasal process of the ethmoid, vomer, and cartilages,' and instead of a prominent nose there was a deep pit with a ridge at the bottom. The plan of opera- tion was to divide the remains of the old sunken member into portions, raise them up, aud secure them in the proper position. Dieffenbach passed a narrow-bladed knife first i The description in Holmes's System of Surgery, vol. v. p. 670, is almost nn- recognizable. It is taken from Malgalgne's incorrect account, and also contains al leiist one gross error in translation - As the original work could not be obtained, this description is made up from BH English translation of the hook, published in 1888, a French translation of the case in the Gazette Mfidlcale, vol. i. p. 65. 1880, and a brief description with plates, in a collection of Dieffenbach'fi riaslic Operations, published by two of hi:- pupils in 1846, PLASTIC OPERATIONS ON THE FACE. 283 iuto one nostril and then into the other, and cut out, mak- ing two incisions, one on each side of the sunken ridge (Fig. 131, C). The strip of skin between these incisions was three times as broad at its lower end, where it was con- nected with the upper lip by the shortened columna, as at its upper part where it joined the forehead. The cheeks were next cut through down to the bones on each side by inserting the knife a few lines below the upper end of the first incision and carrying it obliquely downward, parallel and a little external to the side of the nose, and then around into the nostril, thus separating the lateral attachments of the alse nasi. The columna, being too short, was then elongated by two slight incisions in the upper lip, and the cheeks rendered more movable by dividing their attach- ments to the bone through the lateral incisions. The flaps were then raised, the sides of the incisions pared obliquely in a manner to which Dieffenbach attaches an importance that seems undeserved, reunited, and fixed with harelip pins and sutures, and the whole retained in place by draw- ing the cheeks toward the median line and fastening them there with two long pins passed under the nose and through the detached edges of the cheeks. This compression was aided by two splints of leather through which the pins passed. A quill covered with oiled lint was introduced into each nostril. Osteoplastic Method. Oilier treated successfully a some- what similar case by making a triangular flap, its base con- stituted by the lower portion of the nose and the adjoining cheeks, its apex situated one and a half inches above the eyebrows. The frontal portion of the flap included the underlying periosteum. The left nasal bone and vomer having been destroyed by the disease, central support could be obtained for the new nose only by aid of the right nasal bone, which was accordingly loosened with a chisel and forced downward. The flap was then transferred down- ward, pinched in laterally to increase its height at the bridge, and supported there by drawing the cheeks, previously loosened from their underlying attachments, toward the nose and fastening them there with long pins. 1 1 For further details of this operation the reader is referred to the original ac-- count in the Bulletin de la SociSte de Chirurgie, 1862. p. 62, or to its reproduction 284 OPERATIVE SURGERY. Double Layer, or Superficial Flaps (Fig. 132). Ver- neuil 1 employed successfully a method suggested to him by Oilier, iu which permanent elevation of the bridge of the nose was secured by superposiug two flaps and thereby doub- ling the thickness. The patient had discharged a pistol into his mouth, causing the destruction of a portion of the hard palate and septum, the nasal bones, part of the nasal processes of the superior maxillary, the spine of the fron- tal, and the anterior wall of the frontal sinuses. The alye and lobe were uninjured but much flattened ; above them was a broad deep groove extending to the middle third of the forehead. The two principal indications were to bring the lateral portions nearer the median line and to reconsti- tute the bridge of the nose. The latter could be perma- nently accomplished only by filling in the great cavity which would be left by raising the sunken parts. Fig. 132. -i_i* Rhinoplasty, sunken nose. Double layer, or superposed flaps. Verneuil. Verneuil made an incision along the median line of the depression and a transverse one at each end of the first, and dissected up the two lateral flaps thus marked out. He then raised an oblong flap from the middle of the fore- head, its base remaining adherent between the eyebrows, in Verneuil's Chirurgie Koparatrice, p. 428, and in the Gazette Hebdomadaire, I -v>i. \). !«, and also to a similar operation described more fully on pp. 288, 289 of i hie manual, I Chirurgie Rc'-paratrice, p. 428, and Hull, de la Soc. do Chirurgie, 18G2, p. 70. PLASTIC OPERATIONS ON THE FACE. 285 and turned it directly downward so that its raw surface was directed outward, its tegumentary surface toward the nasal fossae. The two lateral flaps were then placed upon it and united in the median line. The raw surfaces united with each other, and the result was a nose elevated one- third of an inch above the adjoining surface. Subcutaneous Method. Prof. Pancoast 1 operated upon a similar case in the winter of 1842-43 by subcutaneous division of the adhesions. The ossa nasi and septum had been entirely destroyed by disease, and the nose was sunken far below the level of the face. " A narrow long- bladed tenotomy knife was introduced on either side by puncture through the skin over the edge of the nasal pro- cess of the upper maxillary bone. The knife was pushed up under the skin to the top of the nasal cavity, and then brought down, shaving the inside of the bony wall, so as to detach the adherent and inverted nose upon either side. The point of the nose could now be drawn out. . . . The nose still remained adherent to the top of the nasal chasm. The knife was a third time introduced under the skin in a direction corresponding nearly with the long diameter of the orbits of the eyes and the adhesions separated from the nasal spine and internal angular processes of the os frontis." The soft parts on the cheek were loosened by sweeping the knife outward along the surface of the bone so far as to divide the infra-orbital nerve and artery on each side, drawn toward the median line, and held to- gether with quilled sutures passed through the cavity of the nose. In two weeks the root of the new nose had sunk to the level of the face, but the patient was well satisfied, and refused any further operation, beyond the removal of an elliptical piece of skin to raise this portion again. The ultimate result is not known. Dubrueil 2 quotes a similar operation by Malgaigne, but without giving the date. As it is not mentioned in the lat- ter's Medecine Operatoire, edition of 1837, it is probable that Prof. Pancoast's operation autedates it. 1 Operative Surgery, Phila., 1852, p. 858. - Medecine Operatoire, p. 451. 13* 286 OPERATIVE SURGERY. 3. Loss of more or less of the Surface and the Septum. A. Indian Method. This method was introduced into Europe in 1814, by Carpue, an Euglish surgeon, and the stimulus given by it to this class of operations was so great during the succeeding twenty-five or thirty years that this period has been called that of the renaissance of rhinoplas- ty surgery. The ultimate results, however, were not very favorable, and the method has fallen iuto comparative neglect. It was found that the noses, although sufficiently full, or even excessive at the time of the operation, under- went gradual atrophy, and, when central support was lack- ing, sank to the level of the cheeks. The nostrils, too, closed sometimes to such an extent that they would hardly admit a probe ; and, finally, the whole flap had a tendency to slide downward, and collect in a lump at the end of the nose after division or excision of the pedicle. The scar left upon the forehead was a serious disfigurement, and the attempt to diminish it by drawing the sides of the gap to- gether gave rise to complications, which endangered the patient's life. The operation itself was not without dan- ger. Dieffenbach lost two out of six patients upon whom he operated in Paris. Fig. 133. Rhinoplasty. Indian method unmodified. The operation was originally performed as follows (Fig. 133): A flap, the size and shape of which were determined by a pattern previously made of paper or card, was marked PLASTIC OPERATIONS ON THE FACE 287 out upon the forehead immediately above the nose. Care was taken to make it at least a quarter of an inch broader and half an inch longer than the space it was to fill. Its base was situated between the eyebrows, and was half an inch broad. At the upper end of the flap was a projecting tab intended to form the columna. The flap, including all the tissues down to, but not through, the periosteum, was then dissected up, brought down by twisting the pedicle, placed in its new position with its raw surface inward, and attached by sutures to the freshened edges of the gap it was to fill. Prominence was given to the ridge by stuffing the nostrils with plugs of oiled lint, or drawing the cheeks toward the median line by means of long pias passed trans- versely through the edges and under the nose. The gap in the forehead was left to heal by granulation. After the flap had united, the pedicle was divided, and returned to its original position. Modifications. 1 Larrey (1820) pointed out the desira- bility of saving even the smallest fragments of the original nose, especially if they belonged to the free border of the ala. Prof. Bouisson 2 formulated this principle, and ex- tended it to the other methods, as follows: 1st. Save as much as possible of the septum. 2d. Give lateral support to the flaps by means of the healthy portion of the carti- lage of the alee. 3d. Insure the regularity of the outline of the nostril by giving the lower border of the flap carti- laginous support. Dupuytren and Dieifenbach opposed the retraction and closure of the nostrils by folding back upon itself that portion of the edge of the flap which was to form the free border. The torsion of the pedicle involves more or less danger of gangrene by obstructing the return of the venous blood. Lisfranc (1826) was the first to attempt to diminish this defect. By lengthening the incision on one side, the base or attachment of the pedicle was made oblique instead of transverse, and the torsion correspondingly diminished at i The dates of these modifications, and the award of credit for their sugges- tion are mainly taken from Verneuil's Chirurgie Reparalrice, to which the reader is referred for further details and documentary proof. 2 Rhinoplastie laterale. 2 > s OPERA TIVE S UR GER Y. that point. Of course, the total amount of torsion re- mained the same, but, by being spread along the pedicle, it was made more spiral and less abrupt. Von Laugenbeck (before 1856) went a step further, and put the base upon the side of the nose close to the eye, the upper incision end- ing at the eyebrow, the lower just below the tendo oculi. Labbat did about the same thing in 1827. Auvert, a Russian surgeon (date unkuown, but long be- fore 1850), made the flap oblique instead of vertical, still keeping the base between the eyebrows. Alquie, of Mont- pellier (1850), proposed to make the flap horizontal, the lower incision being hidden by the eyebrow ; and Landreau even curved it somewhat upward at the end, so that the base of the pedicle was hardly twisted at all in bringing down the flap. Ward (1854) madf a flap which was di- rected obliquely upward, and Follin (1856) made a trans- verse one ; in each case the base of the pedicle was upon or near the median line of the forehead, a little above the evebrows. Both cases did well. The objection to a trans- verse flap is that the retraction of the cicatrix upon the forehead draws the corresponding eyebrow upward. The advantages are that the torsion is less, and the scar some- what disguised by the natural lines. Various means have been employed to prevent the descent of the flap. Dieffeubach made a longitudinal incision on the side of the nose, and engaged the pedicle in it, paring off its prominences afterward. JBlaudin excised the portion of skin intermediate between the base of the pedicle and the loss of substance, and thus obtaiued a raw surface to which the whole length of the pedicle was then united. Instead of excising this intermediate piece of skin, Buck left it attached by its upper end, and used it to cover part of the gap left upon the forehead. Velpeau divided the pedicle close to its base, trimmed it to a point, and engaged it in a vertical incision made in the underlying skin. B. Ollier's Osteoplastic Method 1 (Fig. 134). A lupus had destroyed the alae, columna, lobe, cartilages, and part of the septum. The nasal bones were uninjured, but had suffered an arrest of development, and were bounded in— 1 Traite de la Regeneration des Os, vol. ii. p. 469. PLASTIC OPERATIONS ON THE FACE. 289 feriorly by a strip of cartilage. The nose was not more than an inch long. The skin of the cheeks and lips had also been involved by the lupus, and, therefore, could not be used for the restoration. Starting from a point in the median line of the forehead two inches above the eyebrows, Oilier made two incisions diverging downward, each of which ended a quarter of an inch to the outer side of the lower border of the nasal orifice. In dissecting up the long triangular flap thus marked out, he included the periosteum from above downward as far as to the upper end of the nasal bones ; he then con- tinued the dissection along the right nasal bone, leaving the periosteum adherent to it, and on reaching the lower end of the bone he separated from it the cartilaginous strip above mentioned, leaving it adherent to the flap. On the left side he divided, with a chisel, the bony con- nections of the left nasal bone, leaving the bone attached to the flap by its anterior surface ; this was accomplished by introducing the chisel, first between the two nasal bones, Fig. 134. Rhinoplasty. Ollier's osteoplastic method. then between the left nasal bone and the frontal, and finally between the left nasal bone aud the nasal process of the superior maxillary. Drawing the flap downward, he then divided the cartilaginous septum from before backward and 290 OPERATIVE SURGERY. downward with scissors, so as to have au antero-posterior flap of cartilage attached by its base to the cutaneous one, and able to furnish central support for the new nose by resting its free border upon the floor of the nasal fossa, or rather upon the rernaius of the lower portion of the origi- nal septum. He next drew the whole flap downward until the upper border of the left nasal boue came into Hue with the lower border of the right nasal bone, and then fastened the two bones together with a metallic suture. The sides of the flap were then united to the cheeks, and those of the frontal incisions drawn together above the apex of the flap. The parts united, the space left by the removal of the left nasal boue was filled with bone produced by the perios- teum brought down from the forehead, and the result was satisfactory. C. Alquie used a flap of similar shape in a case in which the alse and septum were lost, but the columna remained. The apex of the triangle was placed in the space between the eyebrows, and the incisions diverged downward and outward. With a narrow tenotome passed along the in- cisions he separated the skin entirely from the nasal bones and was then able to depress it far enough to attach it to the freshened end of the columna. D. Italian Method (Fig. 135). Tagliacozzi made two nearly parallel incisions along the anterior surface of the arm, their length aud the distance between them varying according to the size of the gap the flap was to fill. The apex of the flap was directed toward the shoulder. The intermediate strip of skin was dissected up, but left adherent at both ends, and a piece of oiled lint passed under it and kept there until suppuration was established. The strip was then cut free at its upper end, and dressed carefully for about a fortnight, or until its under surface was nearly cica- trized. It was then considered fit to be applied, having undergone the necessary shrinking and thickening. Its (flues and those of the nasal aperture were pared and fast- ened together with sutures, and the arm bound fast to the head. When union had taken place between the two, the Lower end of the Hap was cut loose from the arm and its edges trimmed to the proper shape. PLASTIC OPERATIONS ON THE FACE. 291 Graefe did not let the flap suppurate, but tried to get primary union. Fig. 135. Rhinoplasty. Italian method. Dr. Thomas T. Sabine successfully filled by the im- plantation of a finger the gap left by the destruction of the nose. PLASTIC OPERATIONS UPON THE EYELIDS. In these operations it is important to save as much as possible of the original tissues, especially the free border of the lid, the conjunctiva, and the orbicular muscle. As the skin is thin and delicate, the flaps must have broad bases to insure their vitality; they must also be so placed that their natural retraction will not tend to re-establish the pre- vious defect. Blepharorrhaphy. Suture of the eyelids has proved a very valuable adjunct of many of the plastic operations upon 292 OPERATIVE SURGERY. the eyelids, and has even taken the place of some of them, for experience has shown that a loss of substance in either eyelid may be safely allowed to fill and heal by granulation if the borders of the lids are kept fastened together. The eye must be kept closed in this way for six months or a year, after which time the scar, in most cases, shows no ten- dency to retract. When the time comes to separate the lids, this should, at first, be done for only half an inch in the centre, and the opening subsequently enlarged at long intervals of time, any indication of cicatricial retraction being meanwhile watched for. The prolonged occlusion does no harm to the eye ; on the contrary, it may be sufficient in itself to cure a com- mencing keratitis occasioned by ectropion. Operation. A narrow strip of conjunctiva is excised from the border of each lid on the conjunctival side of the lashes, beginning and ending a short distance from thecom- Fig. 136. Canthoplasty. A. Straight incision. B. Richet's modification. missures, so as to leave a space for the flow of the tears. The two raw surfaces are then brought together accurately with silver sutures. To separate the lids afterward a director should be en- tered at the opening left at one of the angles, its point pressed against the centre of the line of union, and cut down upon the two rows of lashes. Canthopla8ty. Enlargement of the palpebral opening (Fig. 136). The external angle of the eye is divided hori- zontally with scissors, and the skin and conjunctiva united PLASTIC OPERATIONS ON THE FACE. 293 along the sides of the incision by three points of sutures, one of them being placed at the angle. Richet's modification 1 (Fig. 136, B). Richet marks out a small flap by two incisions through the skin, beginning at opposite points on the upper and lower lids near the outer angle and meeting at a point external to that angle. The flap, including everything except the conjunctiva, is then excised, the conjunctiva split horizontally, and its two por- tions trimmed and fastened to the edge of the cutaneous incisions. Blepharoplasty, to prevent or remedy — 1. Ectropion. The descriptions will be given for the lower lid only, that being the more frequent seat of the de- formity. Blepharoraphy (q. v.) is often sufficient in itself to prevent ectropion, and is always a useful adjunct of a plastic operation. The lids should be kept united during the process of cicatrization of the wound left by the loss of substance, and for several months thereafter. Wharton Jones (Fig. 137). Wharton Jones included the contracted cicatrix in a triangular flap one inch high, its base occupying nearly the whole length of the lid border. Fig. 137. Ectropion. Wharton Jones. By dividing the bands of cellular tissue, but without dis- secting up the flap, he restored the lid to its normal position, and held it there by uniting the edges of the incision below, thus giving it the form of a Y. 1 Anatomie Medico-Chirurgicale, 4th edition, p. 294 OPERA TIVE S UE GEE Y. Alphonse Guerin 1 (Fig. 138) makes two incisions form- ing an inverted V, the point of which lies just below the centre of the free border of the lid. From the lower ex- tremities of these incisions he makes a third and fourth parallel to the border of the lid. The two triangular flaps bounded by the 1st and 3d, and the 2d and 4th incisions Fig. 138. • 1 t % O Ectropion. Alphonse Guerin. are then dissected up, the lid raised to its normal position, and held there by uniting the adjoining sides of these two flaps in such a manner that their apices and that of the in- verted V meet at a common point. The gaps left by the removal of the two flaps are allowed to granulate, or cov- ered with Thiersch grafts. For greater security Guerin also unites the borders of the lids (blepharoraphy). Fig. 139. M Ectropion. A. Von Graefe's method. B. Knapp's method. Von Graefe (Fig. 139, A). Make an incision along the border of the lid just outside of the lashes from the lach- rymal point to the external commissure. From each ex- tremity of tliis make a vertical incision downward from one- i Chirurgie Op6ratoire, 4th edition, p. 318. PLASTIC OPERATIONS ON THE FACE. 295 half to three-quarters of an inch in length. These incisions should involve only the skin. Cut off the upper inner cor- ner of this flap, not by a straight incision, but by one form- ing an angle, as shown in the figure, and fasten this angle by a suture to that formed by the border of the lid and the inner vertical incision. Reunite the edges of the transverse incision, cutting the euds of the sutures long enough to reach to the forehead, and then fastening them there with adhesive plaster. The excision of the inuer angle of the flap raises the eyelids by shortening its border. Dieffenbaeh, Adams, and Ammon have proposed other methods of shortening the lid. They are indicated in Fig. 140, where the shaded spaces represent the portions of skin to be removed, and the threads the manner in which the edges are afterward brought together. Adams's excision included the whole thickness of the lid. Richet (Fig. 141). Richet makes an incision parallel to the border of the lid, half an inch below it, and extending nearly from one angle of the eye to the other. The lid, having been freed by this incision, is then united to the other (blepharoraphy). Rg. 140. V B Ectropion. A. Dieffenbaeh. B. Adams. C. Amnion. The shaded spaces indi- cate the portions of skin removed ; the threads show how their edges are brought together. He next makes a second incision parallel to the first and one-third of an inch below it, divides the intermediate strip of skin vertically in the middle and dissects up its two halves. Immediately below the lower end of this vertical incision he removes from the lower border of the second incision a V-shaped flap of skin, its point directed down- ward. He then raises the two halves of the middle flap, brings them again into contact with the border of the lid, 296 OPERATIVE SURGERY. excises their superfluous length, and unites them. The sides of the V are then brought together and the edges of the iucisions reunited. Knapp (Fig. 139, B). Knapp employed the following method to remove an epithelioma occupying the inner por- FlG. 141. m Ectropion. Richet. tion of the lower eyelid, the free border of which was in- volved. He circumscribed the tumor by two vertical and two horizontal excisions and excised it. The horizontal iu- cisions were then prolonged on both sides, the lower external one being inclined downward so as to make the base of the flap broader, the two flaps dissected up, drawn together and united by their vertical edges. Fig. 142. ~t$//j3Z&li Ectropion. Jiurow. Burow (Fig. 142). The loss of substance is made tri- angular in shape, the apex directed downward ; the base PLASTIC OPERATIONS ON THE FACE. 297 is then prolonged horizontally outward, and an equal and similar triangle marked out upon the upper side of the pro- longation. The skin contained within the second triangle is then excised, and the irregular flap bounded by the outer sides of the two triangles and the prolongation of the hori- zontal incision dissected outward and downward, and then moved toward the median line until it covers both the open spaces. It is not necessary that the two triangular spaces should touch at one corner ; they may be an inch, or even more, apart ; but they must of course be connected by the hori- zontal incision. Dieffenbach (Fig. 143). When the cicatrix or tumor was large DiefFenbach gave the loss of substance a triangular shape, the apex directed downward. He prolonged out- ward the horizontal incision forming the base of the tri- angle, and carried another incision downward and inward from its outer extremity. The quadrilateral flap thus marked out was dissected up and carried inward to cover Ectropion. Dieffenbach. the loss of substance. The gap left by its removal was then drawn partly together with sutures, and the remainder left to granulate. Indian Method Sedillot refers the first blepharoplasty by the Indian method to Von Graefe in 1809. As this was previous to the introduction of rhinoplasty by the same method, the idea was probably entirely original with Von Graefe. The case is mentioned in his Rhinoplastik, 1818, but without details. The flap can be taken from the fore- 298 OPERATIVE SURGERY. head or cheek ; it should be very large and should include the subcutaneous cellular tissue. Fricke, of Hamburg, took a vertical flap from the temporal region to restore the upper eyelid. One of the modifications of this method, intended to ob- viate the necessity of dividing the pedicle, is showu in Fig. 144, A. Richet (Fig. 144, B). The lids are freed by two in- cisions inclosing all the cicatricial tissue, and then united Fig. 144. Ectropion. A. Modified Indian method. B. Richet. (blepharoraphy), the sutures being cut long and their ends fastened upon the forehead. Two flaps are then marked out as shown in the figure, the external one, C, raised and used to cover the original loss of substance, and the inner one, D, used to fill the gap occasioned by the removal of 0. Hasner d'Artha (Fig. 145) employed the following method in a case where a tumor occupied the commissure and inner portion of each eyelid. He made a curved in- cision, a, beginning at the border of the upper eyelid beyond the limit of the tumor, crossing the eyebrow to the forehead, and then crossing downward to terminate near the root of the nose. A second curved incision, c, began at the same point as the first and was carried along the upper and inner edge of the tumor to the point marked/. A third curved incision, e, began on the border of the lower lid beyond the limit of the tumor and was carried along the lower margin of the latter to the point/. A fourth curved incision, g t parallel to the border of the lower lid, was car- ried from the point outward to the cheek. PLASTIC OPERATIONS ON THE FACE. 299 The tumor and the portion of the lids circumscribed by the incisions e and e were then removed, and each of the flaps d and h dissected up to its base. The former was lowered, the latter raised, and the excess of each cut off. The upper border of the flap h formed the free border of Fig. 145. Ectropion. Hasner d'Artha's method. the lower lid, and the lower border of the flap d formed the free border of the upper lid aud the commissure corre- sponded to the apex of the flap h. The skin of the fore- head and cheeks was mobilized and reunited to the flaps (Dubrueil). Fig. 146. Ectropion. Denonvilliers's method " by exchange." DenonviUiers' 's method " by exchange " (Fig. 146). In a case of ectropion of the lower lid, with deviation of the outer angle of the eye downward, DenonviUiers used the 300 OPERATIVE SURGERY. following method : By making three incisions to meet in the form of Z, he marked out two adjoining triangular flaps ; one of them included the outer angle of the eye, the apex of the other was situated upon the forehead just above the eyebrow. He then dissected up the flaps, restored the augle of the eye to its proper position, brought the upper flap down into the gap made by the lower incision, and the lower flap up into that made by the upper incision. Ectropion due to excess of the conjunctiva may be treated by cauterization of the conjunctiva, or by excision of a portion. The latter operation is simple ; a fold is pinched up with forceps and excised with knife or scissors. The edges of the gap may then be brought together by sutures or left to granulate. 2. Entropion. Canthojplasty (q. v.) may be employed to remedy moderate entropion, especially if it be due to spasm of the orbicularis. Ligature (Fig. 147), proposed by Gaillard to remedy trichiasis, is equally applicable to the cure of entropion. Pig. 147. / Entropion ; ligature. A transverse fold is pinched up, and a needle carrying a stout ligature passed through its base, shaving the anterior surface of the cartilage. The ligature is tied and allowed to cut through the skin. The resulting linear cicatrix maintains the lid in the position given it by the ligature. liau has modified this by planing several ligatures instead of only one Excision or cauterization of a fold of the shin is appli- cable to cases of entropion due to laxity of the skin of the PLASTIC OPERATIONS ON THE FACE. 301 eyelid. A transverse or a vertical fold is pinched up quite near to the margin of the lid aud excised ; the borders of the wound are united by sutures. Instead of excision, cau- terization of the strip, preferably with sulphuric acid, is sometimes used. Von Graefe (Fig. 148) treated a case of spasmodic entropion by removal of a triangular piece of skin. He made a cutaneous incision parallel to the free border of the lid, and about a line from it, and excised a triangular cuta- neous flap, the base of which occupied the median portion of the first incision. The sides of the wound left by the excision of the triangular piece were then drawn together with sutures. For spasmodic entropion of the upper lid, with retraction of the tarsal cartilage, Von Graefe modified the operation Fig. 148. Fig. 149. Entropion— lower lid. Von Graefe. Entropion— upper lid. Von Graefe. as follows (Fig. 149) : After excision of the triangular cutaneous flap, he drew the sides of the wound apart, divided the orbicular muscle horizontally near the edge of the lid, and drew it upward, exposing the cartilage. He then ex- cised a triangular piece of the cartilage, the apex being at its lower border, taking care not to include the conjunctiva in the dissection. The sides of the cutaneous wound were then drawn together with three sutures, the middle one of which included also the sides of the gap left in the cartilage. Excision of a Portion of the Orbicularis. Key cured a case of spasmodic entropion by excising a few fibres of the orbicular muscle. He made an incision through the skin 14 302 OPERATIVE SURGERY. parallel to and near the free border of the lid, exposed the muscle, and removed a bundle of fibres from its central margin. It is well to combine this with removal of a hori- zontal strip of skin. Division or Resection of the Tarsal Cartilage. When the entropion is caused or maintained by shortening or in- curvation of the tarsal cartilage, the operation must be directed to the removal of this cause. Vertical division at one or two points of the entire thick- ness of the lid has been employed. After having been divided, the border of the lid is held in its proper position by ligatures passed through it and fasteued to the forehead (upper lid) or cheek (lower lid), while the wound fills and heals by granulation. A horizontal incision through the conjunctiva from one vertical incision to the other makes it easier to turn the lid out and hold it in place. Longitudinal Tarsotomy (Ammon). The eyelid having been turned out, a knife is passed through it from the con- Fig. 150. Knapp's modification of Desmarres's forceps. junctival side, quarter of an inch from the border, and on a line with the lachrymal point, and an incision made parallel with the border nearly to the outer angle. A longitudinal strip of skin is then excised, and the edges of the gap left by the excision are drawn together. By this means the free border of the lid is drawn away from the surface of the eye, turning upon the longitudinal incision as upon a hinge. Excision of part of the Cartilage (Streatfeild), (Fig. 151). PLASTIC OPERATIONS ON THE FACE. 303 The eyelid is fixed with Desrnarres's forceps (Fig. 150), the flat blade against the conjunctiva, and an incisiou made parallel to the border of the lid at the distance of one line from it, and carried to a depth suffi- FlG - 15L cient to expose the bulbs of the eyelashes. The surgeon, raising the edge of the skin, passes around the bulbs to the tarsal cartilage, and then makes a second incision at a greater distance from the border of the lid than the first one was, meeting the first at its two extremities and in- closing with it an oval strip of skin. These two incisions are carried into the cartilage, circum- scribing a longitudinal wedge-shaped strip, the apex of which reaches nearly to the conjuncti- val side of the cartilage. The wound is left to heal by granulation, with the expectation that the con- traction of the cicatrix will overcome the entropion. 3. Symblepharon. When the adhesion between the two layers of the conjunctiva is incomplete, that is, when it does not extend to the bottom of the sulcus between the lid and eyeball, it is sufficient to throw a ligature around it. After the ligature has cut through, the tabs are succes- sively excised, and the borders of each wound drawn to- gether or left to heal by granulation. To avoid reunion of the surfaces, the second tab should not be removed until after the wound left by the removal of the first has healed. When the adhesion is complete, but not broad, a thread or silver wire may be passed through its base and tied loosely around it. After the hole made by the wire has cicatrized the adhesion is divided. The narrow line of cica- trix left at the bottom of the fold by the wire favors the separate healing of the two sides of the incision. Arlt's Method. A thread is passed through the fold close to the cornea, and the symblepharon dissected awav from the eyeball. Each end of the thread is then attached to a needle and passed through the lid from within outward at the bottom of the wound. By drawing upon the thread and tying it outside the lid the symblepharon is folded upon itself and its point fixed at the bottom of the sulcus. The edges of the wound on the eyeball are then drawn 304 OPERATIVE SURGERY. together with sutures, the conjunctiva being loosened by dissection, if necessary. Teak's Method (Figs. 152, 153, 154). This symble- pharon is separated from the ball of the eye by an incision along the line of its union with the cornea, and dissected down to the bottom of the fold as in Arlt's operation, its Fir,. 152. Fig. 153. Symblepharon. B, C. The flaps. apex, however, being left upon the cornea. Two long, narrow conjunctival flaps, B and C, are then dissected up on opposite sides of the eyeball, their bases directed toward the symblepharon, their borders parallel to that of the cornea. These flaps should not include the subconjunc- tival tissue. The inner flap B is brought down and fast- FlG. 154. Flaps in place. ened to the denuded surface of the eyelid, the outer flap C covers that of the eyeball. They arc fastened in place by means of fine sutures, and the edges of the gaps left by their removal brought together in the same manner. Ledentu's Operation. Where one lid was adherent throughout its entire length, Ledentu divided the adhesion PLASTIC OPERATIONS ON THE FACE. 305 to a depth equal to that of the normal fold, dissected a long conjunctival flap from the other half of the eye, leaving it adherent at both ends, brought it down across the cornea, and applied it to the raw surface left on the eyeball by the division of the adhesion. This flap should beat least one- third of an inch broad. 4. Pterygion. Excision. The pterygion is pinched up with forceps, a knife passed flatwise under it close to the cornea, and the portion of the growth which corresponds to the latter shavecl off. The edges of the conjunctival wound are then drawn together with sutures. Scissors may be used instead of the knife; in that case the incision must begin at the point of the growth. Ligature, Szokalski (Fig. 155). A thread is passed under the pterygion by means of twosmall curved needles, Fig. 155. Pterygion ; ligature. as shown in Fig. 155. The thread is cut close to the needles, and thus made to furnish three ligatures, one at each end, encircling the growth at right-angles to its long axis, and one in the middle, encircling its implantation upon 306 OPERATIVE SURGERY. the sclerotic. The ligatures are tied tightly, and the in- closed portion falls in a few days. 5. Trichiasis. Temporary removal of the deviated lashes is seldom effectual. Permanent removal by destruction of their bulbs, or excision of the border of the lid, is now con- sidered unjustifiable. The direction of the lashes may be changed by operation upon the lid. The retraction follow- ing excision of an oval strip of skin, or the use of ligatures as in entropion, is sometimes sufficient, but it may be neces- sary to act more directly upon the lashes. Simple splitting of the external can thus may be sufficient. Von Graefe's Method. An incision is made along the free border of the lid on the conjunctival side of the devi- ated lashes. From each end of this a vertical incision is next made through the free border and the skin. The flap thus circumscribed and containing the lashes is dissected up a short distauce. It is then easy to fasten it with sutures in such a position that the lashes can no longer touch the eyeball. Anagnostahis made a cutaneous incision parallel to the border of the upper lid and one-eighth of an inch from it, exposed the orbicular muscle by drawing the skin up, and excised that portion of it which corresponded to the upper part of the tarsal cartilage. The lower edge of the cuta- neous incision was then drawn up and fixed to the fibro- cellular layer covering the cartilage by means of three or four sutures, which were then allowed to cut themselves out. PART VII. SPECIAL OPERATIONS. CHAPTER I. OPERATIONS UPON THE EYE AND ITS APPENDAGES. In most operations upon the eye the lids should be held open by an eye-speculum (Fig. 156), and the eyeball fixed Fig. 156. Eye-speculum. by pinching up a fold of the conjunctiva with toothed for- ceps. The instillation of a few drops of a 4 per cent, solution of the hydrochlorate of cocaine under the lids will make most operations painless, but the sensitiveness of the iris is not thereby abolished. THE CORNEA. Removal of a Foreign Body. When the foreign body has penetrated to only a slight depth, it may be easily removed 308 OPERATIVE SURGERY. with the point of a knife or fine forceps ; but, if it lies so near the posterior surface of the cornea that there is danger of forcing it through into the anterior chamber by the efforts made for its extraction, a lance-shaped knife must be en- tered very obliquely and passed behind it, between the layers of the cornea if there is sufficient space, otherwise within the anterior chamber. If the foreign body falls into the anterior chamber, not- withstanding these efforts to prevent it, the surgeon must wait uutil the aqueous humor has reaccumulated, and then make an incision three or four millimetres in length at the lower portion of the periphery of the cornea, in the hope that the foreign body will be washed out during the flow of the liquid. Puncture of the Cornea. This may be made with a broad needle or a well-worn Beer's knife. It is advisable to em- ploy anaesthesia, and to steady the eyeball with fixation forceps. The surgeon stands behind the patient, raises the upper lid, and fixes it against the margin of the orbit with two fingers of his left hand, which also rest against the inner side of the eyeball and prevent it from rotating inward. The needle or knife is then entered a little in front of the edge of the cornea at the outer side. Its di- rection must be sufficiently oblique to avoid injury to the iris, and not so much so that the instrument will remain between the layers of the cornea and fail to penetrate to the anterior chamber. By partly withdrawing the instru- ment aud twisting it slightly, the incision is made to gape and allow the escape of the liquid ; or a fine blunt probe may be passed into the incision after entire withdrawal of the needle. Subsequent tappings are effected by reopening the original wound with the probe. Figure 157 represents a combined needle and probe. The needle is provided with a shoulder to prevent its introduction to too great a depth. Evisceration of the Globe for Staphyloma. The sclerotic is incised with a Beer's knife just in front of the insertion of the external rectus ; into the opening is passed one blade of a pair of small blunt-pointed scksors, and the anterior portion of the globe is cut away, with the lens and all the SPECIAL OPERATIONS 309 Fig. 157 Flu. 158 Stop needle and probe for puncturing the cornea. Beer's knife. 14* 310 OPERATIVE SURGERY. vitreous humor. The wound is then closed with catgut sutures passed through the conjunctiva alone. THE IRIS. Iridotomy. Incision of the iris may be performed for the purpose of establishing an artificial pupil. As its suc- cess depends upon the retraction of the divided fibres, it should be undertaken only when their contractility is not interfered with by too extensive adhesions, or has not been destroyed by disease. The more commou lesions to which the operation is applicable are central opacity of the cornea, occlusion of the pupil, and excessive prolapse of the iris after removal of a cataract ; but the danger of injury to the lens is so great that the operation is practically restricted to the class of cases last mentioned. The best place for an artificial pupil is in the lower inner quarter of the iris, the second best in the lower outer quarter. As the portion of the cornea traversed by the knife or needle is likely to become more or less opaque in consequence, the incision in it should be made as far as possible from the point where the pupil is to be created. Simple Incision. Cheselden, who was the first to per- form this operation, entered a narrow-bladed knife through the sclerotic just anterior to the insertion of the external rectus, the point directed toward the centre of the globe of the eye. After the point had penetrated to the depth of one-eighth of au inch it was directed forward, passed through the iris to the anterior chamber and transversely across the latter, its edge looking backward. By pressing the edge against the iris and withdrawing it a horizontal incision was made in that membrane. Bowman punctured the cornea midway between its centre and external border, passed a narrow blunt-pointed knife through the puncture into the anterior chamber, and thence through the pupil to the posterior surface of the inner half of the iris, which he then divided by cutting forward. The danger of injury to the cornea during the last step of the operation is very great. SPECIAL OPERATIONS. 311 Bell 1 uses a double-edged needle which is " introduced through the cornea near its margin ; on arriving at the place where the pupil ought to be, one edge is drawn against the iris and divides it transversely, if possible, without injuring the lens." Wecker proposes simple iridotomy and double iridotomy ; the former in cases of central opacity of the cornea or lens, the latter when the pupil has become obliterated after re- moval of a cataract. He uses a small lance-shaped knife with a shoulder, straight or bent upon the flat, and a pair of forceps-scissors. Simple Iridotomy (Wecker). The knife is entered mid- way between the centre and border of the cornea on the side opposite to that on which the pupil is to be made. As soon as the cornea has been perforated the knife is with- drawn and the forceps-scissors passed through the wound to the further border of the pupil, where they are opened and one of the blades passed behind, the other in front, of the iris. By closing them sharply the circular fibres are divided from the margin of the pupil toward the periphery of the iris. The scissors are then withdrawn, the iris re- placed if it engages in the wound, a few drops of a solution of atropine placed between the eyelids, and a compress ap- plied. Double Iridotomy (Wecker). The knife is passed per- pendicularly through the cornea and iris one millimetre from the edge of the conjunctiva, on the side toward which the obliterated pupil has been retracted ; its point is then made to pass along the posterior surface of the iris until arrested by its shoulder, when it is withdrawn slowly. The forceps-scissors are next introduced through the incision, and one blade passed behind and the other in front of the iris for a distance of one-quarter of an inch or a little less. Two successive sections of the iris are then made, inclosing a triangular flap, the apex of which is directed toward the incision in the cornea. The pupil is formed by the retrac- tion of this flap. Iridectomy. Excision of a portion of the iris may be employed for the purpose of creating an artificial pupil 1 Manual of Surgical Operations, 3d edition, p. 162. 312 OPERATIVE SURGERY. (optical iridectomy), or for the relief of tension in glaucoma or irido-choroiditis (autiphlogistic iridectomy), or as a pre- liminary to the removal of a cataract. The size of the portion excised is determined by the length and position of the line of the incision on the posterior surface of the cornea ; the nearer this is to the margin of the cornea the larger will be the portion of the iris removed. In antiphlo- gistic iridectomy, therefore, when the entire breadth of the iris from the pupil to its outer margin should be removed, the knife must be entered one millimetre outside of the clear portion of the cornea ; in optical iridectomy, on the other hand, the excised portion should be small and the knife should be entered within the margin of the cornea. In antiphlogistic iridectomy at least one-fourth of the iris should be removed, the piece being taken from the upper segment in order that the loss may be hidden by the upper eyelid. In optical iridectomy the pupil should be made on the inner side of the lower segment unless corneal opacities are in the way. Fig. 159. Fig. 160. Operation for Antiphlogistic Iridectomy. The instru- ments required area lance-shaped knife, straight (Fig. 159) or bent (Fig. 100), iridectomy forceps (Figs. 161 and 162), and scissors curved upon the flat (Fig. 163). The patient having been anaesthetized and placed in a SPECIAL OPERATIONS. 313 recumbent posture, the surgeon takes such a position in front of or behind him as will facilitate the making of the Fig. 161. Fig. 162. Fig. 163. ffl Fig. 164. Iridectomy. Incision of cornea. first iucisiou. The eye-speculum and fixation forceps hav- ing been applied, the latter immediately opposite the poiut 314 OPERATIVE SURGERY. of puncture, the knife is introduced perpendicularly to the surface of the sclerotic one millimetre outside of the margin of the coruea and passed steadily in until its point has entered the anterior chamber at its very rim ; its direction is then changed aud it is carried along the anterior surface of the iris uutil its point reaches the contre of the pupil, or until the length of the incision is considered sufficient (Fig. 164). By inclining the point of the knife to each side, the length of the incision in the posterior surface of the cornea may be made equal to that of the anterior surface. The knife is then withdrawn and the aqueous humor allowed to run off very slowly in order that the relief of intra-ocular pressure may not be so sudden as to lead to congestion and hemorrhage. If the iris does not now present in the wound the iridec- tomy forceps must be introduced closed as far as to the margin of the pupil, which is then seized and drawn out gently through trie incision. An assistant then cuts oft with the curved scissors all the protruding portion of the iris close to the lips of the wound (Fig. 165). Or the fixation forceps may be con- FlG - 165 - tided to the assistant before the introduction of the iri- FlG. 166. Tyrrell's hook. dectomy forceps, and the surgeon left free to use the scissors himself. Instead of the iridectomy forceps, Tyr- rell's hook (Fig. 166) may be used to draw the iris out through the incision. It must be introduced upon its side, hooked around the margin of the pupil, and then its point must be turned toward the cornea and away from the centre of the eyeball so that it will not catch upon the posterior edge of the incision during its withdrawal. If any hemorrhage takes place into the anterior chamber I rldectomy. Excision of the iris. SPECIAL OPERATIONS. 315 the escape of the blood before coagulation should be favored by separating the lips of the incision with a curette, and making gentle pressure upon the eyeball. The edges of the iris must be carefuly replaced with a spatula and not left included in the corneal wound. Iridesis, or displacement of the pupil by ligature. Crit- chett, 1 the inventor of this operation, claims that by it the size, form, and direction of the pupil can be regulated to a nicety, and its mobility preserved. It is applicable to nu- merous groups of cases in which the natural pupil, or even a part thereof, is movable, and has a free edge ; but the simplest class is that of central opacity of the cornea, in which it is only required that the natural pupil should be moved slightly to one side, so as to bring it opposite the transparent part of the cornea. It has also been used in cases of conical cornea, to change the shape of the pupil to that of a slit ; and in a case where the pupil had been ren- dered very small and narrow by broad synechias, Critchett made it large and almost circular by drawing its sides apart at nearly opposite points. The operation is performed as follows : An opening is made with a broad needle through the margin of the cornea close to the sclerotic, and just large Fig. 167. Iridesis. enough to admit the canula forceps. A small portion of the iris near but not close to its ciliary attachment is seized and 1 Ophthalmic Hospital Reports, vol. i. p. 220. 316 OPERATIVE SURGERY. drawn out to the extent considered sufficient for the pro- posed enlargement of the pupil ; a piece of fine floss silk, previously tied in a small loop round the cauula forceps, is slipped down, and carefully tightened around the portion of iris made to prolapse, so as to include and strangulate it (Fig. 167). This manoeuvre is best accomplished by hold- ing each end of the silk with a pair of small broad-bladed forceps, bringing them exactly to the spot where the knot is to be tied, and then drawing it moderately tight. The small portion of the iris included in the ligature speedily shrinks, leaving the little loop of silk, which may be re- moved ou the second day. If it is desired to make the pupil extend to the periphery of the iris, the margin of the pupil must be seized with the forceps and drawn out through the incision. In this case Soelberg Wells prefers a blunt hook to the canula forceps. Corelysis, or rupture of adhesions uniting the margin of the pupil and the lens. The operation was first performed by Streatfeild, as follows: 1 He punctured the cornea with a broad needle on the outer side near its margin, passed his spatula (Fig. 168) along the anterior surface of the iris to the pupil, engaged the adhesions in the notch on the edge of the spatula, and tore them. When the entire margin of the pupil was adherent, he passed the needle along the sur- FiG. 168. Streatfeild's spatula hook. face of the iris, across the pupil to its opposite margin, and cut the adhesions at that point. Then withdrawing the knife, he passed the spatula through the hole thus made, and easily broke up the remaining adhesions. When the adhesions were too strong to be broken with the spatula, he used the canula scissors. A few drops of a solution of atropine should be applied to the eye, both before and after the operation. 1 Ophthalmic Hospital Kurorts, vol. i. p. (>. SPECIAL OPERATIONS. 317 OPERATIONS UNDERTAKEN FOR THE RELIEF OF CATARACT. A cataract is an opacity of the crystalline lens, or of its capsule, or of both : the former being much the more common variety. It may be hard, soft, or semiliquid, and its con- dition, in this respect, has an important bearing upon the choice of a method of operation. The lens is composed of a solid nucleus and a soft cortex ; the whole lying free within the capsule which is itself attached to the vitreous humor. In consequence of the absence of adhesions be- tween the lens and the capsule, moderate pressure is suffi- cient to force out the former after the latter has been divided. In operating upon a cataract, the patient should be recumbent : cocaine anaesthesia is sufficient except with young children or unruly patients, when ether may be necessary. The other eye should be covered with a band- age, unless its sight is entirely lost ; and an eye-speculum may be used to keep the lids apart, if the services of a trained assistant cannot be had. The objection to a spec- ulum is that it is somewhat in the way of the knife, cannot be removed promptly enough, and is apt to make dangerous pressure upon the eye. If used, the screw of the instrument should be loosened as soon as the incision has been made. A few drops of a solution of atropine should be placed under the lids a short time before the operation. The methods of operation may be classified as: Depression or couching ; Division, discission, or solution ; Extraction ; Operation for secondary cataract. Depression or couching, which was the original and, for many years, the only method of removing cataract, is now universally abaudoned, on account of the danger that the displaced lens may set up inflammation of the eye by con- tact with the other parts, especially the iris and ciliary pro- cesses, and thus cause total loss of sight. Soelberg Wells states that about fifty per cent, of the eyes thus operated 318 OPERATIVE SURGERY. upon have been lost by chronic irido-choroiditis. The operation will be described, however, for the sake of ref- erence. If the puncture is made in the sclerotic, the ope- ration is called scleronyxis ; if in the cornea, keratonyxsis. Scleronyxis. A curved couching needle (Fig. 169), its convexity turned upward, is passed through the sclerotic on the temporal side about four millimetres from the margin of the cornea, aud three millimetres below the horizontal diameter of the eye. Its convexity is then turned forward, and the needle carried behind and parallel to the iris, across to the upper and inner margin of the pupil (Fig. 170), when the handle is lightly tilted upward, and the lens slowly depressed by the concave surface of the needle. After hold- ing it in place for a moment, the needle is slightly rotated to disentangle its poiut, and withdrawn. Some authors recommeud that the anterior capsule should be formally divided horizon- tally or vertically before the lens is depressed. Fig. 170. Depressing cataract. Ke?-atonyxis. The needle is passed through the cornea a little below its horizontal diam- eter, and midway between its centre and mar- gin, and carried backward and inward, through the pupil to the lens, which is then Couching needle, depressed as before. In the variety of depression called reclina- tion, the upper edge of the lens is rotated backward about its transverse axis at the same time that it is depressed, so that its anterior becomes its superior surface. SPECIAL OPERATIONS. 319 Fig. 172. Division, Discission, or Solution. The object of this operation is to tear open the anterior capsule with a fine needle, and by thus bringing the aqueous humor into con- tact with the lens to promote the gradual softening and absorption of the latter. The selection of the term discission was made in consequence of an erroneous impression, that the more completely the lens was broken up at first the more rapidly would the work of absorp- tion go on, and surgeons, therefore, tried to cut the whole lens into fragments. Expe- rience has since shown that in most cases the absorption must be gradual and the operation frequently repeated, only a small amount of the substance of the lens being Fig. 171. Bowman's fine stop needle. allowed to come into contact with the aque- ous humor on each occasion. If the lens is all broken up at once, the numerous frag- ments swell and act as foreign bodies in the aqueous humor, and set up inflammation in the iris and cornea, with immediate ar- rest of the process of absorption. This operation is more especially indicated in the cortical cataract of children and of young persons up to the age of twenty or twenty- five years, also in those forms of lamellar cataract in which the opacity is too extensive to allow of much benefit being derived from an artificial pupil. After the age of thirty- Hays's knife needle. 320 OPERATIVE SURGERY. five or forty, absorption is much slower, and the iris much more irritable. There are two methods of performing the operation ; in one the needle is passed through the cornea, in the other through the sclerotic. Division through the Cornea. The pupil is widely di- lated with atropine, the eyelids drawn apart by an assistant, or fixed with the eye speculum, and a fold of conjunctiva on the inner side of the eye seized with the fixation forceps. A fine spear-shaped needle with a shoulder (Fig. 171) is passed through the outer lower quadrant of the cornea, almost perpendicularly to its surface at a point well within the dilated pupil, so that the iris shall not be touched by the needle. One or more incisious, according to the effect desired, are then made in the anterior capsule of the lens, the needle withdrawn, and a compressive bandage applied. The operation may be repeated as soon as all redness and irritability of the eye have disappeared. Division through the Sclerotic (Hays 1 ). The patient hav- ing been prepared as before, the knife-needle (Fig. 172), with its cutting edge upward, is passed through the sclerotic at a point on its transverse diameter three or four milli- metres from the temporal margin of the cornea, and perpen- dicularly to the surface of the eyeball. Its direction is then changed and its point carried between the iris and lens to the opposite margin of the pupil. If it encounters and penetrates the lens on the way, it will probably dislocate it, in which case extraction should be at once performed ; if the needle is pushed into the lens without dislocating it, the instrument should be withdrawn until its point is free, and then pushed on again in a better direction. This being accomplished, the edge of the knife is turned back against the centre of the lens, and a free incision made by withdrawing it a short distance, while pressing its edge firmly against the cataract. In order to expedite the cure, Wells thinks it is a good plan to combine division with extraction, aud remove the whole cataract by a linear incision after it has been softened by contact with the aqueous humor. In children this may 1 American Journal of Medical Sciences, July, 1855, p. 81. SPECIAL OPERATIONS. 321 be done within a week after the division. The same pro- ceeding may be employed in cases of partial cataract, the transparent portion of the lens being made opaque and softened by the introduction of the needle. Extraction. The methods of extraction may be classified as — The flap ; Von Graefe's ; The linear ; The scoop ; Extraction by suction ; and Removal of the lens in its capsule. Flap Extraction. The common flap ope- ration is certainly the best when it is success- ful. It is nearly painless, does not affect the appearance of the eye, and leaves a natural Fig. 173. Sichel's knife. movable pupil. These advantages, however, are offset by serious disadvantages ; the great size of the flap involves the risk of partial or diffuse suppuration of the cornea, accom- panied possibly by suppurative iritis or irido- choroiditis. Prolapse of the iris is a not in- frequent complication, and the after-treatment requires much more care and attention. But at present this operation is performed about as often as von Graefe's, and with the latter's knife instead of Beer's. The instruments required are a Beer's (Fig. 158) or Sichel's (Fig. 173) or von Graefe's (Fig. 177) knife, fixation forceps, Graefe's cystotome and curette (Fig. 174), and a small blunt-pointed knife or pair of scissors for enlarging the wound, if necessary. Von Graefe's cystotome and curette. 322 OPERATIVE SURGERY. The section may be made iu the upper or lower half of the cornea ; the former is rather the more advantageous, the latter the easier of execution. Operation. (Right eye, upper section.) First Stage. Patient recumbent, the operator seated behind him. The eyelids are separated by an assistant standing at the patient's left side, and drawing the lids gently apart with the fore- finger of each hand, without making any pressure upon the eye. The surgeon steadies the eyeball by pinching up a fold of conjunctiva, with fixation forceps, either just below the cornea, as in Fig. 175, or better, perhaps, just below its prolonged horizontal diameter on the inner side, and Fig 175. Flap extraction of cataract. Mode of fixing the eye and making the incision. draws the eyeball gently down. He then enters the point of the knife at the outer side of the cornea half a milli- metre within its margin, and just on its transverse diam- eter, and carries it steadily across the anterior chamber, taking care to keep the side of the blade parallel to the iris, and to press slightly downward with its back so that it may always fill the incision completely and prevent the escape of the aqueous humor. The counterpuncture is made by the steady advance of the knife at a point imme- diately opposite that of entry, the fixation forceps removed, and the knife pushed on in the same direction until the SPECIAL OPERATIONS. 323 section is all but finished ; when only a small bridge of cornea remains undivided at its upper border, the edge of the knife is inclined slightly forward, and the section com- pleted by withdrawing the knife. Close the eyelids for a moment before beginning the second stage. Second Stage. The anterior capsule is next divided by introducing the cystotome through the incision while the patient looks downward, and drawing its point gently across that membrane. Care must be taken not to displace the lens by pressing the point too forcibly against it. Close the eyelids again for a moment. Third Stage. The patient is again directed to look down- ward, and steady gentle pressure is made upon the eye with the forefinger or curette placed upon the lower lid (Fig. 176). This pressure should first be directed backward so Fig. 176. Flap extraction of cataract. Removal of the lens by pressure. as to tip the upper edge of the lens forward, and then up- ward and backward so as to force the lens through the dilated pupil into the anterior chamber and out through the incision. It should be gentle and very steady so as to avoid rupture of the posterior capsule and escape of the vitreous humor. Any portions of the cortical substance of the lens which may have been left behind in the capsule, or stripped off 324 OPERATIVE SURGERY. Fig. 177. Von Gracfe's cataract knife. during the passage of the lens through the pupil and the incision, must then be removed, and the eye closed. Such was the operation employed for extraction of the ordinary, hard, senile cataract. The objections to it, as before mentioned, were the great size of the flap, the possible prolapse of the iris during the after-treatment, and the risk of iritis fig. i7s. excited by the bruising of the iris during the passage of the lens through the pupil. Von Graefe was the first to suggest that this last risk would be diminished by the excision of a portion of the iris, iridectomy, and on putting the suggestion into practice he found that it also enabled him to remove the cataract safely through a much smaller incision. Accord- ing to Mr. Carter, 1 Von Graefe worked very sedulously during sev- eral years at the endeavor to ex- clude, one by one, the chief sources of the dangers by which extraction was beset, and he arrived at last at the point of losing only four eyes out of one hundred operations. A few improvements in detail have been added since his death, but so far as principles and broad outlines are concerned he had covered the ground. In view of the shortness of the incision, which occupies not more than one-quarter of the periph- ery of the cornea, the operation is generally spoken of as a " modified linear extraction ;" but the curved ' Holmes's Surgery, its Principles and Practice, p. 724. SPECIAL OPERATIONS. 325 outline of the incision, and the fact that the lens is removed entire, certainly bring it within the class of flap extrac- tions. Von Graefe's Method. Modified Linear, or Modified Flap Extraction. The instruments required, besides the eye-speculum and fixation forceps, are a long, thin, nar- row knife (Fig. 177), the blade of which is thirty milli- metres long and two millimetres wide, iridectomy forceps (Fig. 178), scissors, a cystotome (Fig. 174), and a small hard-rubber or tortoise-shell curette. The patient is etherized and recumbent ; the surgeon stands or sits behind him, holding the knife in his right hand for the right eye, in the left hand for the left eye. The eyeball is secured with the fixation forceps, and the point of the knife is entered in the sclerotic with its edge upward, one millimetre from the upper and outer margin of the cornea, and two millimetres below a tangent to its circle drawn at the upper end of its vertical diameter (Fig. 179, A). The point of the knife is at first directed toward the centre of the eyeball, but as soon as it has penetrated to the Fig. 179. Fig. 180. Diagram to illustrate the method of Line of Von Graefe's making von Graefe's incision. incision. anterior chamber it is turned so as to pass parallel to and along the anterior surface of the iris downward and inward about seven millimetres to a point corresponding to B in Fig. 179. The handle is then depressed, turning on the back of the blade in the incision, until the point is raised to the horizontal line of the puncture, when the haudle must be inclined somewhat backward, and the point pushed sharply through the sclerotic and conjunctiva at C, Fig. 179. Great care must be taken not to make the counter- puncture too far back in the sclerotic, a mistake which may. 15 326 OPERATIVE SURGERY. easily happen if the blade is carried too far downward and inward before it is turned up to make the counter-puncture. The edge is then directed forward, and the incision com- pleted by steady advance and withdrawal of the knife. The incision is represented by the upper, undotted line in Fig. 180 ; its centre should lie at the juncture of the cornea and sclerotic. The little bridge of conjunctiva which re- mains at the centre of the incision is then divided in such manner as to leave a conjunctival flap two or three milli- metres long adherent by its base to the cornea. If the cata- ract is large and hard, it may be advisable to use a broader knife, and make the points of puncture and counter-puncture one millimetre lower, so that it will not be necessary to use a sco^p or make much pressure on the eye to effect the removal of the lens. Many surgeons prefer to make the incision wholly in the cornea and close to its edge, on the ground that the wound will heal more promptly and kindly, and be accompanied by less risk of loss of the vitreous or of prolapse of the iris. The object of the iridectomy, which is the next step in the operation, is the neutralization of the circular fibres Fig. 181. Diagram of the correct and faulty sections of the iris. rather than the removal of a large portion of the iris, although some surgeons counsel the latter on account of the greater security it gives against subsequent inflamma- tion. The iridectomy forceps are introduced closed, and opened slightly when the point reaches the margin of the pupil. The margin rises between the branches, is seized, withdrawn gently, and cut off with scissors close to the forceps. If tin's is properly done the angles formed by the edges of the incision and the margin of the pupil will appear in the anterior chamber as at A and B in Fig. 181. SPECIAL OPERATIONS. 327 The portion of iris removed should extend quite to its cil- iary insertion so that there may be none to engage in the external incision and prevent its primary union. The capsule is next freely divided by two successive lacerations made with the cystotome. Each should begin at the lower edge of the pupil and extend upward, one along the inner, the other along the outer side, to the upper border of the lens, where it has been exposed by the iri- dectomy. This upper border should also be torn to an extent corresponding to the external incision. This manoeuvre must be executed with great delicacy and light- ness of touch, in order that the lens may not be displaced into the vitreous humor. The escape of the lens is aided by pressure upon the cor- nea with the curette. The fixation forceps are applied at the inner or outer side, and the curette placed upon the lower edge of the cornea and pressed slightly backward and upward so as to cause the upper edge of the lens to present in the section ; the pressure must then be made directly backward, in order that the lens may be rotated around its transverse axis and tilted well forward into the incision. The curette is then pushed slowly upward over the surface of the cornea so as to follow step by step the delivery of the lens. Any fragments scraped off during the passage may be removed by passing the curette again over the surface of the cornea. If the vitreous humor happens to be liquid it may es- cape as soon as the first incision is made. In such a case it is best to excise a portion of the iris and remove the lens in its capsule by passing a scoop behind it into the vitreous humor and lifting it out. Gayet and Knapp's Modification. Instead of lacerating the capsule as above described these surgeons incise it with a knife-needle along the line of the corneal incision. This is followed in the great majority of cases by an unusually uneventful healing free from iritis and other complica- tions, but leaves the pupillary area occupied by the cap- sule of the lens. In order to clear the pupil the capsule is subsequently (in the third week after the extraction, or later) split with the knife-needle, which permanently 328 OPERA TIVE S VRGEB Y. frees the pupil from both the anterior and posterior cap- sules. Linear Extraction. Mr. Dixon suggests 1 rectilinear ex- traction as a more suitable name, because the incision in the cornea is a straight one, in contradistinction to that of a flap extraction which also forms a line, but a curved one. This operation is a modification of one invented by Gibson in 1811, which had fallen into entire disuse be- fore its reintroduction by Von Graefe in 1855. It is de- signed for the removal of soft cataracts through a small corneal incision, especially the cortical cataract of individ- uals between ten and thirty years of age. It is also often employed with advantage as supplementary to the needle operation. It is performed as follows : A straight, vertical incision, from four to six milli- metres long, is made on the outer side of the cornea, about two millimetres within its margin, with a straight lance- shaped iridectomy knife, which is passed into the anterior chamber parallel to the surface of the iris. The capsule is then freely lacerated with the cystotome, and the escape of the soft lens facilitated by the introduction of a curette into the wound, and by making gentle pressure on the inuer side of the eye with the finger. If portions of the cortex Fig. 182. Fig. 188. \ Critchett's scoops. Bowman's scoops. remain behind the iris they cau be brought into the ante- rior chamber by closing the lids and making gentle pressure in circular liues upon them. If the iris protrudes, it must be gently replaced, or, if much bruised, excised. Scoop Extraction. This is a modification of linear ex- traction, devised by Waldau to obviate the dangers and dif- Holines'e System of Surgery, vol, lii, p. 199. SPECIAL OPERATIONS. 329 ficulties occasioned by the pres- ence in the lens of a hard nucleus of greater or less size. As the principal danger lies in the bruising of the iris, Von Graefe met it by iridectomy, which afterward suggested to Waldau the idea of introducing a scoop and removing the lens without making any pressure upon the eyeball. The instruments required are a bent lance-shaped iridectomy knife (Fig. 160), iridectomy forceps and scissors, and a thin, flat, slightly concave scoop. Waldau's scoop resembled a small spoon. Three different kinds are shown in Figs. 182, 183, 184. The eye-speculum aud fixa- tion forceps having been ap- plied, an incision, eight or nine millimetres long, is made at the upper border of the cornea where it joins the sclerotic. The corresponding portion of the iris is removed, and the capsule freely torn with the cystotome, as before described. The scoop, with its convex- ity backward, is then intro- duced and carried carefully down behind the lens, until its extremity has passed the lower margin of the latter, and engaged it in its hook-like end. It is then withdrawn, care being taken not to press the lens against the iris and cor- nea. If a little of the vitreous humor escapes at the same time, it must be snipped off Fig. 185. Curette and mouthpiece for removal of cataract by suction. 330 OPERATIVE SURGERY. and a compress applied. It is better to remove any frag- ments of the lens that may be left behind by gently rub- bing the eyeball, rather than reintroducing the scoop. Removal by Suction. Laugier suggested, in 1847, the removal of soft cataracts by aspiration through a hollow needle. Blanchot modified the method by substituting a small cauula for the needle, and introducing it through au incision in the cornea, but the operation was not favorably received until after it had been again modified by T. Pridgin Teale, Jr , in 186-3, who recommended it as a sub- stitute for pressure in the removal of the harder portions of the cataract by linear extraction, and as supplementary to discission. The instruments required are a broad needle and a suction curette. The latter (Fig. 185) is described by Mr. Teale 1 as consisting of three parts, a curette, handle, and suction tube. " The curette is of the size of the ordi- nary curette, but differs from it in beiug roofed in to within one line of its extremity, thus formiug a tube flattened ou its upper surface, and terminating, as it were, in a small cup. The anterior capsule is first ruptured with a fine needle passed through the cornea, and then an opening is made with a broad needle iu the coruea through which the curette is passed to the centre of the pupil. The soft matter is then withdrawn by suction. Soelberg Wells 2 says this operation has been employed at the Royal London Ophthalmic Hospital with great success, and that it is especially indicated in cases of soft cortical cataract. If the cataract is somewhat harder, it is well to break it up with the needle a few days before attempting to remove it. Removal of the Lens in its Capsule. This operation is indicated when the capsule is opaque, and whenever the eye is exceptionally irritable, or has been chronically in- flamed, so that the accidental retention of any fragments of the lens would be a source of serious danger. When suc- 1 Ophthalmic Hospital Reports, vol. iv. part 2, p. 197. - On the Diseases of the Eye, p. 280. Philadelphia : U. C. Lea. SPECIAL OPERATIONS. 331 cessful, this method gives very fine results, but its risks and dangers are so great that it is seldom employed. Orig- inally iutroduced by Richter and Beer, it was revived by Sperino, Pagenstecher, and Wecker. The former employed the ordinary flap operation without laceration of the cap- sule. Pagenstecher made a large flap in the sclerotic together with iridectomy. Wecker's method was nearly identical, the incision being made at the sclero-corneal junc- tion. Pagenstecher' s Method. The patient having been thor- oughly anesthetized, a large flap is made, usually down- ward, with a Beer's knife, a small bridge of conjunctiva being left temporarily at its apex. Iridectomy is then per- formed in the outer lower quadrant, and the conjunctival bridge divided with blunt-pointed scissors. Any posterior synechias that may exist are torn through with a fine silver hook, and then the lens removed in its capsule by slight pressure upon the eyeball. If the hyaloid membrane should be ruptured and the vitreous escape, the lens must be re- moved with the aid of a small scoop passed in behind its lower edge. Secondary Cataract. Secondary cataracts vary much in thickness and opacity. They may be produced by portions of the lens left behind and becoming entangled in the cap- sule, by the deposit of lymph upon the latter, or by the proliferation of the intracapsular cells. No operation for secondary cataract should be performed, until, at least, three or four months after the removal of the primary cata- ract; and if the pupil has become contracted, or if very extensive posterior synechias have formed, a preliminary iridectomy should be made. Formerly the plan was to remove the opaque and thickened membrane entirely from the eye, but it has proved very much safer and equally efficacious to make a small opening in the membrane with a needle. Cocaine anaesthesia is necessary. The eye-speculum and fixation forceps having been applied, Bowman's fine needle (Fig. 171) is passed through the cornea near its margin, and an effort made to tear a hole with it in the centre of the membrane or at the part which is thinnest and least opaque. 332 OPERATIVE SURGERY. If the membrane yields before the needle, or if it is too tough to be torn, Mr. Bowman's device of a second needle must be employed. This is to be passed through the cornea on the side opposite to that occupied by the first needle, and then the operator, transfixing and steadying the mem- brane with one needle, tears it with the other. If any por- tion of the iris should happen to be bruised or torn, it must be excised through a linear excision. Dr. Agnew passes a needle through the centre of the membrane, thus steadying both it and the eye. He then makes a linear incision on the temporal side of the cornea through which he passes a small sharp-pointed hook, the point of which is passed into the same opening in the mem- brane as the needle. He next tears the membrane, rolls it up about the hook, and either draws it out altogether, or, if this cannot be done, tears it widely open. OPERATION TO CORRECT STRABISMUS — STRABOTOMY. The tendon of the internal rectus is attached to the sclerotic at a distance of five millimetres from the border of the cornea, that of the external rectus at a distance of seven millimetres. Each tendon is seven or eight milli- metres broad and is contained in a firm sheath resembling a glove finger, a prolongation or depression of the capsule of Tenon at the point where it is traversed by the tendon about midway between the anterior margin of the orbit and the posterior pole of the eyeball. The capsule of Tenon is a reflection of the periosteum of the orbit from the anterior margin of the latter to the transverse meridian of the eye- ball and thence backward to and along the optic nerve, thus constituting a diaphragm which divides the orbit into an anterior and a posterior loge, the former of which contains the eyeball (received into a cup-like depression of the dia- phragm), the latter the muscles and optic nerve. The cap- sule sends a prolongation, not only anteriorly along the tendons, but also posteriorly along the muscles, and the union between the muscle and sheath is so firm that even after division of the tendon the muscle can move the eye- ball by acting through the attachments of the capsule. If SPECIAL OPERATIONS. 333 the body of the muscle itself is divided in the posterior loge, its influence upon the movements of the eyeball is entirely lost. This is the chief point to be borne in mind in performing strabotomy, the tendon must be divided, not the muscle, and the amount of deviation of the eye to be overcome is the measure of the extent to which the adjoin- ing tissues must be divided. The Operation for Division of the Internal Rectus will alone be described, that being the one commonly required. The special instruments required are : fine-toothed forceps (Fig. 186), blunt hook (Fig. 187), and blunt-pointed scis- sors, straight or curved on the flat. A small but deep fold of conjunctiva and subconjunctival tissue is seized with the toothed forceps just above the lower extremity of the line of insertion of tendon of the Fig. 186. Fig. 187. internal rectus, that is, two millimetres below a point on the equator of the eyeball five millimetres beyond the inner margin of the cornea, and divided with the scissors just below the forceps ; additional snips are made with the scis- sors within this opening until the tendon or the sclerotic is exposed. The surgeon then passes the point of the stra- botomy hook, which should be somewhat bulbous, through the opening to the lower border of the tendon, and, keep- ing the point and side of the hook constantly upon the sclerotic, sweeps it at first backward, and then upward and forward around the insertion. When this manoeuvre is prop- erly executed, the point of the hook can be seen under the conjunctiva above the upper border of the tendon, while its 15* 334 OPERATIVE SURGERY. course is hidden by the latter and prevented from being drawn forward to the margin of the cornea. If the whole of the hook can be seen under the conjunctiva, it is not under the tendon, and the sweep must be repeated. When the tendon has been secured, the conjunctiva may be pressed back over its point, and the tendon divided with scissors close to its insertion, beginning at its upper border ; or, the conjunctiva being left in place, the scissors may be passed along the hook as a guide, one blade below the tendon, the other between it and the conjunctiva, and the tendou divided with repeated snips. After the tendon has been completely cut through, the hook should be swept upward and downward to ascertain if the lateral expansions of the tendon have been divided, for the persistence of even a few of them might be sufficient to prevent the success of the operation. If it is feared that too great an effect has been produced, a deep suture may be passed through the tendon and the conjunctiva on the side toward the cornea so as to limit the Fro. 188. Fig. 189. B' Method of estimating the degree of squint. Double operation for strabismus. amount of retraction. The accommodative movements of the eye should be tested immediately after the operation, and if there is the slightest tendency to divergence when the object is six or eight inches distant from the eye a suture should be inserted. In the subconjunctival method the incision in the conjunc- SPECIAL OPERATIONS. 335 tiva is made below the insertion of the tendon on a line with the lower border of the cornea, and the conjunctiva is not pressed away from the anterior surface of the tendon after the hook has been passed under the latter. If the squint exceeds five or six millimetres, as estimated by the method shown in Fig. 188, both eyes should be ope- rated upon, but at separate times, the insertion of the in- ternal rectus being set back in each case. Thus, if the de- gree of squint represented in Fig. 189 were corrected by setting back the tendon of the internal rectus from O to D, the muscle could only work at a great disadvantage as com- pared with the internal rectus of the other side, and the result would be the appearance of divergent squint when- ever the attempt was made to look at an object near the eye, because the muscle could not turn the eye far enough inward. The condition must therefore be divided between the two eyes, the internal rectus on one side being set back to E, on the other side to E r . Secondary Strabismus following Tenotomy of the oppo- nent is treated by advancing the insertion of the tendon of the latter (Prorraphy). Thus, supposing divergent squint to have followed division of the internal rectus, an incision half an inch long is made in the conjunctiva in the line of the horizontal diameter of the cornea, and the conjunctiva and subconjunctival tissue dissected up as far back as to the caruncle. A hook is then passed around the insertion of the internal rectus, and the tendon divided as before; a suture is passed through it, and it is drawn toward, and fastened to, the strip of conjunctiva adjoining the inner border of the cornea. The tendon of the external rectus must then be divided according to the rules laid down for division of the internal rectus, remembering that its attach- ment to the sclerotic is distant seven millimetres from the edge of the cornea. ENUCLEATION OF THE EYEBALL. As the globe of the eye lies somewhat nearer the inner than the outer side of the orbit, it will be found easier to 336 OPERATIVE SURGERY. approach it from the latter quarter. Tillaux 1 divides the conjunctiva and subconjunctival fascia with curved scissors along the attachment of the external rectus, divides the tendon of that muscle, carries the scissors backward through the incision, their concavity turned toward the globe, and cuts the optic nerve close to the eyeball. He then seizes the posterior pole of the globe with pronged forceps, draws it out through the conjunctival incision, and divides the remaining conjunctival attachments and tendons close to the sclerotic. Other surgeons prefer to seek and divide each tendon in turn before cutting the optic nerve. Extirpation of the Entire Contents of the Orbit. In order to gain additional room, it is well first to divide the external commissure of the lids. A bistoury is then entered at the inner angle, carried well back toward the apex of the orbit, and swept along the floor to the outer angle, then reintro- duced at the inner angle, and carried along the roof of the orbit to the outer angle. The muscles and optic nerve, which still remain attached to the eye and apex of the orbit, are finally divided with curved scissors introduced from the outer side. Hemorrhage should be arrested by packing the cavity with antiseptic gauze. OPERATIONS UPON THE LACHRYMAL APPARATUS. Extirpation of the Lachrymal Gland (Fig. 190). The principal portion of the lachrymal gland lies just behind the junction of the upper and outer margins of the orbit, envel- oped in a fibrous capsule formed by a reflection of the peri- osteum or capsule of Tenon. The " accessory " portion, to- gether with the ducts, occupies the adjoining eyelid, and is composed of isolated granulations of granular tissue, which, if left behind after removal of the main portion, may con- tinue to secrete tears and discharge them into the wound, thus causing abscesses and fistulas. Tillaux 2 has pointed out that the existence of the fibrous 1 Anatomic Topographique, p. 190. 2 Anatomic Topographique, p. 237. SPECIAL OPERATIONS. 337 capsule renders it possible to enucleate the gland without opening the posterior loge of the orbit, a defect in the older methods which included division of the external commissure. Make an incision one inch in length along the upper and outer portion of the bony margin of the orbit. Carry this incision through all the soft parts, including the perios- teum, down to the bone ; separate the periosteum from the bone at the under side of the incision, and depress it. The Fig. 190. Extirpation of the lachrymal gland. S. Skin. P. Periosteum. B. Frontal bone. Q. Lachrymal gland. T. Capsule of Tenon. R. Reflected periosteum forming the capsule of the gland. E. Eyeball. C. Conjunctiva. L. Eyelid. I. Incision. gland can then be distinctly seen through the thin layer of periosteum which separates it from the roof of the orbit, and can be removed with great ease after the latter has been torn through. Lachrymal Sac, Duct, and Canaliculi. The lower cana- liculus passes downward from the punctum for two milli- metres, then turns at a right angle, and passes horizontally inward to the lachrymal sac, a distance of about five milli- metres ; the upper canaliculus passes at first upward for two millimetres, and then downward and inward to the sac. This sharp turn in the course of the canaliculus, which is an obstacle to catheterization, can be temporarily removed by drawing the border of the lid outward. The lachrymal sac lies just behind the tendo oculi, and receives the cana-. 338 OPERATIVE SURGERY. Fig. 192. Fig. 191. Sharp-pointed Bowman's probe- canaliculus dl- pointed canalicu- rector. lus knife. liculi by a common duct two or three millimetres below its upper extremity, their relations thus resembling those of the ileum and csecurn, a resem- blance which is increased by the presence of a valve at the opening of the duct into the sac. This valve, described by Huschka, is thought to prevent the reflux of the contents of the sac into the canaliculi. The direction of the sac is downward and backward at an angle of 45° ; it occupies the lachrymal groove, which is bounded anteriorly by a ridge on the nasal process of the superior maxillary bone at the inner angle of the orbit, and is crossed by the tendo oculi just at the junction of its upper and middle thirds. The nasal duct is the direct continuation of the sac and passes downward, backward, and outward ; the combined length of the duct and sac is about one inch. It may become necessary to slit up the ccmalieulus in order to correct a malposition of the punctum, or to facilitate cathe- terization of the sac and nasal duct. This little operation is best performed as follows (right eye, lower lid) : The surgeon stands behind the patient, who is recumbent, and introduces a fine grooved director (Fig. 191) vertically through the punctum for a distance of two milli- SPECIAL OPERATIONS. 339 metres. Then drawing the border of the lid outward and somewhat downward with the forefinger of his left hand, he passes the director horizontally, with its groove upward, along the canaliculus to the inner side of the sac. Then, shifting the director to the left hand, he engages a sharp- pointed knife in the groove, and slits up the canaliculus throughout its entire length. Bowman's probe-pointed canaliculus knife (Fig. 192) may be substituted for the director and knife. It should be very narrow, and its probe point very small. When one puuctum has been entirely obliterated, a plan suggested by Mr. Streatfeild may be employed. He divides the other canaliculus, passes a line director, suit- ably bent, through the wound into the obliterated canali- culus and cuts down upon it. If the divided lower canaliculus remains everted, Mr. Critchett advises that the posterior lip of the incision be cut off with scissors, "effecting the treble object of drawing the canal further inward, of forming a reservoir into which the tears may run, and of preventing reunion of the parts." Puncture of the Sac (Fig. 193). The three guides are the tendo oculi, the anterior margin of the lachrymal groove, Fig. 193. Puncture of the lachrymal sac. and the direction of the sac. While an assistant draws the external commissure outward, so as to make the tendo oculi tense and plainly visible, the surgeon places his left fore- 340 OPERATIVE SUBGEBY. finger upon the inner and lower margin of the orbit, so as to have the bony edge between the nail aud the pulp of the finger, and holding the knife in the direction of the canal, that is, nearly parallel to the median plane, aud at an angle of 45° with the horizon, he passes it along his finger-nail into the sac just below the tendon. It is important to mark the position of the anterior margin of the canal, so as to avoid the not infrequent mistake of passing the knife en- tirely outside of the orbit between the soft parts of the face and the bone. Stricture of the Nasal Duct. Division. Dr. Stilling, of Cassel, proposes to treat stricture of the nasal duct by internal division. He divides the canaliculus and ascer- FlG. 194. Stilling's knife. tains the seat of the stricture with a probe, passes his knife (Fig. 194) through it, and divides it in three or four direc- tions. CHAPTER II. OPERATIONS UPON THE EAR AND ITS APPENDAGES. OCCLUSION OF EXTERNAL AUDITORY CANAL. Congenital occlusion of the external meatus is usually associated with absence or defective development of the other portions of the auditory apparatus. Before operating upon such an occlusion, therefore, the hearing power should be tested, and the permeability or impermeability of the bony portion of the canal determined by puncture with a needle. If the occlusion consists of a simple membranous dia- phragm it should be divided crucially, and the flaps excised. For deeper and more extensive obstructions cauterization with nitrate of silver is to be preferred. SPECIAL OPERATIONS. 341 INTRODUCTION OF SPECULUM (ROOSA). The upper portion of the auricle is grasped between the ring and middle fingers of the left haud and drawn gently- upward and backward. Into the canal thus straightened the speculum is introduced with the right hand, and then held in place with the thumb and forefinger of the left, the hand being steadied by resting its ulnar border against the patient's head. Complete control of the speculum is thus obtained, and it can be easily moved about so as to bring every part of the tympanum and canal into view. Light should be thrown into it from a concave mirror perforated in the centre and having a focal distance of six inches. PARACENTESIS OF THE MEMBRANA TYMPANI (ROOSA). 1 This should be performed while the head of the patient is well supported and a good light is thrown upon the mem- brane by a mirror attached to a forehead band. A cataract needle is the instrument usually employed, and the opening should be made in the posterior inferior quadrant of the membrane Tillaux 2 calls attention to the fact that all the important elements of the membrane occupy its upper half, and that an incision or rupture near the handle of the hammer may give rise to troublesome and even dangerous hemorrhage. The lower half is less vascular and less sensitive. If it is desired to maintaiu the opening for several days, a crucial incision maybe made, or a triangular flap excised, but, as a rule, even these incisions heal very quickly. CATHETERIZATION OF THE EUSTACHIAN TUBE. The Eustachian tube is from one and a half to two inches long, its course is from the pharynx upward, backward, and outward. Its pharyngeal orifice is oval and well marked 1 Treatise on the Diseases of the Ear, p. 246. - Anatomie Topographique, p. 111. 342 OPERATIVE SURGERY. except on the lower border, and is situated just above the base of the soft palate. Behind the orifice, between it and the posterior wall of the pharynx, is a depression (Rosen- miiller's fossette) in which the beak of the catheter, if car- ried too far back, may lodge and give the same sensation to the surgeon's hand as if it were enraged in the tube. Of the two mistakes most frequently made iu performing catheterization, one is to pass the beak of the instrument between the middle and inferior turbinated bones instead of along the floor of the nasal fossa, and the other is to mis- take Rosenmiiller's fossette for the orifice. According to Roosa, 1 the first mistake is best avoided by drawing down the patient's upper lip with the left hand, and entering the catheter while it is held in an almost vertical position, its concavity directed toward the mediau line. After the beak has fairly entered the meatus the stem of the catheter is gradually raised to the horizontal position and passed back- ward, its beak resting on the floor of the meatus close to the septum, its convexity upward. Tillaux 2 gives the following directions for fiuding the orifice: 1st. Carry the catheter directly backward, its con- cavity downward, until it touches the posterior wall of the pharynx. 2d. Withdraw it until the beak rests again upon the hard palate. 3d. Carry the catheter again very gently backward, and feel with its beak for the posterior border of the palatine aponeurosis, the firm fibrous continuation of the palatal bone. This aponeurosis feels as hard as bone, and its posterior border can be easily recognized by the softness of the adjoining tissues. 4th. Rotate the beak of the catheter outward and upward, and it will enter the Eustachian tube. OPENING OF THE MASTOID ANTRUM.'' The incision begins just above the apex of the mastoid process and is carried upward one and one-half inches paral- lel to the attachment of the ear, and about one-half an inch behind it. Everything is divided down to the bone, the periosteum elevated, and the posterior margin of the meatus 1 Diseases Of the Kar, p, 94. - Anatomic Topogruphiquc, p. 140. 3 Birmingham Dub. Journ. Med. Sci., 1891, p. 116. SPECIAL OPERATIONS. 343 recognized. A one-quarter-inch drill or gouge is driven straight inward at such a point that the hole it makes shall lie as near as possible to the back of the bony meatus and its upper border be not more thau one-twelfth of an inch above the level of the upper margin of the meatus. It must not penetrate deeper than three-quarters of an inch or the external semicircular canal will be damaged. Deep perforations back of a line one-quarter of an inch behind the posterior margin of the meatus are liable to wound the lateral sinus. The antrum, which is about the size of a pea, is usually reached at a depth of three-fifths of au inch. The opening thus made into it may afterward be enlarged and any necrosis carefully gouged out, and the wound is finally packed and drained. Stacke's Method. 1 An incision penetrating to the bone throughout is made parallel to aud close behind the attach- ment of the auricle to the head, starting from the apex of the mastoid process aud terminating well above and in front of the ear on the temporal region. The soft parts and periosteum are elevated toward the external meatus and the bony margin of the latter thus exposed. The fun- nel of skin, periosteum, and cartilage leading into the meatus is then still further detached with a fine elevator and cut across just external to the membrana tympaui, thus exposing the whole of the bony passage. The malleus, incus, and tympanum, or its remains, are next excised, and the outer surface of the mastoid, together with the posterior wall of the external meatus and middle ear, are chiselled through, making a gutter extending from the top of the tympanic cavity to the floor of the aditus ad antrum. The chorda tympani is inevitably divided, but the facial nerve and the labyrinth are avoided by carefully keeping ex- ternal to the inner wall of the tympanic cavity. After scraping out all diseased tissue the funnel of skin and peri- osteum, which was detached from the external meatus, is split in its long axis posteriorly and the flaps fitted into the bony gutter, thus partially providing au epidermic cov- ering for the denuded surfaces. A couple of sutures in the extremities of the incision aud an iodoform-gauze pack- ing complete the operation. 1 Berlin, klin. Wochensch., 1892, p. 68. 344 OPERA TIVE S UROER Y CHAPTER III. OPERATIONS UPON THE MOUTH AND PHARYNX. EXCISION OF THE TONSILS (AMYGDALOTOMY). The tonsils may be excised with a knife and volsella, or with a specially contrived instrument, the tonsilotome or guillotine. Anaesthesia is not required. If the patient is young or nervous it is well to put a large piece of cork between the Fig. 195. ^ _^ ____^ jsszs^ B /^» ^^ G, T/EMA nn'&.co. (T*~|j A Tonsilotome. jaws on each side to prevent the mouth from being closed. The tonsilotome (Fig. 195) is composed of two rings and a fork mounted upon stems so arranged that they can be worked with the thumb and fingers of one hand. The two rings slide flatwise upon each other, and the inner edge of one is sharp, so that when drawn across the other it divides anything lying within it. The fork is thrust forward across the ring and drawn away vertically from it by the same movement which draws one ring across the other. The rings having been placed over the tonsil, the hook is driven into the latter by a quick movement of the thumb and finger and draws it further into the ring, holding it tense as the other blade cuts across its base. The pain is very slight. If the tonsilotome cannot be used the tonsil must be seized with pronged forceps, and excised between them and the pillars with a probe-pointed knife, the posterior portion of the blade being guarded with diachylon plaster so as to avoid injury to the tongue. SPECIAL OPERATIONS. 345 STAPHYLORAPHY. At the conclusion of his historical account of this opera- tion Verneuil 1 states that it has been invented four different times. The earliest record of the operation is found in a French book published in 1766, 2 in which it is said that a dentist, named Lemonnier, closed a fissure of both hard and soft palates by freshening its edges with a knife and bring- ing them together with sutures. He also closed perforations of the hard palate by exciting suppuration of their borders. In 1799 Eustache, a physician of Beziers, proposed to reunite by sutures the edges of an incision which he had made the day before in the soft palate of a patient for the purpose of removing a pharyngeal polyp. The patient re- fused the operation. Four years later, in 1803, Eustache sent to the Academie Royale de Chirurgie at Paris a re- markable paper upon congenital fissures in the soft palate, and asked the Society's approval of the operation by which he proposed to close them. The approval was withheld, and there is no record of any further steps having been taken. In December, 1816, Von Graefe said, before the Medico- Chirurgical Society of Berlin, that, after many unsuccessful attempts to close fissures of the soft palate, he had at last succeeded by drawing the edges together with sutures after freshening them by applying muriatic acid and the tincture of cantharides. This remark was reported in the proceed- ings of the Society in Huf eland's Journal, January, 1817. Between 1816 and 1820 Von Graefe repeated the operation three times, each time without success. In 1819, Roux, apparently in entire ignorance of Von Graefe's attempt, closed a fissure by paring the edges and applying sutures. The case at once became very widely known, and had much influence in popularizing the opera- tion. When the extent of the lesion which staphyloraphy is designed to repair is considered, the operation seems to be very simple. It is only necessary to freshen the edges of 1 Chirurgie RGparatrice, 1877. Art. Staphylorrhaphie. - Traite des Principalis objets de Medecine, par Robert. 346 OPEEA TIVE S UROER Y. the gap and draw them together with sutures. Practically, however, the operation is a difficult one ; the parts lie at a considerable distance from the surface, the manipulations are constantly interfered with by involuntary movements of deglutition, the flow of blood increases the obscurity, and the practical difficulties in the way of placing the sutures are great. Finally, unless some of the muscles of the palate are divided, the tension exerted by them upon the sutures is sufficient to prevent union. A great variety of methods have been suggested to over- come these difficulties. Mr. T. Smith diminished the first by the invention of a gag (Fig. 196), designed to hold the Whitehead's modification of Smith's gag. jaws apart during the operation. Prof. Van Buren pre- vented the passage of blood into the trachea during the employment of anaesthesia by placing the patient so that the head should hang down over the end of the table, and the blood escape through the nose. The same device was afterward employed by Trelat. Sir William Fergusson relieved the tension by dividing the levator palati on each side. He did this by passing a knife, bent at a right angle, through the cleft and dividing SPECIAL OPERATIONS. 347 the muscle from behind forward, without touching the mucous membrane on the anterior face of the palate. The incision should be perpendicular to the centre of a line joining the hamular process and the orifice of the Eusta- chian tube. The former can be readily felt just behind the last upper molar tooth, the latter can usually be seen through the cleft in the palate. He also recommended division of the palato-pharyngeus muscle. Sedillot 1 divided the muscle from before backward. He drew the velum downward and inward with pronged forceps, and made an incision downward and outward about one centimetre above and on the outer side of the base of the uvula, and just behind and on the inner side of the last upper molar, crossing the levator palati at right angles (Fig. 198). A length of one centimetre is usually suffi- cient, but it must be increased if the muscular contractions persist. The relaxation of the parts produced by these in- cisions is shown by a comparison of Figs. 197 and 199. Unless the incisions are exceptionally large their sides re- FlG. 197 Fig. 198. FIG. 199. main in contact ; in any case they promptly reunite. He then divided the anterior and posterior pillars, seizing each in turn near its centre with pronged forceps, and cutting it with scissors. Mr. George Pollock 2 has modified this slightly by making 1 Medecine Opfiratoire, vol. ii. p. 65. 2 Holmes's System of Surgery, vol. iv. p. 426. 348 OPERATIVE SURGERY the incision on the anterior surface of the palate smaller. One of the halves of the palate is drawn toward the median line by means of a ligature passed through it near the base of the uvula, and a thin, narrow knife is entered close to the hamular process, a little in front of it and on its inner side, and its point carried upward, backward, aud some- FlG. 200. Division of muscles of soft palate. what inward, until it can be seen tli rough the cleft, having divided on its way part, if not all, of the tendon of the tensor palati. The blade now lies above most of the fibres of the levator (Fig. 200), and by raising the handle and cutting downward, as the knife is withdrawn, an incision of considerable length, including the greater portion of the SPECIAL OPERATIONS. 349 levator, is made on the posterior surface of the palate, while that on the anterior surface need not be greater than the breadth of the knife. If the muscle has been effectually divided the palate will be pendulous and flaccid, and will not contract spasmodically when pulled upon. If any re- sistance should persist the knife must be introduced again through the wound and the iucision enlarged downward. Roux placed his sutures by putting a needle at each end of the thread, and passing them from behind forward. Trelat used a needle fixed upon a long handle, the point bearing the eye and curved in the form of a U. After having been threaded the point of the needle was passed through the palate from behind forward, the thread was drawn through with a hook or forceps, and the needle, still threaded, withdrawn and passed in the same manner on the opposite side. The objection to these and to all other methods in which the needle is passed from behind forward, is that, since the point cannot be seen, it is very difficult to make the punctures on one side correspond properly with those on the other. If silk sutures are used each end may be passed from before backward, the two tied together loosely, and the knot pulled back through one of the punc- tures, thus bringing the loop behind the palate. The method now usually employed is the one introduced by Berard. A curved needle fixed on a long handle is threaded with a ligature three feet long, and its point passed through the palate from before backward ; the thread is caught with hook or forceps on the posterior side, and its end drawn out through the mouth, the needle is then with- drawn and slipped off the thread. It is next threaded with a second ligature and passed in the same manner through the opposite half of the plate, the loop seized as before, drawn through a short distance, and held while the needle is withdrawn, leaving the thread double in the puncture — the loop behind the palate, the two ends in front. The poste- rior end of the first ligature is then passed through the loop of the secoud one (Fig. 201, 6), and, by the withdrawal of the latter, drawn through the second puncture (Fig. 201, a). Instead of using the same needle to pass both ligatures, it is more convenient to have two curved spirally in the opposite directions, one for each side. 16 350 OPERATIVE SURGERY. If silver sutures are used, thread loops should be passed from before backward on each side, one end of the wire engaged in each and drawn through. After a suture has been passed, the ends should be brought out through the mouth, and tied together for safety. When all have been passed, the anterior one is drawn upon to bring the edges of the cleft together, and the knot tied. Fig. 201. Staphyloraphy ; passing the sutures. The knot may be an ordinary square one, an assistant hold- ing the first twist with dressing forceps until the second is made, or it may be a noose, as shown in Fig. 201, c, secured by a second knot. If silver wire is used, it may be fast- ened by twisting it, or by clamping a small lead button upon it. Verneuil first passes the ends of the wire through the eyes of a shirt button, and then ties or twists. He thinks this favors more accurate adjustment of the edges, and facilitates removal of the wire. The edges of the cleft are pared by seizing the tip of the uvula with toothed forceps, making it tense, entering the point of a narrow-bladed knife one or two millimetres back from the edge, and cutting down to the tip; then turning the knife and cutting up to the anterior angle of the cleft. Care should betaken to do this thoroughly. When the cleft is very short (bifid uvula), N6laton employed the method SPECIAL OPERATIONS. 351 already described under his name for single uncomplicated harelip. The flaps were left adherent to each other at the apex (angle of the cleft) and to the uvula at their bases, turned down, and the raw surfaces drawn together. When the cleft was too long for this he separated the flaps at the apex, shortened them by trimming off the free ends, turned them down, and united as before. There is no settled rule of practice establishing the order in which the different steps of the operation shall be. exe- cuted, except that most surgeons are agreed upon the ad- visability of paring the edges of the cleft before passing the sutures. Mr. Callender recommended that the muscles should be divided a day or two before the attempt to close the cleft, on the grouud that the second operation is much simplified by the freedom from the bleeding occasioned by division of the muscles. Mr. Smith, on the other hand, stretched the palate by drawing upon all the sutures, di- vided the palato-pharyngeus and levator palati, and then, if the edges of the cleft did not come easily together, made two lateral oblique cuts, one on either side, above the higher suture, separating, to a limited extent, the soft from the margin of the hard palate. Bonfils, according to Dubrueil, closed an opening left at the upper part of the palate by the partial failure of an operation for staphyloraphy, by taking a flap from the hard palate, according to the Indian method of autoplasty (q. v ). URANOPLASTY. Verneuil 1 attributes the success of modern uranoplastic operations to the use of the method by double flaps, ad- herent at both ends and brought together laterally (lam- beaux en pont), and to the retention of the periosteum in the flaps. He ascribes the first use of double flaps to Dief- fenbach, and thinks the retention of the periosteum was brought about by Ollier's most valuable experimental and clinical researches upon the properties of this tissue. To Von Langenbeck, by whose name the method is usually 1 Chirurgie Reparatrice, Art. Uranoplastie. 352 OPERATIVE SURGERY. known, he gives only the credit of being the first to adopt Ollier's suggestion, and to make it a rule of practice. This estimate of the facts does not seem to be entirely correct. It is true that Dieffenbach used double lateral flaps, but a large part of the success of the modern method is due to the greater breadth now given to the flaps. Tillaux has shown that the branches of the posterior palatine artery are given off like the plumes of a feather, and that to avoid division of these branches, and insure the nutrition of the flap, the incision must be made close to the alveolar process. This necessity is as absolute in the case of a small perfora- tion as in that of a larger one. As for the retention of the periosteum, Von Langenbeck was certainly the first to point out its importance as a means of preventing gangrene of the flap. Ollier's investigations turned upon its value in favoring reproduction of the bone. Fissure of the hard and soft palate endangers an infant's life by interfering with the ingestion of food. The exact measure of this danger has not yet been established by statistics, but it is certainly considerable. 1 On the other hand, all recorded operations for cleft palate upon children less than one month old have terminated fatally, aud those undertaken during; the first five or six months of the ehild's life, although not so fatal, show but few successes. Billroth aud Simon think the operation should be performed about the eighth month, but most surgeons are agreed upon the propriety of postponing it until the third or fourth year. If a child has lived six months without operation, it has cer- tainly learned to overcome the mechanical difficulties in the way of its nourishment, and there is, consequently, no reason to interfere surgically until the second indication arises. That is found in the defective articulation and phonatiou occasioned by the lesion, and, as children with cleft palate do not begin to speak before the third or fourth year, the operation may be safely postponed until that time. The special instruments required are a speculum oris, or two blunt hooks to be placed at the angles of the mouth and fastened together by a rubber band passing behind the head, pronged forceps with long handles, curved needles of 1 Lannelongue i M6m. , the apex directed to one side. The attachments of the genio-hyo-glossus muscles to the bone are next divided, the two halves of the jaw drawn apart, the tongue pulled for- ward and to one side, and its attachments to the hyoid bone divided on the other side, in doing which the lingual artery is divided and must be tied at once. The tissues on the other side are then divided in a similar manner, and the other lingual artery having been tied the remaining attach- ments are severed and the tongue removed. The divided maxilla is fastened together again with silver sutures passed through holes pierced in it with a drill, the sides of the incision in the lip accurately adjusted to each other, and the lower angle of the wound left open for drainage. The bone has sometimes been divided on the side instead of in the median line. Von Langenbeck makes an incision from the angle of the mouth vertically down to the thyroid cartilage. Through this the submaxillary and lymphatics are extirpated, the digastric and hyoglossus muscles cut through, the lingual artery tied, and the jaw sawn obliquely in front of the mas- seter from above downward and backward. After drawing apart the segments the mucous membrane is severed from the inner surface of the posterior one as far back as the anterior pillar of the fauces. Through this gap not only the tongue but also the tonsil and soft palate can be re- moved if necessary. The operation is concluded like Sedil- lot's. Billroth's modification of this consists in dividing the jaw and overlying soft parts on both sides, and turning down the intermediate chin segment. Crespi and Bastianelli 1 have still further modified Lang- enbeck's operation as follows: An incision is carried ver- tically down through the middle of the under lip and chin to the lower border of the jaw, along the latter horizon- tally to near the angle, and thence vertically down for 1 Contrail), f, chir., L890, p. 556, SPECIAL OPERATIONS. 361 about an inch to the anterior border of the sterno-mastoid muscle. The soft parts are separated from the outer sur- face of the jaw to within an inch of the insertion of the masseter, the facial and lingual arteries ligated, the salivary and lymphatic glands removed, and the jaw divided ob- liquely from behind forward in front of the second molar tooth. This affords access to the retrobuccal and pharyn- geal region, and permits of removal of the tonsil and ad- joining parts. DIVISION OF THE FRUSTUM. The tip of the tongue is raised upon the handle of a director, in the slit of which the frsenum is engaged, and divided with curved scissors close to the director. Only the semi-transparent edge of the constricting band should be cut, and then the rest torn by pressing the tongue up toward the roof of the mouth. If the ranine vessels should chance to be divided the bleeding can be controlled by tor- sion or ligation or by touching the points with nitrate of silver, or, if necessary, with the actual cautery. J. L. Petit reported a case of suffocation caused by the tongue falling back upon the glottis after division of the frsenum, aud GuSrin mentions another. RANULA. The anterior wall of the cyst should be caught up with toothed forceps and excised. A director should be passed at intervals between the sides of the incision to prevent re- union, and the filling up of the sac may be hastened by painting its interior with nitric acid or tincture of iodine. In some cases it is sufficient to pass a thread or wire setou through the cyst. SALIVARY FISTULA. Salivary fistula communicating directly with portions of the parotid gland can usually be closed by cauterization and compression, but when the fistula communicates with 362 OPERATIVE SURGERY. Steno's duct the cure is much more difficult. If the distal portion of the duct is still permeable a leaden wire may be passed through it from the mouth into the proximal por- tion of the duct. The saliva will follow the wire, and if the fistula does not close spontaneously its edges should be pared and brought together with sutures. The orifice of the duct is readily found opposite the second upper molar tooth. When the distal portion of the duct is obliterated sev- eral methods may be employed. One is that of Deguise, and consists in the formation of a new channel in the cheek for the saliva ; another is that of Professor Van Buren, and consists in the bodily transfer of the fistulous orifice from the outer to the inner surface of the cheek. Deguise's Method. Deguise made a puncture through the fistulous opening obliquely backward to the inner sur- face of the cheek and passed one end of a leaden wire through it; he next made through the same opening a second puncture directed obliquely forward, brought the other end of the wire through it and tied the two ends together. The loop of the wire being thus drawn into the fistula the saliva followed its two branches into the mouth, and the fistula healed at once. Some surgeons use a silk ligature and tie it tightly so as to cut through the tissues included in the loop. Agnew's method of doing this is by the passage of a curved needle around the duct from within the mouth. Prof. Van Buren 1 cured a salivary fistula, the result ot a gunshot wound, by passing two fine silver wires through the skin at opposite points on its edge, then isolating the duct and fistulous opening for half an inch by dissection backward from the latter, making an incision through the wound to the inner side of the cheek, drawing the fistulous opening through it, and fastening it there by means of the wires. The gap left on the cheek was then closed with fine silver sutures. 1 New York Medical .Journal, vol. i. j>. 58, and Contributions to Practical Surgery, 1865, i>. '20. r >. SPECIAL OPERATIONS. 363 The duct was so short, the fistula being an inch behind the anterior margin of the masseter, that it could not be brought quite to the iuner surface of the cheek. The wires, however, which were left in place uutil the fifth week, kept open a track, which became permanent, for the passage of the saliva from the end of the duct to the mouth. CHAPTER IV. OPERATIONS PERFORMED UPON THE NECK. BRONCHOTOMY. This is a general term covering operations undertaken to open the larynx or cervical portion of the trachea. These operations are : Laryngotomy, tracheotomy, aud laryngo- tracheotomy. Laryngotomy is further subdivided into sub- hyoid pharyngotomy, or laryngotomy (called supra-laryn- geal bronchotomy by Seclillot, and indirect laryngotomy by Planchou), thyroid laryngotomy or thyrotomy, crico-thyroid laryngotomy, and tracheotomy, which is further subdivided into high and low, dependiug upon whether the trachea is opened above or below the isthmus of the thyroid gland. The names indicate the points at which the opening is made into the air-passages. Sub-hyoid Pharyngotomy or Laryngotomy. This opera- tion, origiually performed upon animals by Bichat for the purpose of studying the movements of the vocal cords, was afterward proposed by Vidal to give access to an abscess situated in the glotto-epiglottidean folds, and by Malgaigue to allow the removal of a foreign body lodged iu the upper part of the larynx. It is also applicable to the removal of polyps situated at the same point and not accessible through the mouth. Folliu thus removed ten from the anterior surface of the arytenoid cartilages. The shoulders are raised and the head extended. A trans- 364 OPERATIVE SURGERY. verse incision two inched long, its centre in the median line, is made through the skin immediately below the hyoid bone, and the platysma, sterno-hyoid, and thyro-hyoid mus- cles, and thyro-hyoid membrane divided. The mucous membrane lying between the epiglottis and the base of the tongue then presents in the incision, is drawn downward with forceps, and opened with the knife or scissors. The epiglottis is then seized with a hook or pronged forceps and drawn out through the wound, freely exposing the larynx to view. Velpeau made the first incision in the median line, divided the thyro-hyoid membrane transversely, and then plunged the knife backward and downward, making a ver- ical incision in the base of the epiglottis through which he passed the blades of a pair of forceps and withdrew the foreign body. Aplavin 1 has modified this operation as follows : With the head well extended the trachea is opened and plugged by a tampon-canula — a tracheotomy tube surrounded by a rubber bag, which is inflated after its introduction till it fills the lumen of the trachea. The pharynx is incised transversely as above described and the hyoid bone cut through with scissors on each side from one-half to three- quarters of an inch in front of its extremities. If there is fear of wounding the lingual vessels a part of the hyo- glossus muscle is cut close above the hyoid bone and the vessels recognized and drawn up. By raising this segment of bone and depressing the thyroid cartilage, pretty free access can be obtained to the parts close around the open- ing of the larynx. At the conclusion of the operation the mucous mem- brane is sutured first ; then external to it a silk suture is passed on each side through the skin and upper border of the thyroid cartilage behind and over the hyoid bone about one-half an inch in front of its points of division. After uniting the thyro-hyoid membrane and overlying soft parts the two silk ligatures are knotted externally and thus prevent undue tension on the other sutures. 1 Arcblv r. kiln. Chlr., vol. n, i>. 824. SPECIAL OPERATIONS 365 Thyroid Laryngotomy or Thyrotomy. In this operation the thyroid cartilage is divided vertically in the median line, between the anterior attachments of the vocal cords. It is suitable for the removal of foreign bodies or polyps from the interior of the larynx and for fractures, stenosis, or disease of this organ. The head is well extended, or allowed to hang from the edge of the table. A preliminary tracheotomy and plug- ging of the trachea may be necessary. Steadying the larynx with the thumb and forefinger of his left hand, the surgeon makes an incision along the pro- jecting angle of the thyroid cartilage in the median line, from its upper border to the cricoid cartilage. As soon as the crico-thyroid membrane is exposed, he makes a small opening in it near its upper border and passes one blade of a strong blunt-pointed pair of scissors through it to the upper border of the laryux, keeping exactly in the median line, and thus divides the thyroid cartilage throughout its entire length. Or a grooved director may be passed through the opening made in the crico-thyroid membrane, and the cartilage divided upon it with a curved bistoury. Or, again, the division may be made with the knife, layer by layer, from before backward; but whenever possible the upper border of the larynx should be left uncut to preserve the relation of the vocal cords. The conoid and thyro-hyoid ligaments and thyro-hyoid membrane must often be separated to a greater or less extent from the upper and lower border of the thyroid cartilage to permit its lateral halves to be retracted suffi- ciently to expose thoroughly the cavity of the larynx. At the conclusion of the operation the wound may either be closed immediately with silk or silver-wire sutures, or left open and packed for a couple of days. Crico-thyroid Laryngotomy. In this operation the open- ing is made in the crico-thyroid membraue. The French writers, Sedillot, Dubrueil, Chauvel, speak of this method as having been entirely abandoned because the opening cannot be made sufficiently large. Holmes, on the other hand, considers it suitable in all cases in which only the vocal cords or the tissues above them are involved, and says 366 OPERA TIVE S UR OER Y. it is practised in spasm of the glottis from any cause, in erysipelatous affections spreading down the throat, and in cases of foreign body lodged in or above the glottis. If the opening proves to be too small it cau be enlarged down- ward through the cricoid cartilage (laryngo-tracheotomy). The operation may be required in cases of urgency when no tube is at hand. A pair of forceps or scissors, a hair- pin, or pieces of bent wire will suffice to keep the wound open, and the incision can be made with the penknife. Operation. Dorsal decubitus, shoulders raised upon a cushion or narrow pillow so that the head may fall back aud keep the throat tense. The surgeon, standing at the patient's right side, fixes the larynx with his left thumb and middle finger placed on either side, and the index upon its upper border, and makes a cutaneous incision in the median line corresponding to the crico-thyroid membrane. He draws the sterno-thyroid muscles apart, lays bare the membrane, and divides it transversely or vertically ; in the latter case the incision should begin a short distance below the inferior border of the thyroid cartilage, so as to avoid a small artery which crosses at that point, and extend to the cricoid cartilage. (For the method of inserting the canula, see Tracheotomy.) Laryngo-tracheotomy. The opening occupies part of the crico-thyroid membrane, the cricoid cartilage, and the first two or three rings of the trachea. The upper border of the isthmus of the thyroid usually corresponds to the second ring of the trachea ; it should not be divided. In children under six years it commonly rises to the lower border of the cricoid cartilage. Dorsal decubitus, with shoulders raised, head thrown back, and neck slightly stretched. The larynx is fixed as for crico-thyroid laryngotomy, and an incision made through the skin exactly in the median line from the middle of the thyroid cartilage to about one inch below the cricoid. The muscles arc carefully drawn apart, the isthmus of the thy- roid depressed if necesary, after nicking and tearing with blunt hooks the suspensory fascia at its upper border, the trachea steadied aud drawn upward with a sharp hook SPECIAL OPERATIONS. 367 thrust into the upper part of the crico-thyroid membrane, and the point of the bistoury entered close below the hook and made to cut downward through the cricoid cartilage and one or two of the rings of the trachea. The edges of the incision are then held apart and the cauula introduced, or the forceps if the operation has been undertaken with a view to the removal of a foreign body or a polyp. De Saint Germain's Method. Dorsal decubitus, shoul- ders raised, neck extended. The surgeons feels for the cricoid and thyroid cartilages, and the depression between them. Then, standing upon the patient's right side, he places his left thumb and middle finger on either side of the larynx, and by pressing them in between it and the vertebral column, pushes the larynx forward, makes tense the skin covering it, and at the same time marks the situa- tion of the lower border of the thyroid cartilage with the nail of his left forefinger. The knife, a straight, sharp-poiuted bistoury, is held like a pen, its back directed upward, and the middle finger so placed upon its side as to limit to half an inch the depth to which the point can penetrate. It is then entered with a quick sharp stab in the median line close against the nail of the left forefinger and made to cut downward with a sawing motion through the cricoid cartilage and one or two tracheal rings, care being taken to make the incision in the skin fully as long as that in the trachea. The wound is held open with a "dilator," and the canula introduced between its branches; the pressure of the latter is usually sufficient to arrest hemorrhage, but ligatures cau be easily applied if necessary. In only oue case out of ninety-seven did Saint Germain injure the posterior wall of the trachea, and in only three did hemorrhage occur. 1 Tracheotomy. The trachea may be opened at any point between the cricoid cartilage and the upper border of the sternum, a distance averaging in the adult from two and one half to three inches, in the child under ten years of age from one and one-half to two and one-half inches. Its 1 Bull, de la Societe de Chirurgie, 1877, pp. 271 and 327. 368 OPERA TIVE S UEOER Y. course is obliquely backward as well as downward, so that while its upper end is almost subcutaneous it becomes deeply placed before it passes behind the sternum. It is crossed at its upper eud by the isthmus of the thyroid glaud, the breadth, thickness, and vascularity of which vary within very wide limits, although its upper border usually corresponds to the second ring of the trachea. A communicating branch uniting the two inferior thyroid arteries crosses just below the lower border of the isthmus. The lower portion is covered anteriorly by the thyroid veins, always greatly distended when the respiration is ob- structed, and by the thymus glaud in children under two years of age, and occasionally in unhealthy older ones To the dangers depending upon the normal arrangement of the parts are added those of not infrequent anomalies in the origin and course of the arteries and veins. Thus, the left brachio-cephalic vein may cross the trachea well above the sternum, the left carotid may arise from the innominate, and sometimes a thyroidea ima artery is given off from the transverse portion of the arch of the aorta, and ascends along the anterior surface of the trachea in the median line. Finally, an aneurism of the innominate, or of the arch of the aorta, may rise in front of this portion of the trachea. Operation. The patient is placed upon his back with shoulders raised and head thrown back. A trustworthy assistant, standing behind the head, holds it firmly in a straight line with the body; others control the patient's limbs if he has not been anaesthetized. The surgeon, stand- ing at the patient's right side, recognizes with his finger the hyoid bone aud thyroid and cricoid cartilages, and, marking with his left forefinger the upper border of the cricoid cartilage, makes an incision downward from it in the median line from one and one-half to two inches in length, according to the size of the patient. He carries the incision through the skin and fascia, separates the sterno-hyoid and sterno-thyroid muscles with the handle of his knife, and lays bare the isthmus of the thyroid. If any large veins are encountered, they must be carefully drawn aside or di- vided between two ligatures, but bleeding from smaller ones may be safely disregarded, for, as Trousseau pointed out, it will cease as soon as the trachea is opened, and the SPECIAL OPERATIONS. 369 venous congestion relieved by the admission of air to the luugs. It is well to have one or two assistants hold the sides of the incision apart during the dissection, if they can be de- pended upon to do so without disturbing the relations of the parts by drawing too forcibly toward one side or the other. The isthmus of the thyroid is next drawn upward with a blunt hook, and three or four rings of the trachea exposed below it, and divided from below upward. If for any reason it is desirable to make the incision higher up, or if the isthmus is unusually broad, it may be divided between two ligatures, in which case the incision of the trachea should be made from the lower border of the cricoid carti- lage downward. Fig. 204. Fig. 205. Bivalve canula closed. Bivalve eanula with tube in place. The incision in the trachea should always be free enough to admit the canula readily, and should be made by a quick thrust with a sharp-pointed knife, which must be prevented from penetrating too deeply at first, by holding it close to its point. After the puncture has been thus made, it is en- larged by gentle sawing movements of the knife, or with scissors. The knife is retained in the trachea as a guide, until the dilator or bivalve canula (Figs. 204 and 205) has been in- troduced. The best dilator is the three-bladed one ; it is introduced closed, its blades then expanded, and the perma- 370 OPERATIVE SURGERY. nent canula passed in between them. The canula should be curved, double to facilitate cleaniug, and provided with an opening on its convexity through which the expired air can pass to the larynx. Some surgeons steady the trachea by drawing it toward the chin with a tenaculum introduced at the lower edge of the cricoid cartilage. Gurdon Buck used for this purpose a rather narrow lance-shaped knife, bent at a right angle on the flat, and also grooved on the back for use as a director. Galoano- or Thermo-cautery. The danger of hemor- rhage, especially in the adult, has led many surgeons to use the galvano- or thermo-cautery. Its hemostatic advantages, however, are offset by a large eschar which it causes, and the possible necrosis of the tracheal cartilages. 1 The cautery should be used only to divide the soft parts, the trachea should be opened with the knife. Saint Germain has also sought to prevent hemorrhage by making the incision with a red-hot bistoury. LARYNGECTOMY/ Complete. A preliminary tracheotomy is necessary. A pad is placed under the shoulders and the head thrown well back. The incision is in the median line, and extends from the thyro-hyoid space to the second or third tracheal ring. A transverse incision joins this at the upper end and passes outward parallel to the hyoid bone as far as each sterno-mastoid muscle. The skin, fascia, and platysma are drawn aside and the superior thyroid arteries secured at the posterior margin of the thyro-hyoid muscle beneath the sterno-hyoid close to the upper border of the thyroid carti- lage. Next the inferior thyroid arteries are ligated below, beneath the posterior edge of the sterno-thyroid muscles. By means of a periosteal elevator or blunt-pointed scis- sors entered beneath the fascia in the middle line the crico- thyroid, sterno-thyroid, and thyro-hyoid muscles on each side are detached and retracted with the other soft parts. The 1 See the discussion in the Soei6t6 de Chirurgie, May 9 to June 13, 1877. - Hahn. Volkraann's Sammluntf, 1885, No. 260. SPECIAL OPERATIONS. 371 thyroid cartilage is drawn first to one side and then to the other, and the inferior constrictor muscle separated. All cutting should be done with the blunt-pointed scissors kept close to the cartilages. The superior laryngeal nerves and the thyro-hyoid membranes and ligaments are divided, the epiglottis drawn out and its extra-laryngeal attachments cut. The larynx is next pulled forward and separated from any remaining connection with the pharynx or oesophagus to a point just below the cricoid cartilage. Great care is neces- sary to avoid opening the oesophagus. The trachea is secured from slipping down by a temporary suture on each side and is cut across below the cricoid cartilage. The divided end is secured at the surface in the wound with in- terrupted silk sutures and the mucous membrane sutured to the margins of the skin incision. When there is doubt about the extent of the laryngeal disease, immediately after the vertical skin incision the thyroid cartilage should be split in the middle line. This is done by steadying the larynx and cutting from before backward with the knife or from below upward with a blunt-pointed scissors entered through the crico-thyroid membrane. If then on inspection it is found that the whole larynx must be sacrificed the operation is proceeded with as already described. It is usually recommended to remove the cricoid cartilage in all cases of total extirpation, as it is of no functional value and its retention interferes with the act of swallowing. Partial. The vertical skin incision in the median line is employed as in total laryngectomy. At the upper end of the vertical incision a horizontal incision passes out from it parallel to and just below the hyoid bone on the affected side as far as the steruo-mastoid muscle. This in- volves the skin, fascia, and platysma. The thyroid carti- lage is then divided vertically exactly in the mediau line with the knife or scissors. After separation of the alse M. Buttin 1 advises, if the disease i c of limited extent, that it be cut away, with a wide margin of healthy tissue, meaning that it be scooped out of 1 Op. Surg. Malig. Disease, 372 OPERATIVE SURGERY. the concavity of the ala with the surrounding mucous membrane. The ala of the thyroid is then restored to its place. M. Buttin claims that cancer does not infil- trate the cartilage, and therefore it is only necessary to scrape and cauterize the part adjacent to the disease. If one-half of the thyroid cartilage must be removed, the steruo-thyroid muscle is cut at its upper end and laid back. The thyrohyoid, steruo-thyroid, and crico-thyroid muscles are carefully detached with the elevator or blunt-pointed scissors. The thyroid and crico-thyroid membranes and superior laryngeal nerve are cut close to the cartilage, and any vessels are secured as they are divided. The superior cornu of the thyroid cartilage is cut through at its base. The whole or part of the epi- glottis is left and the aryteno-epiglottic fold of mucous membrane spared as much as possible. The pharyngeal wall must be freed with great care. The inferior cornu is divided, any remaining attachments severed with short snips of the scissors and the ala removed. The parts are then sutured in their proper positions as nearly as possible after placing over the denuded surface all the mucous membrane obtainable. PHARYNGOTOMY. This is an operation required for the removal of foreign bodies or diseases from the pharynx or immediately ad- joining parts which are not accessible through the mouth. Langenbeck's (page 361), or the Crespi-Bastianelli methods (page 361), for reaching the base of the tongue are also useful for exposing the tonsil and posterior pharyngeal wall. Aplavin's sub-hyoid pharyngotomy (page 365) gives a somewhat limited view of the parts around the entrance to the larynx. Gaps left after excision of portions of the walls of the pharynx must be left to granulate; if the epiglottis has been disturbed its attachments must as far as possible be replaced and sutured in their proper position. SPECIAL OPERATIONS. 373 Von LangenbecFs Method. 1 After a preliminary trache- otomy the head is extended and chiu turned to the side oppo- site to the one in question. The incision extends from the middle of the lower border of the horizontal ramus of the inferior maxilla downward across the greater cornu of the hyoid bone along the posterior border of the thyro-hyoid muscle to the cricoid cartilage or a little further. After division of the superficial fascia, platysma, and omohyoid, the lingual, and superior thyroid arteries and facial vein are cut and secured. Both branches of the superior laryn- geal nerve are divided. After freeing the attachments of the digastric and stylo- hyoid from the hyoid bone the pharynx is laid open through the whole length of the wound. The thyroid cartilage can be turned on its long axis so that its posterior surface is visible in the wound and the pharynx is accessible as high as the soft palate. Another method of the same surgeon's is as follows : A U-shaped flap of skin and subcutaneous tissue is made, the base of which is above and corresponds in width to the length of the zygoma. Its sides and bottom follow the auterior border of the masseter muscle, the posterior border of the ramus, and the intervening portion of the lower border of the jaw, respectively. The inferior maxilla is sawn through in front of the insertion of the masseter, and the ramus dislocated by turning it outward and upward. Butliu 2 describes an operation by Czerny, which is vir- tually the same as Von Langenbeck's for excision of the tongue. The incision extends from the angle of the mouth to the extremity of the hyoid bone, and the jaw is sawn through obliquely from above and without downward and inward between the second and third molar teeth. Mikulicz's Method? After a preliminary tracheotomy and plugging of the fauces or larynx an incision is made from the tip of the mastoid process to the level of the greater cornu of the hyoid bone. The periosteum and overlying parts are raised from the outer and inner surface of the ascending ramus of the inferior maxilla, special care 1 Archiv f. klin. Chir., 1879, Bd. 24, p. 825. 2 Operat. Surg. Malig. Disease. 3 Deut. nied. Wochens., 1886. vol. xii. p. 157. 17 374 OPERATIVE SURGERY. being taken to avoid injury if possible to the facial nerve, parotid glaud, and external carotid artery. The ascending ramus is then divided horizontally just above the angle, and partially or entirely excised after severing the tendon of the temporal muscle. After drawing aside the body of the jaw, together with the masseter, internal pterygoid, digastric, and stylo-hyoid muscles, the region of the tonsil is exposed. The lateral wall of the pharynx is then incised and access thus ob- tained to the palate, base of the tongue, and posterior pharyngeal wall as far up as the naso-pharynx. If the digastric muscle and hypoglossal nerve are divided the entrance of the larynx can be reached. The disease is re- moved with the knife or scissors, the mucous membrane drawn together, and the wouud closed and drained. Cheever's Method. An oblique incision is made from the lobule of the ear downward along the anterior border of the sterno-mastoid muscle to the hyoid bone or below it. A second is carried forward from this along the lower border of the body of the inferior maxilla. The tissues are divided layer by layer, and the vessels including the external jugular secured. Enlarged lymphatic glands are removed as they are encountered. The branches of the facial nerve are recognized and drawn to one side. The hypoglossal nerve lies behind and in the lower end of the incision, and is drawn outward and backward with the great vessels. The glosso-pharyngeal nerve lies anteriorly. The fascia investing the posterior part of the submaxil- lary gland is slit up, and the facial artery and vein tied. The digastric and stylo-hyoid muscles are divided, the sub- maxillary gland drawn forward and .the parotid up, and the walls of the pharynx thus exposed. The tonsil and the surrounding mucous membrane are then removed. Bird 1 dispensed with the incision along the lower border of the jaw, but slit the check from the angle of the mouth to the angle of the jaw and removed the tonsil, using one finger in the mouth for a guide. 1 Clin. Soc. Trans., vol. xvi. p. '.». SPECIAL OPERATIONS. 375 CESOPHAGOTOMY. The oesophagus begins in front of the sixth cervical ver- tebra in the median line, or just behind the cricoid cartilage ; at first it inclines slightly toward the left, then returns to the median line as it passes behind the sternum, inclines to the right at the arch of the aorta, and again to the left as it approaches the diaphragm. The left recurrent laryngeal nerve lies between its cervical portion and the trachea, the right recurrent nerve lies upon its outer side. It is covered anteriorly by the trachea and left lobe of the thyroid gland, and crossed by the left inferior thyroid artery and vein. The guide to it is the trachea. Internal (Esophagotomy. Dr. Sands employed an in- strument constructed on the principle of the Otis urethra- tome. It consisted of a long shank carrying a bulb with a sheathed knife which could be made to project not more than an eighth of an inch from the surface of the envelop- ing bulb by turning a screw in the handle. Other surgeons have used similar instruments, but on account of the dan- ger of perforating the oesophagus operations performed by the knife from the interior of the organ have been prac- tically abandoned in favor of Abbe's "string saw" method, 1 which is one of combined dilatation and division. It is used for cicatricial strictures which are undilatable and generally impermeable to any instrument passed from above, but which reason and experience have shown may be passed from below, as in the latter situation the tube is contracted aud funnel-shaped, while above it is dilated and pouched. Gastrostomy is first performed, the opening into the stomach being made large enough to admit two fingers with the exploring instrument to the cardiac orifice of the stomach . Into the latter a bougie carrying a long silk cord is passed and brought out at the mouth ; the other end of the cord remains in the abdominal wound. Then the stricture is made tense by engaging in it a conical bougie as large as it will hold, and the string, held well back in the pharynx 1 New York Medical Record, February 25, 1893. 376 OPERATIVE SURGERY. and stomach, is drawn tight and sawed up and down a few times. After this bougies are passed up to the largest size or till firm resistance is encountered. In Abbe's first case external cesophagotomy was performed, and after division aud dilatation of the stricture as above described a rubber tube was drawn up from the stomach and wedged into the contraction for twenty-four hours, thus maintaining the dila- tation. When there is no further trouble in the passage of bou- gies from above, the gastrostomy wound is closed, but in- struments must subsequently be introduced through the stricture at regular intervals till the danger of recontrac- tion is over. 1 External (Esophagolomy. The operation of external cesophagotomy may be required for the relief of stricture, or the removal of a foreign body. In the former case, it may be performed above or at the level of the stricture for the purpose of dividing or dilating it, or below the stricture so as to allow the introduction of food into the stomach. The left side of the oesophagus is more accessi- ble in the neck than the right, and the incision may be made in the median line or parallel to the inner border of the sterno-cleido-mastoid muscle. As the walls of the oesophagus are flaccid, a guide should be used if it is pos- sible to introduce one. The best one is the instrument known as Vacca-Berlinghieri's sound (Fig. 206). It is Fig. '206. Vacca-Berlinghieri's esophageal sound. a hollow metallic instrument, curved at one end like a urethral sound, but to a less degree, with a long opening in the concavity or on the left side, extending not quite to 1 A resum6 of this operation with a report of cases and description of the vari- ous expedients which may be necessary will be found in the Annals of Surgery, March, 1895, p. 253. Dr. Woolsey. SPECIAL OPERATIONS. 377 the end. Within the sound is an elastic staff, the side of which can be made to project through the opening and dis- tend the oesophagus, its point being engaged in the cul-de- sac at the extremity of the sound. In some cases the foreign body cau be used as a guide. Lateral Incision. Dorsal decubitus, head extended, face turned slightly to the right. The surgeon, standing at the patient's left, makes an incision through the skin, subcu- taneous cellular tissue, and the platysma a little on the inner side of the inner border of the sterno-cleido-mastoid from a point one inch above the sternum to the level of the upper border of the thyroid cartilage. If the external or anterior jugular is encountered, it must be drawn aside or divided between two ligatures. The fascia is then divided, the omo-hyoid muscle drawn aside, and then the side of the thyroid gland followed downward. The sterno-cleido-mas- toid and the great vessels are drawn outward with a blunt hook, the trachea and thyroid gland to the right, and then the surgeon, working with his fingers or blunt instruments, separates the tissues at the bottom of the wound and ex- poses the oesophagus, which can be recognized by its flat- tened appearance and muscular wall. If more room is needed, the sternal head of the sterno-cleido-mastoid must be divided. Vacca's sound is then introduced through the mouth, its elastic staff projected through the lateral open- ing so as to distend the oesophagus, and recognized by the ringer at the bottom of the wound ; or an ordinary oesopha- geal bougie is used. The surgeon, having satisfied himself that the recurrent laryngeal nerve and inferior thyroid artery are out of the way, punctures the oesophagus by picking it up with two hooks or toothed forceps and cutting between them, and enlarges the opening with scissors or a blunt- pointed bistoury. At the close of the operation the wound in the oesopha- gus is closed with catgut, that in the overlying parts being left open and packed ; the patient is fed by the rectum or with the stomach tube for several days. If a permanent fistula is desired (below a malignant contraction, for in- stance) the margins of the cutaneous and oesophageal wounds are united with sutures. 378 OPERATIVE SURGERY. THE OPERATIONS ON THE THYROID GLAND. Anatomy. Normally the isthmus is about half an inch long and covers the second aud third tracheal rings, while the lateral lobes extend upward and backward to the lower end of the pharynx, lying on each side of the larynx, and downward, in contact with the upper end of the oesophagus. Fig. 207. b _ 1 11 / N$ a. Chin. b. Sterno-mastoid. c. Omohyoid, d. Sternohyoid, c. Sterno-thy- roid. /. Vena jugularis ext. g, Vena jugularis obliqua. //,. Vena jugnlaris ant. i. Vena jugularis inf. commuuicans. j. Vena jugularis sup. communi- cans. 1, 2, 3. Double ligatures applied to the above-mentioned veins in the line of the incision. Kociier. The thyroid is enveloped by the fascia of the neck and pos- sesses a capsule enclosing the gland tissue proper. When enlarged the organ is covered with a plexus of veins ; the most constant and importaut of these are represented dia- gramatically in Figs. 207 and 208 and need no further ex- SPECIAL OPERATIONS. 379 plauation. The gland is overlapped by the sterno-mastoid and has resting on its surface the sterno-hyoid, omo-hyoid, and sterno-thyroid muscles in this order from before back- ward. One or more accessory thyroids may be found above Fig. 208. a. Sup. thyroid artery, b. Sup. thyroid veiD. c. Cartoid artery, d. Internal jugular vein. e. Accessory sup. thyroid vein. /. Sup. communicating thyroid vein. g. Inf. communicating thyroid vein. h. Accessory inferior thyroid vein. i. Inferior thyroid vein. k. Thyroidea ima veins. I. Left innominate vein. The numerals indicate the points where the above-mentioned veins are ligated. or below the lateral lobes, and it should be noted that the latter may, when enlarged, extend downward behind the sternum. The lateral lobes overlap the great vessels of the neck with their accompanying nerves, and are in contact at their lower posterior portions with the inferior thyroid artery, the recurrent laryngeal nerve, and middle cervical ganglion of the sympathetic. The artery passes horizontally inward from the inner border of the scalenus anticus muscle about half an inch below the carotid tubercle. 380 OPERATIVE SURGERY. then forward on the oesophagus and trachea, and divides into an ascending and descending branch. At its point of bifurcation it is crossed (in front or behind) by the recurrent laryngeal nerve, and at the inner border of the scalenus anticus the middle cervical ganglion lies directly upon it. Great care is necessary in securing the artery not to injure these structures; paralysis of one recurrent nerve produces paralysis of the corresponding vocal cord, of both nerves, severe dyspnoea, which may end fatally if not relieved by tracheotomy ; injury to the sympathetic at this point destroys the three cardiac branches which are given off here or just below. The operations which are considered justifiable are removal of a, portion of the gland, enucleation of the same, and ligation of the afferent arteries, the latter being applicable to rapidly growing, vascular (not fibrous or cystic) goitres in young subjects. Ligation of the Arteries. On account of the danger of a general atrophy only those vessels in immediate connec- tion with the enlarged part should be secured, the superior and inferior thyroid arteries of one side, for example. Then if this fail the others, starting with the nearest, may be suc- cessfully tied. The superior arteries are exposed and ligated as described on page 39, and the inferior preferably by Drobeck's method (p. 40), especially if the gland is much hypertrophied. Enucleation of a Portion of the Gland. Some cases of sharply defined tumor of the thyroid, such as cystic goitre, need only a longitudinal incision over the most prominent part of the growth with division of the tissues layer by layer, and ligation of the vessels encountered till the gland is reached. The capsule and layer of gland tissue (some- times no thicker than a sheet of paper) overlying the tumor is then divided and the latter shelled out. Removal of a Portion of the Thyroid Gland (Kocher). The incision extends vertically in the median line from the sternal notch to the upper limit of the tumor. From this point it runs obliquely toward the angle of the jaw on the sidefrom which the affected half of the gland is to be removed SPECIAL OPERATIONS. 381 (Fig. 207). If the entire gland is to be removed, a pro- cedure which must be seldom justifiable, the oblique incision is made on both sides, thus giving the skin-cut the form of a Y. The integument, fascia, and platysma are divided and the flaps turned back. The sterno-hyoid, sterno-thyroid, and omo-hyoid muscles, which may be much thinned and stretched out over the surface of the tumor, will have to be cut. If adherent to its surface they should be lifted and pushed aside with blunt-pointed scissors or a periosteal eleva- tor. A plexus of large thin-walled veins, which tear very easily, will be found lying close over the surface of the en- larged gland, and should be divided separately between double ligatures. The anterior surface of the growth is thus cleared and the lateral aspect approached. The sterno- mastoid muscle is retracted and the common carotid artery and internal jugular vein are carefully freed with a blunt instrument. The superior thyroid artery is secured at the upper extremity of the tumor and, together with the accom- panying veins, divided between a double ligature. It is generally recommended to cut the branches of the inferior thyroid artery close to the tumor and secure each as it is divided, as in this way there is less danger of injuring the recurrent laryngeal nerve which is in close relationship with it on both sides. Furthermore, on the left side the main portion of the artery lies in contact with the oesophagus and the thoracic duct, which is at first posterior to the artery, arches over it to reach the left subclavian vein, or the trunk of the inferior thyroid artery may be tied, preferably by Drobeck's method, as described on page 40. The dissection is continued close to the capsule, which must nowhere be opened ; every vessel, as it is encountered, is tied and cut separately after careful inspection, and the lateral surface of the tumor cleared. Its margin is lifted up, starting at one side above and working downward and inward ; the trachea and oesophagus are separated with special regard for the recurrent laryngeal nerve which lies in the groove between these structures. Thus the dissection is carried from the side as far as the middle line posteriorly. The gland is then drawn forward and upward. The vessels entering it from below are secured and divided and the gland removed. 17* 382 OPERATIVE SURGERY. Removal of the Isthmus. 1 A median longitudinal incision is employed. It exteuds from the upper to the lower bor- der of the enlarged isthmus aud involves the integument and superficial fascia. The anterior jugular vein, if encountered, is secured and cut between a double ligature. The interval between the sterno-hyoid aud sterno-thyroid muscles is opened up aud the muscles drawn aside. The isthmus is exposed after carefully ligating separately each one of the enlarged veins which may be encountered in front of it. It is then freed on its upper and lower border and posteriorly with a bluut instrument. The capsule itself must not be opened and every vessel should be tied as it is encountered. An aneurism-needle threaded with a double ligature is then made to perforate the isthmus on each side from behind forward at its junction with the lateral lobes, and at these points it is tied off like an ovariau pedicle and the isthmus cut close to 'the ligatures and removed. The parenchymatous injection of tincture of iodine, of iodine and absolute alcohol, or of a mixture of iodoform, ether, and olive oil has been practically abandoned as too dangerous. With every antiseptic precaution a hypodermic needle was plunged into the enlarged gland, and if blood or fluid could be withdrawn it showed that a vessel or cyst had been entered and negatived the injection. When, after reintroduction, the point of the needle was thus demon- strated to occupy only gland tissue, from half a gramme to a gramme of tincture of iodine was slowly injected, the sur- geon desisting immediately on the appearance of syncope or dyspnoea. CHAPTER V. OPERATIONS UPON THE THORAX. AMPUTATION OF THE BREAST. The patient is planed upon her back, inclined somewhat toward the opposite side, and the arm abducted so as to make the skin and pectoral muscle tense. Two curved in- Jonea : Lancet, 1875, vol. i. p. 120. SPECIAL OPERATIONS. 383 cisions are made, one on each side of the nipple, enclosing an elliptical strip of skin of greater or less breadth accord- ing to circumstances, the long axis of which is directed toward the axilla ; that is, upward and backward. The upper and lower skin flaps are then dissected 01T the an- terior surface of the gland, its upper border turned, expos- ing the pectoral muscle, and the loose cellular tissue be- tween it and the muscle rapidly divided with a few strokes of the knife, beginning at the upper border of the inner angle, while the gland is drawn away from the chest wall, and the removal completed along the lower incision, or at the axillary angle of the wound. Bleeding during the operation must be controlled by clamps upon the bleeding points, and the vessels secured afterward with ligatures or by torsion. The incision is then prolonged just posterior to the anterior fold of the axilla, up to the arm. The axillary vein is exposed at the outer end of the incision, where it is most superficial and is kept constantly in sight as the dissection progresses. The axillary glands whether perceptibly enlarged or not, together with the surrounding fat and connective tissue, are removed en masse. Halsted 1 advises that the fascia covering the pectoralis major under the breast be alivays dissected otf from the sur- face of the muscle, and in many cases that the latter together with the pectoralis minor be removed entirely. PARACENTESIS OF THE THORAX. Each of the lower posterior intercostal arteries enters its corresponding intercostal space near the spinal column, and passes obliquely from below upward across the space to shelter itself in a groove on the inner side of the lower border of the upper rib. It occupies this groove until it reaches the anterior third of the space, when it leaves it to anastomose with the branches of the anterior intercostal artery coming from the internal mammary. At this point, however, it is so small that its division is not of much con- 1 Aunals of Surgery, 1894 384 OPERATIVE SURGERY. sequence. The only part of its course where its injury is to be feared is in the posterior third of the intercostal space before it has passed behind the lip of the rib. Consequently, if an opening is to be made into the pleural cavity, either with a knife or trocar, a point in the middle third of one of the intercostal spaces should be selected, preferably the seventh, certainly not higher than the sixth, nor lower than the eighth on the right side, the ninth on the left. After determining the position of the intercostal space, often a matter of considerable difficulty in consequence of the infiltration of the parts, make an incision parallel to it, one or one and one-half inches in length. Divide the tissues layer by layer, until the rib can be distinctly felt with the finger introduced into the wound. Place the end of the finger upon the upper border of the lower rib, and, keep- ing the knife close to the border, divide the muscles and pleura. If a trocar or the aspirator is used, it must be thrust in with a sharp push so as certainly to penetrate the pleura, which is often thick and tough. The outer eud of the cauula is then connected with a Dieulafoy or Potaiu as- pirator by means of a rubber tube and the effusion drawn off. A better method is to make use of the principle of the siphon. After filling the canula and tube, previously rendered aseptic, with sterilized water, the end of the tube is occluded and the canula thrust into the pleural cavity. The tube is then conducted beneath the surface of a 1 : 60 solution of carbolic acid below the level of the patient's bed, and released, thus siphoning off the liquid in the chest. PARACENTESIS OF THE PERICARDIUM. Normally the pericardium is in contact with the chest wall only in the median line under the sternum ; but when its sac is distended with liquid the area of contact becomes much larger, especially by extension downward and to the left. The heart is at the same time pressed upward and backward. The limits of the pericardium can be ascer- tained with great accuracy by percussion and auscultation, and this should always be done before puncturing. At the SPECIAL OPERATIONS. 385 point selected for puncture the pulsations of the heart should be imperceptible, or at least very faint, and it should be absolutely flat on percussion. It should also be remem- bered that the internal mammary artery ruus parallel to the side of the sternum, and a finger's breadth from it. If the knife is used the tissues must be divided layer by layer, aud the finger should always be introduced into the wound before the pericardium itself is incised, to make sure that the heart is not in contact with it. CHAPTER VI. OPERATIONS UPON THE ABDOMINAL WALL, STOMACH, AND INTESTINES. PARACENTESIS OF THE ABDOMEN. In order to avoid injury to the different viscera, and es- pecially to the internal epigastric artery, which runs from the middle of Poupart's ligament toward the umbilicus, the puncture should be made either in the median line midway between the umbilicus and the symphysis pubis, or midway between the umbilicus and the anterior superior spine of the ilium. The iustrumeut used is a trocar aud canula or the needle of an aspirator. The depth to which it shall be allowed to penetrate is regulated by the finger placed upon its side, and it should be plunged in sharply, without a pre- liminary incision, at the selected point, which should be absolutely flat upon percussion. As there is a possibility of syncope occurring during the operation, in consequence of the withdrawal of pressure, it is prudent first to pass a broad, many-tailed flannel bandage about the abdomen, crossing its ends behind, so that an assistant standing at each side can draw upon them and tighten the bandage as the liquid escapes. It is usually sufficient, however, to have an assistant make steady pressure with one hand on each side of the abdomen. During the operation the patient should be seated or inclined toward one side. 386 OPERATIVE SURGERY. Should hemorrhage ensue, the attempt must first be made to control it by the pressure of the canula or of a larger gum catheter introduced through the puncture. This fail- ing, the entire thickness of the abdominal wall must be pinched up and compressed, or, in extreme cases, the wound must be enlarged and the vessel tied. When it is necessary to practise paracentesis upon a pregnant woman, Ollivier recommends the selection of the neighborhood of the umbilicus for the puncture ; Scarpa preferred the left hypochondrium, Velpeau the left flank. LAPAROTOMY. If time permits preparatory treatment with baths and laxatives is continued for several days, and in a female pelvic case the vagiua is rendered as aseptic as possible by numerous 1 : 2000 bichloride douches. An aperient is given the evening before and an euema in the morning of the operation ; the patient passes water or is catheterized imme- diately before being placed on the table. The preparation of the skin surface, the surgeon, the attendants, instru- ments, and accessories has been already given. Sterilized sponges, round and flat, and a few on clamps or handles, and pads of gauze should be at hand, and two sterilized basins of warm boiled water, one to contain the clean sponges, and the other, which will need frequent changing, to rinse the soiled sponges. All parts of the patient, except the abdominal surface, all the tables for instruments, sponges aud dressings, and everything not previously sterilized, which may be touched by any person or thing concerned in the wound, are covered with sterilized towels, dry or wet in a 1 : 1000 bichloride of mercury solution. The numbers of clamps, sponges, and pads are written down immediately before the opera- tion and verified at the close. The incision may be made in almost any part of the ab- dominal wall, but is most often median and should divide; the tissues layer by layer. The linea alba is indistinct below the umbilicus, and if the incision is median one or other rectus sheath will generally be opened. It will then be SPECIAL OPERATIONS. 387 found convenient to immediately unite by a catgut suture the anteror and posterior layers of the opened sheath, and the linea alba can thus be more quickly reformed at the close of the operation. The preperitoneal fat is recognized and all bleeding stopped. The peritoneum is then nicked and the opening eularged with blunt-pointed scissors to the length of the abdominal wound, which must be made large enough to permit easy recognition of everything as it is en- countered. The position of the bladder must be remembered. The field of operation is then fenced in like a well with sterilized gauze pads or flat sponges, and the viscera outside of the spot in question entirely hidden in the rest of the unopened abdominal cavity. Pelvic operations are much facilitated by the Trendelen- burg position — the hips elevated above the shoulders, thus causing the viscera to gravitate out of the way. Each vessel is secured separately, if possible, before division ; there must be no cutting in the dark and no ligation of large masses of tissue en masse. In general catgut is pref- erable to silk for almost all pedicles or vessels. At the close of an aseptic laparatomy the perfectly dry and clean wound is inspected for a few moments to be sure that there is no more bleeding ; the clamps, sponges, and pads are removed and counted, and the viscera are then allowed to resume their normal positions. A flat sponge or pad is placed over the viscera iu the abdominal wound to protect them and to absorb such blood as may flow from the needle punctures, and over this the wound is closed by various methods. Silk, silver wire, or silkworm-gut can be passed through the whole thickness of the abdominal wall and peritoneum, from half an inch to an inch from the margin of the wound, and about the same distance apart ; the amount of tension necessary in tying them will vary with the thickness of the abdominal wall, its laxity, or distention. Before the last one or two are tied the protecting sponge is withdrawn, or the peritoneum may be first sutured over the sponge by the continuous or interrupted catgut suture and the sponge withdrawn before it is entirely closed, then sutures of silk, silver wire, or silkworm-gut are passed as before, but only. 388 OPERATIVE SURGERY. through the parts in front of the peritoneum, or after clos- ing the peritoneum and removing the sponge the overlying parts can be sutured with catgut, layer by layer. Schede 1 recommends buried sutures of silver wire for all the layers except the peritoneum and skin. In a continuously asep- tic wound the sutures should not be removed for at least seven days, and then with every antiseptic precaution, es- pecially if they include the peritoneum. The sutured wound may be covered with a strip of steril- ized rubber tissue. Iodoform gauze is next applied, and over this layers of plain, sterilized, or bichloride gauze. This is held in place with a couple of transverse strips of adhesive plaster and covered with a layer of sterilized ab- sorbent gauze, and the dressing completed by a broad ab- dominal binder or a broad roller bandage applied circularly around the body and each thigh in the form of a spica to prevent slipping. The sponges contaminated in the course of a laparotomy, where any form of sepsis or noxious element is present, should be kept apart from the others as far as possible, and only used in the contaminated area, which latter must be kept separated by sterilized sponges or pads, with the utmost care, from the rest of the abdominal cavity. The towels in the neighborhood of the wound are changed or covered with clean ones as fast as they become soiled, and the wall of pads or sponges surrounding the operation area must be replaced by fresh ones when they become saturated with the noxious materials, and without disturb- ing the position of the protected viscera. The wound at the finish is made as clean and dry as pos- sible. Wherever peritoneum has been divided or stripped up it should be replaced and secured with fine catgut su- tures. There may remain a large denuded area liable to infection or studded with fine bleeding points, as, for in- stance, after dissection of an adherent tumor. This can be conveniently treated with a large square of iodoform or sterilized gauze, the centre of which is tucked down into contact with this area, and the edges brought out of the abdominal wound. Other strips of sterilized gauze are 1 ('entralblatt flir Chirurgie, 1893. SPECIAL OPERATIONS. 389 packed into this as into a bag. If pus has been present one or more sterilized drainage tubes of rubber or glass with lateral perforations must be run down from the surface to the bottom of the infected region. Sometimes a strip of gauze is packed inside of the tubes to aid the escape of fluid on the principle of capillarity. And this strip is fre- quently changed with every antiseptic precaution. In female pelvic cases it may be desirable to pass a tube through a counter-opening in the vault of the vagina. Hence the necessity of the preliminary cleansing of the vagina in every case where there is even a possibility of pelvic complications. The vagina is afterward packed with sterilized or iodoform gauze, the vulva covered with an anti- septic dressing, and the patient catheterized for several days subsequently. After inserting the tubes, and with as little displacement of the protected viscera as possible, the sponges or pads are removed and counted and their places supplied by a light packing of strips of iodoform or simple sterilized gauze, the ends of which protrude through the incision. Before packing the wound it may be advisable to flush out the infected region with warm boiled water or sterilized salt solution, and sometimes a large part of or the whole peritoneal cavity is thus treated and counter- openings for drainage, with packing, are made. At the close of the operation the peritoneum is first su- tured over a sponge or pad down to the point of exit of the tubes and packing, and the sponge then removed. The overlying parts are drawn together to a corresponding ex- tent with silk, silkworm-gut, or silver wire passed through everything in front of the peritoneum, and a dressing which covered the ends of any tubes is then applied, as in an aseptic case. OPERATIONS ON THE INTESTINES. Anatomy. (Fig. 209.) The parts of the intestines which have a mesentery are completely covered by peritoneum except along a narrow interval where the lamina? of the mes- entery diverge to encircle the bowel (Fig. 209, 2). Thus the outer wall of the gut, along the line where the mesentery. 390 OPERATIVE SURGERY. meets it, is formed by a strip of the muscular coat about five- sixteenths of an iuch wide (Fig. 209, 3), and this is apt to be FlG 209 the weak point in a row of sutures l; involving this portion of the cir- i,j 1 cumference of the bowel. The arteries in the mesentery form freely anastomosing loops from which, close to the intestiue, arise straight vessels with little or no intercommunication, and having a circular and fairly well-defined dis- tribution, so that, while a portion of the mesentery at a distance from the intestine may be de- stroyed with comparative impu- nity, an injury to the small- est part in immediate proximity to the gut involves a probability of sloughing of a corresponding extent of intestine. An anatomical knowledge of the mesentery is of value in a search for the upper or lower end of the small intestine. The parietal at- tachment of the mesentery ex- tends from the left side of the second lumbar vertebra down- ward to the right iliac fossa, and, if the finger trace the left layer of the mesentery of a loop of intestine back toward the spine, it passes oft' toward the left side of the abdomen, and the right layer will lead to the right side of the abdomen. This will show which end is the upper or lower in any particular loop. Also the upper end of the small intestine has a greater diameter, is thicker walled (valvnlse conniventcs), and more vascular than the lower end. The coats of the intestine from without inward are : (1) the peritoneal, (2) the longitudinal, (3) circular muscu- lar, (4) the submucosa, a tough fibrous membrane, (5) the muscularis mucosae, and (6) the mucosa, the latter making up about two-thirds of the thickness of the wall. Unless the suture includes a shred of the submucosa it Section of small intestine and mesentery. 1. Mesentery. 2. Triangular space between diverging layers of the mesen- tery. '6. Its base resting on m, the muscular coat of the gut. P. Peritoneum. m,.m. Mucous membrane SPECIAL OPERATIONS. 391 is very apt to tear oat. This coat is recognizable by the increased resistance which it offers to the passage of the needle after the peritoneal and muscular layers have been traversed. 1 The colon and sigmoid flexure are recogniza- ble by their corrugations, their more or less fixed posi- tions, the appendices epiploicse, which are most numerous in the transverse colon, and by the longitudinal bands of muscular fibres. The anterior band is the largest and most prominent, and lies in front of the caecum, colon, and sig- moid flexure. In the trausverse colon it corresponds to the attachment of the great omentum, and in the ascending colon and csecum it is the unfailing guide to the appendix vermiformis, from the attachment of which to the csecum the anterior, inner, and posterior longitudinal bands all start. The appendix lies about opposite a point indicated on the abdomen by the centre of the line passing from the right anterior superior spine of the ilium to the umbilicus. It may or may not have a mesentery and commonly lies behind the lower end of the ileum, and often in close rela- tion with the iliac vessels and ureter, and is not infre- quently found in the pelvis. To be successful the closure of an intestinal wound must be water-tight, and no stitch may perforate all the coats ; there must be no subsequent giving way of any part of the wound, either from slipping of a suture or ulceration or sloughing at the site of its insertion, and the lumen of the bowel must not be unduly narrowed. A round sewing needle and black silk are generally used. The continuous suture is applied like the ordinary continuous suture already described, and is carried a short distance beyond the extremities of a longitudinal wound. The needle penetrates the peritoneal and muscular coats, of the intestine, catching up a few fibres of the sub- mucosa, but nowhere entering the mucosa. The stitches are placed at intervals of about a quarter of an inch close to the margins of the wound, which are turned in to bring the peritoueal surfaces in apposition. The right-angled continuous suture (Fig. 210) only differs from this last in having the buried portions parallel to 1 Halsted : American Journal Medical Sciences, 1887, p. 436. 392 OPERATIVE SURGERY. the line of the wound and the exposed portions at right angles to it. The continuous suture cau be rapidly applied, and is useful for reinforcing weak points in an interrupted suture Fig. 210. Right-angled continuous intestinal suture. (Greig Smith.) line, but it is inapplicable for closing a complete trans- verse division of the bowel. All parts of the continuous suture may not be drawn equally tight, and the contraction of the gut tends to loosen it and allow the wound to gape. The interrupted suture of Lembert is the most approved and generally used intestinal suture. The needle pene- trates a fold of the peritoneal, muscular, aud a few shreds of the submucous coat of the gut on opposite sides of the wound, the margins of which are inverted and the perito- neum brought together. The sutures should be placed about an eighth of an inch from the margin of the wound and about the same distance apart, and each should grasp SPECIAL OPERATIONS. 393 a fold of the intestine about one-tenth or one- twelfth of an inch wide. None must touch the mucosa. Fig. 211. Diagram representing the methods of inserting the Czerny-Lembert sutures. The Lemhert suture is below, the Czerny at the cut edge. Czerny's method consisted of an interrupted line of sutures passing through all coats of the intestine and tied inside. Fig. 212. Halsted quilt suture for the intestines. A second row of Lembert sutures is then added to bring the peritoneal surfaces on each side of the wound in con r 394 OPERATIVE SURGERY. tact over the first row of sutures. Czerny's suture is now generally passed through all coats except the outer one. Ualsted's quilt sutures 1 will bear a considerable strain. It is a modification of Lembert's method. The needle peuetrates the superficial coats of the gut twice on each side of the wound and is then knotted. CIRCULAR ENTERORRAPHY. This is the usual term for designating an end-to-end suture of the intestine from which a segment has been re- moved. Operation. The loop of intestine is carefully drawn out of the abdomen and surrounded by warm pads or sponges while the opening into the peritoneal cavity is protected by a gauze or sponge packing. The feces are squeezed out of the loop, and about an inch above and below the limits of the segment of gut to be removed the intestine is con- stricted tightly enough to close its lumen, either by the fingers of an assistant or by any one of the specially designed clamps. A convenient method is to tie lightly around the bowel at these points a strip of iodoform gauze, which is passed through a small hole made in the mesentery by a blunt instrument at a little distance from the gut. After thoroughly protecting the exposed peritoneal surface, at the spot selected on the lower side of the disease, the intestine is divided squarely across and its interior immediately irri- gated with warm boiled water. With a clean pair of scissors, the mesentery of the diseased part is cut as close to the gut as possible up to the intended upper point of the intestinal division. If there is much distention, the iodoform-gauze band above should not be tied till after the freed portion of intestine has been conducted off to one side and its con- tents ;il lowed to escape, aided by kneading the abdomen. While the gut is being divided the lumen above should be occluded by the pressure of an assistant's fingers; the in- | American Journal Medical Sciences, October, 1887. SPECIAL OPERATIONS. 395 testine is then constricted about an inch above the upper line of division as already described, and cut squarely across, leaving no protrusion beyond the mesenteric attach- ment, and the interior below the constricting gauze band immediately irrigated as before. The divided meseutery should not be removed in the form of a triangle with its base corresponding to the excised gut. Bleeding is checked by separate ligation with fine Fig. 213. Circular enterorraphy. catgut of each vessel. Meanwhile every portion of peri- toneum is scrupulously protected from infectious matter, and before the next step instruments which have touched infec- tious matter or the interior of the intestine are discarded and the hands carefully washed. The ends of the gut are then brought into apposition and the mucous membrane united evenly all around by a con- tinuous catgut or silk suture. The mesenteric border of the 396 OPERATIVE SURGERY. gut is drawn together by a Lembert silk suture and then the opposite free border. By gentle traction on the ends of these sutures (Fig. 213) the gut is flattened out and on the line thus indicated the necessary number of Lembert sutures are added, but not tied till the last is in place. The peritoneal surfaces must be very carefully brought into contact at the mesenteric attachment of the bowel to avoid leakage into the areolar tissue between the diverging layers of the mesentery ; but weak points must not be so reinforced by continuous or interrupted sutures that the lumen of the intestine becomes unduly narrowed. The fold of detached mesentery is drawn together at its cut edge with catgut, and if long enough it is sometimes ad- vised to suture its peritoneal surface over the line of intes- tinal union as far as it will reach without tension. Senn sutures the great omentum over the outer row of Lembert sutures and has thus covered a circular enteror- raphy with a detached omental graft an inch wide and long enough to encircle the bowel. 1 The parts are again irrigated with warm boiled water, the intestinal clamps or gauze bands are removed together with the protective sponge packing, and after returning the gut to the abdomen the parietal wound is closed in the usual way. INTESTINAL ANASTOMOSIS. This is the formation of a lateral communication between the lumina of two different portions of the gut. Owing to the contraction in the calibre of the intestine which follows circular enterorraphy, this operation of anastomosis is fre- quently adopted in its place, though it was originally intro- duced as a palliative means of relieving an irremovable obstruction of the bowel, by uniting the parts above and below the obstruction. Operation. Above and below the obstruction healthy portions of the gut are selected which can be brought into apposition without tension, along several inches of surface. 1 Trans. Int. Med. Cong , !itli session, Washington, 1887, vol. i. p. 435. SPECIAL OPERATIONS. 397 The rest of the peritoneal cavity is walled off with sponges, and if possible the selected loops of intestine are drawn out of the abdomen and surrounded by warm cloths. About one-quarter of an iuch to the under side of the centre of the convex free border as the intestine lies ex- posed, the apposing loops are united for about five inches by a continuous silk suture through the peritoneal coats alone. In front of this, nearer to the free border, is placed a row of Lembert sutures for the same distance. About an inch above and below this suture line, on each loop, an iodoform-gauze band is passed through the mesentery, where it is free from vessels, at a little distance from the in- testine, and tied around the gut just tightly enough to pre- vent the entrance of fecal matter. Each loop is then opened along its convex free border for nearly the same distance (about four inches) parallel to and immediately in front of the second row of sutures already in place. The openings should terminate opposite each other about half an inch short of the end of the suture line. The interior of each isolated loop is immediately irrigated clean with warm boiled water, while the exposed peritoneal surface is pro- tected as far as possible. Soiled towels or protecting sponges are then replaced by clean ones, anything which has touched the interior of the intestine or its contents is discarded and the hands carefully washed. After this the extruded mucous membrane of the opposite intestinal loops is united by a continuous catgut or silk suture. The exposed parts are again irrigated and the protectives and instruments changed. A row of Lembert silk sutures is then placed close to and in front of the already united parts as they lie in view, starting and terminating at the ends of the row of posterior Lembert sutures. This can be strengthened by a continu- ation of the first posterior continuous silk suture through the peritoneal coat. The four gauze constricting bauds are then removed from the intestine, the protective sponges taken out of the abdomen, the bowel returned, and the parietal wound closed in the usual way. In cases of euterectomy the segment of gut to be re- moved is excised as described iu circular enterorraphy. The open ends of the intestine are then turned in to bring 18 398 OPERATIVE SURGERY. peritoneal surfaces into contact, and closed by a continuous silk suture carried back and forth once or twice and in no spot entering the mucosa. The constricting gauze bands are removed from the intestine and the anastomosis pro- ceeded with. Senn 1 reinvented and greatly improved the forgotten method of uniting different portions of the gut laterally by means of perforated absorbable plates which bring into contact broad areas of peritoneum around a central opening. Fig. 214. Senn's plates, a, a, lateral or fixation suture ; b, b, end or apposition suture. Thread passed through 2 is brought out through 1, and that through 4 out through 3. (Treves.) Two contiguous loops of intestine are opened to the same extent longitudinally, on the side opposite the attachment of the mesentery, and sufficiently to admit the plates edge- wise. After introduction the plates are rotated enough to make their perforations correspond to the openings made in the intestine. About a quarter of an inch from the mar- gins of the openings on each side, the wall of the intestine 1 Trans. Int. Med. Cong., 9th session, Washington, 1887, vol. i. p. 435. SPECIAL OPERATIONS. 399 is perforated by the two lateral sutures which are armed with needles. The other two sutures are tied across the ex- tremities of the openings without perforating the intestinal wall. Fig. 215. Intestinal anastomosis, with Senn's plates, a, a, lateral or fixation sutures ; b, b, end or apposition sutures ; c, c, posterior sutures. (Senn.) The sutures serve the double purpose of holding the parts in apposition and keeping the openings patent. After the parts are brought together union is further se- cured by a continuous or interrupted suture through the peri- 400 OPERATIVE SUBGEBY. toneal coat around the margins of the plates. The plates, which Senn made of decalcified bone, are supposed to be- come absorbed or disintegrated between the third and tenth days. This method has been largely abandoned in this country on account of the later contraction of the fistula. The Murphy " button " has lately attained great popu- larity as a means of uniting differeut portions of the intes- tine, although its value for this purpose has been contested by many surgeons. A description of the device and its application will be found in the paragraphs on cholecysten- terostomy. Quite recently a satisfactory substitute has been found in a piece of raw potato perforated and fashioned into similar shape. Various methods have been devised for uniting portions of gut of unequal diameter, but they have now been gen- erally superseded by closing the transversely divided ends aud performing lateral anastomosis. Ileo-sigmoidestomy. Cases of irremovable obstruction in the colon have been successfully treated by an anastomosis Fig. 216. Intcriok of Smaller Secmentof Gut Miiunsell's method ; first two sutures brought out through the incisiou in the lower segment. between the lower end of the ileum and the sigmoid flexure after the ileum has been divided and separated from the SPECIAL OPERATIONS. 401 colon at the ileo-csecal valve. The abdominal incision is made in the median line below the umbilicus. Union of Divided Intestine by Intussusception (Maunsell). 1 The disease is excised by transverse division of the gut as described in circular enterorrhaphy. The cut ends of the intestine are united by one suture through the entire wall at the point of the mesenteric attachment and by another at the point directly opposite. The portion of intestine which lies on the lower or rectal side of the line of division, starting about an inch from this line, is opened longitudinally on its convex free border for about two inches. Through this incision the long ends of the two sutures are passed and the gut invaginated and its partially united cut ends drawn Fig. 217. Maunsell's method ; protruding ends ready for suture. out through the opening. (Figs. 216 and 217.) Sutures of fine silk are then passed through both sides of the ex posed invaginated gut at the same time close to its cut edge, hooked up from the centre, cut apart and tied. The intestine is then withdrawn from the opening and the longitudinal slit closed by Lembert sutures. 1 Amer. Journ. Med. Sci., 1892, vol. 103, p. 245. 402 OPERATIVE SURGERY. ENTEROTOMY. Instead of excision of a portion of the gut with imme- diate restoration of its continuity by circular enterorraphy or lateral anastomosis, circumstances such as an uncertain amount of gangrene, the bad condition of the patient, etc., may require that the bowel he simply freed from its con- striction and the damaged part left outside the abdomen till the slough separates. It is fastened to the margins of the abdominal wound by a couple of sutures through the peritoneal and muscular coats, and protected by a dry anti- septic dressing. In course of time it is treated by the method described for the closure of an artificial anus. Other cases may need to be treated as described for enter- otomy or colotomy, with immediate opening of the gut close to or at the seat of disease. RIGHT INGUINAL ENTEROTOMY (NBLATON's OPERATION). As long ago as 1819, it was proposed to establish an artificial anus in the ileum in case the intestinal obstruction could not be found or removed by laparotomy ; but Nelaton was the first (1840) to substitute this for the other opera- tion, giving up the search after the obstruction entirely. His theory was that many obstructions would relieve them- selves in time, if a temporary outlet should be furnished to the accumulation above; in some cases, on the other hand, where the obstruction is permanent, an artificial anus in the ileum meets the " vital indication" perfectly — for example, when the obstruction is in the lower portion of the small intestine; while in others, again, where the occlusion occurs below the ileo-csecal valve, and the relief afforded would, consequently, be imperfect, the obstruction is usually due to malignant disease, which in itself would soon destroy life, and against which neither laparotomy nor any other operation would avail. It is also essential to the proper nourishment of the patient that the greater part of the small intestine should remain serviceable ; that is, that the opening should be made in the SPECIAL OPERATIONS. 403 lower part of the ileum. Of course, this cannot be accom- plished when the obstruction is situated high up, but, in other cases, Nelaton fouud that the intestinal loops nearest the obstruction always occupied the right iliac fossa, and he, therefore, cut through the abdominal wall just above the outer half of Poupart's ligament on the right side, and opened the first loop that presented in the incision. The portion of the intestine below an obstruction is always empty and shrunken, and does not come into contact with the ante- rior abdominal wall, so that there is no danger of making the opening in it by mistake. It occasionally happens when the obstruction is situated in the colon that the distended caecum fortunately presents in the incision, and the artificial anus is established below the ileo-csecal valve. Operation. Make an incision parallel to and about an inch above Poupart's ligament, beginning at the anterior superior spine of the ilium and ending opposite the internal abdominal ring. Divide the tissues layer by layer, pick up and nick the peritoneum and open it for about one and a half inches. The first distended intestinal loop which presents is drawn out till its free border is on a level with the skin, and re- tained by two silk or silkworm-gut sutures, which, at the same time, draw together the extremities of the abdominal wound. Each suture passes through all the parietal tissues and the peritoneal and muscular coats of the intestine. The skin and bowel are closely united all around by interrupted sutures, none of which must enter the lumen of the gut. The suture line is covered by a strand of iodoform gauze pasted down with flexible collodion, and the centre of the protruding intestinal wall opened in its long axis for about half an inch. The parietal peritoneum can be drawn out and stitched to the skin before the bowel is sutured in place, thus bring- ing into contact a larger surface of parietal and visceral peritoneum. COLOTOMY. Left Inguinal Qolotomy. Make an incision between two and three inches long, according to the thickness of the 404 OPERATIVE SURGERY. abdominal wall, parallel to and about an inch above Pou- part's ligament, with its centre at the level of the anterior superior spine of the ilium, or a little lower. The tissues are divided layer by layer, the peritoneum opened, and the skin and parietal peritoneum united by a few sutures, not including the muscles. The sigmoid flexure, which is recog- nized by its anterior longitudinal band, its convoluted sur- face, or appendices epiploicse, is drawn into the opening and retained by a couple of silk or silkworm-gut sutures passed about two inches apart through both lips of the wound at its extremities and the longitudinal band of the colon. The gut is then closely united to the margins of the wound by fine silk sutures passing through the already joined skin and peritoneum and the outer coats of the intestine. No suture must penetrate to its interior. The amount of the circumference of the gut to lie external to the sutures is about half an inch when the operation is for the temporary relief of obstruction. For a permanent artificial anus two- thirds of the circumference of the bowel should lie anterior to the suture line. The centre of the exposed intestinal wall is then opened longitudinally with a knife or thermo- cautery for about half an inch and drainage tubes inserted. Before opening the bowel the suture line can be covered with a strip of iodoform gauze pasted over with flexible collodion. If there is no hurry the opening can be deferred for five or six days till adhesions have shut oif the general peritoneal cavity. Some surgeons prefer not to unite the skin and parietal peritoneum, but to suture the outer coats of the intestine to the skin alone. The gut adhering to all parts between the skin and parietal peritoneum is thought less liable to retract than if adherent only to the intervening parietal peritoneum with its movable subserous areolar tissue. Maydl 1 hangs the intestine on a sterilized rod passed through the mesentery close to the bowel and laid on the skin transversely to the wound. The apposing walls of this loop are united by a few interrupted sutures through the peritoneal coats and the rest of the walls left to adhere to the abdominal wound ; but if immediate opening is in- > Centralb. f. Chir., 1888, No. 24. SPECIAL OPERATIONS. 405 tended, the sutures are passed through the skin and perito- neum around the margins of the incision, and through the serous and muscular coats of the gut, completely separating the peritoneal cavity. The exposed wall of the intestine is opened transversely for one-third of its circumference, and drainage tubes placed within it. Two or three weeks later the bowel is entirely divided on this line and the cut edges sutured to the skin for a permanent artificial anus. If the operation is merely temporary the intestine is opened longitudinally, and when adhesions have formed the rod is withdrawn, and the bowel retracts and the fistula sometimes closes spontaneously. Right inguinal colotomy only differs from the last opera- tion in that the abdominal incision is placed on the right side and the csecurn is opened instead of the sigmoid flexure. Median colotomy, by fixing the ascending or descending colon in the median line between the umbilicus and pubes, has nothing to recommend it over the inguinal method. Lumbar Colotomy. This operation was first suggested by Callisen, 1 in 1797, as a substitute for Littre's or inguinal colotomy with a view to avoiding the dangers incidental to au incision through the peritoneum. He proposed to open the descending colon in the posterior third of its periph- ery, where it is not covered by peritoneum. So far as known, Amussat was the first to perform the operation in 1839, and although he opened the ascending colon, and by a transverse instead of a vertical incision, the opera- tion was essentially the same as that proposed by Callisen. All that portion of the descending colon which lies above the crest of the ilium is usually uncovered by peritoneum on its posterior aspect, and although the actual breadth of the uncovered portion varies with the degree of dis- tention of the bowel, it usually amounts to one-third of the entire circumference, and is bounded on each side by 1 Erskine Mason : Six Cases of Lumbar Colotomy, Amer. Journ. of Med. Sciences, Oct. 1873. 18* 406 OPERATIVE SURGERY. one of the three longitudinal bundles of unstriped muscle characteristic of the colon. In position it corresponds nearly to the outer border of the quadratus lumborura, and very exactly to a vertical line drawn a full half inch behind the centre of a transverse one, uniting the anterior and posterior superior spines of the ilium (Mason). On the right side (ascending colon) the uncovered portion is more often smaller, and the existence of an actual meso- colon, although rare, is yet more frequent than upon the left side. Callisen proposed a vertical incision a little external to the outer border of the erector spinse ; Amussat made a transverse one midway between the last rib and the crest of the ilium, while Baudens and Bryant used an oblique one passing downward and outward at an angle of 45°. The latter is to be preferred, because, while giving sufficient room, it inflicts less injury upon the vessels and nerves of the parts, the general direction of which is the same as that of the incision. The operation is performed as follows : The patient is etherized, and placed in a position midway between the prone and right lateral, a hard cushion being placed traus- versely uuder the right loin to keep the spine straight or slightly curved toward the left. Mason 1 says the operation has been performed with the patient seated and leaning forward over the back of another chair, local anaesthesia being obtained by means of the ether spray. The anterior and posterior superior spines of the left ilium are then recognized, and a vertical line drawn upward from a point one-half to three-quarters of an inch behind the centre of a transverse line drawn from one to the other. This verti- cal line should be marked with iodine or nitrate of silver, in order to serve as a guide during the operation If the occlusion of the intestine has not been complete, and there is reason to suppose that the colon will be found empty, it may now be distended by injecting air or water through the rectum. Mason prefers air, and gives good reasons for the preference. A transverse or an oblique incision four or five inches 1 Loc. cit. SPECIAL OPERATIONS. 407 long is then made, its centre lying in the vertical line above mentioned midway between the last rib and the ilium. The underlying tissues are recognized and divided layer by layer, until the fascia transversalis and quadratus lumborum are reached. The former is next carefully divided, and, if the adipose tissue covering the colon does not then appear in the wound, the latter should be en- larged on the inner side by dividing the outer fibres of the quadratus. The intestine must always be sought for in the angle of the wound nearest the spine, and when- ever it is desired to increase its exposed area this must be done in the same direction. Bleeding should be arrested as it occurs, certainly before the intestine is opened. The colon can usually be recognized by its distention and greenish hue, and possibly by one of its longitudinal bands. Additional light may be thrown upon the correct- ness of the recognition by noticing whether the supposed colon corresponds exactly to the vertical line marked upon the skin, and whether or not it moves up aud down with the acts of inspiration and expiration, for while the small intestine has this motion the lumbar colon has it not. Two stout ligatures are next passed by means of curved needles through the presenting portion of intestine and used to draw it up into the wound, and fasten it to the skin at the sides of the incision. The wound is then filled with sponges or gauze, and the bowel opened by a longi- tudinal or crucial incision. As soon as the discharge has ceased, the sponges or gauze are withdrawn, the parts cleaned, the extremities of the tegumentary wound closed with silver sutures, and the edges of the opening in the in- testine made fast to the skin with a few sutures of fine silk. CLOSUEE OF AN AETIFICIAL ANUS OE FECAL FISTXJEA. If the opening in the gut is large, the remaining part of the intestinal wall is pressed forward into it and forms a sort of valve or spur, which prevents more or less com- pletely the descending current of feces from entering the lower segment of the bowel. If this spur were absent the fistula might close sponta- 408 OPERATIVE SURGERY. neously, and to accomplish its removal Dupuytren's enter- otome was formerly introduced through the opening and clamped upon the spur, which was thus cut through by four or five days of continued pressure. Fig. 218. Dupuytren's enterotome. Immediately before undertaking any operation the lumen of the gut above and below the fistula is plugged by a sponge tied to a string which serves to withdraw the sponge when all is ready to close the intestinal opening. The interior of the gut is then irrigated clean and the skin surrounding the fistula thoroughly scrubbed and washed with bichloride solution. In most cases the fistulous tract between the intestine and skin is lined with mucous membrane, and if the spur is slight or absent, an attempt to close the fistula should first be made by separating the mucous membrane at its junction with the skin, and after removing the sponge plugs, inverting it, and uniting the freshened surfaces with fine catgut. Over this the pared edges of the abdominal opening are sutured with fine silk, aided, if necessary at the sides, by liberating incisions through the skin and fascia. If this fails or a more elaborate operation seems necessary, an incision two or three inches long is carried across the fistula in any suitable direction, and layer by layer down to the peritoneum. This is opened at one extremity of the incision ami a finger inserted into the abdomen to deter- mine the limit of the adhesions ; and as soon as possible SPECIAL OPERATIONS. 409 the peritoneal cavity is walled off by sponges packed in around the open intestine, which has been previously plugged above and below as already described. Cutting on the finger as a guide, the gut is separated from its parietal attachment around the fistula, and if possible drawn out of the abdomen and constricted above and below the plugs by gauze bands passed through the mesentery. The sponge plugs are withdrawn, the interior of the gut irrigated, and, if the openiug is small, its edges are fresh- ened and inverted, and the peritoneal coat drawn together over it with Lembert sutures. The constricting bands are removed and the gut returned to the abdomen, which is closed tight in the usual way. If the opening is extensive, the damaged segment of the gut is excised and circular enterorraphy performed, or better still, after excision, lat- eral anastomosis. The fistulous tract is then dissected out of the abdominal wall and the wound closed tight. The Operation for the Removal of the Vermiform Ap- pendix. In a case of appendicitis operated on in the period of quiescence, an incision three or four inches long is made at the outer border of the right rectus muscle, with its centre about on the line joining the umbilicus and the an- terior superior spine of the right ilium. The lower ex- tremity of the incision should not reach the deep epigastric artery, the course of which is indicated by a line drawn from the femoral ring to the umbilicus. The tissues are divided layer by layer, all bleeding stopped, and the peritoneum pinched up and opened the whole length of the incision. Adhesions are separated by the finger-nail or blunt-pointed scissors, and if necessary divided between a double ligature. The anterior longi- tudinal band of the colon is traced to its origin at the root of the appendix. After walling off the surrounding peri- toneum with a sponge packing, the appendix is isolated and a double ligature of stout catgut passed by an aneurism needle through its mesentery close to the root of the ap- pendix. The needle is withdrawn, the loop of the ligature cut, and on one side the mesentery, which usually contains a single artery, is tied off, and on the other side the ap- 410 OPERATIVE SURGERY. pendix is Hgated as close to the caecum as possible. The mesentery and appendix are then excised close to the distal side of the ligatures. The csecal stump of the appendix is held isolated and in view till thoroughly cauterized with the Paquelin or pure carbolic acid, but in using the latter care must be taken to prevent its spreading to the neighboring surface of the caecum. The sponge protectives are then removed, the parts allowed to assume their normal position, and one end of a strand of iodoform gauze is placed in contact with the cau- terized stump and the other end brought out of the abdom- inal wound. The peritoneum and overlying parts are closed tight in the usual way except where the gauze drain emerges. Here a suture of silk is passed through the entire thickness of the abdominal wall, including the peritoneum, and left un- tied till the drain is removed forty-eight hours later. This must be done with every antiseptic precaution, and only done if no inflammatory symptoms exist. The dressings then applied are left undisturbed about ten days. Dr. 31cBurney 1 has given us a method which, while more difficult of execution, obviates the risk of hernia : An inci- sion, oblique downward and inward, is made about an inch and a half to the inner side of the anterior superior spine of the ilium. The aponeurosis of the external oblique is split in the direction of its fibres, the sheath of the inter- nal oblique divided transversely, and its fibres and those of the transversalis carefully separated without cutting from the ilium to the rectus. The fascia and peritoneum are divided, the sides of the opening held apart with broad retractors, and the appendix removed as above described. Operation during the Period of Inflammation. If a distinct tumefaction is perceptible, with a probability of the presence of pus, the incision is made about four inches long parallel to the outer border of the right rectus over the most prominent part of the tumor, or, if there is no tume- faction, over the most tender spot, and the appendix 1 Annals of Surgery, 1894. SPECIAL OPERATIONS. 411 removed as already described. If the peritoneum is reached without a previous escape of pus it is opened at an angle of the incision, preferably the upper, and a finger inserted to determine the positiou of the mass and the limit of the adhesions. Through this exploratory opening a sponge packing is inserted as soon as possible, and the inflamed area walled off from the rest of the abdominal cavity. The peritoneal opening is then enlarged and the dissec- tion carried into the densest part of the tumefaction. Fresh adhesions are best separated by tearing with the finger-nail, but the possibility of lacerating the bowel must not be forgotten, and, if necessary, the blunt-pointed scissors and double catgut ligature are used for the strongest adhesions, especially those involving omentum. The moment pus appears the manipulations are suspended, while it is encour- aged to flow out or else sponged rapidly away without disturbing the relations of the surrounding parts. The opening in the abscess cavity is cautiously enlarged without getting beyond the adhesions which protect the rest of the peritoneal cavity. If such an accident does occur a clean sponge is immediately packed into the rent and the dissection continued until the appendix is found. It should always be removed to prevent subsequent attacks, and it is always possible to find it by following the auterior longitudinal band of the csecum. It is excised and the stump cauterized in the manner already described. An abscess cavity in the pelvis may sometimes need to be drained by a tube passed through a counter-opening in the rectum and a cavity in the loin by a tube passed through the back just above the iliac crest. After every trace of pus has been sponged or washed away one or more tubes should extend from the abdominal wound into every recess of the suppurating region and each surrounded with au iodoform -gauze packing. The sponge protectives are then removed and their places supplied by strips of iodoform gauze, the upper and lower angles of the wound are sutured in the usual way, and a strip of iodo- form gauze placed over the intestines beneath them. The ends of all the strips of gauze are brought out at the centre of the wound and counted. After the first twelve to twenty-four hours the dressings 412 OPERATIVE SURGERY. will probably be saturated with the blood-stained serous discharge and need changing, which then and afterward must be done with every antiseptic precaution. The gauze directly beneath the suture line can probably be removed in twenty-four to forty-eight hours, but it will require a vigorous pull. STOMACH. Anatomy. The cardiac orifice lies about one inch to the left of the sternum beneath the seventh left costal cartilage. The pyloric orifice in the empty stomach lies in the median line or close to the right of it and two or three inches below the end of the gladiolus, and is in relation with the neck of the gall-bladder, the portal vein, the gastro-duodenalis, and right gastro-epiploica arteries, the pancreas, and the splenic vein. The lesser curvature is connected with the transverse fissure of the liver by the lesser omentum, which contains from left to right the gastric, pyloric, and hepatic arteries, the portal vein, and common bile duct. The great omentum passes downward from the greater curvature, on which lie the right and left gastro-epiploica arteries, across the colon, to which the anterior layer is generally adherent, the posterior always. The transverse mesocolon is near the posterior surface of the stomach. The left lobe of the liver descends in front of the stomach a variable distance, gen- erally not below the ninth left costal cartilage. When the stomach is distended, it is in contact with the anterior abdominal wall over quite a large area below the left lobe of the liver; when it is empty, this area of contact becomes very small, and lies between the left lobe of the liver and a transverse line drawn at the level of the anterior end of the ninth rib. The guide to this line, as Tillaux has shown, is the anterior end of the tenth rib, which can be readily felt projecting beyond the border of the cartilages of the false ribs, and can be made to yield a sort of friction sound by rubbing it against the ninth. Sedillot claimed that when the stomach was empty, it was nowhere in contact with the anterior abdominal wall, being separated from it by the liver and transverse colon, and recommended that it should be approached by a crucial incision through the left rectus muscle two or three inches below the xiphoid appen- SPECIAL OPERATIONS. 413 dix of the sternum. He passed his finger along the border of the left lobe of the liver to the diaphragm, encountered the stomach there, seized it with pronged forceps introduced along the finger, and drew it up to the incision while press- ing the colon downward. Although, as stated, more recent investigations have shown that the normal stomach when empty is still in contact with the anterior abdominal wall, these directions for finding the stomach may be useful in cases where it has been drawn back and bound down to the posterior wall by inflammatory adhesions or neoplasms. GASTROSTOMY. It consists in the establishment of a fistula through the walls of the stomach and abdomen. Operation. An incision one and a half or two inches long is made parallel to and a finger-breadth from the free border of the left costal cartilage, ending below opposite Pig. 219. Anatomical relations of the stomach with reference to gastrostomy. the end of the tenth rib. The tissues are divided layer by layer, the peritoneum pinched up and opened. When the stricture is close the stomach and intestines are usually empty and the abdomen deeply sunken by atmospheric pressure. In such cases, when each successive layer is divided it rises from the underlying mass, and when the peritoneum is opened the air rushes in and the abdominal wall rises away from the stomach and becomes level with the sternum and ribs. The stomach is recognized just below the left lobe of the liver by its white color, smooth surface, and the arrangement of its arteries. If it does not 414 OPERATIVE SURGERY. present in the wound the transverse colon and omentum are pressed down, the fingers passed up under the left lobe of the liver and to the left close to the diaphragm and vertebral column, and the lesser curvature sought for. When found a fold of the stomach is picked up by the fingers aud a spot fixed upon which avoids too much trac- tion and is suitable for a fistula. The method now in favor in gastrostomy is to stitch the parietal peritoneum to the skin all around the incision, and then to fasten the un- opened stomach in the wound by several sutures which Diagram to show a method of fastening the stomach in a wound of the abdominaJ parietes. (Greig Smith.) traverse its muscular coat but do not enter its cavity, and whose deeper ends then transfix the abdominal wall. This gives a broad surface of contact between the peritoneum of the stomach and that of the abdominal wall, and favors their prompt union. The protruding portion of the stomach may also be transfixed with two long pins which rest upon the skin and prevent strain on the sutures. The opening of the stomach is delayed as long as possible, from one to eight days. If necessary, food can be introduced by punc- turing with an aspirating needle. SPECIAL OPERATIONS. 41 5 Another method, after stitching together the parietal peritoneum and skin, is to pass two retention sutures of silver wire through about half an inch of the stomach wall, and about the same distance apart. A continuous silk suture is next passed through the wall of the viscus in a circle about two inches in diameter and brought out and reinserted at intervals of a quarter of an inch, leaving numerous free loops on its surface. (Fig. 220.) No suture must enter the interior of the stomach. Each loop, as made, is passed through the abdominal wall at the margin of the incision and threaded on a rubber tube, around which the wire retention sutures are also passed to assist in holding the stomach. (Fig. 221.) Fig. 221. Completion of operation represented in Fig. 220. Witzie 1 divides the skin parallel to the ribs and a finger's breadth distant, then the rectus muscle longitudinally, and the transversalis horizontally. Next the anterior wall of the stomach is drawn into the abdominal wound sufficiently to permit of its being folded lengthwise and sutured over a rubber tube, which at one extremity enters the viscus and at the other is brought out of the openiug in the skin. The stomach is then fastened in the wound in the ordinary way by a row of sutures around the folds enclosing the tube, 1 Centralbl. f. Chir., 1891, p. 601. 41 6 OPERA TIYE SUB QER Y. and over the latter the skin is united, leaving only a small hole for the exit of the tube. This is intended to make the fistula communicate less directly ■ r ^"" with the surface of the body, and thus insure better retention of the gastric contents. It is important that the tube should fill and even distend the orifice by which it enters the stomach. The leakage from a straight fistula of this organ can, however, be controlled to a certain extent by a mechanical de- vice consisting of two hollow rubber disks closely joined at their centres by a Plug of two hollow hollow rubber cylinder communicating r^ d ^v 0r n 0Si r with each. The lower disk is passed a gastrostomy w ound. . . . . tr through the fistula into the stomach, and both disks are then distended with air or water and thus made to block the opening. In cases where the stomach need not be opened for some days it is sufficient, after uniting the skin and parietal peritoneum, to pass a couple of harelip pins through its outer coats, enclosing a portion of the stomach wall about three-quarters of an inch square. The pins are simply laid upon the skin transversely to the abdominal wound, and the opening made in the centre of the square they enclose after adhesions have formed. A crucial abdominal incision below the ensiform process was used by Sedillot. Others have employed a vertical in- cision in the linea alba, in the substance of the outer part of the left rectus, or in the left linea semilunaris. Hahn opened and fixed the stomach in the eighth inter- costal space after first entering the abdomen by an incision parallel with the lowest rib. 1 GASTKOTOMY. This is the operation in which the surgeon opens the stomach and then closes it at the conclusion of the opera- tion. 1 Centralb. f. Chir., 1890, p. 193. SPECIAL OPERATIONS. 417 Operation. If it is performed for the removal of a for- eign body which can be felt through the anterior abdominal wall, the incision, at least two inches long, is made over the tumefaction and in the direction which inflicts the least damage on the intervening tissues. Otherwise the incision is made in the median line just below the ensiform process or parallel to the left costal cartilages, as in gastrotomy. The tissues are divided layer by layer, the peritoneum opened, and one finger introduced to locate the foreign body. After protecting the surrounding peritoneal surface by gauze pads or sponges, the part of the stomach wall to be opened is carefully drawn into the abdominal wound and held there by a couple of temporary retention sutures passed through the peritoneal and muscular coats on each side of the intended opening, which is then made parallel to the course of the bloodvessels, that is, transversely to the long axis of the stomach. The foreign body is removed gently, with due regard for its sharp points, or the ulceration or sloughing which may exist, and if necessary the stomach is washed out. There must be as little sponging or irrita- tion of its interior as possible. The incision in the stomach is closed by a continuous silk suture of the mucous membrane, then by a row of Lembert sutures, which are reinforced by a continuous silk suture through the peritoneal coat. After the region of the wound has been made dry and clean, the temporary retention sutures are withdrawn, the protecting sponges are removed from the abdominal cavity and the parietal wound closed and dressed as described for an aseptic laparotomy. Greig Smith does not suture the mucous membrane of the stomach, but closes the wound by a row of Lembert sutures reinforced by a continuous or interrupted suture of the peritoneal coat. The continuous suture prevents gaping of the wound during expansion of the stomach. By gastrotomy Bull 1 and Richardson successfully re- moved foreign bodies impacted in the cesophagus near the cardiac orifice of the stomach. Richardson demonstrated that the lower three inches of the oesophagus are thus 1 New York Medical Journal, October 29, 1887. 418 OPERATIVE SURGERY. accessible by an incision parallel to the left costal cartilages, through which he introduced his whole hand into the stomach and extracted a set of false teeth from the lower end of the gullet. 1 Gaslrotomy for Benign Stenosis of the Pyloric or Cardiac Orifices. (Sometimes called Loretta's operation.) Before the operation the stomach is washed out repeatedly with an alka- line solution. The pylorus is reached by an incision four or five inches long, usually in the linea alba between the xiphoid appendix and the umbilicus ; or else approximately parallel to and about an inch from the right costal cartilages, starting an inch below and an inch and a half to the left of the xiphoid appendix and terminating near the level of the cartilage of the ninth rib. The tissues are divided layer by layer, and the peritoneum opened. The surrounding peritoneal surface is protected and held out of the way in the usual manner, while the pylorus is sought for, and such adhesions as may exist are divided between double catgut ligatures. The anterior wall of the stomach is drawn into the abdominal wound, and after again carefully protecting the surrounding peritoneal surface is incised transversely for from one to three inches between its two curvatures near the pylorus, but outside of the inflammatory zone adjoin- ing it. Guided by two fingers grasping the pylorus ex- ternally, the forefinger of the right hand is passed through the stomach into the pyloric orifice. This may require considerable force, or the orifice may have become so con- tracted that preliminary dilatation with some small instru- ment is necessary. McBurney used a small bivalve anal speculum. Dilata- tion is continued till it is felt that any further stretching would threaten a rupture of the viscus. The wound in the stomach in then sutured as described in gastrotomy for a foreign body, and, after cleansing and drying the field of operation and removing the protective pads or sponges, the parietal wound is closed as usual. To reach the cardiac orifice, the abdominal incision is made obliquely from a point just below the ensiform pro- 1 Lancet, October «, 1837. SPECIAL OPERATIONS. 419 cess parallel to and about one inch from the left costal car- tilages. The anterior wall of the stomach is opened by a longitudinal incision made between the two curvatures and as near the cardiac end as possible. Instead of performing gastrotomy and divulsion of the pylorus, the stricture can be relieved by longitudinal divi- sion followed by transverse reunion. (Fig. 223.) The Fig. 223. B A Pyloroplasty. A. The incision, A, B, along the contracted pylorus. B. Closure of this wound transversely. The point A united to B. median or right oblique abdominal incision is employed, any adhesions about the pylorus are separated, and after carefully walling off the surrounding peritoneum with sponges an incision opening the lumen of the viscera about an inch and a half long is carried across the pyloric ring, through the neighboring anterior wall of the stomach and first part of the duodenum. The opposite extremities of this incision are then united to each other to form the centre of an apparently transverse wound, Fig. 223, which is closed by the Czerny-Lembert suture. The protecting sponges are removed from the cleaned and dried peritoneal cavity, and the parietal iucision closed tight in the usual way. After relieving the pyloric stenosis, the dilatation of the stomach has been lessened by taking a " tuck " in its au- terior wall, a longitudinal fold of which is pushed into the lumen of the viscus, and the opposite external margins of the inverted part united by Lembert sutures. 420 OPERATIVE SURGERY. GASTRORRAPHY. This is the operation for closing a wound or opening in the stomach. Operation. If it is undertaken to close a gastric fistula, the interior of the stomach, the fistulous tract, and surround- ing skin are made as clean as possible. A sponge tied to a string is pushed through the fistula aud held by au assistant against its interior orifice. An incision is then made not less than two inches long in a vertical or auy convenient direction across the fistula and through the abdominal wall, layer by layer, until the peritoneum is reached. This is opened at one extremity of the wound and a finger inserted to determine the limit of the adhesions. On this finger as a director, the peritoneal incision is enlarged around the fistula, which is then surrounded by sponges packed into the abdominal cavity. The liberated stomach is drawn into the abdominal wound, and the margins of the opening in the stomach freshened and closed as described in gastrot- omy, after withdrawing the sponge from the interior of the stomach. The fistulous tract is excised from the abdominal wall, and, after the operation area has been thoroughly cleansed and dried and the protecting sponges removed from the abdomen, the wound is closed in the usual way with or without a gauze packing. If the operation is undertaken for a perforating wound or ulcer of the stomach, immediately after opening the peritoneal cavity by an ample incision, either median, just below the ensiform process, or parallel to the left costal cartilages, all extravasated material must be sponged away or irrigated out of the peritoneal cavity with boiled water, and the opening in the stomach closed as described in gastrotomy. The operation area is walled around by sponges or puds and a sponge is then passed into the lesser peritoneal sac through a small opening made in the great omentum, between the stomach and transverse colon. If the lesser sac is found infected, or there is even a suspicion of an opening on the posterior surface of the stomach, this SPECIAL OPERATIONS. 421 opening must be sought for and closed. If it cannot be reached and sutured through the great omentum (between the stomach and transverse colon), rather than leave it unclosed, Greig Smith advises an incision in the anterior wall of the stomach, and through this suturing the opening in the posterior surface from within. After everything has been made as clean as possible, and all sponges removed from the abdominal cavity, tubes surrounded by a plentiful gauze packing should extend into all the infected regions in the greater and lesser peritoneal sacs and connect them with the skin surface. The parietal wound is then partially closed and dressed antiseptically. PYLORECTOMY. The stomach should be repeatedly washed previously and should be empty at the time of operation. The abdominal incision is made in the linea alba between the ensiform process and umbilicus, or over the most prominent part of the tumor, and more or less transversely, from just to the left of the median line in the direction of the free border of the right costal cartilages and not less than an inch from them. Other forms of incision that have been employed are vertical at the outer border of the right rectus, transverse over the tumor, or crucial. At first the incision is only made large enough for exploration. If then the operation is deemed feasible, it is enlarged till it is from three to five inches long. Sponges are packed into the abdomen around the tumor, which is drawn as much as possible into the abdominal wound. The great and small omenta are cut close to the greater and lesser curvatures of the stomach, after first securing the vessels between double ligatures, till the point toward the left is reached where the stomach wall is to be divided. Great care must be taken not to wound the portal vein, hepatic artery, or common bile duct which lie behind the pylorus, and no damage must be done to the transverse mesocolon. If the disease involves this structure the operation should be abandoned, Fresh sponges are now packed around the liberated 19 422 OPERATIVE SURGERY. pyloric end of the stomach, and the growth, with a margin of healthy tissue, is excised with scissors. All vessels are secured as they are divided, the lumen of the duodenum is immediately plugged by a sponge, aud after removing all extra vasated matter aud renewing the sponge packing around the field of operation, the large opening in the stomach is narrowed on the side of the lesser curvature by Czerny- Lembert sutures till the opeuiug which remains next the greater curvature approximates the size of the duodenum. If circumstances require the implautation of the duodenum Fig. 224. Pylorectomy. Showing method of narrowing the opening in the stomach. near the lesser curvature, the opening in the stomach is narrowed below or on both sides in the same way (Fig, 224), the posterior walls of the stomach and duodenum at their respective points of division are then approximated and the margins of the wounds behind are inverted to bring the posterior peritoneal surfaces in contact. The redundant mucous membrane is raised at its cut edge and sutures of fine silk arc passed beneath it from the inside, at intervals of an eighth of an inch, through the muscular and peritoneal coats of the stomach and duodenum. When knotted the sutures lie beneath the mucous mem- brane, which can be closed over them by a continuous or interrupted suture (Fig. 225), only about the posterior half of the stomach and duodenum can be united in this way. The sponge is then withdrawn from the duodenum and the remainder of the wound is closed by the Czerny- SPECIAL OPERATIONS. 423 Lembert suture. After testing the suture line by filling the stomach with water, the operation area is made clean and dry, the protective sponge packing is removed, and the abdominal wound is closed in the usual way. Senn's omental graft to surround the suture line in the viscera might be useful. In extensive resections of the pylorus, Billroth and others have closed the resulting wounds in the stomach and Fig. 225. Wolfler's methods of uniting the wound in the posterior portion of the stomach after pylorectomy. The shaded line represents the mucosa. duodenum by Lembert sutures and then restored the con- tinuity of the alimentary canal by performing a gastro- enterostomy. On account of the high mortality of pylorectomy for malignant disease, this operation is now rarely done ; in general it may be stated that when the tumor can be felt through the anterior abdominal wall, it is scarcely justifi- able to attempt its removal. GASTROENTEROSTOMY. The preliminary washing of the stomach and the abdom- inal incision are the same as for pylorectomy, but the abdomen is more commonly opened in the median line between the ensiform process and the umbilicus. The first loop of intestine which presents is grasped and traced up- 424 OPERATIVE SURGERY. ward to the duodenum. It should be noted that this part of the gut is thicker, of greater diameter, aud more vascu- lar than that nearer the colon. Czerny advises that the origin of the jejunum be sought for at once by drawing up the stomach, great omentum, and transverse colon, and fol- lowing back the transverse mesocolon to the spine ; imme- diately to the left of this lies the end of the duodenum. A portion is then selected as near to the latter as will per- mit easy coaptation with the stomach, the great omentum is pushed to the left and the intestine drawn to the right Fig. 226. Gastroenterostomy ; diagram to show the method of union to secure similarity in direction of the peristalsis of the stomach and intestine. and upward over the colon. The anterior wall of the stomach near the greater curvature and the selected por- tion of* intestine are drawn as far as possible into the ab- dominal wound, and the loop of intestine should be so twisted or placed that at the conclusion of the operation the direction of its peristaltic wave shall not be opposite to that of the stomach. (Fig. 226.) SPECIAL OPERATIONS. 425 The rest of the abdominal contents are walled off by a protective sponge-packing, and the selected loop of intestine, squeezed empty by the fingers, is prevented from filling by a rubber or gauze band passed through the mesentery and constricting each extremity of the selected loop. A continuous silk suture through the peritoneal and muscular coats is then made to unite the anterior sur- face of the stomach near its greater curvature to the pos- terior surface of the intestine a little to the mesenteric side of its free border, for about four inches. In addition, a row of Lembert sutures may be placed anterior to the continuous suture, although this is not abso- lutely necessary. After the rest of the abdominal contents are protected from extravasated matter by fresh sponges, the stomach and intestine are opened parallel and close to this suture line, and the interiors of each irrigated clean — the incisions should terminate opposite each other and about half an inch short of the extremities of the suture line. Having made the wounds and their surroundings clean and dry, the adjoining posterior margins of the two incis- ions are rapidly sewn together by a continuous suture passed through the entire thickness of the walls, and this suture is continued as far as possible around each angle of the incision and along the anterior margins. The opera- tion is then completed by a row of Lembert sutures or a continuous suture extending along the auterior surface from one end to the other of the first suture line. The constricting baud at each extremity of the loop of intestine is then removed, all parts are made clean and dry, the surrounding sponge-packing is taken out and counted, the viscera replaced, and the abdominal wound closed tight in the usual way. Some German surgeons, before uniting the stomach with the loop of small intestine, pass the latter through the great omentum aud over the colon, or through a vertical slit in the transverse mesocolon and then through the gastro- colic ligament to the anterior surface of the stomach. But the route to the right, around the great omentum, is to be preferred whenever possible. Jejunostomy for inoperable cancer of the pylorus has been performed a few times. A longitudiual incision is. 426 OPERATIVE SURGERY. made to the left of the umbilicus, the omentum and trans- verse colon pressed upward, and a loop of the upper portion of the jejunum brought into the wound and secured there by sutures as in gastrostomy. The opening made in the intestine should be only large enough to admit the tube through which food is to be introduced. Maydl has proposed a more complicated method, as fol- lows : The abdomen is opened transversely about four finger- breadths below the ensiform process, a loop of jejunum some ten or twelve inches long extracted, and, with every antiseptic precaution, divided transversely. The proxi- mal segment is then connected with the distal a few inches below the point of division by an anastomosis opera- tion to preserve the biliary and pancreatic secretions, and the distal segment fixed in the abdominal wound as in gas- trostomy, 1 or the distal segment may be attached to the stomacli thus making a gastroenterostomy. HERNIOTOMY, KELOTOMY. Under this head are to be described the operations for the relief of strangulated inguinal, femoral, umbilical, and obturator hernias, and those for the radical cure of the first three varieties. It has been well said that there is no operation in which the unforeseen has a larger share than in herniotomy, none in which the surgeon is called upon to show more skill, sagacity, and decision. The causes of this are to be found in the absence of absolute guides to the hernial sac, the changes in the sac and overlying tissues brought about by inflammation or time, the character of the hernia — whether composed of omentum, intestine, caecum, or bladder, and, lastly, the difficulty of determining not only the extent of the injury done to the strangulated tissues, but even, in some cases, the route taken by the hernia in its descent. It is desirable, therefore, that the account of the different operations should be preceded by some general considera- tions upon these subjects. 1 Maydl : Wii-n. med. WochenBCh., L892, p. 697. SPECIAL OPERATIONS. 427 General Directions. A. Recognition of the Sac and Bowel. The first difficulty encountered in the course of the operation is that of recognizing the sac. The thickness of the connective tissue covering it varies greatly in different cases; each layer must be pinched up with forceps, opened with the knife lying upon its side, as in opening the sheath of an artery, then raised upon the finger or a director, and divided to the full extent of the cutaneous incision, after having been carefully scrutinized. Occasionally a cyst containing liquid is found in front of the hernia, and may at first be mistaken for it, for usually the sac contains a certain amount of serum. Careful examination of the tissues before division is absolutely necessary, because in those rare cases where there is no sac (hernia of the csecurn or of the bladder), and in others where it is quite undistinguishable, it is only by recognizing the muscular coat when he reaches it, that the surgeon avoids opening the intestine or bladder by mistake. As the sac is approached, each layer should be pinched up in a narrow fold and moved gently across the underlying parts ; if a smooth globular tumor is felt below, the surgeon makes an opening in the fold, confident that the wall of the intestine is not included in it; but if he is unable to pinch up the fold, or if, instead of the sensation of a smooth globular mass, he gets only that of an empty space, he examines the surface again, divides any fibrous bands he may find at the neck of the hernia, and tries to introduce his finger through it into the abdominal cavity. If he succeeds, he knows the sac has been opened ; if he does not succeed, he renews the examination and con- tinues the dissection. Maisonneuve said the surgeon may know he has not reached the intestine so long as he is not certain of having done so ; but this is not true of all cases ; the intestine is not always smooth and shining; it may be dark, dull, con- gested, and thickened, and in hernia of the caecum or sigmoid flexure it may have no peritoneal coat. When the hernia is small and recent the sac is bluish, and can be pinched up between the thumb and finger, so that its smooth opposing surface can be felt to glide upon one another. When it is large and of long standing, the sac may be exceedingly thin and unrecognizable, or very 428 OPERATIVE SURGERY. thick and adherent. If small, it should be thoroughly isolated, and its boundaries everywhere defined; if large and adherent, its neck alone should be cleared. B. Opening of the Sac. The propriety of opening the sac used to be a subject of dispute. The only objection to it, but that a serious one, was the danger of thereby setting up peritonitis. On the other side there was the danger of returning the hernia into the abdomen in a gangrenous condition, or unreduced when the stricture was formed by the sac itself. Now, however, the rule is always to open the sac with every antiseptic precaution and relieve any constriction which may be found by cutting down upon it layer by layer from without. Then either immediately or after au interval a radical cure is performed. The liquid which is usually contained in the sac may not only serve to call attention to its accidental opening, but may also be taken advantage of to open it safely when it has been recognized. It, of course, collects at the most dependent point, and there intervenes between the sac and the bowel, so that the former can be pinched up and opened without injury to the latter. When this is not the case, the surgeon must pinch up a very small fold of the sac wherever he can do so, or do as Mr. Liston did iu a case where, as he says, "there was no possibility of pinching up the sac, either with the finger or forceps ; it contained no fluid, and was impacted most firmly with bowel; very luckily the membrane was there; and, observing a pelleton of fat underneath, I scratched very cautiously with the point of the knife in the unsupported hand, until a trifling puncture was made, sufficient to admit the blunt point of a narrow bistoury." 1 The opening should be enlarged until the finger can be introduced, and then the sac slit up on it as a guide. If the omentum is then found filling the sac, it must be cautiously unfolded or incised, for it is probable, especially in umbilical hernia, that a strangulated loop of intestine will be found in its centre. 0. Division of the Stricture. The left forefinger is passed up into the neck of the sac by which the stricture is usually constituted, the pulp upward, the nail pressing 1 Op. Surgery, p. 402, quoted by Jos. Hell, Manuulof Surgical Operations, p. 231. SPECIAL OPERATIONS. 429 against the intestines ; if the stricture lies or can be drawn outside the opening in the abdominal wall through which the hernia made its escape, it may be divided freely without risk, but if it lies within the opening the division must be made with reference to the anatomy of the region. If the division cannot be made at the desired point, but only at some other where an incision of the necessary extent would be daugerous, the stricture must be slightly nicked at that point, and advantage then taken of the partial liberation to make a second cut in the proper place. The end of the finger, or its nail, is gently engaged in the stricture, its pulp against the selected point of division, and the knife, a probe-pointed, slightly curved bistoury, passed on the flat along its palmar surface until the point has passed through the stricture. The surgeon then turns its edge upward and presses it against the stricture with the end of the finger on which it rests. A slight crackling announces the division, which must be extended or repeated at different points until the finger can be passed freely through into the abdomen. Instead of an ordinary probe-pointed bistoury, a specially constructed hernia knife (Fig. 227) is often used. It is Fig. 227. Hernia knife. probe-pointed and its cutting edge uot more than an inch long. The knife may also be guided upon a director in- stead of the finger. The "hernia director" is broader than the ordinary one, and sometimes has a broad flange on each side to keep the bowel from rolling over against the edge of the knife. It is, however, more surgical to cut down upon the constriction layer by layer and then divide it from without, the gut being protected by the finger or a director. D. Examination and Return of the Bowel. The bowel. 19* 430 OPERA TIVE S UB GEB Y. should be gently drawn out about an iuch in order that the constricted part itself may be examined, for it is very likely to be badly damaged. If the entire loop is in suit- able condition it must be carefully cleaned of all blood and gradually returned into the cavity of the abdomen. It is not always easy to decide, however, whether or not its condition is suitable for return, and some surgeons have recommended that in cases of doubt it should be covered with warm, wet cloths and kept under observation for some time, the stricture, of course, having been previously divided. A very great change in the color of the loop is far from proving the existence of gaugrene. A deep red vinous, even violet color does not preclude recovery, especially if the surface has not lost its lustre ; but if it is black, or deep brown, or grayish-yellow, or if it is dull, flaccid, or wrinkled, it is certainly gangrenous. Of course, when the charac- teristic gangrenous odor, or the fecal odor consequent on perforation, exists, there can be no doubt. If the loops are in good condition, but bound fast to one another, or to the omentum, or to the sac by firm adhe- sions, great caution must be exercised in dealiug with them. The stricture must be freely divided and the loops emptied of their contents by pressure, and the adhesions, which have probably existed for a long time without inconve- nience to the patient, should in most cases be carefully separated. It is not always easy to return the intestines even after the stricture has been divided. The surgeon should try to reduce one end at a time, by squeezing its contents back into the abdomen and pushing the gut in afterward. If the bowel is very tense, aud the hernial orifice cannot be freely enlarged, the gas may be drawn off with a fine aspi- rator. If rupture occurs, and the bowel is otherwise in good condition, it must be closed with Lembert sutures and returned into the abdomen. If the intestine is gangrenous, an artificial anus must be formed, and it is well to stitch the bowel fast to the edges of the hernial ring, as in enterostomy. If the gangrene extends to the point of stricture and the bowel cannot be drawn further out, the stricture must not be divided, lest SPECIAL OPERATIONS. 431 the bowel should slip back and feces escape into the peri- toneal cavity. The gangrenous portion must be incised, and then, if the feces pass freely, nothing more need be done, beyond taking measures to prevent the bowel from slipping back, such as making its edges fast to the sides of the incision, or passing a stout ligature through the mesen- tery and fastening it to the skin with adhesive plaster. But if the stricture still prevents the flow of feces, Gosse- lin's plan of dilating it by introducing the finger into the intestine should be adopted. E. Treatment of the Omentum. If only a small amount of omentum is found in the sac, and if it is in good condi- tion, it may be returned ; but if there is much of it, or if it Fig. 228. Hernia. The relations of the femoral and internal abdominal rings, seen from within the abdomen. Right side. is inflamed, suppurating, or gangrenous, it must be kept out or incised, after its base has been transfixed in one or more places by double ligatures, which are then cut apart and tied. 432 OPERATIVE SURGERY. Strangulated Inguinal Hernia. Inguinal hernia may be oblique or direct. The former leaves the abdomen at the internal (deep) abdominal ring, having the deep epigas- tric artery on the inner side (Fig. 228), passes down the iuguinal canal, and emerges at the external abdominal ring (Fig. 229) ; the latter makes its way through Hesselbach's Epigastric artery Inguinal hernia, showing the transversalis muscle, the transversalis fascia, and the internal abdominal ring. triangle, a space bounded by the epigastric artery, Poupart's ligament, and the rectus abdominis muscle (Fig. 228), and also emerges at the external abdominal ring. The former is by far the more common variety. Operation. The parts having been well shaved and SPECIAL OPERATIONS. 433 disinfected, the patient is anaesthetized and placed upon his back, with his shoulders slightly raised. The sur- geon pinches up a broad fold of skin and subcutaneous tissue across the long axis of the swelling, transfixes it at its base with a straight bistoury, and cuts vertically through it, thus dividing most of the tissues without danger of injury to the sac or intestine ; if necessary, this incision must be lengthened, so that its upper ex- tremity will lie well above the external abdominal ring, and its lower extremity below the bottom of the hernial sac. The underlying layers are then pinched up one by one with the thumb and finger, or with fine forceps, and divided upon a director until the sac is reached and opened, every precaution being taken to avoid injury to the intes- tines. The best point for opening it is at its extreme lower end, because a little serum is usually collected there, separating it from the bowel. It must be pinched up, if possible, at the point selected, and an opening made with the knife held flat against it ; a director or the finger is then passed through the opening, and the full length of the sac slit up. The constriction is then sought for, and, if found above the external ring, must be nicked or divided directly upward, or cut down upon from without. If it can be positively made out that the hernia is of the oblique variety, the cutting should be doue on the outer side, for the epigastric artery lies close to the inner side of the internal ring, through which this variety passes ; and if it is known to be of the direct variety, the cutting must be done upon the inner side. But, unfortunately, in most cases the dragging of the hernia brings the two rings im- mediately opposite each other, so that the inguinal canal can no longer be said to exist, and the diagnosis cannot be made with certainty. The incision must then be made upward, parallel to the course of the epigastric artery. The intestine must next be examined to ascertain if it is in a fit condition to be returned ; and here it must not be forgotten to draw down an inch or more of each end so that the part which has undergone constriction may also be ex- amined. If the condition is satisfactory, the bowel is re- turned gradually, not en masse, and the wound closed by one of the methods about to be described for radical cure, 434 OPERATIVE SURGERY. preferably Bassini's. If it cannot be safely returned, it is resected or fastened in the wound, as in enterostomy. Strangulated Femoral Hernia. The intestine in its descent occupies a canal which begins at the femoral ring under Poupart's ligament, between the free arched border of Gimbernat's ligament and the femoral vessels (Fig. 228), and ends at the saphenous opening in the fascia lata of the thigh. After passing through the opening it turns upward over the groin. The normal length of the canal is about an inch, but in hernias of long standing it is much shortened by the approximation of its two ends. The seat of stricture is now thought to lie in most cases at the saphenous opening, or just above it, and not at the base of Gimbernat's ligament, as was formerly supposed ; free division is possible at the former point on the upper and inner side without the risk of injury to any organ, except possibly the spermatic cord, aud that is at such a distance as to be practically out of harm's way. Under ordinary cir- cumstances, Gimbernat's ligament can also be safely divided on the inner side, but in about one and one-half per cent, of cases the obturator artery pursues the anomalous course shown in Fig. 230, and then lies directly in the way of the Fig. 230. (HI Variations in origin and course of obturator artery. knife. The neck of the sac under such circumstances is entirely surrounded ; on its outer side are femoral vessels, above are the spermatic cord and common trunk of the epigastric and obturator arteries, on its inner side the ob- turator artery, below it the bone. The only safe plan of relieving the stricture, therefore, is to nick it slightly, to SPECIAL OPERATIONS. 435 the depth of one or two millimetres, at several points on its upper and inner borders. The coverings of the hernia are thin and composed of the skin, subcutaneous tissue, cribriform fascia sometimes, septum crurale, and perito- neum. The incision may be straight or curved, the convexity- directed downward and outward, or T-shaped, the hori- zontal branch being made along Poupart's ligament, the other passing directly downward over the saphenous open- ing, and should be made from without inward. The single vertical incision just to the inner side of the femoral vessels is the one usually employed. The underlying tissues must be divided, and the sac exposed or opened in the manner described under General Directions, and the seat of stricture sought for and divided according to the rules above laid down. The gut is then pulled down and examined, and if its condition is satisfactory it is returned and a radical cure performed. If not, it is resected or fastened in the wound. Femoral epiplocele is treated like the inguinal. Strangulated Umbilical Hernia. It is generally claimed that true umbilical hernia, that is, hernia through the um- bilical ring, is almost always congenital, and that the hernias which occur during adult life emerge, not through the ring, but through an accidental opening in the linea alba near it, and therefore deserve the name of peri-umbilical given them by Gosseliu. While this condition, that is, of escape through a chance opening in the linea alba, may exist in some cases, Richet 1 has sought to prove by anatomical considerations and by the results of the examination of three cases of hernia, that true umbilical hernia, on the con- trary, is the rule, and the other is the exception. He shows that the weak point of the ring is its upper portion, and that when the cicatrix is pressed downward and given a semicircular form by the hernia, a complete ring, which seems to be situated above that corresponding to the vein and arteries, is constituted by the cicatrix below and the upper part of the opening above, and exactly resembles a distended accidental perforation. 1 Anatoinie Medico-Chirurgicale, Part II. p. 37S. 436 OPERATIVE SURGERY. The peritoneum is much more adherent to the abdominal wall in the umbilical than it is in the inguinal region, and, consequently, the sac of a hernia, being formed by the dis- tention of a small portion of peritoneum, is exceedingly thin, in fact its existence has been denied. The coverings of the hernia are the skin, cellular tissue, and peritoneum ; its contents are the small intestine, sometimes the transverse colon, and in the adult the omentum. On account of the pathological changes which take place in the sac and its contents, it is best to undertake a formal laparotomy if the hernia is strangulated or irreducible. An incision is made gently curving outward around one side of the base of the hernial tumor, and prolonged a couple of inches above and below it in the median line. The in- cision is deepened layer by layer and the peritoneum opened in the median line above and below the neck of the hernial sac, and in the intermediate space divided on the finger as a guide, in the line of the cutaneous incision close outside the neck of the sac, sparing the margin of the rectus mus- cle as much as possible. A sponge protective packing is placed on the surrounding viscera, and an incision is made through the neck and body of the sac, including the over- lying skin, at right angles to the centre of the curved incision around the base of the hernial tumor, exposing the hernial contents without damaging them. The constriction is thus relieved, and the dissection is continued till the hernial contents are freed from adhesions to each other and the sac. If they consist of omentum alone, the excess is excised on the proximal side of the strangulation and the abdominal wound treated as described below. If of intestine, the gut is surrounded by warm cloths or placed in the abdomen on the sponge protectives. Then the hernial sac, together with the overlying skin and the umbilicus, is excised with division of the peritoneum close around the neck of the sac. The intestine is next inspected, and if gangrene is present the gut is resected or left outside the partially closed ab- dominal wound for the slough to separate. A couple of Lembert sutures, or a stout silk loop through the mes- entery, serve to retain the healthy part above and below the damaged area in the margins of the wound. SPECIAL OPERATIONS. 437 If the gut is healthy, after excision of the excess of omentum and of the sac with its overlying skin and umbilicus, the sponge protective packiug is removed, the edges of the sheaths of the recti muscles are freshened, and the abdominal wound closed in the usual way with close approximation of the recti. The wound is then dressed in the ordinary manner. Strangulated Obturator Hernia. A long incision is made parallel to the femoral vessels and about an inch away from them on the inner side. Tlie pectineus muscle is exposed and divided, as are also any fibres of the obturator externus whose division may be necessary to give access to the seat of the stricture. The relations of the artery and nerve to the neck of the sac must be determined, and the division made in such a direction that they will not be injured. If the gut can be returned into the abdomen a radical cure can then be attempted. This consists simply in isola- tion of the sac, its ligation as high as possible after reduc- tion of the hernia, excision of the distal portion, closure of the orifice with silkworm-gut, and suture of the wound in the overlying soft parts. The same may be said of hernia occurring in such unusual localities as Petit's triangle, the great sacrosciatic foramen, etc. If the gut is gangrenous it must be fastened in the wound as in enterostomy or resected, provided the condition of the patient permits. RADICAL CURE OF INGUINAL HERNIA. Czemy's Operation} An incision is made three or four inches long over the inguinal canal and upper end of the hernial sac, with its centre opposite the external abdominal ring. The aponeurosis of the external oblique muscle and the sac are exposed, and the neck of the latter dissected free from the surrounding parts. This is most easily done after the body of the sac has been opened and the hernial • Wien. med. Woch., 1877, No. 21. 438 OPERATIVE SURGERY. contents freed from adhesions and reduced, and one finger passed through the interior of the neck of the sac to make it tense and serve as a guide in the dissection. The neck of the sac is drawn down and tied off as high up as possible or at the internal abdominal ring, with a stout catgut ligature, which is drawn tight over the tip of the finger placed inside the neck to prevent prolapse of the hernia and its inclusion in the ligature. Czerny drew the serous surface together by a continuous (purse-string) silk suture passed from the inside. The sac distal to the liga- ture is excised, though any part or the whole of it can be left undisturbed if it seem advisable. The sides of the opening in the abdominal wall are drawn together with catgut or silkworm-gut sutures passed through all the layers between the skin and peritoneum, and closed over the cord, which is left to emerge through as small an opening as possible at the lower angle of the suture line. The skin wound is closed with interrupted fine silk sutures, and if it seem necessary a strip of rubber tissue is placed in the lower angle of the wound for drainage. Ball 1 applied torsion to the sac and its neck before li- gating and excising the distal portion. Barker 2 dissects out and divides the neck of the sac, transfixes and ties it off with a silk ligature, and then uses the long ends of the latter as a suture to close the internal riug and overlying wound. He does not remove the body of the sac. The rest of the wound is closed by both as in Czerny's opera- tion. Macewen 3 dissects out the sac, its neck, and the immediately adjoining peritoneum. He then inverts and reinverts the apex of the sac into its neck, transfixes and ties together with a firm catgut or silk ligature the mass thus formed and fastens it on the inner surface of the internal abdominal ring. The latter is closed by suturing the conjoined tendon to the inner surface of Poupart's ligament. The external ring is narrowed as much as pos- sible by silkworm-gut stitches and the cutaneous wound united over it. 1 Brit. Mud. Jour., 1W7, ii. p. 1272. a [bid. p. L208. :: Ibid. p. 1268. SPECIAL OPERATIONS. 439 The main feature of the last three operations is the attempt to obliterate the funnel-shaped depression leading into the neck of the hernial sac and to substitute at this point an elevation. Kocher's 1 method has yielded excellent results, and is as follows : An incision three or four inches long is made in the long axis of the hernial tumor ; its centre is over the external ring ; ouly the skin and subcutaneous tissue are divided ; none of the external oblique muscle is cut. After dissecting out the body and neck of the sac up to the internal abdominal ring and reducing the hernia, a finger is passed up the inguinal canal and on its tip as a director an artery clamp is forced through the external and internal oblique and transversalis muscles at a point about half an inch to the outer side of the internal ring. With- out removing it from the puncture the clamp is passed on down the inguinal canal and made to seize the apex of the sac, which is then drawn up and pulled through the punc- ture and twisted into a round cord. The latter is laid upon the outer surface of the external oblique and lower down in the inguinal canal and secured there by five or six su- tures passed through all the structures (except the skin, subcutaneous tissue, and peritoneum) on each side of the inguinal canal. The last one or two sutures through the extremity of the twisted sac and the pillars of the external ring draw the latter tog-ether. The cutaneous wound is then closed and dressed antiseptically. Bassini's Operation. 2 An incision three or four inches long is made from the level of the upper part ot the inter- nal abdominal ring obliquely downward over the long axis of the hernial tumor. The aponeurosis of the external oblique muscle is exposed and divided from the upper border of the internal abdominal ring over the whole length of the inguinal canal, and the neck of the hernial sac iso- lated from the cord and surrounding parts. (Fig. 231.) The body of the sac is nicked and opened sufficiently to free its contents from possible adhesions, and to permit reduction of the hernia by a finger passed through the 1 Annals Surg., 1892, vol. 16, p. 505. 2 Centralb. f. Chir., 1890, vol. 40, p. 429. 440 OPERATIVE SURGERY. interior of the neck of the sac to its abdominal orifice. The neck is then drawn down, dissected free^ and encircled or transfixed as high up as possible by a stout catgut lig- ature, which is drawn tight over the tip of the finger still Fig. 231. A, A, A. Subcutaneous cellular tissue. E. Spermatic cord. B, C. Aponeurosis of external oblique divided and turned back. Q. Epigastric vessels. F. Internal oblique and transversalis muscles and vertical fascia of Cooper. kept inside the neck of the sac to prevent the prolapse of any viscus and its inclusion in the ligature. The lower portion of the sac is then dissected out and excised. The margins of the wound, including the divided apo- neurosis of the external oblique muscle, arc well retracted, and on the outer side of the internal abdominal ring and SPECIAL OPERATIONS. 441 inguinal canal, the upper border of Poupart's ligament is exposed, and on the inner side the conjoined edge of the internal oblique and transversalis muscles and the trans- versalis fascia. After raising the cord these structures on the inner side of the internal abdominal ring and inguinal canal are united beneath the cord to Poupart's ligament Fig. 232. Suture of the conjoined tendon and transversalis fascia (F) to the posterior border of Poupart's ligament (D). E. The cord. B, C. Aponeurosis of the external oblique. by interrupted silkworm-gut sutures extending upward from the crest of the pubes till onty enough space in the upper and outer part of the internal abdominal ring is left for the cord to pass without undue compression. The lower two sutures should include the outer border of the rectus muscle. (Fig. 232.) 442 OPERATIVE SURGERY. The cord is then placed on this new posterior wall of the inguinal canal and the divided aponeurosis of the external oblique muscle united over it by interrupted silkworm-gut sutures, leaving as small an aperture as possible at the lower angle for the cord to emerge. (Fig. 233.) The skin Fig. 233. \ I Suture of the divided aponeurosis of the external oblique (B, C) over the spermatic cord (E). wound is sutured with interrupted silk and dressed anti- septically without drainage, and in children it is wise to add a plaster-of-Paris spica. Bassini uses silk for the buried sutures and forms the new internal abdominal ring about half an inch to the inner side of the anterior superior spine of the ilium; that is, he divides the internal oblique and transversalis muscles above and to the outer side of the internal abdominal ring, trans- SPECIAL OPERATIONS. 443 plants the cord to the outer extremity of this incision, fastens the internal oblique aud trausversalis under it and the external oblique over it. If the hernia is complicated by undescended testicle Bassini unfolds the vas deferens by a careful dissection and brings the testicle down from the inguinal canal and sutures it to the bottom of the scrotum. If this is impossible castration is performed. Lauenstein places the testicle in the abdomen along with the stump of the sac. In congenital hernia enough of the fundus of the sac is left to form a tunica vaginalis. Fig. 234. Fig. 235. Fig. 236. Method of tying off omentum in sections. In direct inguinal hernia the orifice of the hernia is formed by the external abdominal ring, the neck of the sac is short and passes over the cord and lies to the inner side of the deep epigastric artery. As the hernia in- creases in size the neck of the sac comes to overlap the artery, aud thus in time may pass on both sides of it and contain the artery. After tying off the neck of the sac of a direct inguinal hernia, the parts on the inner side of the abdominal orifice, between the peritoneum and external oblique tendon, are sutured, as in the indirect variety, to Poupart's ligament. 444 OPERATIVE SURGERY. If the hernia is an epiplocele the excess of omentum is tied off with stout catgut close to the neck of the sac aud excised. If it is very large, the pedicle should be spread out and tied in sections, as illustrated in Figs. 234, 235, 236. Halsted's operation 1 is as follows : The aponeurosis of the external oblique and the external abdominal ring are exposed by an incision starting some 5 centimetres above and external to the internal ring and extending to the spine of the pubes. In this line the aponeurosis of the exter- nal oblique and the fibres of the internal oblique and trans- versalis muscles and the transversalis fascia are cut from the external ring to a poiut about 2 centimetres above and ex- ternal to the internal ring. The peritoneum and neck of sac are thus exposed, the latter opened, the hernia reduced, and the neck of the sac ligated or sutured and the distal portion excised. The cord is then isolated, and, after remov- ing all but one or two of its veins, it is transplanted to the outer angle of the incision. Beneath it mattress sutures are passed : on the inner side through the aponeurosis of the external oblique, the internal oblique and transversalis muscles, and transversalis fascia ; on the outer side through the aponeurosis of the external oblique, Poupart's ligament, and the transversalis fascia. This obliterates the canal and places the cord on the outer surface of the external oblique aponeurosis, where it is covered by skin and subcutaneous tissue only. The cutaneous wound is then closed by super- ficial sutures and dressed antiseptically without drainage. m'burney's operation. 2 . The incision, division of the aponeurosis of the external oblique muscle, and the treatment of the sac are the same as in Bassini's operation. Sutures are then passed through the skin, the aponeurosis of the external oblique (including the inner pillar of the external ring), and the conjoined tendon firmly binding i Annals of Surgery, 1803, vol 17, p. 542. 2 New York Medical Record, 1889, vol. 35, p. 312. SPECIAL OPERATIONS. 445 these structures together with deep inversion of the skin. Od the opposite side of the wound the skiu is inverted and sutured to Poupart's ligament, including at the lower part the outer pillar of the external ring ; the lower angle of the wound is sutured with silk over the cord and drawn together above with two or more tension sutures passed through the skin and superficial fascia and tied over pledgets of iodoform gauze. The space of about one-fifth of an inch left between the lips of the wound is packed snugly with iodoform gauze down to the peritoneum to in- sure healing by granulation and the obliteration of the inguinal canal by dense cicatricial tissue. This operation was at first extensively used, but of late has largely yielded place to Bassini's ; it is, however, a safer and surer opera- tion for the less experienced. Radical (Jure of Umbilical Hernia. If the hernia is irreducible, the treatment is the same as that described for strangulated umbilical hernia. If reducible, an incision is made which encircles the base of the hernial tumor, extending an inch or two above and below it in the median line, and deepened layer by layer till the abdominal cavity is opened at one extremity of the incision. A flat sponge is inserted, and on the finger as a guide the peritoneum is divided in the line of the cuta- neous incision around the neck of the sac, and the latter excised together with the body of the sac, the overlying skin, and the umbilicus. The peritoneum is then sutured with catgut, the sponge being removed before the last stitch is tied ; the edges of the sheaths of the separated recti muscles are freshened throughout the whole length of the wound, and the recti closely approximated with interrupted catgut or silkworm-gut sutures. Over this the super- ficial fascia and skiu are united with silk after excision of any redundant portions. Radical Cure of Femoral Hernia. Starting from Pou- part's ligament a vertical incision some three or four inches long is made just to the inner side of the femoral vessels. It must be deepened carefully, as the coverings of the hernia may be very thin and consist only of skin and super- ficial fascia if the hernia has passed through the cribriform 20 446 OPERATIVE SURGERY. fascia. After exposing and opening the sac and returning the bowel or possibly excising the omentum, the neck of the sac is isolated and tied off high up with silk or stout catgut. Various procedures have been adopted for the succeed- ing steps in the operation. Billroth removed the portion of the sac distal to the ligature and sutured the middle third of Pou part's ligament to the fascia covering the ab- ductor muscles, or to that on the inner aspect of the femoral vessels. Berger united Poupart's ligament to the pubic por- tion of the fascia lata covering the pectineus muscle. A flap cut from the latter muscle has been turned up and fastened in the femoral ring. Macewen employs the same principle as for the cure of inguinal hernia (q. v.) ; i. e., the sac is folded into a pad and secured on the inner surface of the femoral ring, which is then drawn together with silk or silkworm-gut passed through the available soft parts adjoining its boundaries. Kocher exposes the sac and saphenous opening by a ver- tical incision, but does not divide the fascia lata overlying the canal ; the sac is then drawn through a puncture in Pou- part's ligament just over the canal, twisted, and its extremity brought down over the ligament into the canal again, and secured there by two or three silk sutures passed through it and Poupart's ligament and the pectineal fascia. After obliterating the track of the hernia by whatever method is adopted, the external wound is closed and dressed antiseptically. EECTUM. Anatomy. The rectum is from six to eight inches long, and for about its first three inches is covered by peritoneum and supplied with a mesorectum. In front the peritoneum descends to within about three inches, and behind about five inches from the anus. The second portion of the rec- tum is in relation in front, in the male, with the trigonum of the bladder, the vesiculae scminalcs, and the vasa defer- entia and the prostate, the posterior margin of which can normally be reached by the finger. In the female this SPECIAL OPERATIONS. 447 portion of the rectum is attached to the posterior vaginal wall. Below the prostate the levatores ani joiu the rectum from one aud a half to two iuches from the anus, at a point just above the internal sphincter. The superior hemor- rhoidal artery lies on the outer surface of the rectum be- hind, a little to the left of the middle line, till within about four inches of the anus. It then divides into its terminal branches, which have a longitudinal distribution between the mucous and muscular coats and communicate freely about the anus. The veins have a similar distribution, and communicate through the superior hemorrhoidal with the portal system, and through the middle and inferior hemorrhoidal with the internal iliac veins. The sphincter is supplied by the fourth sacral nerve. IMPERFORATE ANUS OR RECTUM. In order to understand their different congenital deform- ities, it is essential to bear in mind the manner in which the rectum and anus are developed. The rectum, like the rest of the intestine, is formed by the third blastodermic layer of the ovule, aud originally communicates with the pedicle of the allantoid vesicle, that which afterward becomes the bladder and the posterior portion of the urethra. The anus, on the other hand, is formed by a dimple in the outer blastodermic layer, the one which forms the epidermis. In the ordinary course of events the communication between the rectum and the bladder or urethra closes, and another forms between the rectum and anus by absorption of the layer of tissue between them. The malformations are the result of arrest of development of the colou, rectum, or anus, or of the persistence of the septum, and present several varieties. The first, and slightest, is not a true arrest of develop- ment, but a simple closure of the orifice of the anus by a tegumentary layer or by adhesion of its sides, the deep com- munication between it and the rectum being complete. 448 OPERATIVE SURGERY. This requires only separation of the adherent edges with a director, or division of the layer with a knife. 2. The rectum and anus maybe fully developed, but the thin membranous diaphragm between them may persist, like the hymen in the vagina. The treatment of this also is simple : crucial incision or large puncture of the mem- brane. 3. The anus may be entirely absent, while the rectum is normally developed ; the distance between the lower end of the latter and the surface being from half an inch to an inch. 4. The anal cul-de-sac being properly developed, the rectum or colon may terminate at any distance above it, or may even not exist at all, being represented by a fibrous cord extending from the ileo-csecal valve to the anus. 5. The arrest of development may involve both the anus and the rectum. 6. The rectum may open into the bladder, urethra, or vagina. It is often exceedingly difficult to determine the character of the malformation during life, and yet it is very important that this should be done, for if the imperviousness begins at a point too high up to be reached through the perineum, the only possibility of relief is in the establishment of an artificial anus in the lumbar or inguinal region. Depaul 1 says that when the obstruction begins at the ileo-csecal valve the transverse distention of the abdomen is much less than in rectal obstruction. If the surgeon decides to go in search of the blind end of the rectum and create an anus in the perineum, he must make an incision in the median line from the scrotum to the tip of the coccyx, after having previously introduced a sound into the bladder if the patient is a boy, or into the vagina if a girl. He then divides the tissues layer by layer in the line of the incision, feeling at each step for the dis- tended rectum, which can sometimes be seen and felt to bulge downward when the child strains or cries. Or an exploratory puncture may be made, and the needle or trocar used as a guide if the bowel is reached by it. i Bull, de la Soci6t6 de Chirurgie, 1877, p. 536. SPECIAL OPERATIONS. 449 The search for the bowel should be made in the direc- tion of the axis of the anal cul-de-sac, if the latter is suffi- ciently developed, and advantage taken of the fact pointed out by M. Forget, 1 that a fibrous cord, representing a rudi- mentary portion of the rectum, occupies more or less of the distance separating the two. If, on the contrary, the anus is lacking, the search must be made toward the con- cavity of the sacrum. Verneuil has proposed to excise the coccyx, so as to diminish the danger incurred during the search, but as this is followed by prolapse of the rectum it should be practised only when a simple incision has proved insufficient. When the end of the bowel is reached it must be seized with pronged forceps, or two stout ligatures must be passed through it, and it must be partly separated from the ad- joining tissues, drawn down, opened, and made fast to the integument or the margin of the anus. The anterior and posterior portions of the cutaneous incision must finally be closed by sutures. It would be perfectly proper when in doubt as to the presence or position of the rectum to open the abdomen in the median line or the left inguinal region, and then, after ascertaining the conditions, if necessary per- form a colotomy. When the rectum opens into the vagina it may be reached through a longitudinal or crucial incision in the perineum, separated from the vaginal wall with a knife or curved scissors, and drawn down and fastened as before. The former opening will then close spontaneously. PROLAPSE OF THE RECTUM. The mucous membrane of the rectum is very loosely attached to the muscular coat, and when the sphincter is relaxed or disabled prolapse may occur to a degree that requires operative interference. This interference may in- volve the mucous membrane alone, or it may also include the anus or the entire rectum. In the first case the indica- tion is to promote adhesions between the mucous and mus- 1 Buil. de la Societe de Chirurgie, 1863 and 1877. 450 OPERATIVE SURGERY. cular coats, or to remove portions that may be in excess ; in the second to narrow the anal orifice. The former is accomplished by making deep longitudinal incisions through the mucous membrane, or by pinchiug up folds at three or four different points and tying a strong ligature about each. The incisions are likely to give rise to severe hemorrhage, and consequently the method has falleu into disuse; the actual cautery, however, applied at points or iu lines, has been used as a substitute as follows : In a slight or partial prolapse the bowels are emptied in advance and the parts reduced and put on the stretch with the bivalve speculum. The poiut of a Paquelin cautery is drawn the whole length of the prolapse in four longi- tudinal lines about a quarter of an inch wide and equally distaut from each other, without destroying the entire thick- ness of the mucous membrane. To avoid penetrating two deeply Cripps advises that the cautery be used at a black heat only. If the skin about the anus is not touched the after- pain is slight. A tube reaching above the sphincter is in- serted to give exit to flatus, while the bowels are kept con- fined for several days. For several weeks thereafter the patient must defecate iu the recumbent positiou and avoid straining efforts, while the adhesions caused by the cauteri- zation become firm between the mucous and muscular coats. There are two methods of narrowing the anal orifice. Dupuytren pinched up with forceps several of the radiating folds of integument and cut them off with curved scissors, trusting to cicatricial retraction for the narrowing he de- sired. Robert made two incisions, extending from the extremi- ties of the transverse diameter of the anus to the tip of the coccyx, removed the skin, subcutaneous tissue, and portion of the sphincter contained within the V thus marked out, and brought the sides of the gap together with sutures. Rectopexy. In cases of extensive prolapse the rectum has been returned into the abdomen and secured in the concavity of the sacrum behind or to the abdominal wall in (rout or in the left inguinal region. For the first procedure an incision is made in the median line from just behind the anus to the tip of the coccyx, and deepened backward and upward till the concavity of the SPECIAL OPERATIONS. 451 sacrum is reached. A catgut suture is then passed through the fibrous tissue in front of this bone, and through the back of the rectum without entering its lumen, and the wound either closed immediately or after two or three days, during which it is lightly packed. To secure the rectum to the anterior abdominal wall, the peritoneal cavity is opened in the median line just above the pubes with every antiseptic precaution, and the gut secured at the peritoneal aspect of the wound, as in hyster- opexy, by a silk suture passed through the whole thick- ness of the abdominal wall, and the anterior longitudinal band of muscular fibres in the rectum. The lumen of the latter, of course, must not be entered. In the left inguinal region the abdomen is opened as for colotomy, and the upper end of the rectum fastened to the inner surface of the wound in a similar manner, or by a suture passed through the whole thickness of the mesorec- tum and parietal peritoneum. 1 Ablation. For pronounced cases with gangrene present or threatening Treves 2 divides the rectum circularly layer by layer at the muco- cutaneous junction, taking care to avoid injury to any small intestine which may have become herniated into the pouch formed by the prolapse. The cut edges of the skin and intestinal mucous membrane are then united with catgut. If the peritoneum is opened the wound must be immediately closed with Lembert sutures. Torsion. When the sphincter has been destroyed or removed Gerster 3 supplies a substitute by twisting the rec- tum on its long axis till its walls form a rather close spiral. After isolating some two to five inches of its lower end the gut is turned through about half a circle or more, and its free extremity sutured to the margin of the skin. Rectotomy. There is occasionally found, especially in women, a form of stricture occupyiug the lumen of the rectum like a thin perforated diaphragm, which is probably 1 Berg. Annals Surg., 1893, vol. xvii. p. 37?!. 2 Lancet, 1890, vol. i. p. 376. 3 Annals Surg., 1894, vol. xix. p. 612. 452 OPERATIVE SUBGEBY. the result of a partial persistence of the foetal membrane between the anal portion which is developed from below upward by the dimpling of the skin, and the rectal portion which comes down from above to meet it. For the treat- ment of this, after emptying the bowels, the sphincter is first very thoroughly dilated and then a blunt director is forced through the wall of the rectum in the posterior median line below the stricture and brought back into the rectum in the same line above it. By hooking the finger or a loop of stout wire over the point of the director the stricture can be drawn down within reach from the anus and divided layer by layer, and all bleeding points secured with ligatures. A drainage tube and light packing are passed through the anus to the point of division. Strictures more extensive than these, yet not suitable for excision, are divided with the kuife or cautery in the median line posteriorly carrying the division through the rectal wall below the stricture, and the sphincter toward the coccyx, to secure the most perfect drainage possible. A tube and packing are placed in the incision. FISTULA. After thoroughly dilating the sphincter a blunt director is passed from without till its point is felt within the rec- tum, or if no aperture exists it is thrust through the mu- cous membrane where the least tissue intervenes. The point is then pulled down out of the rectum, or, if this is impossible, the anus is held open with a speculum, and the parts on the director divided at right angles to the anal margin. If there is no external orifice, the director is bent to a sharp angle and passed with the assistance of the speculum from the internal opening, the skin incised on its point and the parts on the director cut as before. Sinuses in all directions must be slit up and granulations scraped away. Multiple fistnhe should be opened into each other if possible, and if more than a single complete division of the sphincter is necessary one division should be allowed to lical before the next is made. In women the sphincter decussates in front with the sphincter vaginae and cannot SPECIAL OPERATIONS. 453 be completely divided at this point without considerable loss of power. HEMORRHOIDS. Ligation. Concerning the treatment of hemorrhoids by ligation there are a few points which deserve mention. The sphincter should be temporarily paralyzed by forcible dila- tation. Every pile that is more than half an inch in diameter must be transfixed by a needle carrying a double ligature, and then strangulated by tying it at its base; the smaller piles do not need to be transfixed, it is sufficient to throw a single ligature about each. When the tegumentary margin is to be included in the ligature it should be cut through it with scissors. The ends of the ligatures should not be cut off as soon as they are tied, but after three or four have been placed at opposite points of the circum- ference, it will be found easy to get an excellent view of the interior by drawing them outward and apart. The tem- porary paralysis of the sphincter not only facilitates the examination and operation, but it spares the patient pain during convalescence. Whitehead's Operation. 1 The sphincter is well dilated, and the mucous membrane starting posteriorly is divided at its junction with the skin by blunt-pointed scissors around the entire circumference of the bowel. It is dissected up with the dilated veins to the internal sphincter, or till all the pile-bearing mucous membrane is drawn outside of the anus. The mucous membrane is then divided transversely by short snips of the scissors close to its still attached upper border, and each part as it is cut sutured to the edge of the skin. The vessels are secured as they are divided. EXCISION OF THE ANUS AND PART OF THE RECTUM. This operation may be rendered necessary by disease otherwise incurable. The resulting condition is seldom satis- factory, owing to the loss of the sphincter if the anus is » British Medical Journal, 1887, vol. i. p. -M9. 20* 454 OPERATIVE SURGERY. excised, and its almost certain paralysis from injury to the nerves during the manipulation, if the anus is left. It must be remembered that the peritoneum descends upon the anterior surface of the rectum to within about an inch of the prostate, but not quite so far upon the sides or be- hind ; its average distance from the anus is from two to two and one-half inches in front and five inches behind. If the upper limit of the tumor on the posterior side can- not be reached by the end of the finger introduced through the anus, its removal should not be attempted from below. The nature and extent of its connections with the impor- tant organs on the anterior surface must also, of course, be carefully determined. A. Removal from below of the Anus and Part of the Rectum. Two curved incisions, meeting in front and be- hind in the median line, are made through the skin, one on each side of the anus, and at a distance of about one inch from it. They are carried down to the rectum, remaining, of course, external to the neoplasm if it has broken through the rectal wall, and the rectum is then dissected upward as far as necessary, using the fingers instead of the knife for this purpose whenever possible. A sound should be introduced into the bladder as a guide if the patient is a man, and a finger into the vagina if the patieut is a woman. When the upper limit of the tumor is reached, the rectum is drawn well down, its posterior wall divided longitudinally, and the diseased portion removed. If the disease extends upward more than one and a half inches, it is advisable to prolong the incision backward to the tip of the coccyx, and perhaps even along the side of this bone. Velpeau took the precaution to pass a number of threads through the intestine above the proposed line of excision, bringing them out through the skin beyond the external limits of the disease. After the removal of the tumor, he had only to tighten and tie these threads to bring the edges of the incisions through the intestine and the skin together. Richard Volkmann 1 has modified this operation somewhat 1 (Jeber den Mastdarmkrebs und 'lie Exstlrpatio recti in Kliuischer Viirtrage, No. 131 (Chirurgie, No. 42), p. 1113, 13th March, 1878. SPECIAL OPERATIONS. 455 and claims that by thorough drainage and the strictest attention to disinfection of the wound during and after the operation, excision of the rectum can be carried to a very considerable height, and even the peritoneal cavity opened, without danger to the patient. He empties the bowel thoroughly, makes a circular incision about the anus, a straight one in the median line back from the circular one to the coccyx, and, if necessary, another in the median line of the perineum ; the bowel itself must not be cut into. He then draws the rectum down, dissects it out circularly to the necessary height, passes ligatures through the healthy portion after Velpeau's plan, and cuts off the lower portion containing the tumor. Bleeding points are temporarily se- cured by self-retaining forceps, and afterward with catgut. If the peritoneal cavity is opened, a sponge soaked in a salicylic acid or thymol solution is kept pressed against the opening, until the excision is completed ; then if the open- ing is small its edges are drawn out with artery forceps, and a ligature thrown around it as if it was a vessel ; if it is large, it is closed with catgut sutures. The upper end of the gut is then drawn down and fast- ened to the skin very accurately with alternate deep and superficial sutures, two or three drainage tubes are inserted, cut off close to the surface, and stitched fast. During the operation, the bleeding surface is constantly protected against infection by irrigation with an antiseptic solution, and for the first three or four days constant anti- septic irrigation is kept up through a tube passed well into the wound near one of the drainage tubes ; daily antiseptic injections are afterward made through the drainage tubes until the wound has healed. Volkmann claims that these precautious strictly carried out insure the patient against the chief danger of the ope- ration, that of exciting diffuse pelvic cellular inflammation, which spreads rapidly upward behind the peritoneum, and causes death by septic peritonitis. Although the bleeding during the operation is very severe, he has never known it to have fatal consequences. He thinks, also, that cancer is much less likely to return locally after excision of the anus than it is when the sphinc- ters are preserved, aud, therefore, he prefers total excision 456 OPERA TIVE S UB GEE Y. of the anus and of the rectum to the upper limit of the disease, even when the anus itself is not involved. I must add that the best result in my experience or ob- servation freedom from recurrence that has now lasted for seven years, followed removal of the tumor alone, a mass two and a half inches in diameter on the posterior wall of the rectum, and beginning one and a half inches above the anus. After dilatation of the sphincter I made an incision through it in the posterior median line up to the tumor, and cut the latter out with scissors, keeping one-third inch from it all around. The bleeding was free, but the vessels were readily secured. The sides of the gap were drawn to- gether in the form of -)-, the longitudinal incision closed with sutures, and a drainage tube placed behind the bowel and brought out at the posterior angle of the incision. B. Resection of the Rectum from below, leaving the Sphincter. After thoroughly emptying the bowels in ad- vance the patient is placed in the lithotomy position, or on the side with the hips and knees flexed. An incision is made in the median line posteriorly through the anus and rectal wall below the disease, and carried to the coccyx. With a sound in the urethra or finger in the vagina, another incision in the median line in front is carried through the anus and lower healthy rectal wall into the perineum. The buttocks are separated and the lips of these incisions drawn apart with blunt retractors. The sound rectum is then divided transversely below the disease and above the sphincter by lateral incisions joining the upper extremities of the incisions through its anterior and posterior walls. By working with the fingers and blunt-pointed scissors from within outward through the transverse incisions in the rectal wall, the diseased rectum above is separated all around on its outer surface from the surrounding tissues and drawn down. The vessels are tied as they are cut, but if the dissection is made mostly by tearing with the fingers the greater part of the hemorrhage can be arrested by pressure. A temporary suture with the ends left long is then passed through the anterior and posterior walls of the rectum above to prevent its retraction, while the diseased part is excised by a transverse division SPECIAL OPERATIONS. 457 of the bowel in the healthy tissue below the retention sutures. The cut euds of the rectum are united all around by in- terrupted sutures passed with a sharply curved needle, and then the incisions in its anterior and posterior walls. A large drainage tube surrouuded by light packing and reach- ing above the point of division is placed in the rectum, the wounds in the perineum and behind, including the sphincter, are closed with deep sutures and a drainage tube placed in the lower angle of each. C. ITueter's Operation by a Perineal Flap. (Fig. 237.) The patient occupies the lithotomy position and a sound is introduced into the urethra. A flap, including the anus and adjoining part of the perineum, is marked out of an inverted U-shape, having the anus a little in front of the centre of the base, which is posterior. To form this an Fig. 237 Resection of the rectum, showing Hueter's curved incision. The straight incision is that for posterior rectotomy. incision is made through the skin and subcutaneous tissue, starting at the level of the posterior end of the tuber ischii outside of the outer border of the sphincter ani, pass- ing forward aud crossing the perineum close to the poste- rior insertion of the scrotum, then backward to terminate on the other side of the anus outside the sphincter opposite the starting point. The incision is deepened, aud anteriorly 458 OPERATIVE SURGERY. in the bend of the U, the junction of the accelerator urinee with the compressor urethra? muscles cut through, and the flap including the sphincter ani turned down. Working in from in front the rectum is isolated on all sides and the diseased portion excised by transverse division of the bowel through healthy tissue above and below the disease. The bleeding in this large wound is stopped by ligation or pressure. The cut ends of the rectum are brought together all around with sutures, and the flap replaced, with a drain and light packing in each lower augle. A tube and pack- ing reaching above the line of division is then inserted through the anus. The mucous membrane might first be united by a separate row of sutures not entering the mus- cular coat, which is afterward brought together by sutures of catgut penetrating the muscular coat alone, so as to bring the suture line in the mucosa below that in the mus- cularis and thus make communication less easy for the feces from the interior of the bowel to the perirectal tissue. Zuckerkandl's method for reaching the seminal vesicles (q. v.) is very similar to this operation. D. Resection of the Rectum from behind (Kraske's Operation) with Removal of the Coccyx and part of the Sacrum. 1 The patient is placed on the right side and an incision is made in the median liue from the middle of the sacrum to the anus and carried down to the bone. The fibres of the gluteus are detached from the lower part of the left half of the sacrum and from the coccyx, and the latter bone removed. The left side of the incision is then drawn forcibly aside and the greater and lesser sacrosciatic ligaments successively divided close to their attachment to the sacrum. This gives access to a large portion of the rectum, but if more room is desired it can be obtained by chiselling away the lower left part of the sacrum below the third sacral foramen and including the fourth without opening the sacral canal. The anterior branches of the fourth and fifth sacral nerves are necessarily divided in this procedure. 1 Arch. f. kiln. Chlr., 1886, vol. xxxiii. p. 56G. For a review oi this operation and its modilications, see Frank : Wien. klin. Woch., 1891, vol. iv. p. 800. SPECIAL OPERATIONS. 459 The posterior branches and the fifth nerve are of no im- portance, but the nerve-supply of the levator ani, coccygeus, and sphincter ani on the left side is of course cut off. Fig. 238. JDpper half of fifth i-, posterior sacral foramen. Resection of the rectum from behind. A, B. Portion of the sacrum removed in Kraske's operation. A, C. Hochenegg's modification. Hochenegg's modification of the bone removal is repre- sented in Fig. 238. Bardenheuer still further modified it by the removal of all the sacrum below the third sacral canal, which destroys 460 OPERATIVE SUEGEBY. the possibility of subsequent restoration of the function of the sphincter. The rectum is now freed by division of the connective tissue binding it to the sacrum, and drawn downward so far as may be necessary to bring the subsequently cut ends of the gut into apposition without undue tension on the sutures. To give more room and greater protection to the important male organs lying close in front of the rectum, the sphincter and rectal wall from the anus up to the tumor can be cut posteriorly in the median line; but it is not always necessary. The growth is then freed by the finger and blunt- pointed scissors from its lateral and anterior connections and ex- cised with a margin of healthy tissue, by transverse divi- sion of the rectum above and below. If the relations of the tumor make it necessary, the peri- toneal cavity must be opened and involved portions of the peritoneum, together with any glands which can be felt, removed with the tumor. The peritoneum is then drawn together with fine catgut sutures and secured against infec- tion by an iodoform-gauze packing. The anterior half of the divided bowel is united by silk sutures through its mucous and muscular coats, while the posterior half is left open and, if possible, sutured to the skin at the margins of the wound ; it can afterward be closed by a secondary oper- ation. If the anus and adjacent rectal wall have been split pos- teriorly, the rectal part of the wound is closed by inter- rupted catgut sutures and the sphincter drawn together by deep silk or silver-wire sutures passed in the manner described for restoring a completely ruptured perineum. The overlying parts and the upper and lower angles of the posterior wound are drawn together with silk sutures, and a drainage-tube and packing placed in each angle. The centre of the wound, with the open half of the rectum, is packed and a drainage tube passed into the bowel above. Afterward the patient will have to be kept on a water-bed. A colotoray performed a week or two before this oper- ation is of great assistance in keeping the wound aseptic and avoiding the very frequent and early dressings other- wise necessary. SPECIAL OPERATIONS. 461 Heineke recommends an L-shaped incision from the anus to the coccyx, then along the left border of the sacrum up to the fourth sacral foramen, and then transversely to the right border of the sacrum. The bone is chiselled through in this line aud the soft part of the flap turned down and to the right. Rydygier dispenses with the transverse incision in the skin. Levy divides the sacrum transversely a finger's breadth above its lower extremity, and from each end of the trans- verse incision carries one downward toward the ischial tuberosities, the soft parts attached to the side of the sacrum below its point of transverse division are cut, and the bone- and-skin flap turned down. Hegar employs a V-shaped incision starting at the pos- terior inferior spines of the ilia and following the sides of the sacrum to the tip of the coccyx. The periosteum is separated from the anterior surface of these bones ; the sacrum sawed transversely and turned up. Almost any of these methods of operation gives access to the female pelvic organs. LIVER. Anatomy. The level of the upper surface of the liver is indicated by a line drawn through the fifth chondro sternal articulation on the right side and through the sixth on the left. It is uncovered by the ribs where it crosses the sub- costal angle, from the ninth right to the eighth left costal cartilage. The left lobe extends one and a half to two inches beyond the left margin of the sternum. The lung descends over the upper surface of the diaphragm and liver on the right side to the lower border of the sixth rib in the mammary line, in the mid-axillary line to the upper border of the eighth rib, and in the scapular line to the upper border of the tenth rib. The pleura descends about half an inch lower, following the costo-chondral junction, or the bony extremities of the ribs, aud the lower border of the eleventh rib. As the twelfth rib is sometimes very short, it may be overlooked. Therefore the ribs should be counted, and the lower edge of the pleura will be found 462 OPERATIVE SURGERY. passing horizontally from the lower border of the twelfth dorsal vertebra to the lower border of the eleventh rib. The gall-bladder is about four inches long and an inch wide, and normally holds about au ounce. Its fundus touches the abdominal wall immediately below the ninth costal cartilage near the outer border of the right rectus muscle. The cystic duct is about an inch long, and the common duct three inches long. The latter descends in the right border of the lesser omentum behind the first portion of the duodenum, in front of the portal vein and to the right of the hepatic artery ; it then passes between the pancreas and duodenum, behind the pancreatico duodenal is artery, to empty into the middle of the inner side of the second portion of the duodenum. Abscess of the Liver. An incision, preferably longi- tudinal, three or four inches long is made over the most prominent part of the tumor below the ribs. The incision is deepened to the peritoneum, and if the liver is found adherent beneath this incision the abscess is simply in- cised for about an inch and drained with a large tube, and packing if necessary, bearing in mind the very friable character of the abscess-walls. If the liver is not adherent where the abdomen has been opened, but is found to be so at some other spot below the ribs, another incision is made through the parietes over this spot, and the abscess reached through the safely adherent area. The first in- cision, having served as a guide, is closed in the usual way and well protected from infection before the abscess is opened. If the abscess must be opened immediately, and there are no adhesions to the parietal peritoneum, a sponge pack- ing is inserted to protect the rest of the abdominal cavity, and the point of an exploring-needle buried in the liver. The piston is immediately withdrawn and the needle slowly pushed on in a straight line. By withdrawing the piston as soon as possible pus will flow into the cylinder when it is first reached, and by pushing the needle always in a straight line unnecessary and easily-inflicted damage to the gland is avoided. If the first exploration fail, the needle must be taken out and reinserted in different straight di- rections till pus is found. SPECIAL OPERATIONS. 463 With the needle as a guide, a knife is then passed through the liver-substance iuto the abscess-cavity, while the liver is kept in as close coutact with the abdominal wall as possible, rolliug the patient on oue side if neces- sary. The index-finger is quickly passed along the track of the knife and the opening enlarged to an inch or more and hooked up without force into the abdominal wound. Hemorrhage is controlled by packing. After the pus has been evacuated, the interior of the abscess-cavity is irri- gated with warm boiled water; its opening is then plugged with a sponge, and the parietal peritoneum and the skin around the margins of the abdominal wound are united with catgut. After removal of the protective packing from the abdomen the liver is fastened in the wound by interrupted catgut or fine silk sutures passed through its substance at a little distance outside of the abscess-opening, to shut off its communication with the general peritoneum. If the stitches show a tendency to tear out, sterilized gauze must be packed around the opening in the liver and the ends brought out of the abdominal wound. The sponge plug is then removed and a large drainage tube inserted. Immediately before incising the liver an attempt can be made to closely unite the parietal and vis- ceral peritoneum with catgut sutures around the proposed area of the incision. But the stitches may tear out or puncture and cause leakage from the abscess into the gen- eral peritoneal cavity. As the liver ascends and descends with respiration it cannot be fastened to the abdominal wall at a less distance than half an inch from the free border of the ribs and costal cartilages. Whenever there is time it is always best to secure firm adhesions of the liver to the parietes in the selected region before evacuating the pus. A longitudinal incision two or three inches long is carried down layer by layer and the peritoneum opened and the liver exposed. After carefully protecting the surrounding viscera with sponge, the pres- ence of pus is verified with a fine aspirating needle, and the point of puncture is then covered with an iodoform- gauze packing large enough to hold the margins of the abdominal wound apart and in contact with the liver. In addition, the parietal peritoneum and skin can be united 464 OPERATIVE SURGERY. with catgut around the margins of the incision. If omen- tum should happen to intervene between the liver and parietes it must be pushed aside. A fairly tight antiseptic dressing is applied, and in the course of two or three days adhesions will have shut off the abdominal cavity and the abscess can be safely opened without an anaesthetic. As before remarked, some surgeons supplement the pack- ing placed ou the exposed surface of the liver to cause its adhesion to the abdominal wall by sutures of catgut or fine silk passed with a curved needle deeply through the sub- stance of the liver and fastened in the margins of the abdominal incision. But they are unnecessary and dan- gerous from possible leakage of the abscess alongside the sutures. It is generally unwise to approach an abscess of the liver through the thoracic cavity ; but if unavoidable, the selected intercostal space should be enlarged by resection of a rib, and the layers of the parietal and diaphragmatic pleura carefully united with catgut sutures around the pro- posed line of drainage. The surface of the liver is then exposed by an incision through the diaphragm and the future drainage track packed with iodoform gauze till ad- hesions have formed. If the liver and diaphragm are already adherent, the abscess can be opened immediately, provided the pleural cavity is secured from infection. It is unsafe to aspirate a possible abscess of the liver through the unopened abdominal or thoracic wall. HYDATID CYST OF THE LIVER. The operative treatment of hydatid cyst of the liver is almost identical with that of abscess. After partial evacua- tion of its contents by a trocar and canula or aspirating needle the cyst wall can be more readily drawn into the abdominal wound and sutured there, and thus the rest of the abdominal cavity is more effectually protected than in the case of an abscess, and a cyst can be more safely opened immediately. SPECIAL OPERATIONS. 465 Cholecystostomy. (Fig. 239.) An incision three or four inches long is made vertically downward from the lower border of the liver opposite the tip of the cartilage of the tenth rib (Fig. 239), and deepened layer by layer and the peritoneum opened. If an extensive dissection or an opera- tion on the cystic or common duct is anticipated more room will be needed, and it is better to use an incision about four inches long, starting from the median line an inch below the ensiform process, extending obliquely downward and outward, and terminating horizontally (Fig. 239). If the liver is enlarged the oblique incision should follow a line -#^ Incisions for exposing'the gall-bladder. parallel to and just above its free border. When a dis- tended gall-bladder is encountered it is carefully surrounded with a protective sponge packing and enough fluid drawn off with an aspirator to allow the walls thus relaxed to be pinched up on each side of the needle by the fingers or padded forceps and drawn into the abdominal wound. Sponges are wedged arouud it to prevent leakage into the peritoneum, and the fluid is evacuated by a trocar and canula, or a knife plunged into the bladder wall at the point of puncture made by the needle. In selecting this point of puncture allowance must be made for retraction of a distended bladder. If the bladder is not distended irnme- 466 OPERATIVE SURGERY. diately after opening the abdomen a finger is passed along its inner surface following the cystic and common duct, to explore for the trouble as far as the intestine. A careful dissection with the finger nail and blunt-pointed scissors may be necessary to separate adhesions to surroundiug viscera and even to find the gall-bladder. After protecting the rest of the abdominal cavity with a sponge packing the fundus of the bladder is drawn as far as possible into the abdominal wound and opened enough to admit one finger. All stones are then gently scooped or irrigated out, the abdominal wound partially closed in the usual way, and the protective sponges removed. The gall- bladder is fastened in the opened part of the wound by a continuous silk suture passed through the skin, peritoneum, and the whole thickness of the bladder wall around the margin of the opening iu it. The suture line must be far enough away from the free border of the ribs to allow for the respiratory movements of the liver. Some operators precede the continuous suture through all coats of the bladder with interrupted sutures uniting its serous coat to the parietal peritoneum ; but this is unnecessary. A large rubber drainage tube is passed into the fistulous opening and an abundant absorbent dressing applied which will need frequent renewal. It is not advisable to close a wound of the gall bladder by the Czerny-Lembert method of suture and leave no communication with the abdominal incision. Operations Involving the Cydie or Common Bile Duct. (Fig. 229.) The oblique incision is used, or the vertical changed later if necessary into a crucial or J -shaped in- cision. After locating the stone by the exploring finger and protecting the rest of the abdomen by a sponge pack- ing, an attempt is made to manipulate the calculus back into the bladder or forward into the intestine, but with the recollection that the ducts are easily lacerated and very slightly distensible. If it seem feasible to reach the stone from the interior of the gall-bladder, this viscus is opened in the manner already described, and one of the specially devised cholelithotomy forceps used to clip or nibble the stone into fragments, SPECIAL OPERATIONS. 467 guided by the other hand in the abdomen. The operation is completed as described for cholecystostomy. On the same principle an impacted calculus has been crushed by padded forceps applied to the exterior of the duct, and has been broken by the point of an aspirating needle punc- turing the duct. Dr. McBurney extracted one after split- ting the distal portion of the duct through an opening made in the duodenum for the purpose. For a stone otherwise irremovable from the cystic duct cholecystectomy is pre- ferable to needling or crushing externally with padded for- ceps. But there must be no doubt about the patency of the common duct. For a calculus impacted below the cystic duct, the ob- lique abdominal incision is used and the surrounding viscera are well protected and retracted by a sponge packing. The duct is opened in its long axis over the stone sufficiently to extract the latter, and the opening then closed by inter- rupted Czerny-Lembert sutures, which is more possible than it sounds, owing to the generally increased thickness of the duct wall from the irritation caused by the presence of the calculus. A drainage tube and iodoform gauze packing is carried from the abdominal wound down to the neighbor- hood of the suture line and the abdominal wound partially closed in the usual way. If an opened gall bladder must be sutured in the abdomi- nal wound at the same time, its opening must be separated as far as possible from the drainage tube by intermediate suturing. CHOLECYSTENTEROSTOMY. This term is used to designate the establishment of a permanent fistulous communication between the gall blad- der and the intestine. The operation is designed to create a route by which the bile can pass into the intestine when the common duct is permanently obstructed, and when both the cystic and hepatic ducts are patent and communicate, and for some cases of persistent biliary fistula. The abdo- men is opened, preferably by the vertical incision, and a convenient loop of intestine as near the duodenum as pos- sible is isolated by iodoform-gauze bands tied around the 468 OPERATIVE SURGERY. gut above and below, and to this isolated loop the gall- bladder is sutured and the communication established in the same manner as described for intestinal anastomosis. The bladder is first emptied by an aspirating needle entered as near as possible to the site of the future fistula. A continuous fine silk suture is passed uniting the serous coats of the bladder and the intestine at the convex free border of the latter for a distance of about an inch and a half, and in front of this, as the parts lie exposed, a row of Lembert sutures is inserted. After carefully protecting the surrounding parts by a fresh sponge packing, the op- posing surfaces of the gall-bladder and intestine are opened longitudinally for about an inch close in front of the Lem- bert sutures, and the interior of each irrigated clean. The mucous membranes are united by a continuous fine silk or catgut suture, and a row of Lembert sutures continuous with those already in place completes the serous apposition all around. The gauze, constricting bauds, and sponges are removed and an iodoform-gauze packing placed around the suture line and the ends brought out of the abdominal wound, which is partially closed in the usual way. Murphy, of Chicago, 1 has invented a mechanical con- trivance called an "anastomosis button" for establishing a fistula between any of the hollow viscera without the em- ployment of sutures. It consists of two buttons which slide on a hollow cylinder, so arranged with a spring that the opposed margins of their concave surfaces are kept in contact and cause a pressure-necrosis of the visceral walls in their grasp, thus making a hole in the diameter of the button, which is later passed in the feces. However it may be criticised for other purposes, it seems a peculiarly valuable contrivance for performing cholecyst- enterostomy. The button can be made small enough to be easily passed off by the intestine, and at the same time leave a communication with the gall-bladder large enough to be useful in spite of any probable subsequent cicatricial contraction. The abdomen is opened by the vertical incision, the blad- der is aspirated, and a selected loop of intestine isolated as 1 New York Med. Rec, Dec. 10, 1892. SPECIAL OPERATIONS. 469 usual, and a protective sponge packing placed in the abdo- men. A "purse-string" suture of fine silk is passed through the serous coat of the bladder and intestine en- closing an area on each large enough to contain a slit the length of the diameter of the buttons. The buttons are inserted in the longitudinal slits then made in the bladder and gut, and the wounds are drawn tight around the central cylinder by tying the sutures. The buttons are simply pressed together, and the wounds, with the suture in each, are shut within the concavity bounded by the margins of the buttons holding the serous surfaces in apposition. The calculi are not disturbed, but left to be defecated with the button, and the abdominal wound is closed with- out drainage after removing the sponges. CHOLECYSTECTOMY. The abdomen is opened by the oblique incision and the gall-bladder surrounded with sponges. Starting at the fundus, an incision is made on each side of the bladder through the peritoneum at a little distance from the liver, and the bladder dissected out with blunt-pointed scissors as far as the cystic duct. The latter is divided between a double ligature of silk and the peritoneal flaps closed over the liver by a continuous catgut suture. The abdominal wound is partially closed around a tube, and light iodoform- gauze packing carried down to the former site of the gall- bladder. SPLEEN. Anatomy. The pedicle of the spleen will be formed by the gastro-splenic omentum passing from the hilum to the stomach and, continuous with this above, the suspensory ligament passing to the diaphragm. The splenic artery lies above the vein behind the upper border of the pan- creas. The gastro-splenic omentum contains its terminal five or six branches which arise at a variable distance from the spleen and may enter its hilum over a considerable area. Most of the vasa brevia arise from these and turn 21 470 OPERATIVE SURGERY. backward to the stomach, and near the termination of the main splenic artery the gastro-epiploica sinistra is given off. The venous branches correspond to the arterial. SPLENECTOMY. A vertical incision three or four inches long is made along the outer border of the left rectus muscle above the umbilicus, and the peritoneum opened. If the spleen has prolapsed into an already existing wound, the latter is simply enlarged as much as necessary. Adhesions are separated or divided between double catgut ligatures, and the tumor, which must be very gently handled, is fully ex- posed. After surrounding it with a sponge packing it is turned out of the abdominal wound, generally the lower end first. The abdominal opening should be made large enough to allow the tumor to pass without force, and the margins of the wound should be held back to avoid all traction on the pedicle. Startiug at its lower edge, suc- cessive pairs of artery clamps are applied to the pedicle in advance of the line of division which is then made be- tween them. The spleen is then removed and the vessels in the grasp of each clamp are ligated separately with silk. As each clamp is removed bleeding points are sought for and secured ; after this Greig Smith advises that the whole pedicle be sur- rounded by a ligature drawn moderately tight to lessen the arterial pressure distal to it on the ligatures of each vessel. The abdominal wound is then closed tight in the usual way. KIDNEY. Anatomy. The kidney lies imbedded in fatty tissue which is more abundant behind than in front, and from which it can be easily enucleated. Posteriorly the upper half rests against the diaphragm and the lower half upon the transversalis aponeurosis, and is crossed posteriorly by the last dorsal, the ilio-hypogastric, and ilio-inguinal nerves. In front, from above downward, the liver, duodenum, and SPECIAL OPERATIONS. 471 hepatic flexure of the colon are in contact with the right kidney ; the stomach with the spleen externally, the pan- creas, and descending colon are in relation with the anterior surface of the left kidney. Thus the colon generally lies vertically in front of a renal growth on the right side, and ou the left side crosses it obliquely from above downward and outward. The peritoneum over such a tumor can be divided on the outer side of the colon, but not on the inner, without interfering with the blood-supply of the bowel. The renal artery, which may divide into one or more branches before entering the hilum, subdivides into ter- minal branches, which are said commonly to lie in front of the veins. The renal vein subdivides earlier than the artery, and the left vein receives the left spermatic and left inferior phrenic veins which are within reach of injury during treatment of the renal pedicle. The vessels lie in front of the ureter, which terminates near the lower border of the kidney in its pelvis. The latter subdivides in the hilum into two or three short trunks (infundibula), which in turn subdivide into the calices opening over the papillae ; so that a finger cannot pass from the pelvis into the first subdivision and much less into the second or calices. As the twelfth rib may be rudimentary or absent the ribs should always be counted before a lumbar operation, in order to avoid the pleura, which is generally found to pass horizontally from the lower border of the twelfth dorsal vertebra to the lower border of the eleventh rib. EXPOSURE OF THE KIDNEY. Lumbar Methods. The patient lies upon the sound side with a sand-bag under the loin to widen the opposite ex- posed costo-iliac space. A. The longitudinal incision is made along the outer border of the muscular mass formed by the erector spina? and sacro-lumbalis, which is about two and a half to three inches from the vertebral spines, and it should extend through the skin from the eleventh rib to the iliac crest. 472 OPERATIVE SURGERY. (Fig. 240.) It is deepened through the middle layer of the lumbar fascia or the aponeurosis of the trausversalis, and the posterior surface of the quadratus lumborum is exposed. The outer border of the muscle is cleared and drawn toward the spine, and after retraction of the sides of the wound, the peri-renal fat can usually be seen through the thin ante- rior layer of the lumbar fascia, moving synchronously with respiration. Space can be advantageously gained by divid- ing the outer portion of the quadratus close to its attach- ment to the ilium. Fig. 240. Incisions for exposing the kidney. L. Longitudinal or vertical incision. T. Transverse incision. K. Konig's incision. On division of the thin intervening fascia the fatty cap- sule of the kidney is reached, and by tearing through it and stripping it toward the sides the posterior surface of the middle and lower portions of the kidney and its pelvis are exposed to sight and touch. At the outer border of the quadratus muscle the last dorsal, the ilio-hypogastric, and ilio-inguinal nerves will be encountered, and one or all may be divided if they cannot be sufficiently retracted. Some additional space can be gained by drawing the last rib forcibly upward with a blunt hook, which is safer than SPECIAL OPERATIONS. 473 resection of a portion of the twelfth and even the eleventh rib, as has been done in a few cases. If the pleural or peritoneal cavity is accidentally opened, the rent should be immediately closed with fine catgut sutures and protected by an iodoform-gauze packing. Except in persons who are very fat, this incision gives ample room for exploration, nephropexy, nephrotomy, and even for nephrectomy when the kidney is not very much enlarged. B. The transverse incision (Fig. 240, T) is begun just within the outer margin of the sacro-lumbalis, a little below the twelfth rib, and carried outward parallel to the rib for about four inches. The muscular and aponeurotic layers are successively divided after recognition, until the retro-peritoneal layer is reached, and the kidney exposed by division of its fatty capsule, as in the preceding descrip- tion. Additional space can be gained by a short longi- tudinal cut at the inner (vertebral) end of the main incision. This incision is advantageous in nephrectomy when the kidney is much enlarged, and whenever it may be necessary to insert a hand into the peritoneal cavity. C. The combined longitudinal and transverse incision consists of the longitudinal incision joined at any part by the transverse. D. Konig's incision 1 (Fig. 240, K). Starting from the last rib, the incision passes vertically downward along the outer border of the sacro-lumbalis and erector spinas, curves forward just above the highest part of the iliac crest, and passes horizontally toward the umbilicus to end at the outer border of the right rectus. The vertical part of the incision is deepened first and carried down layer by layer until the peritoneum is reached in front of the anterior layer of the lumbar fascia. After the fingers are placed in the lower angle of this wound to protect the peritoneum beneath the horizontal part, the latter is deepened through the succes- sive muscular layers until the peritoneum is exposed. It 1 Oeutralbl. f. Chir., 18S6, No. 35, p. 593. 474 OPERATIVE SURGERY. may often be advisable to make the vertical part of the incision run obliquely iuto the horizontal in the form of a flattened curve. This incision affords very free access to the kidney and a good part of the ureter, and the size of the wound does not materially add to the risks, but rather lessens them by the increased facility afforded for dealing with the pedicle or any complications. At the close of the operation the divided muscles in the horizontal and curved parts of the incision are united by deep sutures and heal readily, while the vertical part can be packed and drained if necessary. In any ordinary case the horizontal part of this incision need not be extended beyond the vertical prolongation of the anterior axillary line. Nephrotomy. The kidney is exposed by the lougitudiual lumbar incision, and if the abscess or cyst which has made the operation necessary is perfectly apparent it only remains to cut into the most prominent part of the diseased tissue with the knife or thermo-cautery. But if there is any doubt about the presence or location of the disease it must be sought by an aspirating needle passed through the convex border of the kidney and its track followed by a knife. A finger then plugs and enlarges this incision while, if necessary, an assistant makes counter-pressure through the anterior abdominal wall to lift the kidney into the in- cision ; then if the cavity is very irregular, or if there are separate pouches, the septa should be freely broken down to secure efficient drainage, and the interior of the cavity thoroughly scraped with a sharp spoon if its condition re- quires it. Occasionally it will be possible and desirable to draw the edges of the sac iuto the parietal wound and stitch them to the skin or deeper tissues. Rubber tubes packed around with iodoform gauze are passed into all parts of the abscess cavity for drainage, and into any spaces in the cellular tissue about the kidney which may have been opened up and infected. The extremities of the external wound are drawn to- gether with silk, and a large absorbent dressing applied. SPECIAL OPERATIONS. 475 Nephrolithotomy. After the kidney has been exposed, preferably by Konig's incision, which also gives access to the upper part of the ureter, the surgeon proceeds to seek for signs of the presence and location of a calculus ; the horizontal part of this incision should not be made at first of the full length, but later it is prolonged if found neces- sary. The posterior surface of the gland is freed and the kid- ney palpated between the thumb and finger and any click or spot of especial density noted. A fine needle is then passed systematically through the cortex or wall of the pelvis at intervals of half an inch, and not deeper than two and a half inches in a normal adult kidney, in order to avoid possible injury to the main vessels. Should this fail to detect the stone, some authors recommend that the finger should be introduced through an incision in the cortex and thus a thorough digital examination be made of the interior of the pelvis and calices. , If no stone is found the wound is closed with catgut sutures passed through the substance of the kidney, and the external wound is brought together around a drainage tube placed in contact with the renal wound. But unless the operator feels very sure of his diagnosis this method of exploration should not be carried out. When a stone is felt by the needle, an incision is made with the knife or thermo-cautery through the cortex longi- tudinally or in a liue radiating from the pelvis to the con- vex border. Unless it is very manifestly better to open the pelvis directly, an incision through the cortex is preferable to one through the walls of the pelvis on account of the less danger of a urinary fistula and troublesome hemorrhage. The latter can be readily checked by the pressure of the finger or by a catgut suture passed deeply through the renal substance. Through the opening thus made the stone is picked or scooped out. If it is large or branched it may have to be crushed witli a lithotrite or strong sequestrum forceps ; septa should be divided with blunt-pointed scissors ; occasionally stones have been encountered so large, or so numerous and difficult of removal, that nephrectomy has 476 OPERATIVE SURGERY. been considered wiser than nephrolithotomy. After re- moval of the stone the orifice of the ureter is sought and that canal explored to determine whether it is free or whether plugged by a stone or mass of fibrin. If such an obstruction is fouud it may be pushed back iuto the kidney, or washed out by a stream of water directed into the distended ureter through the renal wound, or perhaps pushed downward into the bladder. The stone or stones having been extracted from the kid- ney, the wound in its substance or in the pelvic wall is closed with catgut sutures unless there is so much sup- puration present that every facility must be given for the escape of pus. Sometimes the gland will have become a mere abscess cavity containing the stone. Rubber tubes and iodoform-gauze packing are placed in contact with the kidney wound or in its interior, as its condition may re- quire, and in the space possibly opened up behind it. A strip of gauze is carried down to the peritoneum beneath the curved part of the external wound, if Konig's incision has been used, and the wound closed with silk sutures up to the space where the drainage emerges. Lumbar Nephrectomy. The kidney is exposed by Konig's incision, but, if there is any doubt about its re- moval, it should first be explored by the longitudinal incision, and afterward a transverse incision of the neces- sary length can be added at any convenient part of the longitudinal. The length of the transverse or horizontal part of Konig's incision is regulated by the size of the tumor. If inflammation has not materially changed the tissues immediately surrounding the kidney, it is compara- tively easy, after reaching its posterior surface and tearing through the perirenal fat, to work the fingers in close con- tact with the capsule around the convex border and the two extremities and enucleate the kidney from its bed by separating all the attachments except the pedicle constituted by the renal vessels and the ureter. In cases of long-continued suppuration where every- thing has become matted together, as, for instance, after nephrotomy for abscess, it may be easier to open the capsule and separate the kidney from its interior. The manipula- SPECIAL OPERATIONS. 477 tions must be gentle and without undue traction on the pedicle, and if abnormal vessels are encountered at the extremities of the gland they should be divided between double catgut ligatures. After isolation of the pedicle it may be tied off in sections by silk ligatures passed on a large full curved aneurism pedicle needle ; occasionally the main artery can be recognized by sight or touch, and it is desirable that it, as well as the ureter, should receive a separate ligature whenever possible. If the pedicle cannot be isolated and brought into view or reached on account of the condition or situation of the adhesions, the entire pedicle can be tied en masse, preferably by the elastic liga- ture, which is drawn tight by the fingers in the depths of the wound and retained by a knot or stout clamp. The part of the kidney substance distal to the ligature is then cut away, leaving enough margin to prevent slipping of the ligature, and the large stump which sometimes re- mains when the adhesions to the anterior surface have been very extensive is scraped as much as is safe and the elastic ligature is left to slough out. Occasionally the pedicle may be secured by a long, strong clamp till the kidney is excised and then the pedicle is tied by one or more ligatures on the proximal side of the clamp. If the ureter has been separately divided it is well to close it with a ligature, and if necessary to disinfect the stump or fix it in the external wound. The pedicle is finally again inspected to avoid any chance of hemorrhage, and then after the insertion of rubber drainage tubes and iodoform-gauze packing the external wound is partially closed. During the course of a nephrectomy it may be necessary to enter the abdominal cavity ; this can be done through the anterior extremity of Konig's or of the trausverse in- cision ; the surrounding peritoneal cavity is protected by the usual sponge packing, and after removal of the latter at the close of the operation an iodoform-gauze packing is inserted unless there is a certainty of asepsis, in which case the peritoneum can be again closed tight. Abdominal Nephrectomy. The place of selection for the parietal incision is at the outer border of the rectus muscle, where it is sometimes called Langenbuch's incision. It 21* 478 OPERATIVE SURGERY. should not be less than four inches long, and should have its centre as nearly as possible opposite the centre of the tumor. The incision is sometimes made parallel to this, but further outward with the idea of making the operation wholly extra-peritoneal, and then it is only a modification of lumbar nephrectomy by the longitudinal incision. Sometimes the abdomen is opened in the median line. After division of the tissues in successive layers, including the peritoneum, the viscera are pushed aside and protected by flat spouges or brought out of the abdomen and wrapped in warm cloths. The peritoneum over nearly the whole length of the en- larged kidney is then incised longitudinally on the outer side of the colon in order not to interfere with the blood- supply of the latter. This must always be done in this way unless the size of the tumor and the position of the colon make it impracticable. Occasionally it is possible, as shown by Halsted, to attach the edges of the divided peri- toneum covering the kidney to those of the divided anterior parietal peritoneum, and thus entirely to shut off the gen- eral peritoneal cavity from the field of operation. By work- ing with the fingers or blunt-pointed scissors the peritoneum is stripped from the anterior surface of the gland and the structures at the hilum exposed. All vessels, as they are encountered, are secured in advance whenever possible and divided between double ligatures. It may even be advan- tageous to go directly to the artery through a special inci- sion in the peritoneum aud tie it as the first step in the operation. The ureter is then isolated between two liga- tures, and if extensively diseased it is brought out of the abdomen behind and fastened to the skin through the wound made in the loin for drainage; or if healthy the stump is simply disinfected and left. During the removal of the kidney every effort must be made to avoid infection of the peritoneal cavity by its con- tents or those of the ureter. After this the gap in the pos- terior parietal peritoneum may be rapidly closed with a continuous catgut suture, and lumbar drainage provided for the space formerly occupied by the kidney by the inser- tion of a rubber tube and gauze, if necessary, through a small incision made in the loin. The abdominal wound is SPECIAL OPERATIONS. 479 closed in the usual way, with or without drainage, accord- ing to the necessities of the case. The presence and condition of the other presumably sound kidney should always be ascertained as soon as the peritoneal cavity is opened iu abdominal nephrectomy. In cases of floating kidney in which the gland is fully pedunculated and invested by peritoneum, its removal will be conducted as in the case of auy other pedunculated ab- dominal tumor, without stripping off the peritoneum. Neurorrhaphy or Nephropexy. This is the operation by which an abnormally movable kidney is permanently fixed in its proper position by suturing it to the abdominal wall. The kidney is exposed by the longitudinal lumbar in- cision at the outer border of the sacro-lumbalis, and the fatty capsule divided longitudinally and stripped back from the surface of the kidney. Three or four stout catgut or silkworm-gut sutures are then passed with a curved needle from the anterior to the posterior surface, well within the convex border, at intervals of about half an inch, and then through the cut edge of the lumbar fascia in the inner lip of the wound, so that when tied they hold the kidney snugly up against the abdominal wall. The wound may then be closed for primary union, or packed with iodoform gauze to heal by granulation. Guyon sought to strengthen the cicatricial connection by removing a lung strip of the fibrous capsule ; and Sulzer 1 recommends that the capsule be split and reflected so as to form a flap which can be stitched in the parietal wound. UEETEE. Anatomy. 2, The ureter lies behind the peritoneum on the psoas muscle and genito-crural nerve in the upper part of its course, and is crossed from within outward by the sper- matic or ovarian vessels. As the ureters approach the pelvis they lie close to the spine between the psoas and the body of the vertebra, the right ureter being a little further out- 1 Deut. Zeit. f. Chir., vol. xxxi. 2 Cabot : American Journal of the Medical Sciences, 1892, vol. ciii. p. 43. 480 OPERATIVE SURGERY. ward than the left, owing to the interposition of the in- ferior vena cava, with which it is in close relationship. When the peritoneum in this region is stripped up from the parts beneath the ureter will always be found adhering to its under surface and on the left side, about half an inch to an inch outside of the point where the peritoneum be- comes attached to the spine ; on the right side the distance is slightly greater. The ureters cross the common or ex- ternal iliac vessels to enter the pelvis, where they lie pretty closely over the lateral edges of the sacrum. They then run in the recto- vesical fold of peritoneum to enter the base of the bladder at a distance of two inches from each other and pass for a half to three-quarters of an inch between the mucous and muscular coats of the viscus before termi- nating. The vas deferens is between the ureter and the bladder. The narrowest part of the canal is close to the bladder, and this region, which is the most difficult of access, is also the one where a calculus is most likely to lodge. In the female the ureter for the last two, and in some cases three, inches of its course, lies in the broad ligament in close relationship with the cervix and vault of the vagina, and it can be reached by an incision in the vault extending outward and backward within the layers of the broad liga- ment. Operations on the Ureter} Almost the only indications for operations upon the ureter are found in wounds of it or in the necessity for the removal of an impacted calculus. The ureter should always be opened extra-peritoneally for the removal of a stone, inasmuch as the wound cannot be satisfactorily closed with sutures, and it has been proven that at least a longitudinal wound will in time, if there is proper drainage, spontaneously close and allow the urine to pass in its natural channel. The ureter should generally first be explored through a median abdominal opening made below the umbilicus, and always thus explored if there is doubt about the location of the stone. In some instances it has thus been possible to manipulate the calculus up into the pelvis of the kidney or 1 A Bummary of this subject with the bibliography will he round In the Annals of Surgery, 1894, p. 267. SPECIAL OPERATIONS. 481 down into the bladder, and even when it was soft to break the stone into fragments with the fingers and then get them into the bladder. If the ureter must be opened, an incision is made three or four inches long wherever necessary in a line drawn from a point on the anterior edge of the sacro-lumbalis a finger's breadth below the twelfth rib, parallel to the rib as far as its tip, thence downward toward the middle of Pou- part's ligament till about opposite the anterior superior spine of the ilium. From this point the line again turns inward to end at the outer border of the rectus muscle. The tissues are divided layer by layer till the peritoneum is reached, and then the latter membrane is gently raised by the fingers from the parts beneath till the ureter is ex- posed adhering to its under surface. In the middle third of the course of the ureter it will be found about half an inch to an inch from the spinal attachment of the peri- toneum. The ureter is incised longitudiually over the stone sufficiently to extract the latter. In several instances this wound has then been closed by a continuous suture of fine silk through the outer wall of the ureter, but not penetrat- ing its lumen, and with one end of the suture left within reach from the parietal opening to remove it in case of sup- puration. This may at any rate narrow the opening and so hasten its repair, though Cabot 1 considers suturing a wound of the ureter unnecessary. A rubber tube aud iodoform-gauze packing is placed in contact with the ureteral wound for drainage of escaping urine, and the ends brought out of the exterual incision which is partially closed around them. In some cases where the stone can be felt through the vault of the vagina, and it is between the layers of the broad ligament not more than an inch or an inch and a half from the bladder, an incision can be made in the vault outward and backward and the finger pushed up separating the intervening tissues in the broad ligament till the stone is reached. The ureter is then opened longitudi- nally on its under side and the stone picked out. This wound has been successfully closed with sutures, but it 1 Loc. cit. 482 OPERATIVE SUBGEBY. will generally be found sufficient to place a drainage tube and packing in contact with it and bring the ends out through the vagina. 1 In other cases if the stone has reached the bladder cavity and lies between the mucous and muscular coats, it should be attacked through the interior of the bladder, probably by a suprapubic cystotomy ; but, if it is further off and the bladder wall must be opened to expose the stone, there is great danger of urinary infiltration in the surrounding parts, and Cabot's method, described below, should be used. With these exceptions the lower third of the ureter must generally be approached from behind. An incision is made three or four inches long, starting just below the tip of the coccyx and following the lateral border of that bone and the sacrum on the side of the affected ureter. The sacro- sciatic ligaments are divided close to the sacrum and the coccyx excised, and if necessary the lower lateral border of the sacrum also, as in Kraske's operation. With a large sound in the rectum to map it out and push it aside, the ureter is sought for close to the edge of the sacrum and opened longitudinally on its under side opposite the calculus sufficiently to extract the latter. The resulting wound is simply packed and drained. Wounds of the Ureter. Extraperitoneal wounds of the ureter involving a part of its circumference should be treated as already described, i. e. y by a counter-opening and drainage through the abdominal wall in a direction as nearly as possible directly backward. When the wound has been intraperitoneal or has involved the entire circum- ference of the ureter, the divided ends have been ligated with catgut and the stumps disinfected and covered with an iodoform-gauze packing, which was brought out of the abdomen, and the corresponding kidney has then been extirpated. Or, after ligating and disinfecting the divided lower end of the ureter, the upper end has been brought out in the loin through a counter-opening made above the crest of the ilium behind, and a urinary fistula established, for the cure of which nephrectomy has been subsequently per- formed. 1 Cabot : Loc. cit. SPECIAL OPERATIONS. 483 Some recent experiments on dogs 1 seem to prove that one ueter can be implanted in the rectum, or colon, with- out especial danger or subsequent inconvenience, and this fact might be of great service in case of an accidental divi- sion of one ureter during a pelvic operation. There is also reason to believe that it may be possible to obtain reunion of the divided ureter and re-establishment of the flow of urine to the bladder by partial suturing of the divided ends after trimming them obliquely or into cor- responding salient and re-entrant Vs. If union can be thus obtained over a part of the wall, the remaining fistula may heal as after longitudinal or oblique wounds. In several reported instances, when it has been divided near its lower end, the ureter has been implanted in the bladder above the point where it normally enters this viscus. The cut end of the ureter is slit up longitudinally for half an inch and its margins sutured with catgut to the edges of an opening iu the bladder. Drainage must be provided for. Kelly 2 has successfully employed on the human subject a method used by Van Hook in experiments on dogs, and has called the operation uretero-ureterostomy. Other similar cases are being reported. The divided extremity of the distal segment is tied off by a ligature and just below the latter the lumen of the distal segment is opened longitudinally suffi- ciently to permit the upper segment to be inserted into the lower. A couple of sutures in the cut edge of the proxi- mal stump are threaded on needles and passed through the slit into the lumen of the lower stump and out through its walls just below the longitudinal opening and used to draw the upper into the lower portion of the tube. The ends of these sutures are tied, and one or two others inserted at the point where the stumps are in contact. Gauze is then packed around the suture line and brought out of the abdominal wound for drainage. CASTRATION. The usual preparations for an antiseptic operation are made, and a sterilized towel wet in a 1:1000 solution of 1 Annals Surgery, 1892, vol. xvi. p. 193. 2 Annals Surgery, 1894, p. 70. 484 OPERATIVE SURGERY. bichloride of mercury is wrapped around the penis and pinned to the loose skin at its root. The scrotum on the affected side is grasped by the thumb aud fingers of the left hand and drawn tight in such a way as to make the diseased testis and its cord prominent and tense. An in- cision is then made from the external abdominal ring along the entire length of the anterior portion of the scrotum ; but if the skin is involved this incision should be made elliptical in the direction required to include the diseased area. After division of the skin and dartos the testicle is slipped out of the wound, and the remainder of the dis- section and isolation of the gland and cord is completed more by tearing with the fingers and blunt-pointed scissors than with the knife. The tunica vaginalis may be opened or not, and is removed with the testicle. A part of the cord is selected well above the disease, and, if necessary, the inguinal canal is opened by division of the tissues over it in successive layers. A silk thread is passed through the cord to insure control of it, and then the latter is divided through the sound portion by repeated cuts of the knife and the vessels are caught and tied with catgut as they bleed. Hemorrhage from the scrotal wound must be completely checked by ligation or by torsion and pressure. There should be three arteries in the stump, the sper- matic, the artery of the vas, and the cremasteric. The ligatures are all cut short and the internal incision is closed by interrupted sutures of fine silk, taking care not to in- vert the edges of the scrotal portion. Drainage is unnec- essary unless the wound has been exposed to infection, in which case a small rubber tube with lateral perforations is placed in its depths and brought out at the most dependent angle, while the surface is partially drawn together around an iodoform-gauze packing. Sometimes a healthy part of the cord cannot be reached and it must be tied through diseased tissue. It is then especially necessary to ligate each vessel separately, and an iodoform-gauze packing is placed in contact with the stump. A dry dressing is applied with a hernia bandage, over which is placed a sheet of rubber tissue, perforated for the SPECIAL OPERATIONS. 485 penis, to prevent soiling by urine, and the whole retained by a flannel spica bandage. HYDROCELE. The operations for the relief of hydrocele are palliative or radical. The object of the former is simply to remove the liquid from the sac ; that of the latter to prevent its reaccumulation by excising the sac, or by obliterating its cavity by exciting adhesive inflammation of its walls. Injection of the tincture of iodine is the means most com- monly employed for the latter purpose. The position of the testicle within the sac should always be ascertained, in order that it may not be injured by the trocar. This is best accomplished in most cases by examining the sac by transmitted light, the testicle appearing as an opaque spot in the general translucency ; its usual position is at the lower posterior portion of the sac. Puncture of the Sac. After the adoption of every anti- septic precaution the tumor is grasped at its upper portion in such a manner as thoroughly to stretch the skin covering it, and a sterilized trocar is plunged into the centre of its anterior surface, supposing the testicle to occupy its usual position below and behind. The depth to which the trocar enters is regulated by the finger placed along its side, and the surgeon satisfies himself that the point is well within the sac by moving it freely in all directions. The canula should fit the trocar snugly in order that its anterior end may not push the tissues before it instead of penetrating them. If the intention is only to remove the liquid, the canula is withdrawn as soon as the flow has ceased, and the puucture closed with adhesive plaster or collodion ; but if a radical cure is to be attempted, the tincture of iodine must first be thrown in. The French surgeons use the tincture diluted with two or three parts of water, and prevent precipitation by adding iodide of potassium to the mixture. They throw a considerable quantity into the sac, retain it there for three, four, or five minutes, and then withdraw it. 486 OPERA TIVE S UR GER Y. Van Buren and Keyes 1 recommend the " pure tincture thrown iu gradually, retained several minutes, and worked around in such a way that every portion of the inner wall of the sac may come into contact with it ; " the quantity of the tincture used should be equal to half the amount of liquid drawn off. Large hydroceles must first be reduced in size by one or two tappings. The injection of fifteen to thirty minims of 95 per cent, carbolic acid has given good results. Care must be taken that the injection is not thrown into the subcutaneous connective tissue, an accident that is very likely to be followed by sloughing of the scrotum ; the surest way of avoiding this accident is to throw in the injection before the liquid has entirely ceased to flow out. If the accident does occur, free incisions must be made at once into the scrotum at the seat of the infiltration. Radical Cure by Excision (Volkmanu). With every antiseptic precaution the sac is freely laid open by a longi- tudinal anterior incision and the cut edges of the skin and tunica vaginalis stitched together all around. The cavity is then lightly packed and allowed to heal by granulation, a process which requires a couple of weeks. If the surgeon is sure of the asepsis the packing may be withdrawn at the end of three days, aud then, by applying firm pressure, the wound can be caused to heal much sooner. VARICOCELE. The treatment of varicocele may be palliative or radical. By the former, support is given to the testicle and the over- distended veins ; by the latter, it is sought to obliterate the lumen of the veins at one or more poiuts. There are several risks involved in the radical treatment, which, when taken in connection with the usual harmlessuess of the affection and the efficacy of palliative measures, should make the surgeon slow to employ it. The risks are : Possible phle- bitis, which may lead to pyaemia ; possible atrophy of the testicle, in consequence of the obliteration of all the veins 1 Genlto-Urinary Discuses with Syphilis, New York, 1874, i>. 104. SPECIAL OPERATIONS. 487 or the inclusion of the artery in the ligature ; and, finally, the likelihood of a return of the affection if all the veins are not obliterated. The palliative treatment consists in wearing a suspensory bandage, or in excising a large portion of the scrotum, with the expectation that what is left will act as a natural suspensory. Excision of the Scrotum. A long clamp is required, between the blades of which a large fold of the scrotum is pinched up parallel to and including the raphe. This fold is then cut off about one-eighth of an inch from the outer side of the blades, and numerous interrupted sutures applied before the clamp is removed. If bleeding is feared, these sutures should be cut about a foot long, and not tied until after the clamp has been taken off and all bleeding points secured. The radical treatment consists in obliterating the lumen of the veins by dividing them with the knife or the cautery, excising a portion of their length, compressing and strangu- lating them by means of ligatures or clamps, or simply exposing them to the air. Of these excision is the only method to be commended. Subcutaneous Ligature. A needle carrying a catgut or antiseptic silk ligature is passed through between the veins and the cord, reentered at the point of emergence, passed around the other side of the veins close under the skin and brought out and tightly tied at the first point of entry. If this is very exactly done, so as not to include the deeper part of the skin at either puncture in the loop, and is treated antiseptically, it will usually heal without suppuration. Its execution is facilitated by making the punctures with a knife. Open Method of Ligation. A fold of the scrotum over the enlarged veins above the globus major is pinched up and divided with scissors, making a longitudinal incision about an inch loug. The thumb and forefinger of the left hand grasp the vas deferens, pushing it backward, while the veins at the same time are forced forward into the cutaneous wound. The veins are isolated by a slight 488 OPERATIVE SURGERY. dissection with the knife or blunt-pointed scissors and a ligature of catgut or fine silk is passed under them by an aneurism needle. After another inspection to make certain the vas is not included, the ligature is tied tightly and the ends cut short. The small incision is then closed without Irainage and closed antiseptically. Some surgeons pass the ligature double, tying off a knuckle of vein, which is then excised and the divided ends brought into apposition by the long ends of the lig- ature, which are then cut short. AMPUTATION OF THE PENIS. Partial. The root of the penis is constricted by a piece of rubber tubing and the skin is slightly drawn back toward the pubes and divided by a circular sweep of the knife. With a sound in the urethra the corpora cavernosa are cut transversely at the level of the retracted skin down to the corpus spongiosum, which is then dissected out by a few strokes of the knife, and, after withdrawal of the sound, is cut transversely, including the urethra, about half an in inch louger than the corpora cavernosa to allow for retraction of the urethra. The cut ends of the vessels in sight, including the two dorsal arteries and the arteries of the corpora cavernosa, which lie in the centre of these bodies, are tied with fine catgut, the tourniquet removed, and, after checking the hemorrhage by ligation or torsion, the cut edges of the urethra and skin are united with fine silk. To prevent cicatricial contraction of the mouth of the urethra, the latter should be split longitudinally for about half an inch on its under surface before stitching it to the skin. Complete. The patient is placed in the lithotomy posi- tion, a sound introduced into the bladder, and the scrotum is split from before backward along its raphe. The corpus spongiosum is dissected out as far as the triangular liga- ment, and divided about an inch in front of the latter after withdrawal of the sound. A circular incision continuous with the anterior ex- SPECIAL OPERATIONS. 489 tremity of the scrotal incision is next made through the skin around the root of the penis ; the suspensory ligament is divided, and by dragging on the penis and retracting the sides of the scrotal wound, the corpora cavernosa and their posterior prolongations, the crura, are removed from the rami of the pubes and ischium by the knife or periosteal elevator. All the attachments of the penis having thus been severed and the bleeding points tied, as they are en- countered, with fine catgut, the urethra is split for half an inch on its floor and sutured to the edges of the wound well forward in the perineum, and the remainder of the wound is united between the testicles so as to form a sepa- rate scrotum for each of them. When this extensive operation is undertaken for cancer of the penis the inguinal glands on both sides should be removed at the same time, whether perceptibly enlarged or not. OPERATIONS FOR PHIMOSIS. Dorsal Incision. A director is passed through the pre- putial orifice along the dorsum of the glans to the corona, a curved, sharp-pointed bistoury guided along it, the skin transfixed at the point of the director and divided straight down to the preputial orifice. Nothing more is absolutely required, for the wound left to itself will heal promptly ; but it is well to round off the corners and to unite the edges of the mucous membrane and skin by fine sutures. This is a very satisfactory operation when the prepuce is not redund- ant, but if there is much excess of tissue the foreskin will present an awkward, lop-eared appearance for many years, and in such cases, therefore, circumcision is to be preferred. This operation is often required in cases of sub-preputial chancroid, and then it becomes a matter of considerable importance to prevent inoculation of the wound by the chancroidal virus. A method introduced by Dr. J. H. Lowman into the venereal wards of Charity Hospital, New York, has proved very efficient in this respect. A solution of nitrate of silver, forty grains to the ounce, is injected under the prepuce, and followed by the injection of a satu- rated solution of common salt, to remove the excess of the caustic. The sore having been thus rendered temporarily 490 OPERATIVE SURGERY. innocuous by the coagulation of its secretions, the incision is made and the sore cauterized with nitric acid. Circumcision. A number of instruments have been in- vented and a great variety of methods proposed, which do not need to be repeated here, for the object they had in view, that of insuring division of the skin and mucous mem- braue of the prepuce at the same level, is not a matter of much importance, since any excess of the latter can be readily removed afterward. There is, however, one modi- fication iutroduced by Dr. Keyes 1 which is of great im- portance, for it insures the removal of the coustriction and protects the wound from beiug harmed by erections while healing. This modification consists in an additional longi- tudinal division of the skin for about half an inch along the dorsum of the penis, and sometimes, also, on the opposite side along the course of the urethra, after the end of the prepuce has been cut off (Fig. 242, AC). The corners left by these incisions are rounded oif, and the effect is to increase the circumference by twice the length of the inci- sion. As the stricture is sometimes due to insufficient breadth of the skin covering the glans, the value of this simple modification is evident. Operation. A probe is first introduced and swept over the surface of the glans to break up any adhesions that may exist, and the edge of the preputial orifice is then caught at opposite points with the thumb and forefinger of each hand and drawn forward, care being taken to make the tension upon the less elastic mucous membrane, and not only upon the skin. While the prepuce is thus drawn for- ward, an assistant clasps a pair of long narrow-bladed forceps vertically upon it just in front of the apex of the glans, directing the blades forward as well as downward (the penis being horizontal) parallel to the general direc- tion of the corona, and the glans should then be moved freely behind them to make sure that it is not caught be- tween the blades. The portion of prepuce in front of the forceps is then cut away with scissors or a knife (Fig. 241) and the forceps taken off. 1 Van Jiuren mid Keyes : Genito-Urinary Diseases, with Syphilis, New York, 1874, p. 11, SPECIAL OPERATIONS. Fig. 241. 491 Fig. 242. Circumcision. First incision. It will then be seen that the glans is still covered by a more or less tightly fitting sheath of raucous membrane, while the looser and more elastic skin retracts to or beyond the corona, leaving a belt of raw surface below (Fig. 242). The mucous membrane is next divided with scissors along the dorsum back to the corona (Fig. 242, BU), and the skin divided in the same direction along the dorsum for a distance of half an inch from its cut edge (Fig. 242, AC), and also on the under side along the urethra, if con- sidered necessary. The corners of these incisions are rounded off, and the edges of the mucous membrane and skin fasten- ed together with numerous fine sutures, the first being placed exactly in the me- dian line in front, the second at the frsenum. If fine silk is used, and the sutures placed close to the edge, they may be left to cut their way out and come away in the dressings. circumcision . Raw surface left by retrac- tion after first inci- sion. 492 OPERATIVE SURGERY. It is always difficult to get accurate adjustment of the edges at the ends of the longitudinal incisious on the dor- sum, and usually a small triangular gap is left to fill by granulation. Dr. D. B. Delavau 1 proposes to meet this objection by leaving a triangular piece projecting in the centre of the dorsal portion of the cutaneous incision. Fig. 243 shows the line of incision, Fig. 244 the resulting tri- angles of skin and mucous membrane ; the apex of the latter, H, which at first is drawn upward by its close connection Fig. 243. Fig. 244. Circumcision. Delavan. First incision. Circumcision. Delavan. Fitting in the triangle. with the apex of the skin triangle, A, so that its mucous surface is outward, is represented in the figure as it appears after having been freed by dissection, if necessary, and turned down, leaving its raw surface out. The mucous membrane is then slit up to the corona at D, as usual, after cutting away its triangle, and the point A is stitched last to D, B to E, C to F, and the remainder of the edge as usual. The only objection to be made to this device is that it sacrifices the liberating longitudinal incision of the skin, and Dr. Keyes 2 has met this by taking the triangular flap from the mucous membrane instead of from the skin. He cuts off the prepuce by a straight incision, and divides the skin along the dorsum as before ; and then, instead of splitting 1 Oral communication, 1870. 2 Oral communication, 1870. SPECIAL OPERATIONS. 493 the mucous membrane in the same manner (Fig. 242, BD), he makes a Y-shaped incision (Fig. 245, BDC), and removes the anterior strip of mucous mem- brane by continuing the incision from C and D around to the frseuum. The point DBC is then reflected, fitted into the triangular gap G E F left by the longitudinal incision in the skin and the rounding of its corners, and the edges are united by sutures, as before. If broad adhesions exist between the glans and prepuce, and it is feared that the raw surfaces left by their division will reunite, all the mucous membrane may be removed, except a ring about one-eighth of an inch wide adjoining the corona; the skin is then drawn forward, and united to the narrow ring of mucous membrane. The raw surface on the glans, having nothing to adhere to, cicatrizes naturally. Circumcision. Keyes. PARAPHIMOSIS. A description of the methods of reduction by taxis or by compression of the engorged prepuce and gland does not lie within the proposed scope of this work, and the operation of division of the constricting band hardly needs to be described, for it consists simply in dividing the band from without inward at one or more points, until the constriction is sufficiently relieved to allow the prepuce to be drawn for- ward. It is well to make the first incision in the median dorsal line so as to profit by it afterward, if an operation for phimosis is considered necessary. If inflammatory ad- hesions have formed along the line of the constriction, forcible attempts to reduce the paraphimosis should not be made, but, after division of the band, the parts should simply be dressed with cold and soothing lotions. 22 491 OPERA TIVE S UB GEE Y. DIVISION OF THE FPwENUM. Verneuil 1 employs the following method : He makes the fneuum tense, transfixes it close to its attachment to the glans with a narrow bistoury or tenotome held with its side parallel to the surface of the penis, and cuts out backward, making a triangular flap nearly half an inch long, with its apex directed backward. The liberated glans is drawn forward, the flap disappears, and the edges of the wound, which assumes the shape of a lozenge, are united by sutures. EPISPADIAS. The deformity known as epispadias is characterized by fissure of the roof of the urethra. In its complete form it is associated with separation of the symphysis pubis, and often with exstrophy of the bladder, in which case its treat- ment is subordinate to that of the more important defect (q. v.). In its slightest degree it is confined to a fissure occupying the dorsal portion of the glans penis, and extend- ing from the meatus to the corona (epispadias balanique). The existence of this form has been denied, but Verneuil 2 reports two cases, in neither of which did the malformation cause any disturbance of function. In the more important varieties the urethra lies above the corpora cavernosa in- stead of below them, and is open on the roof from its an- terior extremity nearly to the bladder ; the glans is fairly developed, and may be grooved more or less deeply along its dorsum, while the rest of the corpus spongiosum is represented by a thin layer of erectile tissue under the urethra. There is sometimes partial or complete inconti- nence of urine, and the operative indication is to supply a channel through which the urine can be conducted without dribbling to a urinal. NSlaton's Method. The prepuce is drawn downward and forward by means of a ligature passed through it, and held in this position during the operation. An incision is then 1 Chimrgle JU-paratrice, 1887, p. 730. - Loc. cit., p. 718. SPECIAL OPERATIONS. 495 made along each side of the urethral gutter at the junction of the skin and raucous membrane, beginning at the prepuce and ending at the abdominal wall. The external lip of each incision is dissected up for about one sixth of an inch, forming a flap on each side continuous with the skin ; the inner lip of each incision is also slightly loosened. The flaps must be made as thick as possible. A third flap is then marked out upon the abdominal wall, immediately above the urethral orifice leading to the bladder, by two vertical incisions united at their upper ends by a transverse one ; it should be as broad as, and a Fig. 246. Epispadias. Nelaton's operation. A. Abdominal flap. B. Urethral infundi- bulum. C, C. Lateral incisions at junction of skin and mucous membrane. F, F. Scrotal incisions circumscribing 6, the scrotal flap. little longer than, the penis, dissected from above down- ward to its base, which corresponds to the interpubic liga- ment, and then reversed, its cutaneous surface inward, and its sides made fast by sutures to the inner lips of the in- cision on the penis, care being taken to make the contact as broad as possible. Demarquay 1 and Dolbeau 2 preferred to make the flap by prolonging the first two incisions up 1 Maladies Chirurgicales du Penis. 1877, p. 623. 2 De l'Epispadias, Paris, 1861. Planche IV., Fig. I. 496 OPERATIVE SURGERY. the abdomen, thinking that the continuity of the incisions upon the abdomen and penis would increase the chances of success (Fig. 246, C C). In order to give the abdominal flap greater thickness, aud prevent its retraction during the process of cicatriza- tion, Nelaton reiuforced it by another taken from the scrotum. This scrotal flap is limited by concentric curved incisions (Fig. 246, F F), the upper one circumscribing the under half of the root of the penis in the peno-scrotal angle, the other at a distance below the first equal to the length of the penis, and is left adherent at both ends. After the flap has been dissected up, the penis is passed under it, bringing the raw surface of the reversed abdominal flap into contact with that of the scrotal flap, and the great circumference of the latter is fastened by three sutures to the outer lips of the two incisions made along the sides of the urethral gutter. The canal thus formed is very large, and both Nelaton and Dolbeau found it necessary to diminish its size by ap- plying the actual cautery to its interior. The operation de- vised by Thiersch is generally deemed superior. Thiersch's Method. 1 This operation requires several months for its completion, since it is composed of four dis- A Epispadias. Thiersch's operation. 1. The plans seen fiom ahove. A, A. The incision on each side of the gutter C. B, B. The freshened surface. 2. Trans- verse section of glans showing the incisions. 3. The freshened surfaces brought together and closing in the urethra U. tinct operations performed at different times. In order to prevent the urine from coming into contact with the raw surfaces of the flaps Thiersch makes an opening into the 1 Are.hiv fiir Ueilkunde, 18(i'J, pp. 20-30, and Langenheck's Archiv, vol. xv. Part II. p. 379. SPECIAL OPERATIONS. 497 urethra through the periueum and maintains it during the entire period of treatment. First Step (Fig. 247). Creation of the meatus and the portion of the canal occupying the glans. The surgeon makes a deep incision along each side of the urethral groove in the glans, pares the surface of the outer lip of each in- cision, brings the freshened surfaces into contact, and fixes them with two or three points of twisted suture. Second Step (Figs. 248, 249). Creation of the urethra along the body of the penis. The surgeon makes an in- cision through the skin aud subcutaneous tissue at the edge Fig. 248. Fig. 249. Epispadias. Thiersch. Se- cond step. Incisions limiting the two lateral flaps. Epispadias. Thiersch. Transverse section of penis, showing flaps, of the urethral gutter on the right side, makes a short transverse cut outward from each end, and dissects up the rectangular flap thus marked out. On the left side he makes a longitudinal incision one centimetre external to the edge of the gutter, and a transverse incision from each end. This flap is dissected up, making it as thick as possi- ble, and turned over so as to form a roof for the urethral gutter, its cutaueous surface directed downward, its raw surface upward. Several ligatures are passed through it near its free border and then through the base of the right- 498 OPERATIVE SURGERY. hand flap, and the latter drawn across the former so that their raw surfaces are brought into contact throughout. The free edge of the right flap is then fastened to the skin forming the outer edge of the incision on the left side. Third Step. To close the gap remaining between these two new portious of the urethra. A transverse incision is made in the prepuce, the glans passed through it, the bor- ders of the gap pared and fastened to the edges of the in- cision in the prepuce. Fourth Step. To close the posterior portion of the canal or infundibulum. The method employed is similar to that used in the second step of the operation, the flaps being taken from the groins. The left flap has the form of an isosceles triangle, and its base occupies the left half of the upper semi-circumference of the openiug ; it is turned over so that its cutaneous surface is directed downward, and its free border is united to the freshened posterior edge of the roof of the new urethra. The other flap is quadrilateral, its base corresponds to the right inguinal ring, and it is drawn over the first one so that their raw surfaces are brought into contact and fastened together with sutures. Finally, the fistula established in the perineum is closed. HYPOSPADIAS. The deformity known as hypospadias is characterized by a congenital abnormal opening of the urethra upon the under surface of the penis. Sometimes the urethra ends at the abnormal opening, sometimes it is continued more or less imperfectly beyond it either in the form of a tube, which is usually imperforate at one or two points, or in that of a gutter. The varieties of hypospadias are usually classified in three groups, the balanitic, penile, and scrotal, according as the abnormal opening is found at a point in the urethra corresponding to the glans, the pendulous por- tion of the penis, or the scrotum. The balanitic is the most frequent and least important, and the penile is less frequent and less important than the scrotal. The defect never ex- tends further back than the bulb of the urethra, and conse- quently never causes incontinence of urine. In the scrotal SPECIAL OPERATIONS. 499 and in some of the penile varieties the anterior portion of the urethra forms a tense fibrous cord binding down the glans, curving the body of the penis upward, and prevent- ing its erection. In the balanitic variety, when the anterior portion of the urethra exists in the form of a gutter, no treatment is required unless the opening is too small. The slight defi- ciency in length involves no loss of function, and attempts to reconstitute the defective portion of the canal by some plastic operation usually fail. In fact, if the canal exists between the meatus and the abnormal opening, it is better to slit it up than to try to close the latter. The scrotal variety is considered irremediable, and has never been the subject of surgical interference. In it the scrotum is bifid, the penis usually very small, and the urethral orifice at the bottom of an infundibulum resem- bling a vulva. Individuals thus deformed have often been mistaken for hermaphrodites and sometimes for females. In the penile variety, when the anterior portion of the urethra is normal, the opening may be closed by freshening the surface about its edge and covering it with a flap taken from the adjoining skin. When the anterior portion exists only in the form of a more or less shallow groove, it may be transformed into a complete canal by one of the methods of urethroplasty hereinafter described. The two other modes of operating, urethroraphy and perforation, have now been discarded ; in the former the edges of the groove were pared and brought together with sutures, in the latter a trocar was passed along through the tissues of the uuder side of the penis from the extremity of the glans to the abnormal opening of the urethra, and the route thus created kept open by the frequent passage of sounds. If the penis is incurvated it must be straightened as a preliminary to any operation. To accomplish this it is not sufficient to divide only the fibrous band on its under sur- face, for the retraction is partly maintained by the short- ness of the inferior portion of the sheaths of the corpora cavernosa and the septum between them. If the skin on the under surface is flexible enough to allow the penis to be straightened after the internal bands have been divided, this division may be madejsubcutaneously, following the. 500 OPERATIVE SURGERY. example of Bouissou, by introducing a tenotome and press- ing its edge against the sheath of the corpora cavernosa and the septum while the glans is drawn steadily away from the scrotum. Ordinarily, however, this is not possi- ble, and one or two transverse incisions one centimetre long must be made through the skin and deeper parts. By the straightening of the penis these transverse incisions are transformed into longitudinal ones, and their sides are then drawn together by sutures. Several months must then be allowed to elapse before the subsequent plastic operation is undertaken, in order that the cicatrix may be- come perfectly soft and attain its full vitality. In the earlier operations of urethroplasty the floor of the urethra was formed by a long narrow vertical flap taken from the scrotum, its base adjoining the orifice of the urethra, and its borders fastened to the edges of two longitudinal incisions on the under side of the penis. In short, the method resembled that already described as employed by Nelaton for the relief of epispadias, even to the reinforce- ment of the flap by a transverse one taken from the skin above the root of the penis. The results of these attempts were so unsatisfactory that when Nelaton was consulted, in 1872, concerning a patient affected with hypospadias, he advised that nothing should be done, saying that he had made many canals through which the urine was carried to the end of the penis, but they interfered with erection, and did not facilitate fecundation. 1 The surgeon who received this advice, Theophile Auger, thereupon devised another method, ignorant that a similar one had been employed shortly before by Thiersch in epispadias and by Scymanow- ski for urethral fistula, and, having put it into execution, obtained an excellent result. TliSophile Anger's Method. In this case the urethral opening was at the peno-scrotal angle, the anterior portion of the canal was entirely lacking, and the penis was so curved that the extremity of the glans was not more than half an inch from the opening. The penis was first straight- ened by two short transverse incisions carried to such a 1 ThC-ophile Anger in Hull, do la Soc. de Chirurgie, n6ance du 21 Jaiivier, 1874 SPECIAL OPERATIONS. 501 depth that the corpora cavernosa were exposed at the bottom of the wound; the bleeding was slight, and the wound healed promptly. The plastic operation was performed nearly four mouths afterward, and was only partially suc- cessful, the posterior portion of the flap disappearing by absorption. A second operation, six months later, was en- tirely successful, and the condition of the parts, when the patient was shown to the Societe de Chirurgie five months afterward, was entirely satisfactory ; the tissues were supple, there was no stricture in the canal, and erection was per- fect, except for a very slight incurvation downward. Fig, 250. Hypospadias. Theophile Anger's method. The first plastic operation was as follows : An incision, extending from theglans to the scrotum, was made through the skin on the left side parallel to the mediau line and one and a half centimetres from it, and from each extremity of this an oblique incision was carried to the median line, the posterior one ending on the scrotum just behind the urethral opening (Fig. 250). The cutaneous flap circumscribed by 22* 502 OPERATIVE SURGERY. these three incisions was dissected np so that it could be turned back with its epidermic surface directed inward, and thus constitute the floor of the new canal. A second longi- tudinal incision was then made a little to the right of the median line, parallel to and as long as the first, a trausverse incision one and a half to two centimetres long carried out- ward from each end of it, and the flap thus circumscribed dissected up. A sound was then introduced into the urethra, the first flap drawn back over it, and six sutures placed close to its free longitudinal border ; the two ends of each suture were then attached to a needle and carried through the base of the second flap from within outward, as shown in the figure, drawn tight, and fixed by pinching a tube of lead upon them. Finally, the second flap was drawn over the first, and its edge made fast to the outer lip of the first incision, thus covering in all the raw surface. Anger tied in the catheter and left it for several days, but admits that this was a mistake. When he repeated the operation he left the catheter in for only twenty-four hours, and then reintroduced it only when the urine had to be drawn off. Duplay's Method. The operation has three steps or stages. In the first, the penis is straightened and a meatus made ; in the second, the portion of the urethra which is lacking is restored ; and, in the third, this new portion is united to that which previously existed. First Step. The penis is straightened by transverse or subcutaneous incisions as before described, and the meatus made by paring a strip of the surface of the glans on each side of the groove representing the urethra, and bringing them together with one or two points of twisted suture over a piece of gum catheter placed in the groove. If necessary, the groove may be deepened by one or two longitudinal in- cisions on its floor (roof of the urethra). Second Step. Two longitudinal incisions, extending from the glans nearly to the abnormal urethral opening, are made, one on each side of the median line, at a distance from each other equal to the circumference to be given to the new urethra; and from each end of these a short transverse in- cision is made toward, but not quite to, the median line SPECIAL OPERATIONS. 503 (Fig. 251, A). The rectangular flaps thus circumscribed are dissected up toward the median line, turned back over a gum catheter, and their free borders fastened together with sutures (Fig. 25 1 , B and C). The outer lips of the two incisions are then loosened sufficiently by dissection to allow them to be drawn over the others and fastened to- gether in the median line with interrupted or twisted sutures. Fig. 251. ! Hypospadias. Duplay's method. Care must be taken to attach the anterior ends of all four flaps to the pared surface of the glans, so that the new urethra may be continuous with the piece previously made. Third Step. To close the gap between the termination of the old and the beginning of the new portions of the urethra, Duplay freshened the edges and brought them to- gether with double rows of sutures. URETHRAL FISTULA. Urethral fistula, as a rule, are more difficult to close the further they are from the bladder. Those occupying the perineum and scrotum are long, pass through thick tissues, and will usually heal spontaneously if the full calibre of the urethra iu front of them is maintained. Occasionally it becomes necessary to freshen their sides with a knife, caustics, or cautery. 504 OPERA TIVE S UE OEB Y. Fistulse occupying the pendulous portion of the penis have but little tendency to close spontaneously, unless they are recent and small ; the distance between the mucous and cutaneous surfaces is so short that the walls of the fistula cicatrize promptly without uniting, and that renders a spon- taneous cure practically impossible. Operations undertaken for the purpose of closing them, exclusive of simple cauteriz- ation, are divided iuto two classes, urethroraphy and urethro- plasty. In the former, the sides of the fistula are pared and brought together in the median line; in the latter, the loss of substance is made good by the transfer of cutaneous flaps. It has always been held that the principal obstacle to the closure of a fistula is the frequent passage of urine through it, and although this has been occasionally questioned, espe- cially with reference to normal, unaltered urine, it is still considered one of the principal indications to prevent this passage. The choice lies between three methods : 1st. In- troducing a catheter and drawing off the urine as often as it becomes necessary to empty the bladder ; 2d, tying in a catheter ; 3d, establishing a free passage for the urine at some point on the proximal side of the fistula. Each method is open to serious objections; the frequent passage of the catheter is calculated to disturb the adjustment of the flaps, stretch the sutures, and irritate the urethra ; and, moreover, a small quantity of urine is sure to escape through the canal beside or behind it. A catheter retained in the urethra for several days is even worse ; as Ducamp 1 pointed out more than fifty years ago, it violates the two conditions necessary to the cicatrization of every wound, moderate degree of inflammation and of humidity, by irritating the canal, provoking an excessive flow of mucus, and acting upon the wound itself as a pea docs in an issue. After two or three days at the latest it not only fails to remove the urine as fast as it collects in the bladder, but actually favors its escape alongside and through the wound. It excites cystitis of the vesical neck, and sooner or later gives rise to the complex of symptoms known as urinary fever. In short, it is not only inefficient after the first day or two, 1 Trait6 des K6tentiou« d'Urine, 1825, p. 237 ; quoted by Verneuil. SPECIAL OPERATIONS. 505 but is positively harmful. The objections to the third method, unless perineal fistula exist and can be sufficiently enlarged, are that as usually practised it involves a consider- able wound in the perineum, which may itself give rise to a fistula more obnoxious than that which it is designed to cure, and that by destroying the integrity of the spongy tissue of the bulb it may cause dribbling and imperfect ejaculation of the last of the urine. Urethroraphy. This term is applied to the simple ap- proximation of the sides of a fistula after they have been pared. Verneuil 1 considers the method applicable to all circular fistula? not more than one-fifth of an inch in diam- eter if the surrounding tissues are thick, and also to ob- long fistula? of much greater size when their long axis is in the median line and their sides can be easily brought together. He thinks the numerous failures which have fol- lowed the use of the operation have been caused by a lack of attention to details, and he suggests that the paring of the edges should be oblique so as to give the fistula the form of a funnel with its apex at the opening into the urethra, the mucous membrane of which should not be included in the paring. Fine metallic sutures should be used, applied at short intervals, not penetrating to the canal of the urethra, and tied over a leaden plate on the surface. The line of reunion should be longitudinal, not transverse, and if pri- mary union is not obtained the sutures should be retained to favor secondary union. During the operation a sound should be kept in the urethra in order that the canal may have its full size. Urethroplasty. The methods that have been suggested and employed have been very numerous, but most of them count more failures than successes. This is especially true of those by which longitudinal or transverse flaps have been dissected up on opposite sides of the fistula, and brought together by their edges across its centre, for the tissues are usually too thin to afford a sufficiently broad surface of coap- tation, and the urine finds its way at once through the wound. It has been proposed to overcome the latter ob- 1 Chirurgie Reparatrice, p. 696. 506 OPERA TIVE S UR GER Y. stacle to union by passing a piece of thin India-rubber under the flaps (Fig. 252), but it is doubtful if the presence of the foreign body would not have a more unfavorable effect upon the thin, delicate flaps than the urine which it is designed to keep away. Fig. 252. Fig. 253. Urethroplasty. Urethroplasty. Nelaton. Xr/aton's Method. Nelaton pared the edges of the fistula and dissected up the skin subcutaneously for about au inch around it by entering the knife through a short transverse incision below it (Fig. 253). The skin thus liberated was pinched up in a longitudinal fold along the median line, and fixed in this position by twisted or quilted sutures. Reybard made the dissection through the fistula, thus avoiding the transverse incision of the skin. Dicffenbach and Before employed a similar method, but instead of dis- secting up the skin subcutaneously they raised two longitu- dinal or transverse flaps and fastened them together by their raw and under surfaces (not edges) in the centre, the former passing his sutures through a leather splint on each side, the latter applying them in three rows, one above the other. SPECIAL OPERATIONS. 507 Delpech and Alliot dissected up a single flap, drew it entirely across the fistula, and fastened it to a raw surface prepared upon the opposite side. Sir Astley Cooper cut away the skin iu such a manner as to leave a raw surface of quadrilateral form with the fis- tula in its centre, and then covered it with a flap of the same shape, taken from the scrotum by the Indian method of autoplasty. Arlaud 1 obtained a complete success in a remarkable case, where the urethra had been completely divided just in front of the peuo-scrotal angle, and its two cut ends were nearly an inch apart, by adapting a method previously employed by Roux to close a fistula in the trachea. The principle is the same as iu Delpech's method, the difference iu detail being that two flaps are used instead of only one ; the second one, that which has its cutaneous surface pared, being drawn under the first. Two transverse flaps, one in front of the fistula, the other behind it, were marked out by longitudinal incisions four centimetres apart; the anterior one was dissected up for a distance of two centimetres toward the glaus, and the pos- terior one dissected back over the scrotum, until it could be easily drawn forward far enough to cover the fistula entirely. The anterior portion of the cutaneous surface of the second (scrotal) flap was then thoroughly pared, the flap drawn forward so as to cover the fistula, and the anterior flap drawn back over the other and fastened there by four points of twisted suture. Sedillot dissected up a small flap on each side, its base adjoining the edge of the fistula, its free border directed outward, reversed and united them by their free borders in the median line (their epithelial surfaces directed inward), and brought the sutures out through the meatus. The raw surface of the flaps was then covered by a third flap trans- ferred by the Indian method, or by sliding. Rigaud closed a large fistula at the peno-scrotal angle by the method already described as Nelatou's method of treat- ing epispadias. He took a quadrilateral mediau flap from 1 Bull, de la SociOto de Chirurgie, 1857. p. 550, and Verneuil's Chirurgie Ke- paratrice, p. 654. 508 OPERATIVE SURGERY. the scrotum, its base adjoining the fistula, turned it forward over the fistula, and covered its raw surface with two flaps taken from the sides and drawn together to meet in the median line. Theophile Anger has likewise proposed to close urethral fistula? by the method he employed so successfully in a case of hypospadias ; and Scymanowski 1 reports a success obtained by a method which differed but slightly from Anger's. He made the flaps much longer than the fistula, and freshened the cutane- ous surface of the reversed flap by blistering it, so that it could unite with the raw surface upon which it was laid. Dr. McBurney, by the use of methods similar to the last named, has obtained a number of brilliant succeses in ure- thral fistula and hypospadias ; several of the cases are re- ported in the proceedings of the New York Surgical Society between 1881 and 1884. In cases in which previous opera- tions had failed and had left cicatricial tissue about the open- ing he sought to close, he first removed the cicatricial tissue and supplied its place with flaps taken from the adjoining skin. To close the openings he used flaps similar to Anger's (Fig. 250), leaving the epidermis upon the surface of the one first turned in over an area corresponding exactly to the opening, and freshening with the knife all the remaining portion of its surface. He also dissected up for a line or two the anterior edge of the central unfreshened portion and tucked it under the freshened anterior margin of the opening. INTERNAL URETHROTOMY. Every antiseptic precaution is necessary. A stricture in the penile urethra is conveniently divided under cocaine by the Otis urethratorae up to any desired size ; the blad- der may then be washed with a sterilized saturated solution of boric acid, about four ounces of which arc left in. The passage of full-sized sounds must be kept up subsequently. For anterior strictures too tight to admit this urethra- tome, and for deep strictures, with the observance of certain 1 Handbuch dor Opcrativen Chirurgie, 1870. SPECIAL OPERATIONS. 509 precautions, the instrument of Maisonneuve is very useful. The flexible filiform bougie is passed through the stricture and secured to the staff, which then follows the bougie into the bladder, and the stricture is divided by slipping the knife along the whole length of the groove while the penis is drawn out on the staff to straighten and render tense the urethra, care being taken to make the section exactly in the median line of the roof. The knife is blunted on its summit and is supposed to divide only the narrowed Fig. 254. McBurney's gorget and grooved sound. portions of the canal. After a stricture beyond four and a half inches from the meatus has been cut in this way, the patient is placed in a lithotomy position, the perineal region thoroughly disinfected and shaved, and a broadly-grooved staff, about the size of a No. 28-30 F. sound, is passed to the bladder. It is so held in the mediau line by au assist- ant as to make the curved part of the staff prominent in the perineum. McBurney's gorget (Fig. 255), with the knife protruded, is then plunged into the centre of the peri- 510 OPERATIVE SURGERY. neiim, opening the membranous urethra and striking the groove in the staff, into which the gorget is pushed, sheath- ing the knife, which is then withdrawn, while at the same time, by slightly tilting the staff and advancing the gorget, the latter slips into the bladder as evidenced by the gush of urine. A soft rubber catheter is inserted into the blad- der on the gorget through the perineal puncture and re- tained by a silk suture through the skin, and the gorget is withdrawn. The bladder and urethra are thoroughly irrigated with a saturated solution of boric acid, and the catheter connected with a tube terminating beneath the surface of a 1:60 solution of carbolic acid in a bottle under the bed. A very slight dressing retained by a split T-bandage around the catheter is sufficient, and at the end of five days a sound is passed through the whole length of the urethra entering the bladder alongside of the catheter, which if all goes well, is removed twenty-four hours later, and a single antiseptic pad placed on the punctured wound in the perineum. When the bladder and urine are not extensively diseased and there are no other complications, such as multiple fistula, this method of treating deep strictures is generally preferred to the usual external urethrotomy. EXTERNAL PERINEAL URETHROTOMY. A. With a Guide. Prof. Syme, who introduced this operation, employed as a guide a staff, the straight por- tion of which was of full size, and its curved portion much smaller and grooved on the convexity. The change .from the full to the small size was abrupt, not gradual (Fig. 256). This instrument has been superseded, in the United States at least, by the tunnelled instruments intro- duced by Prof. Van Buren, 1 which are passed into the bladder over a fine whalebone bougie as a guide, the beak of the instrument being bridged over or drilled out for a distance of about one-quarter of an inch, so that it can be slipped over the bougie (Fig. 255). If a Syme's staff or 1 Van Buren and Keyes, Genito-Urinary Diseases, p. 127. SPECIAL OPERATIONS. 511 a tunnelled catheter cannot be had, any instrument may be used which can be got into the bladder, but it is a great advantage to be able to pass a full-sized instrument step by step as the stricture is divided. The patient is placed in the lith- otomy position (dorsal decubitus, thighs flexed upon the abdomen, 1 ankles made fast to the wrist, the perineum shaved, the whalebone guide introduced into the bladder, a tunnelled silver catheter of full size, grooved on the convexity, Fig. 255. Fig. 256. Syme's staff for perineal section. passed down over it to the stricture and confided to an assistant, who also draws the scrotum forward out of the way. An incision, vary- ing in length according to the posi- tion of the stricture, is made in the median line, and the end of the catheter exposed. If the stricture is deeply placed the sides of the incision must now be held apart by means of two stout ligatures passed through them, one on each side, while the guide is carefully followed from before backward with short cautious strokes of the knife in the median line, and the catheter pushed along as the route Tunnelled instrument and whalebone guide. 1 A convenient method of keeping the thighs fixed is to pass a stout cane under the knee and fasten it with a cord or roller bandage passed from one end around the patient's neck to the other end. An instrument has been specially constructed for the purpose (Fig. 257), but a stout stick does very well. 512 OPERATIVE SURGERY. is opened, uutil the posterior limit of the stricture having been passed, it slips into the bladder. Care must be taken not to divide the whalebone guide by a careless stroke of the knife. Fig. 257. Clover's crutch, for operations upon the perineum. If Syme's staff is used, the incisiou is carried down until the groove in the curve of the staff can be felt by the finger ; the handle of the staff is then grasped with the left hand, the point of a narrow bistoury passed into the groove behind the stricture, and the latter divided by cutting from behind forward. Any bands that are found on the roof of the urethra must be divided, and a full-sized steel sound passed to make sure that the stricture has been thoroughly relieved. B. Without a Guide. The cases are very rare in which a filiform whalebone bougie cannot be passed through a SPECIAL OPERATIONS. 513 stricture which allows urine to pass, and consequently ex- ternal urethrotomy without a guide is not ofteu required. The patient is placed in the lithotomy position, the perineum shaved, and a full-sized catheter passed down to the stricture and confided to an assistant, who also draws the scrotum forward, keeping its raphe exactly in the median line. An incision, two and a half to three inches long, is made in the median line, and the end of the catheter exposed by open- ing the urethra one-quarter of an inch in front of the stric- ture. The catheter is then partly withdrawn, the sides of the wound held widely apart by means of stout ligatures passed through them, and an effort made to pass a fine probe or whalebone bougie through the stricture from before backward ; if the effort succeeds, the operation becomes one " with a guide," and is completed as before described. If the probe can be passed for only a short distance, a line or two, the tissues are divided upon it, and the attempt re- newed until the canal behind the stricture is reached. If these efforts fail entirely, the urethra must be sought for behind the stricture — a most difficult task unless a peri- neal fistula exists through which a guide can be passed into the bladder, or unless this portion of the urethra is dis- tended with urine and can be punctured in the median line. Van Buren and Keyes 1 recommend that the surgeon should feel for the hole in the triangular ligament, and cut into it through the fibrous mass by repeated strokes with the knife, always in the median line. Others prefer to pass the index finger of the left hand into the rectum, place it against the apex of the prostate, and continue the dissection backward with a view to opening the urethra at that point. When this has been accomplished, a sound is passed from behind forward to the posterior face of the stricture, and the latter divided as thoroughly as possible between the two sounds. If the stricture lies in front of the triangular ligament, the centre of the arch of the pubes is an invaluable guide, toward which the incisions should be constantly directed. Perineal Urethrotomy for Exploration of the Bladder (Thompson). The instruments needed are a median grooved 1 Diseases of the Genito-Urinary Organs with Syphilis, p. 125. 514 OPERATIVE SURGERY. staff and a long straight, narrow-bladed knife, with the back blunt to the point. Having placed the left index fiuger in the rectum and introduced the staff, the knife is introduced, edge upward, about three-quarters of an inch above the anus, with or without a small preliminary incision of the skin, until the point reaches the staff about the apex of the prostate, where it divides the urethra for half an inch, and is then drawn out, cutting upward a little in the act, but so as to avoid any material division of the bulb. The index finger is then slowly passed into the bladder through the wound as the staff is withdrawn, and the interior of the bladder explored with the aid of firm pressure above the pubes with the other hand. EXSTROPHY OF THE BLADDER. The first operation for the relief of this deformity was performed, according to Gross, by Prof. Paucoast, of Phila- delphia, in 1858 ; according to Erichsen, by Dr. Daniel Ayres, of Brooklyn, in 1859. The deformity is much more frequent in males than in females, aud the operative indi- cation is to cover in as much as possible of the exposed mucous membrane and facilitate the adaptation of a urinal by making the urine escape through a comparatively small opening; for, as the sphincter cannot be restored, there will always be incontinence. The method employed is the same as NSlaton's for epispadias : a tegumentary flap is raised from the abdomen above the bladder, reversed so as to cover the latter, and then covered itself in turn by lateral (laps, one from each side. The first flap (Fig. 258) should be square, its base ad- joining and slightly broader than the upper margin of the opening, its length should be sufficient to cover in the bladder completely when turned down over it. A pyriform flap is dissected up on each side, its breadth equal to the length of the first flap, and its base directed downward and inward, as shown in Fig. 258, or downward and outward so as to require less twisting and include more of the cuta- neous branches coming from the femoral artery. These two flaps are then drawn across the reversed umbilical flap, SPECIAL OPERATIONS. 515 meeting in the median line, and are fastened to each other with twisted sutures, the pins including a portion of the thickness of the umbilical flap also, so as to keep the raw surfaces in contact (Fig. 259). Fig. 25S. Fig. 259. Wood's operation for exstrophy of the bladder. Incisions. Flaps in place. The edges of the gaps left by the removal of the flaps are drawn together as well as possible with twisted and wire sutures, broad strips of adhesive plaster applied to give support aud relieve tension, and the patient kept in bed in a sitting posture with the knees drawn up. The sutures may be removed at the end of a week. Healing may be hastened by using Thiersch skin grafts on granulating sur- faces. When the symphysis is absent Trendelenburg first per- forms an operation to remedy the epispadias. Later he divides the sacro-iliac synchondrosis on each side from behind forward, sufficiently to mobilize the iliac bones and allow the gap in front to be closed by pressing together the sides of the pelvis. Subsequently the margins of the defect in the soft parts are freshened and brought together with sutures. This may need to be supplemented by a flap operation aud Thiersch skin grafts. Czerny, starting at the edges of the defect, frees the mucous membraue from the underlying parts and sutures its margins together to form a closed sac. Then this is 516 OPERATIVE SURGERY. covered in by two lateral flaps, base down, as in the first operation described. Afterward the neck of the bladder and the freshened edges of the prostatic portion of the urethra are brought together, and then the epispadias is attended to. A perfect result in this condition is an impossibility. Even if no fistula persist the sphincter will not, at the best, be of much value, and the wearing of some sort of urinal is a necessity. CATHETERIZATION (WITH CURVED METAL CATHETER). The obstacles to the passage of a catheter, exclusive of stricture and of false passage, are found either at the trian- gular ligament in the membranous or in the prostatic por- tion of the urethra. As the fixed portion of the canal begins anteriorly at the opening in the subpubic or triangular liga- ment, the flaccid pendulous portion in front of this point may be carried aside if the catheter is held improperly, and doubled upon itself in front of the beak of the instrument, thus forming a sort of pouch or cul-de-sac which arrests the progress of the catheter. This difficulty is overcome by drawiug the penis gently up the shaft of the instrument so as to straighten out the portion of the canal yet to be traversed, and by keeping the beak in the median line and making it follow the roof rather than the floor of the urethra, so as to avoid especially the normal pouch-like dilatation found on the under side just in front of the opening in the ligament. The obstacle in the membranous portion is caused by the spasmodic contraction of the muscles which envelop this part of the canal. The nature of the obstruction is recog- nized by the tight grasp of the instrument by the muscles, the quivering of the fibres transmitted through it to the hand of the surgeon, and by the knowledge of the fact that the instrument has reached this part of the canal where organic obstacles do not often exist. The difficulty is over- come by making gentle pressure with the beak of the ca- theter in tin; proper direction, so as to tire out the muscles. The most serious obstacle is found in the prostatic por- SPECIAL OPERATIONS 517 tion, aud is due either to inflammatory swelling of the mu- cous membrane or of the gland (abscess of the prostate), or, much more commonly, to senile change in the shape and size of this organ. A description of the nature of • Fir 260 these changes aud lesions does not come within the scope of this work, and the reader is referred for them to special treatises upon the subject. It is sufficient here to say that in the former case the inflammation must be reduced or the abscess evacu- ated secundum artem, or, failing this, the bladder must be punctured above the pubes, or through the rectum. In the other case, catheters of different curves should be tried, such as Mott's long catheter of large curve, or Mercier's soft, single or double- elbowed catheter (Fig. 260). It is also well to pass the forefiuger of the left hand into the rectum to make sure that the catheter has entered at the apex of the prostate, aud that it has not passed out of the canal into a false passage, and to try to lift its beak over the obstacle by making direct pressure upon the curve in front of the prostate, while the handle is simultaneously depressed. If these means fail, and soft instruments of gum or vulcanized rubber cannot be introduced, the bladder must be punctured. Passage of the Catheter. The patient having been brought to the side of the bed or placed upon a lounge, the surgeon, standing on one side, pre- ferably the left, separates the lips of the meatus with the thumb and forefinger of the left hand, in- troduces the beak of the catheter, previously well warmed and oiled, and passes it down to the peno- scrotal augle, holding the shaft of the instrument Mt parallel to the groin. He then sweeps the handle Mer- around to the median line of the abdomen, keeping cier ' s it close to the surface, draws the penis gently up the ^^eter shaft, and presses the instrument bodily downward toward the feet ; as soon as the beak reaches the lower border of the symphysis he draws the scrotum up and presses the catheter gently onward, still holding it parallel to the body, aud then when the beak has closely approached or 23 5 1 8 OPERATIVE S UBOER Y. engaged in the opening in the triangular ligament he gradu- ally raises the handle, brings it forward in the median line, and depresses it between the thighs. Failure to enter the opening in the triangular ligament is indicated by the bulg- ing of the curve of the instrument in front of the sym- physis, its rebound when the slight pressure on the handle is removed, and the mobility of the beak when the handle is gently rotated about its longitudinal axis. As the shaft passes the vertical line the root of the penis and the integument covering the symphysis should be pressed down with the palm of the right hand laid broadly upon it, so as to stretch the suspensory ligament. PUNCTURE OF THE BLADDER. Above the Pubes. The only instrument required is a straight, or, better, a curved trocar and cauula, the trocar having a groove in its side which permits a small stream of urine to pass as soon as the bladder is reached. The sur- geon satisfies himself by percussion that the distended blad- der rises well above the pubes, and then making the skin tense with the thumb and fingers of his left hand, he plunges in the trocar close above the symphysis pubis in the median line, the concavity of the instrument turned toward the bone. Some surgeons prefer to make a preliminary incision in the median line, and others (Holmes) even continue the use of the knife until the bladder can be felt at the bottom of the wound. LITHOLAPAXY. It is the operation of introducing a lithotrite into the bladder through the urethra and with it crushing a stone into fragments, which are then removed by the wash bottle and evacuators represented in Fig. 266. The modern lithotrite is a steel instrument consisting of a straight shaft eleven inches in length, having at one end a " beak " about an inch long inclined at an angle of from 110° to 130°, and at the other a cylindrical roughened SPECIAL OPERATIONS. 519 handle containing a screw. It is composed throughout of two parts, one fitting accurately in a deep groove in the other, and having at the handle a male screw which can be thrown into and out of gear by means of a button upon the other part. While trying to catch a stone the screw should be out of gear, in order that the male blade may be advanced and withdrawn more rapidly, but when the stone has been fairly caught the button must be pressed back and the screw-power used to crush it. Many different patterns have been proposed for the beak 520 OPERATIVE SURGERY. or jaws with the view either of securing the thorough pul- verization of the fragments, or of preventing the clogging of the instrument by the impaction of the mortar-like detritus between the jaws. The latter difficulty can be overcome by leaving the jaw of the female blade entirely open, that is, with a large fenestra extending from side to side and from the extremity of the beak to its angle, and by making the male blade long enough to allow its jaw to be passed entirely through the female one and even to project beyond its con- vex surface. In its simplest terms, then, the jaws should consist of two parallel bars, one-fourth of an inch apart, between which a third one, fitting loosely in the gap, can be forced. Of course, the male jaw must not be allowed to project beyond the convex surface of the female one during its passage through the urethra. A small fenestra at the angle of the beak will not prevent clogging, although it may diminish it if there is a cor- responding projection at the heel of the male jaw, as in Fig. 263. " Scoop" lithotrite. Fig. 263 ; and it is open to the very serious objection that it may lodge a sharp angular fragment, which, projecting beyond its edges, will lacerate the neck of the bladder and the floor of the urethra during the withdrawal of the instru- ment. The arrangement of open spaces in the female jaw cor- responding to guttered projections or teeth upon the male jaw, as in Reliquet's model, is entirely insufficient to prevent clogging. The detritus packs across the gaps and presents ;iii absolute bar to the closing of the instrument. Whenever SPECIAL OPERATIONS. 521 such corresponding teeth and spaces are used they should be cut to fit each other very loosely, that is, with a clear space of at least one millimetre between them. For catching and crushing small fragments the "scoop'' lithotrite is commonly used ; the jaw of its female blade is broad and shallow, with no fenestra or with only a small one at its angle. The edges of both jaws should be bevelled, and the male considerably narrower than the female, so that they maybe brought together with the least pos- sible danger of including a fold of mucous membrane between them. Prof. Bigelow, 1 of Boston, re- commends an instrument (Figs. Fig. 264. Bigelow's lithotrite 264 aud 265) combining, as he claims, the advantages of the fenestrated and the scoop lithotrites. The female jaw 1 The American Journal of the Medical Sciences, Jan. 1878. 522 OPERATIVE SURGERY is shallow, so that small fragments are easily caught and crushed in it, and clogging is prevented by deep notches opening outward on the sides of the male jaw (Fig. 265), and by a small fenestra at the angle to provide for the escape of the detritus engaged in the groove of the female blade. He also substitutes for the button on the handle of Thomp- son's lithotrite, a mechanism partly shown in Fig. 264, by which the screw can be thrown into gear by a turn of the hand holding the end of the male blade ; and, further, curves the beak of the instrument to facilitate its passage through the prostatic urethra. It must be admitted, how- ever, that with a soft, phosphatic stone the instrument will become impacted ; and when the stone is large and hard the connecting catch is liable to be torn away. I prefer, therefore, the instrument recommended by Prof. Keyes (Fig. 262) ; it cannot clog, and the lateral catch cannot be broken by any force exerted through the screw. Operation. The patient is anaesthetized and placed upon his back, with his hips raised upon a firm pillow or cushion in order that the stone may gravitate away from the neck of the bladder. If the urine is turbid, and especially if it is ammoniacal, it should be drawn off before the operation and the bladder thoroughly washed with a borax solution (one or two drachms to the pint), of which from two to four ounces should be left in the bladder to facilitate the crushing. The surgeon, standing at the patient's right side, introduces a freshly boiled lithotrite after greasing the in- strument with vaseline. Great care must be taken not to depress the handle too soou, a mistake which is likely to be made on account of the apparently great depth to which the instrument has to penetrate before the bladder is reached. As soon as the instrument has entered the bladder, it is allowed to glide across it, its shaft being held steadily in one position, and if the stone is free it will generally be touched on the way. The surgeon then gently turns the beak away from the stone, withdraws with his right hand the male blade for a distance determined by previous measure- ment of the stone, presses the jaw of the female blade gently against the floor and posterior wall of the bladder, rotates the beak toward the stone, and closes the male blade upon it. As soon as the stone is felt to be firmly caught, SPECIAL OPERATIONS. 523 the beak is rotated back to the vertical position, and the screw thrown into gear by pressing back the button on the handle with the thumb of either hand. The lithotrite with the stone in its grasp is then drawn away from the pos- terior wall and rotated to either side to make sure that the mucous membrane is not caught between its jaws, and then, grasping the cylindrical handle firmly with his left hand, the surgeon crushes the stone by turning the screw with his right, and continues this action until the register upon the handle shows that the male blade has been driven well home. The screw is then thrown out of gear, the male blade drawn back, the beak turned again toward the spot where the stone was caught, and the instrument closed whether the fragments are felt or not, for it may be confi- dently expected that they will be found there. Evacuating-tube and washing-bottle. After crushing the stone in this manner several times the smaller fragments are washed out by the evacuating tube and washing-bottle (Fig. 266) and the lithotrite reintro- duced ; and this alternation in the use of the instruments is continued until the bladder is emptied. This frequent washing is important because by the removal of the smaller 524 OPERATIVE SURGERY. fragments it is made easier to seize and crush the larger ones. The washing is done as follows : The washing-bottle is filled with tepid water, then the tube is introduced, and as soon as the urine begins to flow through it the bottle is coupled to it. Or the coupling may be done just before the tube has entered the bladder, and the air in the tube allowed to rise to the top of the bottle, by turning the stopcock, before the introduction is completed and the washing is begun. By quick compression and relaxation of the rubber bulb the water is rapidly forced into the bladder and drawn back again, bringing the fragments with it ; these fragments sink to the bottom of the bottle and are not returned with the returning stream. The amount of water driven back and forth at each movement will vary with the sensitiveness and distensibility of the bladder ; two or three ounces are suffi cient to wash effectively. If the curved tube is used, its eye should be in turn directed to different quarters of the bladder ; if the straight tube with a square end is used, it must be passed just through the neck, and its outer end well depressed between the thighs. At the close of the operation the surgeon should place his ear upon the hypogastrium and listen while washing, to detect the click against the tube of any fragments that may remain. This is a much more delicate test than the use of the searcher. LITHOTOMY. The anatomy of the perineum is sufficiently well shown in Fig. 267 to render a detailed description unnecessary. It must be remembered, however, that the distance between the anus and the bulb diminishes with advancing years, and that the diminution of the distance is due to an increase in the size of the bulb. The dangers incident to incision of the bulb increase, therefore, with the difficulty of avoiding it. The dimensions of the prostate have been studied with much attention, and have been the basis of many of the modifications of perineal lithotomy, for it has been held, mid still is held by many, that the incision should not be SPECIAL OPERATIONS. 525 carried beyond the limits of the gland. The greatest radius, measuring from the urethra, is one inclined about 30° back- ward and downward from the transverse diameter, and in the normal adult prostate this measures about three-quar- PlG. 267. Avtery of corpus cavernosum Dorsal artery of penis Artery of bulb. Internal pudic artery J| Cowpefs gland. A view of the position of the viscera at the outlet of the pelvis. ters of an inch at the largest part of the gland, that which adjoins the neck of the bladder. But, as the diameter of the prostate diminishes as the distance from the bladder in- creases, an incision which remains within its limits at one point may extend far beyond them at another ; and this fact, taken in connection with the great variations in the size of the gland, indicates the futility of attempts to regu- late the incision with mathematical precision. Fortunately, the depth of the incision is not a measure of the size of the 23* 526 OPERATIVE SURGERY. stone which can be safely removed through it, for the nor- mal dilatability of the neck of the bladder and the prostatic portion of the urethra (to a diameter of two centimetres, ac- cording to Dolbeau) is thought to be considerably increased by even slight incisions. Dupuytren thought the opening in the prostate could be greatly enlarged by making an oblique incision on each side (bilateral lithotomy), but the gain has not proved so great as was expected. Fig. 268. Incision in lateral lithotomy ; the dotted lines mark its limits. A. Vas deferens. B. Seminal vesicle. C. Continuation of the capsule or prostato-peritoneal liga- ment. By reference to Figs. 268 and 269, which show the ex- tent of the incision of the prostate and neck of the bladder in lateral lithotomy, it will be seen that the limits of the prostate are exceeded everywhere, the capsule remaining intact, however, for a distance of about half an inch at the thickest part of the gland. The sulcus between the bladder and the prostate is opened, and the bladder wall divided for fully half an iuch in the direction of the orifice of the left ureter. These figures are taken from a dissection of a cadaver upon which lateral lithotomy had been performed for the purpose of determining these points. 1 If the stone is large and the tractions made with too much force, the neck of the bladder may be torn off, but more commonly the incision is lengthened by tearing at its outer i The incision was made as if for the removal of a stone one inch in diameter. The cadaver was tliut of a mulatto ahout twenty-five years old. SPECIAL OPERATIONS. 527 end, an accident which is much less dangerous than extend- ing the incision with the knife would be, for it spares the rich plexus of veins about the prostate. Fjg. 2C9. Lateral lithotomy. Incision of the neck of the hladder as seen from within. A is a rent in the wall made by the introduction of the finger. B is an extension of the incision involving only the mucous membrane. Lateral Lithotomy. The instruments required are a staff with a long curve, deeply grooved on its convexity (Fig. 270), a stout scalpel with a cutting edge of one and one- half inches (Fig. 271), a Blizard's kuife (Fig. 272), a blunt gorget (Fig. 273) if the patient is fat, a scoop (Fig. 274), forceps of different patterns (Figs. 275, 276, 277), a syringe and tube for washing out fragments, and a shirted canula (Fig. 278) to control hemorrhage. The latter can be readily made by passing the beak of a female silver catheter through the centre of a piece of iodoform gauze eight inches square, and tying the two firmly together, as shown in the figure. It is then introduced into the wound, the beak of the catheter in the bladder, the pouch tightly packed afterward with pledgets of gauze, and the whole kept in place by a T-bandage. Three assistants, at least, are required : one to administer the anaesthetic, the others to hold the knees and the staff. 528 Fig. 270. OPERATIVE SURGERY. Fig. 271. Fig. 272. Fig. 273. Fig. 274. Gorget. Scoop. Lithotomy stall. Operation. 1 The patient, having had his bowels emptied by an enema, is placed upon his back, his ankles bound fast to his wrists (Fig. 279), the staff introduced, and the stone touched with it. It is an absolute rule that if the stone > Van Buren and Keyes : Genito-Urinary Diseases and Syphilis, p. 335. SPECIAL OPERATIONS. 529 cannot be felt with the staff or a searcher after the patient has been etherized and placed upon the table, the operation must be postponed. It is not necessary that the beak of the staff should rest upon the stone during the operation ; Fig. 275. Figs. 276, 277. Fig. 278. Shirted canula. on the contrary, it is better to hook the staff up under the symphysis so as to keep it steady, with its curve bellied out in the median line of the perineum, and the integument stretched over it by drawing the scrotum up around the staff. The operator passes his index-finger into the rectum, and satisfies himself that the staff enters at the apex of the pros- tate and passes centrally through it, and that the rectum is empty. Then withdrawing his finger he feels along the raphe of the perineum for the groove in the staff, aiding himself, if necessary, by depressing and raising the handle several times. 530 OPERA TIVE S URGER Y. Having found the groove he confides the staff to his chief assistant, enters the scalpel a little to the patient's left of the raphe, from one and one-quarter to one and one-half inches in front of the anus, and passes it in almost parallel to the rectum so as to enter the groove about half an inch in front of the apex of the prostate, guiding it, if he thinks Fig. 279. Position of patient and line of incision in lateral lithotomy. best, by keeping his left index-finger upon the prostate in the rectum. (If the knife should be passed directly in to the nearest point on the staff, the bulb would be involved to an unnecessary extent.) As soon as the point of the knife has entered the groove, it is pushed along for half an inch, dividing the floor of the urethra to that extent, and then withdrawn, cutting steadily downward and outward so as to make a cutaneous incision about three inches long, passing midway between the anus and left tuber ischii. The probe-pointed Blizard's knife, guided upon the left index-finger, is passed into the groove, and the surgeon takes the handle of the staff from the assistant, depresses it somewhat, and pushes the knife along until its point is ar- rested at the termination of the groove at the end of the staff. Then depressing the handle of the knife, and bear- ing in mind the shape and position of the prostate, he SPECIA L OPER A TIO NS. 531 makes an incision in it downward and outward at an angle of about 30° with the horizon (Fig. 280). The index-finger is next introduced, the staff withdrawn, and the neck of the bladder gently dilated with the finger, or, if the perineum is deep and fat, with the blunt gorget carried in along the groove in the staff. If the stone is more than an inch in diameter, the Blizard knife must be reintroduced and the prostate cut upon its right side also. Fig. 280. Lateral lithotomy. Relations of the two incisions to each other and. to the prostate. (Thompson.) The forceps are then introduced as the finger is with- drawn, and the stone sought for by opening and closing the blades at different poiuts on the floor of the bladder ; or the small end of the scoop may be introduced, placed in contact with the stone, and the forceps guided along it. If the stone is seized in a faulty direction, it must be dropped and caught again, or straightened with the fingers while still held between the blades. Extraction should be made slowly downward and outward in the line of the external 532 OPERATIVE SURGERY. incision, and aided by lateral movements of the handles. The old rule was that the force used should be two-thirds lateral, one third extractive. If it is found that the stone is too large to be removed without employing too much force, it must be crushed and the fragments removed sep- arately. Small stones and fragments are best removed with the scoop and by thorough washing. In operating upon children certain modifications are re- quired. The prostate being very small the incision usually passes quite beyond its limits, but this is a matter of slight importance since the ill results which follow in adults and old men do not occur at this age. If the incision in the urethra and at the neck of the bladder is not sufficiently free, it may happen that, in the attempt to introduce the finger, the urethra will be torn entirely across and the blad- der pushed up before it. Again, the bladder is placed higher in the child than it is in the adult, aud therefore the point of the knife must be more raised in making the deep incision, and care must be taken not to let it slip in between the rectum and bladder. Mr. Erichsen 1 says he has known this to occur in several instances, and the for- ceps to be passed into this space under the impression that it was the bladder. It has also happened to some surgeons to force the beak of the staff through the roof of the urethra into the space between the bladder and posterior face of the pubes, and to be so deceived by its freedom of motion in the loose cellular tissue of that region that they thought it was in the bladder, aud cut upou it accordingly. Median Litlbotomy. The only instruments required other than those used in the lateral operation are a staff, director, and knife. The staff has a central, broad, deep groove on its convexity (Fig. 281), the director has a ball-point (Fig. 282), and the knife is straight, stout, and sharp-pointed, with a cutting edge upon the back also for a short distance from the point (Fig. 283). The patient having been bound in the lithotomy position and the staff introduced, the surgeon places his left index- 1 Science and Art of Hurgery, vol. ii. \<. 682, Phila., 1878. SPEC! A L OPERA TIONS. 533 finger in the rectum against the apex of the prostate, and plunges the knife with its edge upward into the raphe of the perineum half an inch in front of the anus in such a direction that its point will enter the groove of the staff just at the apex of the prostate. The knife is pushed very Fig. 281. Fig. 282. Fig. 283. Staff for median lithotomy. Ball-pointed director. Double-edged scalpel. slightly back along the groove so as certainly to open the urethra and nick the end of the prostate, then brought for- ward, dividing the membranous portion of the urethra, and swept around the bulb by raising the handle, making an external incision upward along the raphe for about one and 534 OPERATIVE SURGERY. a quarter inches. The director is next passed along the staff into the bladder, the two separated angularly to make partial dilatation of the neck, the staff withdrawn, and the dilatation completed with the finger. The forceps are then introduced and the stone removed as in lateral lithotomy. Frn. 284. Median lithotomy with rectangular stafl'. Sir Henry Thompson makes the incision from without inward, and Mr. Erichsen uses a rectangular staff (Fig. 284), placing its augle close against the apex of the prostate. SUPRAPUBIC CYSTOTOMY FOR VESICAL CALCULUS. The patient aud the skin surface are prepared in the usual way for an aseptic operation, and after etherization the bladder is irrigated clean with a warm saturated solution of boric acid. The viscus is then distended with as much of this solution as can be injected from an irrigator vessel ele- vated not more than two feet ; such a pressure is harmless, while the injection of a fixed amount of fluid or the use of a hand syringe may not be, owing to the uncertainty as to the capacity of the bladder and the condition of its walls. The catheter is then withdrawn from the urethra and a thin-walled soft-rubber bag, which is better than the ordi- nary stiff colpeurynter, is placed in the rectum above the sphincter and cautiously distended by a Davidson syringe, SPECIAL OPERATIONS. 535 using not more than eight or ten ounces of water. This simply presses the bladder forward and brings its floor more within reach, but it does not materially alter the rela- tion of the peritoneum to its anterior wall, and hence the use of the colpeurynter can frequently be dispensed with. After filling the bladder it is unwise to constrict the penis, as is so often done, but the urethra should be left free to relieve any excessive strain on the bladder wall. An incision two or three inches long is then made in the median line from just below the upper border of the sym- physis pubis upward in the median line and deepened layer by layer as nearly as possible between the recti, and the underlying fascia is divided. If more space is required the recti and fascia can be cut transversely to a greater or less extent close to the pubes. The peritoneum does not descend below the urachus, which cau sometimes be felt as a cord attached to a knot on the fundus, and by carrying the dissection directly inward through the prevesical fat with blunt-pointed scissors, aided by the finger, and avoiding unnecessary laceration of the tissues, the bladder is exposed; after pushing upward the fatty and cellular tissue which carries the peritoneum with it, a tenaculum is inserted in the highest-exposed part of the bladder wall and a knife is plunged into it just below the tenaculum, opening the bladder longitudinally downward for about an inch. Each side of the incision is immedi- ately grasped by catch forceps which serve to hold the opening in the abdominal wound. The peritoneum may descend unusually low in front, and this must be recognized in the dissection, which in such cases should be first downward and inward behind the pubes and theu up over the anterior surface of the bladder, push- ing the unopened peritoneum out of the way ; the numer- ous veins which are encountered are drawn aside or ligated as they are divided, but it is unnecessary to waste time searching for bleeding points, as the hemorrhage generally ceases spontaneously on opening the bladder. The interior of the latter is then carefully explored by sight and touch, and any loose stones are picked up with instruments, preceded, if necessary, by crushing ; the mouth of a diverticulum containing a stone may have to be gently 536 OPERATIVE SURGERY. dilated, but never cut, and the stone scooped or irrigated out, or first nibbled into fragments by forceps ; projecting portions of the prostate preventing the free escape of urine are excised as described under prostatectomy, and finally the interior of the bladder is washed free from all clots and debris with warm boric solution. As a general rule, a wound in a comparatively normal bladder wall should be closed with sutures, but if there is much pus or inflammatory change present it is better to leave the wound open. To insert the sutures a blunt tenaculum is placed in each extremity of the incision in the bladder, lifting up and steadying it. Interrupted sutures of chromicized catgut are then inserted by a fine-curved needle at intervals of a quarter of an inch close to the edges of the wound and passing through the cut surface without entering the thin Pig. 285. Muscular coat Mucous coat Method of suturing a wound of the bladder. mucous membrane; over and between these is placed a row of chromicized catgut Lembert sutures extending a short distance beyond the extremities of the incision, and after all the sutures have been tied the bladder is filled with boric solution to test their efficacy. Weak points are then reinforced by additional Lembert sutures. An iodoform -gauze packing is placed in contact with this suture line, and if considered necessary one or more rubber drainage tubes can be added ; the abdominal wound is then partially closed with silk sutures, a couple of which are left untied till the drainage is removed several days later if all goes well, when the wound can be closed tight. SPECIAL OPERATIONS. 537 An antiseptic dressing is applied and a catheter for con- tinuous drainage is fastened in the bladder through a peri- neal puncture as described under external urethrotomy by McBurney's gorget. Some surgeons prefer to leave the unne to escape by its natural path, or tie a catheter in the urethra for a day or two. In about half of the properly selected cases primary union of the bladder may be expected. If the bladder wound must be left open its lips may be temporarily fastened in the margins of the abdominal inci- sion, and the latter is partially closed above and below, while a light iodoform-gauze packing is placed in any pockets which may have become infected around the opening in the bladder. A rubber drainage tube with lateral perforations near its lower extremity is then inserted into the deepest part of the bladder, and the other extremity passing out of the wound is connected with a tube which terminates be- low the surface of a 1 : 60 carbolic solution contained in a bottle under the bed. To favor the intended siphon action of the tube, at its exit from the bladder it is surrounded by a tight iodoform- gauze packing, but still a large proportion of the urine will inevitably escape into the dressings, which will need very frequent renewal ; no other drainage is required. The tube is prevented from slipping out by a silk suture passed through it and the skin. Transverse Incision. If the bladder is very contracted and it is deemed unsafe to use the rectal bag, so that the bladder must be sought at a greater depth than usual, a transverse incision dividing both recti gives easier access to it. This incision, slightly convex downward, is made close along the upper margin of the symphysis and extended about two inches to either side of the median line. After it has been carried through the recti and fascia into the pre- vesical space the subsequent operations are as above de- scribed. Langenbuch divides the suspensory ligament of the penis and exposes the lower part of the bladder below the pubes by an inverted ^-incision. The vertical limb lies over the symphysis and the oblique ones follow the edges of the descending rami of the pubes. 538 OPERATIVE SURGERY. PROSTATECTOMY. Suprapubic. The rectal bag is inserted and filled, and the bladder is opened and washed out, as already described, and if the enlargement is pedunculated it is simply sur- rounded with or without transfixion by a silk ligature, the ends of which are left long and brought out of the abdom- inal wound, while the mass is left to slough away or is immediately excised with scissors. When the projection cannot be ligated it may be removed with the ecraseur or galvano-cautery. The uniform " collar " projection of the prostate is excised by dividing its margins transversely above and below, and shelling out each semi- circular half with the fingers after incising the mucous membrane on the summit of the ridge. Keyes strongly recommends the use of the rongeur for- ceps to cut away the hypertrophied posterior lip of the orifice. In no case should any portion of the projecting valve be left behind, and finally the patency of the urethral canal is ascertained by the passage of the finger as far as the first joint. Hemorrhage is controlled by packing with iodoform gauze or by the cautery. At the close of the operation the extremities of the abdominal wound are drawn together around the opening in the bladder, which, if possible, is sutured to the margins of the wound, while all spaces which are liable to infection are packed with iodoform gauze, and a siphon drain is placed in the bladder. Perineal Prostatectomy. The urethra is opened in the membranous portion for about an inch or an inch and a half by an external urethrotomy, and after inserting a gorget the finger is passed to the bladder by gradual dilata- tion of the urethra and the projection located and explored. The finger must then be withdrawn to make room for the ecraseur, galvano-cautery, or one of Thompson's forceps, by which the growth is snared or torn from its attachments. Hemorrhage is checked by irrigation with very hot or very cold water, or by packing, and the subsequent treat- ment is the same as for external urethrotomy. This method SPECIAL OPERATIONS. 539 is seldom used because of its limited applicability and the difficulty of manipulation. For hypertrophy of the lateral lobes of the prostate Dittel 1 proposes an incision from the coccyx to the median line of the perineum, passing around one side of the sphincter. The dissection is carried down to the prostate in front and at the sides of the rectum, which is rendered prominent by packing, and a cuneiform section is removed from the enlarged portions of the gland like a tumor, with- out opening the urethra. The resulting wound is then drawn together with catgut and a strand of iodoform gauze inserted for drainage. Enlarged Prostate Treated by Castration. Cases of hy- pertrophied prostate complicated by retention and cystitis have been successfully treated by White, of Philadelphia, and others by castration. The prostate atrophies within a year or less and the obstruction to the escape of urine thus disappears. The operation is simpler and less dangerous than prostatectomy, and the results have been satisfactory. TUMORS OF THE BLADDER. The bladder is rendered as aseptic as possible by wash- ing and is then explored by a suprapubic cystotomy. When malignant disease is found lying near the fundus (which is its rarest location), and of limited extent, a sponge is placed iu the interior of the bladder to soak up all the urine, and if the peritoneal cavity must be opened to effect a thorough removal of the disease, it is protected by a sponge packing and the bladder wall divided with scissors, including the peritoneum, if necessary, well outside the limits of the growth. The peritoneal part of the wound in the bladder is then closed by Lembert silk sutures, which must not enter the mucous membrane, the protective packing removed, after thorough cleansing of the abdominal cavity, and the peri- toneum above the bladder drawn together with catgut. 1 Wien.rued. Wocli., 1890, No. 1S-19. 540 OPERATIVE SURGERY. The rest of the bladder wound is treated as in simple supra- pubic cystotomy. If the cancer occupies the sides or base of the bladder most surgeons, in this country at any rate, advise against an attempt at radical removal and are content with curet- ting to ameliorate symptoms. A few successful cases are reported in which the disease has been removed with the surrounding mucous membrane, but leaving the muscular coat from which the growth is sometimes found separated by a layer of fat. Helferich 1 resects the pubes through a transverse incision above the symphysis and so gains access to the anterior sur- face of the bladder. Niehans 2 performs a very similar operation which he calls an osteoplastic resection of the pubes. Zuckerkandl 3 exposes the base and adjacent posterior surface of the bladder by a curved transverse incision through the perineum in front of the anus and rectum, which are turned down and drawn back. (See removal of seminal vesicles.) Bramann 4 chisels out a small piece of the symphysis, in- cluding the portion connected with the recti, by a T-shaped incision, the horizontal limb lying above the pubes between the cords and the vertical over the symphysis ; at the con- clusion of the operation the bone is sutured back in posi- tion and the patient fixed in a half-sitting position with the legs flexed. For total extirpation of bladder or its mucous membrane, see American Journal of the Medical Sciences, January, 1891, p. 101, and Wien. med. Presse, 1889, No. 27-28. Benign growths which are more or less pedunculated are treated in the manner described for suprapubic prostat- ectomy and their bases scraped or cauterized or touched with a ten per cent, solution of chloride of zinc. If the tumor has a small enough pedicle, the latter can be grasped by a pair of forceps close to the bladder wall, and the tumor twisted off on the distal side of the forceps, which are held immovable ; but unless all portions of the growth i Archiv f. Klin. Chir., 1888, p. 625. 2 Centralb. f. Chir., 1888, p. 521. ; Wien. med, Presse. 188'.). No. 21-22. * Centrul.b. f. Chir., 189:!. No. 17. S FECI A L OPERA TTONS. 541 are removed it is liable to recur. Benign tumors can oc- casionally be torn from their attachment by forceps intro- duced through an external urethrotomy wound, but care must be taken not to force the bladder wall into the grasp of the instrument by pressure on the hypogastrium. There is less danger of rupturing the bladder than might be sup- posed, owing to the usual hypertrophy of the muscular coat underlying the tumor. REMOVAL OF THE SEMINAL VESICLES. Zuckerkandl' s Incision. 2 lithotomy position with a sound in tne uretnra to mam its position and the bladder partially filled with a saturated *jwn*,i witiH a jluviowh,. The patient is placed in the lithotomy position with a sound in the urethra to mark its Fig. 286. m; Zuckerkandl's incision for removal of the seminal vesicles. P. Prostate. Vd. Vas deferens, i's. Vesicula seminalis. M. Rectum. solution of boric acid. A slightly curved incision with its concavity towards the anus is made transversely across 1 See also Ullmann : Centralb. f. Chir., Feb. 22, 1890. - Wien. mcd. Presse, 1889, p. 856. 24 542 OPERATIVE SURGERY. the perineum, having its centre about one inch aud a half in front of the anus. From each extremity of this a straight diverging incision about au inch aud a half long passes back on either side of the anus to end near the tuber ischii. After division of the skin and subcutaneous tissue a finger is placed in the rectum and the perineal septum cut through, avoiding the anterior rectal wall. The dissection is deepened till above the sphincter ani, which is then turned down with the rectum while the bulb of the urethra is pushed forward, and the pubic portion of the levator ani is divided on each side of the prostate. Free hemorrhage may be expected from the hemorrhoidal and prostatic plexus of veins, but it is easily controlled by pressure or clamps. Then, by tearing through the loose connective tissue, the rectum is easily separated a little more fully from the bladder, the base of which can be made more prominent by manipulating the sound, and the pros- tate, vasa deferentia, and seminal vesicles are brought into clear view. It only remains to dissect off one or both vesicles and to ligate the corresponding vas deferens with catgut. The wound is closed and dressed antiseptically with a rubber drainage tube and light iodoform-gauze packing in its most dependent angles. The vas deferens, cord, and testicle can be extirpated at the same time by an incision starting over the internal ab- dominal ring and passing down through the inguinal canal into the scrotum. This incision is deepened layer by layer above the pubes, the peritoneum recognized and pushed up, and then by working with the fingers from above and below (through Zuckerkandl's incision) the vas can be separated from the bladder and pulled out through the opening in the abdominal wall. SPECIAL OPERATIONS 543 CHAPTER VII. OPERATIONS UPON THE GENITO-URINARY ORGANS OF THE FEMALE. CATHETERIZATION. The surgeon, standing on the right side of the patient and holding the catheter in his right hand, with its convex- ity lying on the palmar surface of the index-finger and its beak not quite reaching to the end of the distal phalanx (Fig. 287), separates the nymphse with the thumb and mid- dle finger of his left hand, introduces his right index-finger at the fourchette and brings it forward, recognizing the entrance to the vagina and its anterior border, and stopping when he feels the pouting orifice of the urethra. Then keeping the pulp of the finger below and in contact with the orifice he passes the catheter in. Fig. 287. Mode of holding the catheter. Unless there is some reason to the contrary, this should always be done without exposure of the parts. EXTERNAL URETHROTOMY. The Buttonhole Operation (Emmet) (Fig. 288). The patient is anaesthetized and placed on the left side, and the 544 OPERATIVE SURGERY. fourchette retracted with a small Siras's speculum. A full- sized metal sound is introduced iuto the urethra, then the tissues in the vaginal surface are caught up with a tenacu- lum and divided longitudinally midway between the meatus and the neck of the bladder. The incision may then be extended with scissors. Neither the neck of the bladder Fig. 289. nor the meatus should be divided. If the incision is to be kept open, the urethral mucous membrane must be drawn SPECIAL OPERATIONS. 545 out through it and stitched with catgut to the edge of the divided vaginal surface. The incision may be conven- iently made with Emmet's buttonhole scissors (Fig. 289). LITHOTOMY. Besides the suprapubic, which is performed in the man- ner already described, there are the urethral and vesico- vaginal operations. In the former the stone is removed through the urethra after the calibre of this canal has been increased by an incision along its anterior (upper) wall, or on one or both sides, incisions which do not extend into the vagina. In the latter the stone is removed through an in- cision made in the vesico- vaginal septum. Urethral Lithotomy. The only instruments actually re- quired are a director, a probe-pointed knife, and forceps, but some surgeons prefer to make the incision with a single or double lithotome introduced alone or upon a director. Lateral incisions should incline upward rather than down- ward ; consequently, if the double lithotome is used, its concavity should be turned toward the symphysis. The extraction of the stone requires no additional description. Vesico-vaginal Lithotomy. The patient may be placed in the usual lithotomy position, or upon the side, or upon Fig. 290. Sims's speculum. the face. A Siras's speculum (Fig. 290) is pressed against the posterior wall of the vagina, and a grooved catheter in- 546 OPERA TI VE S UBGEB Y. troduced into the bladder and confided to an assistant, who keeps it pressed well against the vesico- vaginal septum. Guiding his knife upon the groove the surgeon makes an autero-posterior incision in the median liue of the anterior wall of the vagina, about one inch in length, and not in- volvingthe neck of the bladder, passes in his index-finger, and then the forceps upon the finger as a guide. Emmet places no sutures, but allows the wound to close spontaneously, keeping the bladder clean by frequent washings. Guyon closes the incision immediately with sutures. In a discussion in the Soci6te de Chirurgie 1 the fact was brought out that lithotomy and lithotrity upon the female are more dangerous operations than they are usually said to be. The fatal complications are of two kinds : peritonitis in patients who have previously been affected by it; and pyaemia, originating in inflammation of the spongio vascu- lar tissue constituting part of the vesico-vaginal septum. Speaking generally, it may be said that lithotrity 2 is more dangerous in the female than lithotomy, that the supra- pubic operation should be used for large calculi, dilatation of the urethra for small ones, and, with crushing, for large friable ones when the inflammation is not high and there has been no previous peritonitis ; urethral or vesico-vaginal lithotomy in other cases. As to the comparative merits of urethral and vesico-vaginal lithotomy opinions are divided ; the former is followed occasionally by permanent inconti- nence ; the latter by fistula ; probably, too, the latter is somewhat more dangerous than the former. OCCLUSION, OR ATRESIA VAGINAE. When the occlusion is due simply to an imperforate hymen it may be relieved by successive punctures with a small trocar or aspirator, and when all the accumulated menstrual blood has been thus removed, and the cavity 1 Bull, de la Society de Chirurgie, 1877, pp. 182 and 400. - In this remark reference is made to the old operation of lithotrity. The few cases of litholapaxy in the female of which I have knowledge have been success- ful. SPECIAL OPERATIONS. 547 well washed out with a two or three per cent, solution of carbolic acid, the hymen may be excised, or a large punc- ture made, and kept open by frequently passing a sound. It must be remembered that very serious complications, such as peritonitis and septic poisoning, may follow this simple operation when there has been a large accumulation of menstrual blood above the obstruction. When, on the other hand, the occlusion is due to incom- plete development of the vagina, a more systematic opera- tion is required. The surgeon first assures himself by digital examination through the rectum of the existence of the uterus, then places the patient upon her back with her thighs flexed and abducted, and introduces a sound into the bladder and confides it to an assistant. He next passes his left index-finger into the rectum, makes a transverse in- cision across the centre of the obliteration, and carries it in the direction of the uterus by successive short cuts with the knife, or by tearing with a director or his fingers, guiding his course by the sound in the bladder and the finger in the rectum. As soon as fluctuation can be felt in front of the uterus he punctures with a trocar and enlarges the puncture with a probe-pointed bistoury. PERINEORRAPHY. Dr. Emmet 1 has shown that the lesion previously kuown as " partial rupture of the perineum," and supposed to be a laceration along the posterior median line of the tissues at the lower part of the vagina and perineum, is actually a transverse rent at or within the ostium vagiuse, which, by the dropping aud eversion of the lower lip of the wound, is made to present the appearance of a longitudinal one. He has also recently recognized and described a variety of this lesion in which the laceration is submucous, in which the muscular and fascial diaphragm, constituted in part by the sphincters and closing the outlet of the pelvis, is torn away from the supporting fascia? and muscles which run upward to attach its centre to the inner side of the bony pelvis, 1 Principles and Practice of Gynecology, 18S4, p. 364. 548 OPERATIVE SURGERY. and, having thus lost its support, allows the posterior part of the vulva to be everted, with production of a rectocele by protrusion of the rectum through the (subcutaneous) gap. To this latter condition he gives the name prolapse of the posterior wall of the vagina. The two conditions, the subcutaneous and the complete rents, are essentially the same, and require nearly the same denudation of the sur- face. The aim of the operator in either case is to lift up the depressed and everted lower lip, unite its edge to that of the mucous membrane of the vagina at the crest of the rectocele, aud thus cover iu the latter and renew its ante- rior support. Laceration of the vulvar orifice in the posterior median line may occur without coexistence of the above-described lesion, beginning at the fourchette and extending backward, but such laceration is unimportant because it involves only parts that lie outside the real support of the viscera. Fig. 291. Fig. 292. Fig. 293. JEVfe mmMMi Fig. 291. Curved scissors. Fig. 292. Emmet's scissors. Fig 293. Thomas's toothed forceps. Fig. 294. Sponge-holder. A third form is the important one in which laceration of the sphincter ani in the median line takes place. In non- SPECIAL OPERATIONS. 549 instrumental delivery this begins as a longitudinal slit in the recto-vaginal septum and extends from within outward and forward. When caused by the forceps it begins at the fourchette and extends backward. To this form Dr. Emmet limits the term rupture of the perineum. Accepting this classification, I shall describe the oper- ation for, 1st, prolapse of the posterior wall of the vagina — two varieties, with and without laceration of the mucous membrane of the vagina ; and, 2d, rupture of the perineum (and the sphincter ani). Prolapse of the Posterior Wall of the Vagina. (1st variety, without surface laceration.) Operation. Thighs flexed on abdomen and supported under the arm of an assistant on each side, who also draw aside the labia and hold the tenacula during the act of denudation. The operator seizes with a tenaculum the mucous membrance of the vagina at the crest of the rectocele in the median line at a point which can be drawn down to the urethral orifice by gentle traction, and having thus drawn it down, has it held in place by the assistant. Then, with two other tenacula, he hooks up the lowest caruncle, or vestige of the hymen, on each side, and draws them upward and outward to the first tenaculum. This movement creates an inverted, crescentic, transverse fold within the vagina just below the first tenaculum, its horns shading gradually into the sulcus on each side, and a shallow longitudinal fold in the median line between the last two tenacula. The op- posed surfaces of these folds constitute the area to be de- nuded. Dropping one lateral tenaculum, he gives the other to an assistant who draws it gently outward to define by this trac- tion the limits of the denudation on that side, and then the surgeon denudes by catching up the mucous membrane with a hook or pronged forceps and removing it with scissors in successive strips. The process is then repeated on the oppo- site side. Care must be taken not to denude too high on the posterior wall. Silver sutures are then passed to unite the parts in the positions given them by the first approximation of the three tenacula, producing the line of union indicated in Fig. 295. The sutures of the crescentic part should be of silver wire ; 24* 550 OPERATIVE SURGERY. those of the central line may be of silver, silk, or catgut. A final silver suture should be passed through the labium near the caruncle on one side, across to the posterior wall of the vagina, under its mucous membrane for nearly an Fig 295. Diagram showing the line of union and direction of the sutures. inch just above the edge of the denudation, and then through the other labium at a point opposite to that at which it began. Fig. 296. Appearance at completion of operation. In passing the sutures a thick, straight sewing-needle armed with silk should be used, and the tissues to be tra- SPECIAL OPERATIONS. 551 versed by it should be pressed forward by the finger in the rectum. The sutures should not be buried throughout their course, but should cross the fold midway between its Diagram showing area of denudation. The parts bearing corresponding figures are brought into apposition by the sutures. Fig. 298. Emmet's operation for diminishing the vaginal outlet by external sutures. free edge and its bottom. The silver wire is drawn through in the loop of the silk. The appearance, when the opera- tion is completed, is shown in Fig. 296, the crescentic part being hidden within the vagiua. 552 OPERATIVE SURGERY. 2d Variety. Prolapse with Surface Laceration. The position of the patient is the same as in the preceding form, and the area of denudation is determined in like manner ; speaking generally, it must extend downward to the line of junction between the skin and the cicatricial mucous mem- brane. Its shape, when spread out, is that of a trefoil (Fig. 297). The sutures are passed in order from below upward, and none tightened till all are in place. The lower ones are buried throughout their course ; the upper ones are partly exposed on each side, as shown in Fig. 298. The suture marked D includes about an inch of the recto- vaginal septum ; the uppermost suture, C, passes through the mucous membrane of the septum above the denudation, and when tightened draws it down like a hood to protect the approximated edges, and also sustains all the traction while the opposed denuded surfaces are uniting. Dr. Emmet leaves the sutures in place for about three weeks. PEEINEOEBAPHY. Method of Hegar or Simon-Hegar. Incomplete Rupture. This is based on the principle that the rent when spread out has the form of a triangle with its apex in the posterior vaginal wall. (Fig. 299.) After every antiseptic precau- tion, bullet forceps are hooked in the three following points : in the crest of the rectocele, in the posterior vaginal wall, and in the opposite lowest caruncles, which lie on the inner surface of each labium majus. The labia are held apart and traction is made on the forceps, thus putting the tissues be- tween them on the stretch, while a narrow strip of mucous membrane is removed on the lines made straight by traction, which join the crest of the rectocele with the two caruncles in the grasp of the forceps. The space between these limits is rapidly denuded, and the denudation is continued on the posterior vaginal wall and adjacent skin as far as the cicatricial tissue extends, so that the raw surface when flattened out has the form of a triangle with its apex in the rectocele, and its base, which is slightly convex toward the anus, between the two lower forceps on the inner sur- faces of the labia majora. SPECIAL OPERATIONS. 553 Starting at the apex (Fig. 299), at intervals of about three-eighths of an inch, sutures of silver wire or silk- worm-gut are passed on a well-curved needle, so as to be just buried under the denuded surface, emerging about a quarter of an inch from its edge. Fig. 299. ggF" ^% Incomplete rupture of the perineum. Perineorraphy by Simon's method. (Pozzi.) At least two of these sutures should pass deeply enough in the upper lateral portions of the raw area to grasp some of the fibres of the levator ani muscle. Martin's continuous circular suture applied in tiers is considered better by many surgeons than the interrupted suture. Catgut is used, threaded on a sharply curved needle. Laceration of the Perineum, including the Sphincter Ani. If the anterior wall of the rectum is ruptured for more 554 OPERA TIVE SURGER Y. than one or one and a half inches above the upper margin of the sphincter, Dr. Thomas prefers to close it by a pre- liminary operation, leaving the restoration of the perineum for a subsequent one. Dr. T. Addis Emmet was the first to show why it is not sufficient simply to close the gap be- tween the vagina and rectum, and to demonstrate the need of bringing the ends of the severed sphincter into close con- tact with each other, and with the end of the recto-vaginal septum. Let Fig. 300 represent the perfect sphincter, and Fig. 301 the sphincter ruptured and spread out with the points Fro. 800. of entrance and exit of needle A A, the dotted line showing the course of the suture, including the end of the recto- vaginal wall C. As the suture is twisted, the three points are brought nearer together, as in Fig. 302, until they finally unite, as in Fig. 303. If the first needle is passed in and out at BB, complete union of the ends of the muscle will not be obtained, and loss of function will persist. The SPECIAL OPERATIONS. 555 first suture is the important one, and must briug the toru ends of the muscle into contact with each other and with the end of the septum. In freshening the parts before passing the needles the two lateral triangles, forming the ruptured surface of the body of the perineum, are denuded, and the line of denuda- tion is prolonged backward along the edge of the recto- vaginal septum. This denudation must extend along the edge of the mucous membrane of the rectum, but not include it. Fig. 304 is a schematic representation of the end of the Fig. 304. Fig. 305. Ruptured sphincter. First suture. Complete perineal rupture. First and second sutures in place. ruptured bowel, the poiuts of entrauce and emergence of the needle, and the course of the first suture. The rule for passing the first suture, then, is to euter the needle as low down as the lower edge of the anus, pass it 556 OPERATIVE SURGERY. thence upward through the recto- vaginal septum, completely encircling the rent, and bring it out alongside the lower edge of the anus on the other side. Its action, then, is like that of a purse string, it puckers up the open parts, controls the action of the sphincter, and guards against the two principal sources of failure, recto-vaginal fistula and non-union of the sphincter (Fig. 305). Flu. 306. e^SSSSSSSSS ^^^gsssss^ssss Half-section through the pubes. Dr. Emmet now recommends that this injury should be treated as if it were "a recto-vaginal fistula in the median line, with the sides easily approximated." The denudation is done with scissors, beginning at the outlet and near the rectal surface, and continuing from below upward, so as to avoid the flow of blood over the surface yet to be freshened. Since the sides of the tear, after re- traction, are not sufficiently broad to give a good surface for union, a portion of the adjoining vaginal mucous membrane SPECIAL OPERATIONS. 557 must be removed, and the angle must also be extended on the vaginal surface for half an inch or more beyoud the rectal edge. Then, beginning at the angle, several trans- verse, interrupted silver sutures are passed from the vaginal edge on one side, under the denuded surface, across the gap, and under the opposite denuded surface to the opposite vaginal edge, and two or three additioual sutures are passed Fig. 307. Complete laceration of the perineum. Perineorraphy— Simon-Hegar method : general disposition of the sutures. (Pozzi.) by the old method, that is, beginning in the skin near the lower edge of the anus, continuing up through the tissues alongside the rent, through the septum, and down on the other side, so as completely to include the rent. Fig. 306 shows these different sutures. The last two mentioned are the 2d and 4th in the figure, counting from below upward. 558 OPERATIVE SUJRGEBY. Complete Laceration icith Rupture of the Sphincter Ani. A slight modification of Hegar's method is used in the gynecological service of Roosevelt Hospital, and it gives most excellent results. Before denuding the perineum the rectum is first sutured. The edges of the rent in the rectum are freshened and the raw surface is made a little broader below than above to thoroughly expose the extremities of Fig. 308. A B Complete laceration of the perineum, l'erineorraphy— Martin's method. A. Deep plan of continuous suture. D. Passage from the deep to the superficial. (Pozzi.) the sphincter muscle. The denuded areas of muscular and mucous tissue are then brought into apposition by inter- rupted sutures of chromicized catgut or silkworm-gut passed just within the limits of denudation at intervals of about a quarter of an inch and knotted in the rectum from above downward (Fig. 307). The ends are left long and protrud- ing from the anus, and at the expiration of a couple of weeks SPECTAL OPERATIONS. 559 those sutures which can be reached are removed and the ends of the others are cut short and the sutures are left to cut their way out. The rest of the operation is then finished by Hegar's method for incomplete rupture with Martin's continuous sutures of catgut placed in tiers from the bottom of the rent just external to the rectal wall up to the original level of the vaginal mucous membrane (Fig. 308). A tension suture of silk should be passed through the skin of the perineum, without entering the rectum, a little beyond the extremities of the freshly united sphincter and the ends of the suture fastened over lead buttons or balls, which will permit it to be loosened if there is much subsequent swell- ing or oedema. VESICOVAGINAL FISTULA. The patient is prepared for the operation by measures directed to the improvement of her general condition, by regularly syringing the vagina with warm water, and by dividing any cicatricial bands that may have formed in it. Position. Dr. Thomas recommends the position known as Sims's. The patient is placed upon the left side, with the thighs flexed, the right rather more so than the left, the left arm is drawn behind her back, and her chest brought flat down upon the table. Others prefer the knee-elbow position, and Simon placed the patient flat upon her back, raised the hips, and flexed the thighs as far as possible upon the abdomen. Fig. 309. a b o ' e a. Vesical surface. 6. Vaginal surface, cc. Line of paring. If the first position is employed, an assistant stands be- hind the patient, draws the posterior wall of the vagina back by means of a broad Sims's speculum held in his right hand, while with his left he raises the right side of the nates. 560 OPERATIVE SURGERY. The surgeon then pinches up, with toothed forceps or a tenaculum, the vaginal edge of the fistula at the point most difficult of access, and cuts off a piece including in breadth Fig. 310. Drawing down the uterus to facilitate the paring. all between the vesical edge of the fistula and a point in the vagina at least one-third of an inch from the vaginal edge of the fistula. The cutting may be done with curved scissors SPECIAL OPERATIONS. 561 or a narrow-Waded knife. Successive portions of the edge are raised and removed in like manner, until the denudation is complete, the resulting raw surface being funnel-shaped, with its narrowest part at the edge of the vesical mucous a Vesical surface, b. Vaginal surface, c. Needle. Fig. 313. as Needle-holder. Passing the needle. membrane, the membrane itself not being included in it (Fig. 309). Or the point of the knife may be entered into the mucous membrane of the vagina one-third of an inch from the edge of the fistula, brought out at the vesical 562 OPERATIVE SURGERY. border, and then carried right and left around the opening so as to cut off a complete ring of tissue. If the anterior wall of the vagina is freely movable, Simon brings the fistula into plain view by passing a stout ligature through the cervix of the uterus and drawing it down toward the vulva (Fig. 310). He also pares the edges of the fistula very freely, and does not hesitate to include the mucous membraue of the bladder in the incision. Fig. 314, 315, 316. Fig. 317. As soon as the hemorrhage has ceased, the sutures may be passed. The needle, three-quarters of an inch long, round, slightly curved, and armed with a fine double silk suture, is fixed in a needle-holder (Fig. 311), and entered at the angle of the wound which is most difficult of access, half an inch from theedgeof the raw surface, and its point brought out at the edge of the vesical mucous membrane, but not including it (Fig. 312), and there fixed with a blunt SPECIAL OPERATIONS. 563 hook (Fig. 316), until it can be seized and drawn through with the needle forceps. It is then entered at the corre- sponding point on the opposite side, and brought out on the Fig. 318. Simon's method of placing the sutures. vaginal surface half an inch from the edge of the opening (Fig. 313). The ends of the ligature are given into the charge of the assistant who holds the speculum, and another 564 OPERATIVE SURGERY. needle is passed in the same manner at the distance of one- sixth of an inch from the first : and so on, nutil a sufficient number have been passed. During the passing of the needles the sides of the fistula are fixed by the tenaculum. When the needle is seized with forceps and pulled through, counter-pressure must be made upou the tissues, and this is best done by means of the split rod or fork, represented in Fig. 315, its prongs passing on either side of the needle. After all the ligatures have been passed, a silver wire, about twelve inches long, is fastened to the loop of the first ligature (Fig. 317, C), and drawn through with the help of the fork. The silk is cut oif, the ends of the wire drawn aside out of the way, and the others passed in the same manner. Simon used fine silk sutures (two rows when the fistula was large) tied in the ordinary manner, and often passing through the vesical mucous membrane (Fig. 318). The ends of the silver sutures being drawn together, and the edges of the wound carefully approximated, each thread is slightly twisted so as to keep the parts in apposition, and then the ends of the first are seized with forceps and twisted with the help of the shield (Fig. 314), as shown in Fig. 317 ; care being taken not to twist so tightly as to stran- gulate the tissues engaged in the loop. The other sutures are then twisted in the same manner, and the euds of each cut off about half an inch from the surface (Fig. 319). Fig. 319. The bladder is then syringed to remove any blood that may have collected in it, and a Situs's catheter (Fig. 320) passed into it and left there. The sutures may be removed during the second week. SPECIAL OPERATIONS. 565 Creation of a Vesico-vaginal Fistula. This operation is sometimes required in the treatment of chronic cystitis. Dr. Emmet 1 performs it as follows : Ansesthesia ; Sims's position. A Sims's speculum is introduced into the vagina, and a director, abruptly curved an inch and a half from its extremity, introduced through the urethra. While the director is held by an assistant with its point firmly press- ing in the median line against the base of the bladder a Fig. 320. Sims's catheter. little behind the neck, the surgeon seizes the projecting tissue on the vaginal surface with a tenaculum, and ex- poses the beak of the director by cutting upon it with a pair of scissors. One of the blades of the scissors is then passed through the opening and a cut made backward in the median line. If the opening tends to close spontaneously too soon, a hollow glass stud made of half-inch tubing should be but- toned into it. The vesical rim of this stud need not be more than a slight flare, the vaginal rim should be larger. OBLITERATION OF THE VAGINA ; KOLPOKLEISIS. (Fig. 321.) When a vesico-vaginal fistula cannot be closed by the means above described, the escape of urine may be prevented by closing the vagina. Vidal de Cassis first performed this in 1833 by effecting union between the labia majora, but it has been found that complete closure canuot be thus obtained, a small opening remaining at the lower angle. Simon's method of uniting the anterior and 1 Chronic Cystitis in the Female, American Practitioner, February, 1872, and Vesico-vaginal Fistula, p. 43. 25 566 OPERA TIVE S URGER Y. posterior walls of the vagina instead of the labia is much more trustworthy. It was first performed in 1855. Fig. 321. iWiiiBW^ Obliteration of the vagina. A strip of mucous membrane encircling the vagina just below the fistula is removed, the opposing raw surfaces brought together by sutures, and the bladder kept empty by a catheter until union has taken place. SPECIAL OPERATIONS. 567 ELYTRORRAPHY, OR NARROWING OF THE VAGINA. This is an operation intended to prevent prolapse of the uterus. The method, introduced by Sims, of removing a lougitudinal strip of mucous membrane from each side of the vagina, and bringing the raw surfaces together, has Fig. 3 Emmet's operation for procidentia. proved not ouly inefficient, but often actually harmful by supplying a pouch in which the cervix became engaged, thus causing extreme retroversion. Dr. Emmet avoided this defect by closing the pouch at its upper end, but the mechanical difficulties in the way of performing the opera- 568 OPERATIVE SURGERY. tion are so great that he has substituted for it another in which he catches up ou a tenaculum three folds of the vaginal mucous membrane, one on each side, and the third in front of the cervix (Fig. 322), denudes them over a space half an inch square, and draws them together with a suture. The three folds radiating from these points are then pared, and united stitch by stitch along the anterior wall of the vagina. Dr. Thomas suggests 1 a method which, he thinks, prom- ises well. It may be performed upon either vaginal wall, or on both in two successive operations. While doing it, the uterus may be left in complete prolapse, or it may be previously returned to the pelvis. Suppose an operation on the anterior wall, the uterus prolapsed. Dorsal decubitus. The mucous membrane of the vagina half an inch from one side of the cervix is pinched up, and a small hole made in it through which a grooved director is passed directly across the anterior face of the uterus, between it and the vagina, to the correspond- ing point on the other side of the cervix. Upon this di- rector the vagina is cut transversely. The director is again entered at the centre of the transverse incision, worked up through the loose areolar tissue between the bladder and vagina nearly to the meatus, and then withdrawn. A steel instrument (Fig. 323), as large as a No. 9 sound, with blades three inches long, is passed along the channel made Fig. 323. G.T I EM A UN-CD. Thomas's dilating forceps. by the director and opened forcibly so as to tear the sub- cutaneous tissue and separate the bladder from the vagina over a triangular space, the apex of which is near the meatus and the base at the cervix. The ends of the transverse incision are then brought together by a suture, the result being that the loosened 1 Discuses of Women, 4th edition, p. 3")4. SPECIAL OPERATIONS. 569 triangular portion of mucous membrane hangs down and forms a longitudinal fold ; this fold is engaged between the blades of a toothed clamp three inches long and half an inch Fig. 324. wide (Fig. 324), placed with its hinge at the cervix and tightened by means of the screw. Then the portion of the Fig. 325 Colpo-periueorraphy by Hegar's method. (Pozzi.) vaginal mucous membrane hanging out of the clamp is cut off, the edges of the wound brought together with interrupted silver sutures, and the uterus returned with the clamp still 570 OPERA TIVE S UR GER Y. in place. The vagina is then firmly plugged with cotton wet with a solution of alum and carbolic acid, to prevent hemorrhage; this plug should be removed at the end of twenty-four hours, the clamp after forty-eight hours, and the sutures in eight or nine days. Fig. 326. Colpo-perineorraphy by Martin's method. Bilateral denudation of posterior vaginal wall ; continuous sutures in layers. (Pozzi.) For the operation upon the posterior wall of the vagina, or when the uterus is in place, the transverse incision at the cervix should not be made, the dilating forceps being passed in the opposite direction. Posterior Elytrorraphy or Oolporraphy. (Hegar's Method.) The entire thickness of a portion of the mucous membrane is removed from the posterior vaginal wall in the form of an isosceles triangle (Fig. 325), with its base about two inches broad at the fourchette, and its apex in the median line two inches above the fourchette. For very marked prolapse these measurements may be extended a SPECIAL OPERATIONS. 571 quarter or half an inch. The denuded area is folded together by the interrupted, or better by Martin's suture as described for perineorraphy. Martin's Method (Fig. 326). Two narrow strips ot mucous membrane are removed from the posterior vaginal wall on each side of the median line from just below the cul-de-sac to a finger's breadth above the fourchette. The operation is completed by perineorraphy with Mar- tin's suture throughout. Anterior. A portion of the entire thickness of the mu- cous membrane on the anterior vaginal wall is excised in the form of a circle, oval or diamond, measuring generally about an inch or an inch and a half in its longitudinal diameter, and situated about the same distance from the meatus. The denuded surface is folded together by the interrupted or purse string or Martin's suture. LACERATED CERVIX. Dr. Thomas Addis Emmet 1 was the first to point out that after laceration of the cervix the lips rolled out, their mu- cous membrane became eroded by contact with the floor of the pelvis, and that the proper method of treatment was to freshen the torn surfaces and bring; them together with sutures, so as to restore to the cervix its normal size and form. In cases which have long remained unrecognized or untreated, the lips become centrally enlarged by the inflam- matory process, so that they canuot be properly brought together until after the removal of a thick piece on each side of the inside of each lip (Figs. 327 and 328). In like manner, when the eversion is increased and the coapta- tion of the lips prevented by cystic degeneration of the mucous follicles lining the cervical canal, and by vascular engorgement due to the inflammation and to a constriction by the everted edge of the cervix, similar to that observed in paraphimosis, free punctures must be made with the 1 American Journal of Obstetrics, November, 1874. 572 OPERA TIVE SUBGER Y, point of a knife to let out the blood aud the contents of the cysts. It is well to do this several days or weeks before the operation, apply tincture of iodine to the cervix, and bring the lips together temporarily by putting a plug of cotton into the posterior cul-de-sac and leaving it there for several hours at a time. The puncturing and application of iodine must be frequently repeated until the cysts shall have all disappeared and the erosions become nearly or entirely healed. The patient is placed on her left side, a Sims's speculum introduced, aud a loop of wire placed around the cervix above the vaginal reflection and tightened by drawing its Fig. 327. Fig. 328. Lacerated cervix. Side Lacerated cervix. Showing denuded surface (the view. shaded part) and sutures. ends down through a canula so as to prevent bleeding ; or an injection of hot water just before the operation will answer the same purpose. The lips are then separated and the lacerated surfaces thoroughly freshened with curved or angular scissors or a knife, leaving a broad uudenuded strip in the centre to form the lining of the restored canal. This strip should be shaped somewhat like an hour-glass in order to allow for the shrinking of the cervix which follows the operation (Fig. 328). The freshening should be done from below upward, so that the blood may not interfere, and must be carried deeply enough to remove all diseased glands and follicles. A tenaculum is then engaged in each lip, and the two SPECIAL OPERATIONS. 573 drawn together ; if proper coaptation is prevented by the central enlargement of the cervix above mentioned, simple freshening of the surface is not sufficient, but a greater thickness of tissue must be removed. The freshening at the angles of the fissure should be superficial, so as not to involve the circular artery which often lies just at that point. The sutures should be of silver wire, and passed with a short, round needle if the tissues are soft, or with a lance- shaped one if they are dense and indurated. From three to five will be needed on each side if the laceration is ex- tensive and double. The first one on each side should be entered just beyond the angle of the fissure so as to include the branches of the circular artery if necessary. The needle is entered on the outside of the lip and brought out at the edge of the undenuded strip which is to form the canal, and then passed in the opposite direction (from within outward) at corresponding points through the other lip. Care must be taken to obtain accurate approximation along the vaginal edge, but the inner edges of the denuded surfaces do not require attention. POSTERIOR SECTION OF THE CERVIX. This operation may be rendered necessary by irreducible flexion of the uterus. The patient being placed in position Fir. 329. Sims's knife. and a Sims's speculum introduced, the cervix is fixed by a tenaculum and its posterior lip divided with scissors as high as to the vaginal junction. The blade of a Sims's knife (Fig. 329) is then introduced through the os internum, and the tissues cut so as to lay open the posterior wall of the 25* 574 OPERA TIVE S UB GEB Y. cervix (Fig. 330). The blade is theu turned toward the anterior wall, and the little shoulder which, as Dr. Emmet has pointed out, usually exists there at the poiut of flexion is cut through. Instead of making this second incision Dr. Wylie practises and recommeuds divulsion with a strong steel dilator. Fig. 330. Posterior section of the cervix. A roll of cotton saturated with a solution of persulphate of iron, one part to two of water, is placed so as to occupy the whole cervix, and retained by a plug of wet cotton in the vagina. OPERATIONS ON THE UTERUS AND ADNEXA. Anatomy. The broad ligaments, consisting of two layers of peritoneum, continuous with that which covers the uterus, are attached to its sides from the cornua to the level of the internal os ; externally they arc attached to the sides of the pelvis in a vertical but broader line, about midway between the obturator foramen and the great sciatic notch. The Fallopian tube passes outward from the angle of the uterus in the highest part of the broad ligament, while in front SPECIAL OPERATIONS. 575 and a little lower down the round ligament diverges to the internal abdominal ring, and contains a branch of the epi- gastric artery passing to the uterus. Behind the Fallopian tubes are the ovaries which are subject to great variation in position — normally each occupies the apex of a liga- mentous triangle directed backward, the base of which is in the broad ligament, and through which the branches of the ovarian artery and the pampiniform plexus of veins enter the gland. The inner angle of the ligamentous triangle passing to the fundus of the uterus is a rounded fold of peritoneum containing muscular fibre, and called the utero-ovarian ligament. The outer angle blends with the upper border of the broad ligament, aud is called the infundibulo-pelvic ligament. The ovarian arteries arise from the abdominal aorta, and at the brim of the pelvis cross the bifurcation of the com- mon iliac vessels and the ureter, and run iu a tortuous course in the upper border of the broad ligament, or more exactly in the infundibulo-pelvic ligament, to the cornua of the uterus, where they anastomose with the uterine arteries along the respective sides. Each ureter crosses the common iliac artery near its bifurcation, and runs from behind downward, forward, and inward in front of the internal iliac artery and its anterior division, lying in the base of the broad ligament, which is limited by the levator ani muscle. Near the level of the external os the ureter is crossed on its inner side by the uterine artery, and then runs aloug the side of the vagina about half an inch from the cervix, entering the bladder just above the middle of the anterior vaginal wall. The uterine artery arises from the anterior trunk of the internal iliac near the synchondrosis, and passes downward and forward to a point just above the spine of the ischium, where it leaves the pelvic wall, but still descends almost to the tuberosity of the ischium ; it then turns up toward the vagina, reaching the uterus at the utero-vaginal junction. Opposite the external os it gives off the circular artery of the cervix and continues along the side of the uterus be- tween the layers of the broad ligament, and at the superior cornu it anastomoses with the ovarian artery. The peritoneum is firmly adherent to the fundus of the 576 OPERATIVE SURGERV. uterus, but gradually becomes more loosely attached uutil it can be readily stripped up with the finger in the vesico- uterine depression. Posteriorly it descends about three- quarters of an inch on the vaginal wall, and is likewise easily peeled off to the same level as in front. With a normal uterus and an empty bladder, the latter lies upon the cervix for about half an inch. OVAEIOTOMY. The patient is prepared in the usual way for a lapar- otomy, and immediately before the operation she is cathe- terized, the sponges, pads, and clamps are counted and the number of each written down. An incision three or four inches long is made in the median line between the umbil- icus and the pubes, which, if necesary, is later extended upward with a slight semicircular deviation, including the umbilicus and passing to the left of it to avoid the falciform ligament. The incision is deepened layer by layer and the peritoneum first opened above by pinching up a fold with the fingers or forceps and nicking it, and then enlarging it downward by cutting on the fingers inside as a director, care being taken to avoid the bladder, which is usually recogniz- able from within as a thickened fold lying near the pubes. When the peritoneum is adherent to the tumor it may be simpler to prolong the incision above the latter to make certain that the abdominal cavity has been opened and that the peritoneum is not simply stripped from the parietes. Sometimes, also, the bladder is drawn far up above its usual position, but it can be recognized by its vascularity or by a sound passed into it through the urethra. A sponge protective packing is wedged around the exposed cyst, which is then punctured with a large trocar and can- ula, the latter being provided with a tube to conduct the fluid to one side, and as soon as possible the walls are grasped by the fingers or by forceps and drawn into the wound, while, at the same time, pressure is made on the parietes, or the patient is rolled on one side to favor the escape of the contents. If the latter are too thick to flow readily, the puncture may have to be enlarged sufficiently SPECIAL OPERATIONS. 577 to permit them to be scooped out by hand, and through this opening other loculi are entered by the finger, knife, or trocar, and enough liquid evacuated to permit of an at- tempt to turn the cyst out of the abdomen. The adhesions are cautiously separated by the finger- nail and blunt-pointed scissors or divided between double catgut ligatures ; if the intestiue is torn the rent must be immediately closed by Lembert's sutures. The peritoneal cavity must be constantly protected by the addition of fresh sponges as the dissection progresses, though usually no harm follows from the escape into it of some of the cyst-contents. When the pedicle has been fully exposed, often by bringing the cyst out of the belly, if broad it is secured in sections by the interlocking silk ligature passed on a blunt-pointed aneurism needle, and the tumor or what remains of it is excised ; or the pedicle may be divided with scissors and the vessels secured as they are encountered by clamps, and after removal of the tumor ligated separately. A comparatively small pedicle cau be ligated en masse with stout silk, or by the Staffordshire knot, in which the pedicle is transfixed by a stout silk ligature passed double and the loop drawn back over the tumor to lie be- tween the long ends of the ligature, which are then tied over it. If there have been few or no adhesions and the cyst has been removed practically without opening it, the abdomi- nal wound can be closed entirely in the usual way, after taking out and counting the sponges and clamps. But drainage by rubber tubes and iodoform-gauze packing is imperative whenever there is even a possibility of infec- tion, and especially if a portion of the cyst wall has been necessarily left behind owing to its too firm adhesion to important structures. If there has been much peri- toneal laceration accompanied by oozing from minute blood- vessels, drainage and hemostasis are conveniently provided for by a large sheet of iodoform gauze placed in contact with the lacerated surface and having all its edges brought out of the abdominal wound. This pouch is then stuffed with strips of gauze which are subsequently removed one by one, to gradually reduce 578 OPERATIVE SURGERY. its bulk. The parietal opening is partially closed aud dressed antiseptically in the usual way. OOPHORECTOMY. This term is used to designate the removal of macro- scopically normal ovaries and Fallopian tubes for hemo- static or analgesic purposes. After the usual preliminaries, including catheterization, the patient is placed in Trendelenburg's position, which greatly facilitates all intra-abdominal operations on the pelvic organs. A convenient extemporaneous way of doing this is to invert a chair upon the table and lay the patient upon its back so that her knees are hooked over the cross-bars be- tween its hind legs. An incision about three inches long is made in the me- dian line above the pubes, and deepened layer by layer till the peritoneal cavity is opened. Two fingers are passed through the incision to the fundus of the uterus and theuce outward, following one Fallopian tube to its extremity, which is drawn up into the abdominal wound together with the ovary. Flat sponges are placed around them, and a stout silk ligature is passed double on a blunt-pointed aneurism needle through the broad ligament in the angle between the Fallopian tube and the uterus, and the Staf- fordshire knot is made and tied as close to the uterus as possible, with care to get beyond the ovary and not leave any portion of the gland in its grasp. The ovary and tube are then excised, and after a final inspection of the pedicle for hemorrhage it is dropped back into the abdomen. The same proceeding is repeated upon the other side, the flat sponges are removed, and finally the abdominal inci- sion is closed tight in the usual way and dressed without drainage. SPECIAL OPERATIONS. 579 SALPINGO-OOPHORECTOMY, OR THE REMOVAL OP A TUBE DISTENDED WITH PUS, AND ITS OVARY. After the usual preliminaries, including antiseptic vaginal douches, the patient is catheterized aud placed in Trende- lenburg's position, as described for o5phorectomy, and if, at the same time, a bougie is inserted in the rectum, it may later be found very useful for mapping out its position. An incision not less than four inches long is made in the median line above the pubes, afterward extended, if neces- sary, around the umbilicus to afford plenty of room for manipulation. The incision is deepened layer by layer, the bleeding stopped, and the peritoneum nicked in the upper angle of the wound and opened downward on the finger as a guide, stopping short of the bladder, which can be recognized on the inside as a thickened fold near the pubes ; or, if there is any doubt, by a sound passed through the urethra. The omentum and intestines are pushed back, separating adhesions with the finger-nail or blunt-pointed scissors, till there is a full exposure of the uterus and its appendages, which are then surrounded with flat sponges or pads, completely shutting off the rest of the peritoneal cavity. The fingers are passed outward from the fundus of the uterus, following every crevice around first one tube and then the other, till some spot is found where, by slight pressure or tearing, the tip of the index-finger can be worked under or around the mass and the tube freed, gen- erally in company with its ovary. If pus should be dis- covered escaping, the dissection is stopped till it has been entirely sponged away, enlarging, if necessary, the hole from which it comes. The somewhat free oozing is con- trolled by sponge packing, and when a more or less dis- tinct pedicle has been formed, or the finger recognizes a dangerous amount of resistance to its progress, the strip- ping up and gently tearing process is stopped. With a blunt-pointed aneurism needle a stout catgut ligature is then passed under the infundibulo-pelvic liga- ment, or the outer attachment of the freed mass consisting of the ovary and diseased tube, tying off this ligament 580 OPERATIVE SURGERY. close to the mass and including the ovarian artery, the position of which can be ascertained in advance by pal- pating the broad ligament and notiug the pulsation. Another catgut ligature is passed through the broad liga- ment in the angle formed by the junction of the uterus and Fallopian tube, and the latter is secured with the termina- tion of the artery close to the uterus. Beginning on the uterine side of the outer ligature, the tissues attached to the under side of the tube are cut with blunt-pointed scissors, clamping each vessel or bleeding point as it is encountered, and in this way, when the tube alone is diseased, it is generally easy to leave the ovary un- disturbed, and this is always done by some surgeons; but in such an instance there should be no preliminary ligature of the infundibulo-pelvic ligament with the ovarian artery, and the scissors must be kept close to the tube, while bleed- ing is controlled by individual ligature of each vessel as it is cut. The diseased mass is then excised on the distal side ot the ligature next to the uterus and the stump disinfected. Before its division the tube is secured by a clamp to pre- vent the escape of pus if it has not already occurred. Ligature en masse of the pedicle, which is almost always bulky, is only mentioned to be condemned. After chang- ing the sponges and securing any vessels which still bleed, the cut edges of peritoneum forming the broad ligament are united with fine catgut sutures over the deuuded area which lies under the Fallopian tube, and when it has been possible to perform the operation without the escape of a drop of pus, and without leaving a large oozing surface, the protective sponges are removed and the abdominal wound closed tight in the usual way. Otherwise the peritoneal cavity is made as clean and dry as possible and rubber tubes with lateral perforations are placed in the suspected regions, with one always in Douglas's pouch, and surrounded by strips of iodoform gauze, around the ends of which the abdominal wound is partially closed. Sometimes the Fallopian tube will be found changed into an abscess sac, with very firm adhesions, which only permit the sac to be opened, or not more than partially SPECIAL OPERATIONS. 581 removed ; very rarely it can be only partially exposed, but the pus can always be reached somewhere by a careful dis- section, aided possibly by a guiding puncture with an aspirating needle. The surrounding parts are then care- fully protected by a sponge packing and the abscess cavity thoroughly evacuated and washed out with boiled water, and drained with rubber tubes and iodoform gauze. Com- munication between the abdominal wound and the opening in the sac, which may be at a distance from the surface, is maintained by packing, which should also extend into and protect all possibly infected regions around the abscess. Aided by an exploring finger in the vagina it will some- times be possible and very advisable to force a blunt pointed forceps from the bottom of the abscess cavity into the posterior foruix, and thus pass a tube to afford drain- age in the most dependent regions as well as from the sur- face of the abdomen. The vagina is packed around the tube and a dressing is placed on the vulva, while every pre- caution is taken to prevent infection from the urine and feces. If the vermiform appendix is found involved or adherent to a diseased tube, as often happens, it should be excised at the same time. Whenever in a case in which the abdominal wound has been closed tight symptoms of secondary hemorrhage appear, the diagnosis should be at once verified by untying a stitch in the lower angle of the wound and passing a small sponge on a holder into Douglas's pouch. If done with every antiseptic precaution this exploration is free from danger, even if no hemorrhage is found. TUMORS LYING BENEATH THE BROAD LIGAMENT. An opening is made in the overlying peritoneum generally in front of the Fallopian tube, and through this the dissec- tion, guided by the sense of touch, is carried out by the tip of the finger tearing through the loose connective tissue sur- rounding the capsule of the tumor, and the latter enucleated. The few vessels are clamped as they are encountered and tied later, and drainage is provided for as after salpingo- odphorectomy. 582 OPERATIVE SURGERY. OPERATIONS FOR ECTOPIC GESTATION. In the early stages of this condition before the placenta has formed, the operation is conducted, according to the situation of the mass, in the same way as in ovariotomy or salpingo-oophorectomy, or for a tumor lying below the broad ligament. Later, after the formation of the placenta, the general rule is to open the abdomen in the median line below the umbilicus, and, after protecting the peritoneal cavity by a sponge packing, the sac is entered in front like an ovarian cyst, avoiding if possible the site of the placenta, which can usually be recognized by the surrounding vascularity. But sometimes the placenta may have to be perforated, and then the hemorrhage from it is controlled by clamps or deep sutures. The foetus and amniotic liquid are extracted while the surrounding parts are well guarded, and when it seems per- fectly feasible the sac may be dissected out with the pla- centa, separating adhesions with the tip of the finger or bluut-pointed scissors and arresting the bleeding as it occurs ; but more often the complete removal is impossible, and the opening in the sac is either stitched to the margins of the abdominal wound or kept in communication with it by packing and drainage applied on the principles already enunciated, while the placenta is left to slough away with the attached umbilical cord. If the operation is performed for hemorrhage following rupture of an extra-uterine gestation, the abdomen is opened in the same way aud one hand passed to the fundus of the uterus and thence outward to the boggy mass, which, if it can be raised to the surface, is easily secured and treated. But if this is impossible, an attempt, guided by the hand inside the belly, is made to seize one or both extremities of the broad ligament with its contained vessels, by long- bladed clamps. The blood and debris are then rapidly scooped out of the peritoneal cavity and a search is made for bleeding points, which are immediately caught and tied, and then a decision can be made as to extirpation of the sac, which does not SPECIAL OPERATIONS. 583 differ from an inherent tube or an ovarian cyst, except that the placenta in the great majority of cases should not be disturbed. The treatment of a case in which suppuration has occurred does not differ from that of an intra-abdominal or pelvic abscess. HYSTEROPEXY. The peritoneal cavity is opened by a median incision of about three inches just above the pubes, and the fundus of the uterus is brought up to the abdominal wall, to which it is fixed by a couple of silk or silkworm-gut sutures passed through all the tissues on each side of the wound, and through the muscular tissue of the fundus of the uterus, Fig. 331. Hysteropexy. Wylie's method of shortening the round ligaments. including about three-quarters of a square inch of the peri- toneal coat. Other sutures are placed in the wound above and below, which is thus closed tight without drainage when all are tied. The fundus of the uterus may be previously scraped or scratched to promote adhesions, and Wylie 1 shortens the round ligaments by throwing a suture around a loop of each in the abdomen (Fig. 331). 1 Amer. Journ. Obst., 1889, p. 478. 584 OPERATIVE SURGERY. Alexander's operation 1 for shortening the round ligaments. With every antiseptic precaution an oblique incision an inch and a half or two inches long is made over the inguinal canal terminating near the spiue of the pubis. The exterual abdomiual ring is cleared and the inter- columnar fascia is divided, exposing the fine yellow fat in which the reddish cord-like round ligament will be found near the upper limit of the external abdominal ring. The other side is treated in the same manner. A slight dissection may be necessary to isolate the round ligament, and, aided by a sound in the cavity of the uterus, enough tractiou is made on the cords to raise the uterus to the desired position. Often four or five inches of the round ligament can thus be easily drawn out through the ring. The ligaments on each side are held in their new position by a couple of sutures of catgut or silkworm-gut passed through them and the external and internal pillars of each ring. The wound in the intercolumnar fascia is closed with fine catgut and the external wound is sutured and dressed antiseptically without drainage. Tampons or pessaries must be worn for a month. LAPARO-HYSTEROTOMY. By this term is meant the making of an opening into the cavity of the uterus for any purpose, commonly the ex- traction of a foetus. In the latter instance the time of elec- tion, according to Senn, 2 is during the first stage of labor. The patient is catheterized, and with every antiseptic precaution, including preliminary antiseptic douches for the vagina, an incision about six inches long is made in the median line above the pubes, and, bearing in mind that the abdominal wall is apt to be very thin and that the enlarged uterus is in contact with it without the interposition of 1 Liverpool Med.-Chir. Journ., January, 1888, p. 118, " Amer. Journ. Med. Sci., Sept. 1893. SPECIAL OPERATIONS. 585 other viscera, the incision is cautiously deepened layer by layer till the peritoueal cavity is opened in the whole ex- tent of the wound and the surface of the uterus exposed. Sponges are packed around the latter and a longitudinal incision about an inch long is made in its anterior wall at a point midway between the junction of the Fallopian tubes with the uterus. To lessen the hemorrhage this incision is enlarged downward by tearing sufficiently to extract the child, head first, which must be done as rapidly as possible after rupturing the membranes. As the bleeding is worst from the cervical region, the rent must not approach this too closely. Fig. 332. Closure of the uterine wound after Csesarean section. B. Muscular wall of the uterus. A, Peritoneum. The uterus is immediately turned out of the abdomen, which is then protected by a warm towel and its neck be- low the opening constricted by an elastic ligature secured by a clamp tightly enough to arrest the bleeding. The placenta is next peeled off with its attached membranes, and after cleansing the interior of the uterus the rent is closed by a row of interrupted stout catgut sutures passed at intervals of half an inch through the entire thickness of the uterine wall, exclusive of the peritoneum, and about half an inch from the torn edge. Another row of sutures is placed between these in the same way, but including only half the muscular thickness, and these are covered in by a row of catgut Lembert sutures, which should pass through enough of the muscular tissue to secure good peritoneal apposition over the line of suture. (Fig. 332.) 586 OPERATIVE SURGERY. The abdominal cavity is cleansed and the elastic ligature removed from the uterus, but the latter is not replaced in the belly until after contraction has occurred or been induced by pressure, rubbing, or the subcutaneous injec- tion of ergot. The abdominal wound is then closed tight in the usual way and dressed without drainage, and an iodoform-gauze packing is placed in the interior of the uterus from the vagina. SYMPHYSIOTOMY. 1 The patient is catheterized, and, after thorough disinfec- tion of the abdominal wall and the external genitals, a longitudinal incision two or three inches long is made over the symphysis and carried down to the bone. The origin of one pyramidalis muscle is divided suffi- ciently to admit the index-finger, which is inserted behind the pubes, separating and pushing back from the bone the prevesical tissues, aud on this finger as a guide the sym- physis, which usually is not exactly in the middle line, is divided by a probe-pointed cartilage knife from above and behind downward and forward, sparing if possible theliga- mentum arcuatum or triangular ligament. A sound is sometimes first placed in the urethra and bladder to draw them to one side. After extraction of the child, per vias uaturales, the pubic bones can be reunited by buried silk sutures, or the wound may be closed by silk sutures passed through the skin and the anterior portion of the symphysis. But it will gener- ally be found sufficient to insert simple superficial sutures, and, after dressing the wound antiseptically, to immobilize the pelvis by a stout binder or bandage. MYOMECTOMY, OR THE REMOVAL OF A SUBPERITONEAL, " FIBROID " TUMOR OF THE UTERUS. The abdomen is opened as usual in the median line be- low the umbilicus sufficiently to admit the hand, and after i Morisani ; Ann. de (iynec. et d'Obst., April, 1892, p. 241. Oharpentier: Bull. de I'Acad. de Mod., March, 18>Jii, p. 852, SPECIAL OPERATIONS. 587 exploration the incision is enlarged if necessary, and adhesions carefully separated or divided between double catgut ligatures. The rest of the peritoneal cavity is shut off by a sponge protective packing, and when the growth has a distinct pedicle the latter is simply surrounded by a silk ligature which may in addition first transfix the pedicle if it is large, and the growth is excised ; or, when there is no pedicle and the tumor is sharply defined, two semilunar flaps are cut from the peritoneum on its base, and through the gap thus made the tumor enucleated by the tip of the finger or blunt-pointed scissors. The vessels, which are principally superficial, are clamped and tied as they are encountered, and if there is bleeding from vessels buried in the base it can be controlled by a deep catgut suture passed on a curved needle. The peritoneal flaps are closed over the denuded sur- face with fine catgut, and if it seems advisable after removal of the sponge protectives an iodoform-gauze packing is placed in contact with any region where hemor- rhage or infection is possible, and the abdominal wound is partially closed around the ends of the gauze. When all goes well this packing is removed after twenty-four or forty- eight hours, and the wound is then closed tight for secondary union by a stitch inserted for this purpose at the time of the operation. ABDOMINAL HYSTERECTOMY. If the uterus is comparatively normal, there is no un- usual difficulty about this operation. After rendering the vagina aseptic, the patient is catheterized and placed in Trendelenburg's position and a median incision about eight inches long is made above the pubes and deepened layer by layer till the abdomen is opened. The intestines are covered and pushed back from the pelvis by flat sponges or pads, and the Fallopian tube and utero-ovarian and round ligaments are secured together on each side close to the uterus by a double ligature of stout catgut passed through the broad ligament under these structures on an aneurism needle. Then the pulsations of 588 OPERATIVE SURGERY. the uterine arteries are felt for at the sides of the cervix, aud each artery is ligated near the vault of the vagina by stout catgut passed through an incision in the peritoneum on an aneurism needle, which must be kept as close to the artery as possible. Starting at the cornu, the tissues are divided between the double ligatures, and each broad liga- ment is cut at the lateral border of the uterus as low as the utero- vesical fold of peritoneum, which is divided transversely by cutting toward the uterus and hugging close to the cervix ; with short snips of the scissors the anterior fornix of the vagina is entered. Posteriorly, the peritoneum is cut transversely at the level of the internal os or a little lower, and the posterior fornix is entered like the anterior and the uterus removed. After tying the bleeding points, which are few, a rubber drainage tube and iodoform-gauze packing are passed from the abdominal wound out through the vagina, leaving the internal extremities in contact with the stumps of the tubes and the opening made in the vagina, and not communicat- ing with the abdominal wound, which is then closed tight in the usual way and dressed without drainage. An an- tiseptic dressing is placed over the termination of the tube and packing at the vulva, and every precaution taken to prevent infection by the urine or feces. It may often be desirable to divide the outer instead of the inner end of the broad ligament between a double cat- gut ligature, and, after securiug the uterine artery at the cervix, to free the tubes aud ovaries by cutting close beneath them, as formerly described, and then, following the sides of the uterus, to excise the latter, together with the appendages. If the uterus has become greatly altered by the growth of a tumor, no description can be given which is applicable to all cases. The abdomen is opened by a median incision which may have to be prolonged from the symphysis to the ensiform process, and the limits of the bladder, which is apt to be drawn above its usual position, are ascertained by a sound in the urethra if necessary. Adhesions, which may exist between the tumor and any abdominal viscus, are carefully separated or divided between double catgut ligatures, and the mass is gradually lifted out of the belly SPECIAL OPERATIONS. 589 by a hand placed beneath it, ascertaining its counectious and the position of the ovaries, tubes, and the broad liga- ments, and the cavity is immediately protected by a sponge packing or warm towels. It may be possible to follow the formal method of re- moval already given, but otherwise the enlarged uterus is transfixed below by a couple of pins made for the purpose with guarded points, and under these, which prevent it slipping, an elastic tourniquet or ecraseur is applied, including both broad ligaments, with due regard for the position of the bladder ; frequently a smaller pedicle can or must be manufactured, generally by dividing the broad ligaments in sections between double catgut ligatures. The mass distal to the tourniquet is then excised and the cervical canal disinfected by a drop of pure carbolic acid. If the stump is to be treated extra-peritoneally, it is left in the lower angle of the wound with the tourniquet in place and the pins resting on the surface of the abdomen ; the protective packing with blood clots, etc., is removed ; and the wound is closed in the usual way around the stump, with care to secure peritoneal apposition, if necessary, by sutures below the ligatures. Sometimes the pins may have to be withdrawn from the stump and the latter fixed at the level of the parietal peritoneum, where it can be retained by a couple of silk sutures through the abdominal wall on each side of the wound, which is then closed above and below around a packing placed in contact with the stump and its edges. If the pedicle is to be treated by the intra-peritoneal method, the base of the growth is cut in the form of a cone or triangle with its apex in the cervical canal at the level of the rubber tourniquet, and, after disinfecting the canal and securing the open mouths of any vessels in sight, the peritoneal margins of the stump are united with catgut, the tourniquet removed, and deep catgut sutures placed to arrest whatever bleeding follows. The stump is then dropped back into the abdomen, and the latter cleansed, drawing the peritoneum as far as possible over any exposed raw surfaces, and the parietal wound is closed around drainage carried down to the stump, or it is closed tight without drainage. 26 590 OPERATIVE SURGERY. It is always advisable, when practicable, to place independent catgut ligatures upon the ovarian arteries. Ligatures en masse are so apt to slip, and dangerous hemorrhage is so frequent an accident after their use, that if the condition of the patient permit the attempt should always be made to secure vessels on the cut surface of the pedicle and then remove the ligature en masse. Amputation of the Gravid Uterus. (Poito's Operation.) In a true Porro's operation the foetus is viable and is extracted before the uterus is excised. The abdomen is opened and the fcetus removed as described for lapaix)- hysterotomy, except that the longitudinal direction of the uterine incision is of less consequence. In Midler's modi- fication the parietal incision is made sufficiently long to permit the uterus to be turned out of the abdomen before the child is removed. After tying the cord the uterus is immediately lifted out of the belly and an elastic ligature or ecraseur is thrown around the cervix and broad ligaments. The uterus with the ovaries and tubes is then amputated transversely about three-quarters of an inch above the constrictiou, and the stump is fastened in the lower angle of the wound by a couple of pins transfixing it distal to the ligature and rest- ing on the skin with the poiuts protected. The abdominal cavity is cleansed and the protective sponges are removed and the wound is closed in the usual way around the stump, stitching the edges of the peritoneum with catgut to the uterine peritoneum below the constricting band, though this is not always necessary. In this, as in similar operations, it is advisable to place two dressings on the wound, the upper to remain undis- turbed, while the lower, covering the sloughing pedicle, is changed as often as required. Vaf/inal Hysterectomy. The patient is catheterized and placed in the lithotomy position and the external genitals are thoroughly disinfected. The vagina is held open by broad retractors and the uterus is pulled down by vol- sella forceps grasping the cervix, while the adjoining mucous membrane is cut well clear of the disease bv blunt- SPECIAL OPERATIONS. 591 pointed scissors. Keeping close to the uterus the dissection is contiuued on its anterior and posterior surface by the tip of the finger aud short snips of the scissors, but at the sides, after division of the mucous membrane, the cellular tissue is simply pushed up as high as possible, or till the pulsatious of the uterine artery are felt. The finger is finally thrust through the utero-vesical fold of peritoneum, and after cleansing the vagina of clots aud debris flat sponges are poked in around the uterus. Douglas's pouch is entered in the same manner, con- trolling the hemorrhage from the vaginal wound by a few catgut sutures through its cut edges, and then the finger is hooked over the fundus, pulling it down into the posterior opening and thus bringing within reach the upper border of the broad ligaments, which are seized by long-bladed clamps and divided on the uterine side. Guided by the finger, other clamps are placed on the remaining tissues close to the uterus, which is then excised. Injury to the ureters is avoided by thorough separation of the lower lateral cellular tissue early in the operation, the ureters being pressed forward with the anterior layer of the broad ligament. Richelot 1 leaves the clamps in place for twenty-four to forty-eight hours, but whenever possible it is better to secure with a silk ligature, at a proper distance from the clamps, the tissues in the grasp of each before they are severed from the uterus. Then if the adnexa can be separated and drawn down the pedicle of each may be secured with one or more clamps, which can be either left in place or the tissues in their grasp can be ligated with silk and the ovaries and tubes thus excised. A rubber drainage tube surrounded by iodoform-gauze packing is placed' in the vaginal wound and covered by an antiseptic dressing on the vulva. AMPUTATION OF CERVIX UTERI. Infra-vaginal. The cervix may be removed with the bistoury or scissors, the ecraseur, or the galvano-cautery ; 1 Annals of Surgery, September, 1893, p. 33 592 OPERA TIVE S UBQER Y. flaps may be made and united as shown in Fig. 333. In the latter the cervix is split transversely from below up. The patient is placed in Sims's position, the speculum in- troduced, the cervix slit transversely, and each lip seized in turn with forceps, and cut off as near the vagiual junc- tion as is considered proper. The mucous membraue of Fig. 333. A. B. Amputation of the cervix with double Haps. (Simon.) A. Sectional view showing lines of incision for formation of Haps and method of suture. B. Front view of cervix, operation complete. (Pozzi.) the interior is then drawn down and made fast with silver sutures to the outer edge of the cervix so as to cover iu the raw surface. The hemorrhage is often very severe. Hapra-v(i//hud. After thorough disinfection of the ex- ternal and internal genitals the patient is placed in the lithotomy position and the cervix is grasped by a volsella forceps. The mucous membrane around the cervix well clear of the disease is divided by scissors curved on the SPECIAL OPERATIONS. 593 flat, and, keeping close to the uterus, the mucous membrane is dissected or peeled off with the left forefinger and the scissors in front and behind, but at the sides, after the first incision of the mucous membrane, the cellular tissue between the broad ligaments is simply pushed aside. When a point is thus reached in front and behind where the peritoneum ceases to strip up readily, guided by the finger, the structures within the broad ligaments are seized by long-bladed clamps close to the uterus and divided on Fig. 334. Amputation of cervix by one flap or excision of the mucosa. (Schroeder's operation.) A. Showing method of placing the sutures. (1 and 2 are those uniting the com- missures.) B. Section showing shape of incisions (e f) and (b c) line of suture. C. Shows position of flaps after suturing. the uterine side. The uterus can then probably be dragged lower, and, with a sound in the canal, the uterine tissue is cut obliquely upward from the exterior to the sound, while the finger protects the surrounding parts, and in this way the cervix and a considerable portion of the body of the uterus is removed. A packing of iodoform gauze is placed in the vagina in contact with the cut surface, and 26* 594 OPERATIVE SURGERY. the clamps are left in place for twenty-four to forty-eight hours, when they can be removed without disturbing the packing. Schroede^s Flap Operation for the Removal of Diseased Cervical Mucous Membrane. The cervix is split trans- versely from below up to the vault of the vagina and the front and back halves thus formed retracted. The mucous membrane and underlying tissue are then removed from the lower part of the cervical canal, as shown in Fig. 334, B f, e, d. After this the remaining external part of the cer- vix (Fig. 334, B, x) is folded in and sutured over the raw surface, as illustrated in Fig. 334, A and C. The opera- tion is concluded by uniting the lateral commissures (Fig. 334, A, 1 and 2). INDEX. ABDOMEN, operations on, 385 paracentesis of, 385 Alexander's operation, 584 Amputations, 68 circular method, 69 flap methods, 70 Teale, 71, 107 oval method, 70, 119 Anaesthesia, general, 13 local, 14 rectal, 16 Anastomosis, intestinal, 396 Ankle, amputation at, 95 excision, 155 osteoplastic, 159 Antrum, trephining, 216 Anus, closure of artificial, 407 excision of, 453 fistula, 452 imperforate, 447 Aorta, ligature of abdominal, 54 Appendix, removal of vermiform, 409 Arm, amputation, 80 with scapula, 85 Arteries, ligature of, 30 Astragalus, excision, 157, 196 Atresia vaginre, 546 Axillary artery, ligature, 41 BASSINI, inguinal hernia. 439 Bladder catheterization, 516, 543 exstrophy, 514 puncture, 518 tumors, 539 Blepharoplasty, 293 BlepharoraphV, 291 Birth-mark, 242 Brachial artery, ligature, 43 plexus, 227 Brain, topography, 203 abscess, 211 ventricles, 213 Breast, amputation of, 382 Broad ligament, tumors of, 581 Bronchotomy, 363 Buccal nerve, 225 pALCANEUM, excision, 193 \J Canthoplasty, 292 Carotid, ligature of common, 47 of external, 48 of internal, 51 Castration, 483, 539 Cataract, depression or couching, 31S division or solution, 319 extraction, 321 operations for, 317 Catheterization, female bladder, 543 male bladder, 516 Cervical glands, 247 plexus, 228 Cervix, amputation of, 591 lacerated, 571 posterior section, 573 Cheiloplasty, 263 Cholecystectomy, 469 Cholecystenterostomy, 467 Cholecystostomy, 465 Chopart's amputation, 92 Circumcision, 490 Clavicle, excision, 182 Cleft palate, 351 Coccyx, excision, 189 Colotomy, 403 left, inguinal, 403 lumbar, 405 Colporrhaphy, 570 Corelysis, 316 Cornea, operations on, 307 Crural nerve, anterior, 232 Cuneiform osteotomy for talipes, 253 Cystotomy, supra-pubic, 534 DORSALIS pedis, ligature, 65 Dressings, preparation of, 21 Dupuytren's contraction, 245 EAR, operations on, 340 Ectopic gestation, 582 Ectropion, 293 Elbow, amputation at, 7S excision, 131 of anchylosed, 13S reduction of dislocated, 139 Elytrorrhaphy, 567 posterior, 570 Enterorrhaphy, circular, 392 Enterotomy, 402 Entropion, 300 Epispadias, 494 Erectile tumors, 240 Estlander, resection of ribs, 181 Eustachian tube, 341 Excision of joints and bones, 124 Exstrophy of bladder, 514 Eye, operations on, 307 596 INDEX. Eyeball, enucleation, 335 Eyelids, plastic operations, 291 FACIAL artery, ligature, 53 nerve, 227 Femoral artery, ligature, 60 Femur, creation of false joint, 150 excision of head, 146 of shaft, 189 division of neck, 151 osteotomy, 249 Fibula, resection, 191 Fifth nerve, extra-cranial resection, 217 intra-cranial resection, 215 Fingers, amputation, 72 Dupuytren's contraction, 245 web, 234 Fistula in ano, 452 salivary. 361 urethral, 503 vesico-vaginal, 559, 565 Foot, amputations, 90-102 excision of bones, 193 Forearm, amputation, 76 Fracture, operation for ununited, 256 Frsenum of tongue, 361 of penis, 494 Frontal sinus, 216 Innominate artery, ligature, 34 Inferior dental nerve, 222 Inferior thyroid artery, ligature, 39 Intestines, "anastomosis, 396 operations on, 389 suture of, 391 Iridectomy, 311 Iridesis, 315 Iridotomy, 310 Iris, operations on, 310 Ischa-mia, artificial, 19 [AW, anchylosis of, 179 KELOTOMY, 426 Kidney, methods of exposure, 471 operations on, 470 Knee, amputation at, 110 through the condyles, 111 Carden, 111 Gritti, 112 disarticulation, 110 excision, 152 Kolpokleisis, 565 Kraske, excision of rectum, 458 GALL-BLADDER, operations on, 465 Gastro-enterostomy, 423 Gastrorrhaphy, 420 Gastrostomy, 413 Gastrotomy, 416 Genito-urinary operations in female, 543 Glands, cervical, 247 Gluteal artery, ligature, 59 Goitre, operations lor, 378 Gritti, amputation at knee, 112 Guyon, amputation of leg, 105 HALLUX valgus, 252 Halsted, inguinal hernia, 414 Harelip, 273 complicated, 276 double, 276 Hemorrhage, arrest, 17 Hemorrhoids, 453 Hernia, radical cure of femoral, inguinal, 437 umbilical, 445 strangulated femoral, 434 inguinal, 482 obturator, 437 umbilical, 435 Herniotomy, 426 Hip, amputation at, 117 Hip-joint, excision, 146 anchylosis, 150 Humerus, resection, 186 Hydrocele, 485 Hypospadias, 498 Hysterectomy, abdominal, 587 vaginal, 590 Hysteropexy, 583 ILIAC artery, ligature of common, 65 or external, 58 of internal, 57 LACHRYMAL apparatus, 336 gland, removal, 336 sac and duct, 337 Laminectomy, 259 Laparo-hysterotomy, 584 Laparotomy, 386 Laryngectomy, 370 Laryngotomy, 363 cricothyroid, 365 thyroid, 365 Leg, amputation, 102 Lingual artery, ligature, 51 nerve, 226 Litholapaxy, 518 Lithotomy, 524 lateral, 527 median, 532 supra-pubic, 534 in female, 545 Liver, operations on, 461 hydatids of, 464 MASTOID cells, 342 Maxilla, inferior, anchylosis, 179 excision, 174 superior, excision, 102 temporary, 169 McBurney, appendix, 410 inguinal hernia, 444 Median nerve, 230 Medio-tarea] amputation, 92 Metacarpal bone, amputation, 74 excision, 188 Metatarsal bone, amputation, 89 excision, 197 Mikulicz, excision of heel, 159 Month, operation on, 344 Musculospiral nerve, 251 Myomectomy, 586 INDEX. 597 NASOPHARYNGEAL polyp, 169 Neck, operations on, 363 Nephrectomy, abdominal, 477 lumbar, 476 Nephrolithotomy, 475 Nephropexy, 479 Nephrotomy, 474 Neurorrhaphy, 232 Neurotomy, 217 Nose, plastic operations, 278 OCCIPITAL artery, ligature, 53 CEsophagotomy, 375 Olecranon, suture, 258 Oophorectomy, 578 Operation, conduct of, 27 preparation for, 27 Osteotomy, 249 cuneiform, for talipes, 253 for hallux valgus, 252 of femur, 249 of tibia, 252 Ovariotomy, 576 PALATE, cleft, 351 I Patella, suture of, 257 Paracentesis, abdomen, 385 thorax. 383 pericardium, 384 Pariphymosis, 493 Pelvis, resection of bones, 188 Penis, amputation of, 488 Pericardium, paracentesis, 384 Perineorrhaphy, 547 Hegar, 552 Perineum, laceration, 553, 558 Phalanges, contraction of, 244 excision, 188, 197 Phimosis, 489 Pharyngotomy, 372 subhyoid, 363 Pirogoff, amputation at ankle, 99 Plastic operations, 261 eyelids, 291 lip, 263, 271 mouth, 270 nose, 278 Popliteal artery, ligature, 62 nerve, 232 Pott's fracture, reduction of old, lfil Preparation for operation, 27 Prostatectomy, 538 Ptervgion, 305 Pudic artery, ligature, 59 Pylorectomy, 421 Pylorus, stricture of, 418 RADIAL artery, ligature, 45 Radius, excision, 1.S7 Rauula, 361 Rectum, excision, 453 operations on, 446 prolapse, 449 Rhinoplasty, 278 Ribs, resection, 181 Round ligaments, shortening, 584 Rous:, amputation at ankle, 98 ; OALPINGECTOMY, 579 U Salpingo-oophorectomy, 579 Scapula, excision, 183 Seminal vesicles, removal, 541 Sciatic artery, ligature, 59 nerve, 232 Shoulder, amputation at, 80 excision of, 127 Skin-grafting, 238 Spinal accessory nerve, 229 Splenectomy, 470 Sponges, preparation of, 21 Staphyloraphy, 345 Sterilization, 26 Sternum, resection of, 180 Stomach, operations on, 412 Strabismus, operation for, 332 Subastragaloid amputation, 94 Subclavian artery, ligature, 36 Superior thyroid artery, ligature, 39 maxillary nerve, 219 Supraorbital nerve, 217 Suprapubic cystotomy, 534 Sutures, 21 Symblepharon, 303 Syme, amputation at ankle, 95 Symphysiotomy, 586 TALIPES, osteotomy, 253 Tarso-metatarsal amputation, 90 Temporal artery, ligature, 54 • Tenorrhaphy, 236 Tenotomy, 233 Thiersch, skin-grafting, 238 Thigh, amputation, 114 Thorax, operations on, 382 paracentesis, 384 Thyroid artery, ligature of inferior, 39 superior, 39 gland, operations, 378 Tibia, osteotomy, 252 resection, 190 Tibial artery, ligature of anterior, 63 posterior, 65 Toenail, ingrown, 245 Toes, amputation, 87 Tongue, excision, 355 Kocher, 358 Tonsils, amputation, 344 Torticollis, 229 Tracheotomy, 367 Trephining, cranium, 197 omega flap, 200 for abscess, 211 for hemorrhage, 213 to reach cerebellum, 212 Trichiasis, 306 ULNA, excision, 187 Ulnar artery, ligature, 46 nerve, 231 Uranoplasty, 351 Ureter, operations on, 480 wounds of, 482 Urethral fistula. 503 Urethroplasty, 505 Urethroraphy, 505 Urethrotomy, external, 510, 543 internal, 508 598 INDEX. Uterus, amputation of gravid, 590 of cervix, 591 laceration of cervix, 571 prolapse of, 567 tumors of, 5S6 VAGINA, atresia of, 546 > narrowing of, 567 obliteration of, 565 prolapse of posterior wall, 549 Varicocele, 486 Ventricles, puncture of, 213 Vermiform appendix, 409 Vertebral artery, ligature, 40 Vesico-vaginal fistula, 559 creation, 565 Vesicles, removal of seminal, 541 WEB-FINGERS, 243 Wrist, amputation at, 75 excision of, 140 Wrv-neck, 229 Catalogue of 1Book$ PUBLISHED BY Lea Brothers & Company, 706, 708 & 710 Sansom St., Philadelphia, in Fifth Avenue (Corner 1 8th Street), New York. The books in the annexed list will be sent by mail, post-paid, to any Post Office in the United States, on receipt of the printed prices. No risks of the mail, however, are assumed, either on money or books. Gentlemen will therefore in most cases find it more convenient to deal with the nearest bookseller. PERIO DICALS 1836. 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